Kevin C. Chung MD MS - Operative Techniques - Hand and Wrist Surgery-Elsevier (2021)

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Operative Techniques In
Hand and Wrist Surgery
4th Edition
Kevin C. Chung, MD, MS

Charles B. G. de Nancrede Professor of Surgery
Chief of Hand Surgery, Michigan Medicine
Director, University of Michigan Comprehensive Hand Center
Assistant Dean for Faculty Affairs
Section of Plastic Surgery
Department of Surgery
University of Michigan Medical School
Ann Arbor, Michigan
Elsevier
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
OPERATIVE TECHNIQUES IN HAND AND WRIST SURGERY, ISBN: 978-0-323-79415-2

FOURTH EDITION
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Previous editions copyrighted 2008, 2012, 2018
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Contributors
Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Phillip R. Ross, MD

Associate Professor of Surgery Research Director Assistant Professor
Adjunct Associate Professor The Curtis National Hand Center Department of Orthopaedic Surgery
of Orthopaedic Surgery Baltimore, Maryland University of Cincinnati College
Chief of Hand Surgery, Division Assistant Professor of Medicine
of Plastic Surgery Department of Plastic Surgery Cincinnati, Ohio
Chief of Plastic Surgery, Eskenazi Georgetown University
Hospital Washington, DC Sarah E. Sasor, MD
Indiana University School of Medicine Assistant Professor Assistant Professor
Indianapolis, Indiana Department of Plastic Surgery Department of Plastic Surgery
Johns Hopkins University Medical College of Wisconsin
Chun-Yu Chen, MD Baltimore, Maryland Wauwatosa, Wisconsin
Assistant Professor
Department of Orthopaedic Surgery David W. Grant, MD, MASc Brian W. Starr, MD
Kaohsiung Veterans General Hospital Hand Surgery Fellow Hand Surgery Fellow
Kaohsiung, Taiwan Combined Hand Surgery Fellowship Department of Surgery
University of Michigan Section of Plastic Surgery
Kevin C. Chung, MD, MS Ann Arbor, Michigan Michigan Medicine
Charles B. G. de Nancrede Professor Ann Arbor, Michigan
of Surgery Benjamin K. Gundlach, MD
Chief of Hand Surgery, Michigan Orthopaedic Surgery Resident Yu Zhou, MD, PhD
Medicine Department of Orthopaedic Surgery Attending Surgeon
Director, University of Michigan Michigan Medicine Department of Gynecological Plastic
Comprehensive Hand Center Ann Arbor, Michigan Surgery
Assistant Dean for Faculty Affairs Plastic Surgery Hospital
Section of Plastic Surgery Rachel C. Hooper, MD Chinese Academy of Medical Sciences
Department of Surgery Staff Plastic Surgeon Beijing, China
University of Michigan Medical School Department of Surgery
Ann Arbor, Michigan Henry Ford Hospital Robert L. Kane, BS
Detroit, Michigan Medical Student
Elissa S. Davis, MD New York Medical College
Staff Surgeon Shepard Peir Johnson, MD Valhalla, New York
BJC Medical Group Orthopedics & Hand Fellow
Sports Medicine Department of Surgery Natalie B. Baxter, BSE
Belleville, Illinois Section of Plastic Surgery Medical Student
Michigan Medicine University of Michigan Medical School
Matthew Florczynski, MD, MSc Ann Arbor, Michigan Ann Arbor, Michigan
Resident Physician
Division of Orthopaedic Surgery
University of Toronto
Toronto, Ontario
iii
Preface
Operative Techniques in Hand and Wrist Surgery, 4th Edition

After 2 years of capturing operative pictures and videos, I am proud to present you
with a new edition of this classic textbook. Over 90% of the chapters were rewritten
and updated with new photos, illustrative figures, and all-new videos. This textbook
embodies the spirit of innovation and describes techniques that are safe and appli-
cable to your practice. Rather than simply offering stylistic changes, each edition of
this book has undergone fundamental revisions that enhance its content. We refined
the description of procedures and highlighted key narratives to facilitate ease of
learning for our readers. Tips and pearls are provided liberally, particularly in the
videos that I have narrated. This textbook has served as an essential teaching forum
in all corners of the world. During my travels in the United States and abroad, I have
received enthusiastic endorsement of this series that guides the care of people with
hand problems. I can confidently say that this new edition is one of the best textbooks
in the field of hand surgery because of its artistic delivery and focused discussion of
essential procedures.
The content in this textbook is a collection of over 25 years of my experience,
in collaboration with my past trainees, many of whom are in academic practices in
charge of teaching hand surgery. Instead of presenting a multitude of procedures to the
readers without endorsing a best approach, we strive to endorse techniques that
we know will work. I am grateful to my coauthors who toiled tirelessly on this volume.
We recognized the enormity of our responsibility as we wrote this 4th edition, for you
are applying our philosophy in rendering the best treatments for your patients.
A book of this depth and breadth can only be accomplished by a team of highly
dedicated assistants whose devotion made this book a reality. Every word, every
photo, and every video has undergone intense scrutiny by my team to assure a flawless
delivery. I am grateful to two of my assistants, Natalie Baxter and Robert Kane, who
supported each author by extracting images from my own archives and from Elsevier’s
collection. They meticulously edited each chapter and worked with the production team
at Elsevier to meet the strict timeline that we imposed on ourselves. We are also in-
debted to our international fellow, Yu Zhou, MD, from the Plastic Surgery Hospital
in Beijing, for taking the heavy responsibility of editing over 100 new videos for this
volume. Dr. Zhou’s meticulousness and creativity in capturing the images and videos
imparts a compulsive spirit that resonates throughout this volume.
I am also encouraged by the trust of the Elsevier team in supporting this 4th edition.
My production team includes Belinda Kuhn, London, and Deborah Poulson, Philadelphia.
Their devotion and contribution are immeasurable. Finally, I cherish the longstanding re-
lationship with our readership, whose guidance and feedback drove me to complete this
4th edition. A number of my readers have approached me at national and international
meetings to share how this series has transformed their practices. Earnestly sharing ev-
erything we have learned through our experiences has contributed to the far-reaching
influence of this book. We have learned so much from our patients, and a key component
of education is reflection. It is our culture to collect pictures and videos for all the opera-
tions I do so that I can refine my procedures in striving for excellence. Only through humil-
ity and self-enrichment can one emerge as a thoughtful, outstanding surgeon. I wish you
great success in your practices. I am profoundly indebted to you for choosing to embark
on a lifelong journey of learning with us through this 4th edition of Operative Techniques
in Hand and Wrist Surgery.
v
vi Preface
As the 75th president of the American Society for Surgery of the Hand (ASSH), I
dedicate this book to members of the ASSH for their devotion to the art and science of
hand surgery.
Kevin C. Chung, MD, MS

Charles B. G. de Nancrede Professor of Surgery
Chief of Hand Surgery, Michigan Medicine
Director, University of Michigan Comprehensive Hand Center
Assistant Dean for Faculty Affairs
Section of Plastic Surgery
Department of Surgery
University of Michigan Medical School
Ann Arbor, Michigan
Foreword
I felt deeply honored when Dr. Chung asked me to write the foreword to the 4th edition
of his now classic textbook Operative Techniques in Hand and Wrist Surgery. This multi-
authored textbook was first published in 2008 and with each new edition, the individual
chapters have been updated, refined, and structured for ease of readability. The
4th edition is no exception.
Each chapter is stylistically consistent and methodically written by a seasoned se-
nior surgeon and many of them are coauthored by an aspiring academician. Surgeons
will appreciate the user-friendly format, particularly when preparing for a procedure for
the first time. Each procedure is presented in a bulleted format that includes indica-
tions, a preoperative evaluation, relevant surgical anatomy, and a methodical guideline
(including pearls, pitfalls, and complications) for carrying out the intended procedure.
Each chapter not only outlines core treatment principles, but also consistently demon-
strates that there are many ways to tackle a problem. Another highlight of Operative
Techniques is the exemplary quality of Dr. Chung’s narrated videos, illustrations, and
clinical photographs. His trademark green towel background, devoid of bloodstains
and wrinkles, is a sure sign that the reader is getting the finest in clarity and precision.
In contrast to many textbooks, it is not laden with countless and often irrelevant refer-
ences. Each chapter concludes with a brief but highly germane annotated bibliography,
a feature I found very useful.
Dr. Chung’s text is a must for any hand surgeon’s library. It is encyclopedic, easy to
navigate, and exceptionally well illustrated. With the combination of text and narrated
videos, the preparation, performance, and rehabilitation of hand and wrist procedures
will without a doubt enhance both the experienced and beginning surgeon’s opportu-
nity to optimize outcomes.
Peter J. Stern, MD
Norman S. and Elizabeth C.A. Hill Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
University of Cincinnati College of Medicine
vii
Contents
Section I Anesthesia and Emergency Procedures, 1
CHAPTER 1 Anesthesia of the Hand, 2

Benjamin K. Gundlach and Kevin C. Chung
CHAPTER 2 asciotomy for Compartment Syndrome of the Hand
F
and Forearm, 4
Yu Zhou, Rachel Hooper, and Kevin C. Chung
CHAPTER 3 Digit Amputations, 5
CHAPTER 4 Proximal Upper Extremity Amputations, 7
CHAPTER 5 inger Infections (Paronychia, Felons, Pyogenic Flexor
F
Tenosynovitis), 8
CHAPTER 6 Splints and Orthoses, 16
Section II Hand Fractures and Dislocations, 17
CHAPTER 7 Principles of Bone Fixation and Healing, 18

Chun-Yu Chen and Kevin C. Chung
CHAPTER 8 Kirschner Wire Fixation of Mallet Fractures, 19
CHAPTER 9 echniques for Fixing Extraarticular Phalangeal
T
Fractures, 20
CHAPTER 10 ynamic External Fixation of Fracture-Dislocation
D
of the Proximal Interphalangeal Joint, 21
CHAPTER 11 pen Reduction and Internal Fixation of Intraarticular
O
Phalangeal Fractures, 22
CHAPTER 12 olar Plate Arthroplasty of the Proximal
V
Interphalangeal Joint, 23
Kevin C. Chung
CHAPTER 13 Hemi-Hamate Arthroplasty, 24
Shepard Peir Johnson and Kevin C. Chung
CHAPTER 14 Techniques and Fixation of Metacarpal Fractures, 33
Matthew Florczynski and Kevin C. Chung
ix
x Contents
CHAPTER 15 pen Reduction for Metacarpophalangeal Joint

O
Dislocation, 34
CHAPTER 16 orrective Osteotomy of Metacarpal Fracture
C
Malunion, 40
CHAPTER 17 econstruction of Acute and Chronic Ulnar Collateral
R
Ligament Injuries of the Thumb, 41
Elissa S. Davis and Kevin C. Chung
CHAPTER 18 echniques for Fixing Bennett and Rolando
T
Fractures, 52
Section III Wrist Fractures and Carpal Instability, 53
CHAPTER 19 Wrist Arthroscopy, 54

CHAPTER 20 epairing Tears of the Triangular Fibrocartilage
R
Complex, 68
Aviram M. Giladi and Kevin C. Chung
CHAPTER 21 Scapholunate Ligament Repair, 80
David W. Grant and Kevin C. Chung
CHAPTER 22 Scapholunate Ligament Reconstruction, 93
CHAPTER 23 unotriquetral Ligament Reconstruction Options
L
Using Tendon Grafts, 113
CHAPTER 24 capholunate and Lunotriquetral Ligament
S
Reconstruction with Internal Brace and Tendon
Grafting, 125
CHAPTER 25 pen Reduction and Internal Fixation of Acute
O
Scaphoid Fracture, 131
CHAPTER 26 Treatment of Scaphoid Nonunion, 142
CHAPTER 27 Salvage Procedures for Scaphoid Nonunion, 161
CHAPTER 28 pen Reduction and Fixation of Acute Lunate
O
or Perilunate Dislocation, With or Without Fracture,
174
CHAPTER 29 lnar Shortening Osteotomy for Ulnar Impaction
U
Syndrome, 184
CHAPTER 30 istal Radioulnar Joint Reconstruction Using
D
Palmaris Longus Graft, 185
Contents xi
CHAPTER 31 rocedures for Avascular Necrosis of the Lunate

P
(Kienböck Disease), 194
Section IV Forearm Fractures, 211
CHAPTER 32 Operative Treatment of Distal Radius Fractures, 212

CHAPTER 33 Corrective Osteotomy of Radius Malunion, 243
CHAPTER 34 ssociated Ulnar Fixation (Ulnar Styloid and
A
Metadiaphyseal Fractures), 258
CHAPTER 35 orearm Fracture-Dislocations (Galeazzi
F
and Monteggia), 266
Section V Rheumatoid Arthritis and Degenerative Disease, 277
CHAPTER 36 etacarpophalangeal Joint Synovectomy, Crossed

M
Intrinsic Tendon Transfer, and Extensor Tendon
Centralization, 278
Sarah E. Sasor and Kevin C. Chung
CHAPTER 37 endon Transfers for Rheumatoid Tendon Attrition
T
Rupture, 285
CHAPTER 38 tabilization of Extensor Carpi Ulnaris Tendon
S
Subluxation with Extensor Retinaculum, 297
CHAPTER 39 Correction of Swan-Neck Deformity, 304
CHAPTER 40 Correction of Boutonniere Deformity, 312
CHAPTER 41 Metacarpophalangeal Arthroplasty, 319
CHAPTER 42 Proximal Interphalangeal Arthroplasty, 334
CHAPTER 43 Distal Interphalangeal Joint Arthrodesis, 344
CHAPTER 44 J oint Fusion for Thumb Metacarpophalangeal
Instability, 345
CHAPTER 45 Carpometacarpal Joint Fusion for Basilar Arthritis, 346
CHAPTER 46 econstruction for Thumb Carpometacarpal Joint
R
Instability Using Flexor Carpi Radialis (Littler
Procedure), 353
xii Contents
CHAPTER 47 rapeziectomy and Abductor Pollicis Longus

T
Suspensionplasty, 360
CHAPTER 48 Revision Carpometacarpal Joint Arthroplasty, 368
CHAPTER 49 Distal Ulnar Resection (Darrach Procedure), 380
CHAPTER 50 Sauvé-Kapandji Procedure, 386
CHAPTER 51 Hemiresection Ulnar Arthroplasty, 393
CHAPTER 52 Total Wrist Arthroplasty, 399
CHAPTER 53 Total Wrist Fusion, 413
CHAPTER 54 Wrist Denervation, 420
Section VI Nerve Conditions, 426
CHAPTER 55 Open Carpal Tunnel Release, 427

Rachel C. Hooper and Kevin C. Chung
CHAPTER 56 Endoscopic Carpal Tunnel Release, 433
Kevin C. Chung
CHAPTER 57 evision Carpal Tunnel Release and Coverage Using
R
a Hypothenar Fat Pad Flap, 440
CHAPTER 58 Procedures for Ulnar Compressive Neuropathy, 446
CHAPTER 59 Radial Nerve Decompression, 459
Section VII Nerve Injuries and Palsy, 465
CHAPTER 60 Digital Nerve Repair, 466

CHAPTER 61 Ulnar Nerve Group Fascicular Repair, 472
CHAPTER 62 edian Nerve Epineural and Group Fascicular Nerve
M
Repair, 476
CHAPTER 63 endon Transfers for Low Median Nerve Injury, 482
T
CHAPTER 64 Tendon Transfers for High Median Nerve injury, 494
Contents xiii
CHAPTER 65 endon Transfers for Low and High Ulnar Nerve

T
Injury, 502
Phillip R. Ross and Kevin C. Chung
CHAPTER 66 endon Transfers for High and Low Radial Nerve
T
Injury, 521
CHAPTER 67 Tendon Transfers for Combined Nerve Palsy, 530
CHAPTER 68 istal Anterior Interosseous Nerve Transfer to Motor
D
Branch of Ulnar Nerve, 540
Section VIII Tetraplegic Conditions, 546
CHAPTER 69 endon and Nerve Transfers for Spinal Cord Injury

T
Patients, 547
Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung
CHAPTER 70 estoration of Elbow Extension: Deltoid to Triceps
R
Transfer and Biceps to Triceps Transfer, 555
CHAPTER 71 estoration of Wrist Extension: Brachioradialis
R
to Extensor Carpi Radialis Tendon Transfer, 562
CHAPTER 72 estoration of Active Key Pinch: Brachioradialis and
R
Pronator Teres to Flexor Pollicis Longus Transfer, 566
CHAPTER 73 Restoration of Passive Key Pinch, 572
CHAPTER 74 estoration of Active Pinch and Grasp: Extensor
R
Carpi Radialis Longus Transfer to Flexor Digitorum
Profundus, 582
CHAPTER 75 Intrinsic Tendon Reconstruction, 587
CHAPTER 76 Nerve Transfer for Spinal Cord Injuries, 597
Rachel C. Hooper, Chun-Yu Chen, Kevin C. Chung
Section IX Tendon Conditions, 601
CHAPTER 77 Wide-Awake Approach for Tendon Transfers, 602

CHAPTER 78 cute Repair of Flexor Tendon Injuries in Zones
A
I to V, 610
CHAPTER 79 wo-Stage Flexor Tendon Reconstruction with Silicone
T
Rod, 626
CHAPTER 80 2 Flexor Tendon Pulley Reconstruction With Free
A
Tendon Graft, 635
xiv Contents
CHAPTER 81 Tenolysis of Flexor Tendons, 637

CHAPTER 82 cute Repair of Extensor Tendon Injuries: Zones I
A
To VII, 638
CHAPTER 83 Release of Trigger Finger, 640
CHAPTER 84 Release of De Quervain Tenosynovitis, 641
Section X Flaps and Microsurgery, 642
CHAPTER 85 Management of Mangled Extremities, 643

Kevin C. Chung and Natalie B. Baxter
CHAPTER 86 ocal Tissue Rearrangement for Treatment
L
of Scar Contractures, 653
CHAPTER 87 Flap Coverage of Fingertip Injuries, 663
Brian W. Starr and Kevin C. Chung
CHAPTER 88 Flap Coverage of Thumb Defects, 664
CHAPTER 89 orsal Metacarpal Artery Flap and Dorsal Metacarpal
D
Artery Perforator Flap, 666
Yu Zhou and Kevin C. Chung
CHAPTER 90 Pedicled Forearm Flaps, 673
CHAPTER 91 Groin Flaps, 674
CHAPTER 92 Lateral Arm Flap, 684
CHAPTER 93 Venous Flap, 694
Yu Zhou, Chun-Yu Chen, and Kevin C. Chung
CHAPTER 94 evascularization and Replantation of Digits
R
and Hand, 704
Kevin C. Chung
CHAPTER 95 Toe to Thumb Transfer, 715
CHAPTER 96 ympathectomy of Radial, Ulnar, and Common Digital
S
Arteries for Raynaud Phenomenon, 728
CHAPTER 97 lnar Artery to Superficial Arch Bypass with a Vein
U
Graft, 736
Section XI Contractures and Spastic Conditions, 744
CHAPTER 98 urgical and Nonsurgical Treatment of Dupuytren

S
Contracture, 745
Contents xv
CHAPTER 99 Biceps and Brachialis Lengthening, 757

CHAPTER 100 tep-Cut Fractional Lengthening of Flexor Tendons
S
and Flexor Digitorum Superficialis to Flexor Digitorum
Profundus Transfer, 764
CHAPTER 101 Flexor-Pronator Slide, 770
Joshua M. Adkinson and Kevin C. Chung
CHAPTER 102 Thumb Adductor Release, 774
CHAPTER 103 apsulotomy for Proximal Interphalangeal
C
Contracture, 779
CHAPTER 104 apsulotomy for Metacarpophalangeal
C
Contracture, 780
Section XII Congenital Hand Disorders, 785
CHAPTER 105 Pediatric Trigger Digits, 786

CHAPTER 106 elease of Finger Syndactyly Using Dorsal
R
Rectangular Flap, 794
CHAPTER 107 Duplicated Thumb and Finger Treatment, 802
CHAPTER 108 Index Pollicization for Hypoplastic Thumb, 814
CHAPTER 109 Pediatric Opponensplasty, 825
CHAPTER 110 Camptodactyly Correction, 833
CHAPTER 111 Macrodactyly Correction, 842
CHAPTER 112 Release of Constriction Ring Syndrome, 849
CHAPTER 113 Centralization for Radial Longitudinal Deficiency, 857
CHAPTER 114 Cleft Hand Reconstruction, 865
CHAPTER 115 Arthrogryposis Reconstruction, 873
Section XIII Tumors, 882
CHAPTER 116 Hand Masses, 883

xvi Contents
CHAPTER 117 Excision of Vascular Lesions of the Hand, 892

CHAPTER 118 Excision of Metacarpal Enchondroma, 893
CHAPTER 119 Excision of Peripheral Nerve Schwannoma, 894
CHAPTER 120 Excision of Malignant Skin Tumors, 900
Index, 901
Video TOC
1.1 Anesthesia of the Hand

3.1 Digit Amputation
4.1 Mid-Forearm Amputation
4.2 Regenerative Peripheral Nerve Interface
9.1 Closed Reduction with Kirschner Wire Fixation of
Extraarticular Phalangeal Fractures
11.1 Open Reduction and Internal Fixation of Intraarticular
Phalangeal Fractures
12.1 Volar Plate Arthroplasty of the Proximal Interphalangeal
Joint
14.1 Open Reduction and Internal Fixation of Metacarpal
Shaft Fractures
17.1 Ulnar Collateral Ligament Repair Using the Mitek Mini
Anchor
18.1 Bennett Fracture Treated with Metacarpal Corrective
Osteotomy and Placement of AlloDerm in the
Carpometacarpal Joint
19.1 Diagnostic Wrist Arthroscopy
20.1 Arthroscopic Repair of the Triangular Fibrocartilage
Complex
20.2 Open Repair of TFCC
22.1 Scapholunate Ligament Reconstruction Using Bone-
Ligament-Bone Construct
22.2 Scapholunate Ligament Reconstruction Using Extensor
Carpi Radialis Brevis Tendon Graft and the Arthrex
InternalBrace System
23.1 Lunotriquetral Ligament Reconstruction Using a Slip of
Extensor Carpi Ulnaris Tendon
23.2 Lunotriquetral Ligament Reconstruction Using the Arthrex
InternalBrace System
24.1 Scapholunotriquetral Ligament Reconstruction with the
Arthrex InternalBrace System
25.1 Open Reduction and Internal Fixation of Acute Scaphoid
Fracture Using a Dorsal Approach
26.1 Nonvascularized Bone Graft for Scaphoid Nonunion
26.2 Pronator Quadratus Vascularized Bone Graft for Scaphoid
Nonunion
26.3 Medial Femoral Condyle Vascularized Bone Graft for
Scaphoid Nonunion
xvii
xviii Video TOC
27.1 Scaphoidectomy and Four-Corner Fusion

27.2 Proximal Row Carpectomy
28.1 Open Reduction and Internal Fixation of Acute Perilunate
Dislocation with Fracture
29.1 Transmetaphyseal Ulnar Shortening Osteotomy
30.1 Distal Radioulnar Joint Reconstruction Using the Palmaris
Longus Graft
31.1 Capitate Shortening Osteotomy With Vascularized Bone
Graft for Avascular Necrosis of the Lunate
32.1 Percutaneous Kirschner Wire Fixation of Distal Radius
Fracture
32.2 External Fixation of Distal Radius Fracture
32.3 Volar Plating for Distal Radius Fracture
32.4 Dorsal Plating for Distal Radius Fracture
34.1 Open Reduction and Internal Fixation of Distal Ulna
and Radius
36.1 Cross Intrinsic Tendon Transfer
37.1 Distal Ulna Excision, Extensor Tenosynovectomy, and
Extensor Indicis Proprius to Extensor Digitorum
Communis Transfer
38.1 Extensor Carpi Ulnaris Subluxation Repair with Extensor
Retinaculum
39.1 Proximal Interphalangeal Lateral Band Release for
Swan-Neck Deformity
40.1 Correction of Boutonniere Deformity
41.1 Metacarpophalangeal Arthroplasty with Silicone Implant
41.2 Metacarpophalangeal Arthroplasty with Pyrocarbon
Implant
42.1 Proximal Interphalangeal Silicone Arthroplasty
43.1 Distal Interphalangeal Joint Fusion
44.1 Thumb Metacarpophalangeal Fusion
45.1 Carpometacarpal Fusion with Synthes Locking Plate
46.1 Thumb Carpometacarpal Joint Stabilization with Flexor
Carpi Radialis
47.1 Trapezium Excision and Abductor Pollicis Longus Tendon
Stabilization to Extensor Carpi Radialis Longus
47.2 Carpometacarpal Arthroplasty with Trapeziectomy and
Abductor Pollicis Longus Suspensionplasty with Suture
to Flexor Carpi Radialis Tendon
49.1 Distal Ulna Resection
50.1 Distal Ulna Excision and Shelf Arthroplasty
51.1 Hemi-Resection Arthroplasty of the Distal Ulna
52.1 Total Wrist Arthroplasty
Video TOC xix
53.1 Total Wrist Fusion Using a Synthes Plate and Cadaveric

Bone Grafting
54.1 Wrist Denervation: Anterior and Posterior Interosseous
Nerve Neurectomy
55.1 Open Carpal Tunnel Release
57.1 Revision Carpal Tunnel Release with Flexor
Tenosynovectomy and Hypothenar Fat Pad Flap
58.1 Ulnar Nerve Neurolysis at Guyon Canal
58.2 In-situ Ulnar Nerve Release at the Cubital Tunnel
58.3 Intramuscular Anterior Transposition of the Ulnar Nerve
59.1 Posterior Interosseous Nerve Release at the Level of the
Supinator
60.1 Neuroma Excision and Digital Nerve Repair
62.1 Wrist Laceration with Median Nerve Repair
63.1 Palmaris Longus to Abductor Pollicis Brevis
63.2 Extensor Indicis Proprius to Abductor Pollicis Brevis
64.1 Superficialis to Profundus Transfer and Intrinsic Slide
64.2 Brachioradialis to Flexor Pollicis Longus, and Extensor
Carpi Radialis Longus to Flexor Digitorum Profundus
65.1 Flexor Digitorum Superficialis Transfer to Correct Claw
Deformity
65.2 Extensor Carpi Radialis Brevis with Palmaris Longus Tendon
Graft for Adductorplasty
65.3 Partial Flexor Pollicis Longus to Extensor Pollicis Longus
Tenodesis Stabilization
65.4 Abductor Pollicis Longus and Extensor Carpi Radialis Brevis
Graft to First Dorsal Interosseous Tendon
65.5 Flexor Digitorum Superficialis - Lasso Procedure
65.6 Metacarpophalangeal Capsuloplasty/Volar Plate
Advancement
66.1 Flexor Carpi Radialis to Extensor Digitorum Communis,
Flexor Digitorum Superficialis to Extensor Pollicis Longus
and Extensor Indicis Proprius
66.2 Palmaris Longus to Extensor Pollicis Longus
67.1 Flexor Carpi Radialis to Extensor Digitorum Communis,
Palmaris Longus to Extensor Pollicis Longus, Brachioradialis
to Flexor Pollicis Longus, Extensor Carpi Radialis Longus to
Flexor Digitorum Profundus, Flexor Digitorum Superficialis
to Abductor Pollicis Brevis
67.2 Tendon Transfers for High Median and Ulnar Nerve Injury:
Brachioradialis to Flexor Pollicis Longus, Extensor Indicis
Proprius to Abductor Pollicis Brevis, and Extensor Carpi
Radialis Longus to Flexor Digitorum Profundus
68.1 Distal Anterior Interosseous Nerve Transfer to Motor Branch
of Ulnar Nerve
xx Video TOC
69.1 Supinator to Posterior Interosseous Nerve Transfer

70.1 Deltoid to Triceps Transfer
71.1 Brachioradialis to Extensor Carpi Radialis Tendon Transfer
75.1 Intrinsic Tendon Reconstruction
76.1 Ulnar Digital Nerve and Radial Digital Nerve Transfers
78.1 Acute Repair of Flexor Tendon and Ulnar Digital Nerve
(Zone I)
78.2 Tendon Rupture of the Thumb, Index Finger, and Small
Finger (Zone V)
78.3 Flexor Pollicis Longus Tendon Repair (Zone TIV)
79.1 Stage I: Silicone Rod Placement for Flexor Tendon
79.2 Stage II: Tendon Reconstruction with Palmaris Tendon
Grafting
81.1 Tenolysis of Flexor Tendons
82.1 Thumb Extensor Tendon Repair (Zone TIV)
84.1 Release of de Quervain Tendovaginitis
85.1 Arm Reconstruction with Neuromusculocutaneous Gracilis
Free Flap
86.1 Webspace Contracture Release with 5-flap Z-plasty
87.1 Fingertip Reconstruction Using Thenar Flap
87.2 Homodigital Neurovascular Island Flap Coverage
of Fingertip Injury
88.1 Moberg Flap Transfer to Repair Thumb Defect
88.2 First Dorsal Metacarpal Artery Flap Reconstruction for Skin
Defect of the Thumb
89.1 Dorsal Metacarpal Artery Propeller Perforator Flap
90.1 Perforator Flap From Radial Artery
91.1 Groin Flap Transfer
93.1 Dermatofasciectomy for Dupuytren Contracture with
Arterialized Venous Flow-Through Flap
95.1 Second Toe to Thumb Transfer at the Thumb
Metacarpophalangeal Joint
96.1 Sympathectomy of Radial, Ulnar, and Common Digital
Arteries
97.1 Ulnar Artery Repair with Vein Graft
98.1 Open Fasciectomy for Dupuytren Contracture
99.1 Biceps and Brachialis Lengthening
100.1 Superficialis to Profundus Transfer and Intrinsic Slide
100.2 Fractional Lengthening of Flexor Tendons
101.1 Flexor Pronator Slide
102.1 Thumb Adductor Release
Video TOC xxi
103.1 Proximal Interphalangeal Volar Capsulotomy

104.1 Metacarpophalangeal Dorsal Capsulotomy
104.2 Metacarpophalangeal Dorsal Capsulotomy of Index, Middle,
Ring, and Small Fingers
106.1 Release of Finger Syndactyly
107.1 Reconstruction of Type I Duplicated Thumb
107.2 Excision of Type IV Duplicated Thumb
108.1 Index Pollicization for Hypoplastic Thumb
109.1 Pediatric Opponensplasty
110.1 Proximal Interphalangeal Flexion Contracture Release
111.1 Finger Amputation for Macrodactyly
112.1 Release of Constriction Ring in Great Toe
114.1 Cleft Hand Reconstruction
116.1 Dorsal Wrist Ganglion Cyst Excision
116.2 Volar Wrist Ganglion Cyst Excision
116.3 Giant Cell Tumor Excision
117.1 Subungual Glomus Tumor Excision
118.1 Excision of Metacarpal Enchondroma
119.1 Excision of Peripheral Nerve Schwannoma
120.1 Nail Tumor Excision and Dermal Substitute Coverage
ddsf
SECTION I
Anesthesia and Emergency

Procedures
CHAPTER 1 Anesthesia of the Hand 2
CHAPTER 2 Fasciotomy for Compartment Syndrome
of the Hand and Forearm 4
CHAPTER 3 Digit Amputations 5
CHAPTER 4 Proximal Upper Extremity Amputation 7
CHAPTER 5 Finger Infections (Paronychia, Felons, Pyogenic
Flexor Tenosynovitis) 8
CHAPTER 6 Splints and Orthoses 16
1
CHAPTER 1
Anesthesia of the Hand
Full text of this chapter is available online at expertconsult.com.

This chapter includes the following video: Video 1.1 – Anesthesia of the Hand.
KEY CONCEPTS
• Local anesthesia has many practical uses and is straightforward to administer be-
cause of the superficial nature and consistent anatomic course of the sensory
nerves surrounding the hand and wrist. It is increasingly used as the sole anesthetic
in the outpatient setting for WALANT (wide awake, local anesthesia, no tourniquet)
procedures.
• Local anesthetics can be administered to individual digits (digital block); along
named sensory nerves, such as the superficial radial and dorsal ulnar branches; or
locally in random patterned areas to provide complete anesthesia. This technique
facilitates detailed examination of important structures within the digits and hand in
an emergency room setting, such as ensuring tendon continuity in a patient with an
acute digit laceration.
• Local anesthesia is also useful when evaluating a patient’s motion in real time in the
operating room. For example, it may be used to ensure that a complete A1 pulley
release has been performed with no residual triggering. This technique is also useful
Superficial radial nerve
Dorsal cutaneous branch of ulnar nerve
Median nerve
Ulnar nerve
FIGURE 1.1 Sensory distribution of dorsal hand.
2
CHAPTER 1 Anesthesia of the Hand 3
for patients with critical cardiopulmonary illness because it can obviate the need for
general anesthesia.
• Lidocaine is the most widely used agent, with an onset of action of 3 to 5 minutes
and duration of action of 60 to 120 minutes.
• Blocks are most easily performed with the patient supine and the arm extended on
a hand table.
• All patients should be educated on the common phenomenon of rapid dissipation of
the local anesthetic, leading to a rebound pain response.
Procedures reviewed in this chapter:
• Radial nerve block
• Median nerve block
• Ulnar nerve block
• Intermetacarpal block
• Subcutaneous digital block
• Intrathecal block
CHAPTER 1
Anesthesia of the Hand
INDICATIONS
• Local anesthesia has many practical uses and is straightforward to administer be-
cause of the superficial nature and consistent anatomic course of the sensory
nerves surrounding the hand and wrist. It is increasingly used as the sole anesthetic
in the outpatient setting for WALANT (wide awake, local anesthesia, no tourniquet)
procedures.
• Local anesthetics can be administered to individual digits (digital block) along
named sensory nerves, such as the superficial radial and dorsal ulnar branches, or
locally in random patterned areas to provide complete anesthesia.
• This technique facilitates detailed examinations of important structures within the
digits and hand in an emergency room setting, such as ensuring tendon continuity
in a patient with an acute digit laceration.
• Local anesthesia is also useful when evaluating a patient’s motion in real time in the
operating room. For example, it may be used to ensure that a complete A1 pulley
release has been performed with no residual triggering.
• This technique is also useful for patients with critical cardiopulmonary illness be-
cause it can obviate the need for general anesthesia.
Contraindications
• WALANT is often not appropriate for children and adults who cannot follow instruc-
tions or remain still for prolonged periods of time.
CLINICAL EXAMINATION
Anesthetic Agents
• Lidocaine is the most widely used agent, with an onset of action of 3 to 5 minutes
and duration of action of 60 to 120 minutes. It is most often found in either 1% or
2% concentrations.
• Bupivacaine is also commonly used for longer duration of pain control (400–450
minutes). It has a much longer onset of action of 15 to 20 minutes. It often comes in
either 0.25% or 0.5% concentrations.
• Lidocaine and bupivacaine can be mixed in various ratios to provide the com-
bined benefits of quick onset with lidocaine and long duration of action with
bupivacaine.
• The advantages of using epinephrine mixed with a local anesthetic (1:200,000 or
even 1:100,000) are twofold; it causes vasoconstriction within the surrounding
tissue, limiting blood loss during any open procedure, and it also increases the
lidocaine/bupivacaine duration of action by preventing systemic absorption. We
recommend using epinephrine for common surgical procedures, such as first
dorsal compartment release or carpal tunnel release, to limit bleeding in these
highly vascular areas.
• A solution of 1% lidocaine in epinephrine is nearly 1000 times more acidic than
subcutaneous tissue. It can be buffered with standard 8.4% sodium bicarbonate
(NaCO3) in a 1 mL:10 mL (NaCO3:Lidocaine) ratio. The reduction in acidity is neces-
sary to reduce the pain associated with injection.
SURGICAL ANATOMY
• Fig. 1.1 shows the sensory distribution of the dorsal hand.
• Fig. 1.2 shows the location of the radial, median, and ulnar nerves. The radial nerve
crosses the wrist in the area of the radial styloid. The purely sensory nerve arborizes
3.e1
3.e2 CHAPTER 1 Anesthesia of the Hand
Dorsal cutaneous branch of ulnar nerve
Median nerve
Ulnar nerve
FIGURE 1.1
Median nerve
Ulnar nerve
Radial sensory
nerve
FIGURE 1.2
proximal to the radial styloid and crosses the wrist divided into a few major branches
that travel in subcutaneous tissues anywhere from just volar to the styloid and as far
dorsal/ulnar as the area in line with the middle finger metacarpal (Fig. 1.3).
• The median nerve crosses the wrist within the carpal tunnel, and the palmar cutane-
ous branch crosses in a similar region of the wrist but more superficially. The nerve
runs between the palmaris longus (PL) and the flexor carpi radialis (FCR) tendons,
and for patients with PL, this tendon can be used to help landmark for injections.
CHAPTER 1 Anesthesia of the Hand 3.e3
Extensor pollicis longus

Styloid process
of radius
Scaphoid
A B Abductor pollicis longus
FIGURE 1.3
Flexor carpi
radialis
Median
nerve
Palmaris
A B longus
FIGURE 1.4
• To identify the PL, have the patient pinch their thumb to their ring/small finger and
locate the tendon bulge in the wrist (Fig. 1.4).
• If not present or identifiable, the ulnar border of the FCR tendon can be used as
the landmark.
• The ulnar nerve crosses the wrist in the area of the flexor carpi ulnaris (FCU) tendon,
proximal to its insertion on the pisiform (before entering the Guyon canal).
• The ulnar artery is radial to the nerve and to the FCU tendon.
• The dorsal sensory branch also runs ulnar to FCU at the level of the wrist, more
superficial to the major ulnar nerve trunk (Fig. 1.5).
• Common digital nerves travel between the metacarpals. The injection site to perform a
block of the common digital nerve to anesthetize multiple fingers at once is at the level of
the distal palmar crease, approximately 1 cm proximal to the metacarpophalangeal joint.
• Each finger has a volar and dorsal nerve on the ulnar and radial sides (for a total of
four digital nerves). The volar branches are larger, and within the finger are volar to
the corresponding digital artery. The volar branches pass from the common digital Ulnar nerve
nerve proximal to each webspace and enter the finger (Fig. 1.6).
POSITIONING
Blocks are most easily performed with the patient supine and the arm extended out on
a hand table. The great degree of motion through the shoulder, elbow, and wrist allow
for these blocks to be performed in a variety of hand and arm positions. FIGURE 1.5
STEP 1 PEARLS Dorsal sensory nerve Dorsal branch of the volar digital nerve
• Aspirate the syringe before injecting to avoid

intravascular administration of local anesthetic.
STEP 1 PITFALLS
• The superficial radial nerve lies within the sub-
cutaneous tissue. The needle tip should remain
just beneath the dermis, and the injection
should be met with almost no resistance. If it Volar digital nerve
is difficult to administer fluid, the needle has
likely advanced too deep into the periosteum FIGURE 1.6
or within the tendons of the brachioradialis/
first dorsal compartment.
RADIAL NERVE BLOCK

STEP 2 PEARLS
Step 1
• To maintain depth within the subcutaneous tis-
sue, first create a small wheal beneath the • Begin by palpating for the radial artery, which lies immediately radial to the FCR
dermis with the local anesthetic. With the sub- tendon.
cutaneous layer identified, it is easier to ad- • With the radial artery identified, inject directly radial to the artery (along the radial
vance the needle without exiting the correct border of the forearm/wrist), proximal to the radial styloid. (Fig. 1.7).
tissue plane.
• This technique often requires multiple needle
insertion points to cover adequate territory
Step 2
around the curvature of the wrist without in- • Adjust position and move the needle along the radial border of the radius, then dor-
jecting too deeply. Additionally, it often requires sally to the area of the radial styloid, and then further into the dorsal hand, injecting
more anesthetic than the other described local anesthetic along the way (Fig. 1.8).
techniques, with at least 10 mL needed for
adequate infiltration of the entire area.
MEDIAN NERVE BLOCK
STEP 1 PEARLS Step 1
• For most procedures around the median nerve, • Identify the interval between PL and FCR (or just ulnar to FCR). Enter approxi-
such as carpal tunnel release, local anesthetic mately 0.5 cm deep and infiltrate with approximately 5 to 10 mL of local anes-
can be administered superficial to the trans- thetic (Fig. 1.9).
verse carpal ligament (TCL) to permit diffusion
into the surrounding tissue. This provides
adequate anesthesia and reduces the risk for ULNAR NERVE BLOCK
median nerve injury from a direct injection.
Step 1
• Identify the FCU tendon and place the needle immediately ulnar to it. Administer 5
STEP 1 PITFALLS
to 10 mL of local anesthetic to the surrounding area (Fig. 1.10).
• It is critically important to avoid injecting directly
into the median nerve. Before injecting anes- Step 2
thetic, flex or extend the fingers to see if the nee-
dle “bobs.” If so, the needle has advanced too far • At the level of the distal ulna, insert the needle and slide under the area of FCU
and should be withdrawn. Additionally, any resis- (dorsal and ulnar to the tendon).
tance to flow should raise concern of an intraten- • Inject approximately 5 mL of anesthetic solution in this plane.
dinous or, worse, intraneural needle placement.
Flexor carpi radialis

Palmar cutaneous branch
Range of infiltration
FIGURE 1.7 FIGURE 1.8


Flexor carpi ulnaris

Palmaris longus
FIGURE 1.9
FIGURE 1.10
STEP 1 PEARLS
Step 3 • The ulnar nerve block can be administered
• Withdraw slowly and inject again in the subcutaneous tissues to block the dorsal radial or ulnar to FCU; however, we prefer
sensory branch as well. the ulnar approach to minimize the risk for
injection into the ulnar artery or nerve.
DIGITAL NERVE BLOCK
Blocking digital nerves can be achieved with a variety of techniques. INTERMETACARPAL BLOCK PEARLS
• The injection site is at the distal palmar
Intermetacarpal Block crease, proximal to the metacarpophalangeal
• If the goal is to block multiple adjacent fingers, an intermetacarpal block (also known joint.
as a transmetacarpal block) technique can be used (Figs. 1.11 and 1.12). • The approach can be volar or dorsal, but many
patients report less discomfort with a dorsal
• Inject alongside the metacarpal neck to block the common digital nerves to the
approach.
fingers on either side of the corresponding webspaces (see Fig. 1.11A).
Flexor tendon
Common
digital nerve
Distal
palmar crease
A B
FIGURE 1.11A
Common
digital nerve
A B
FIGURE 1.12
Subcutaneous Digital Block

SUBCUTANEOUS DIGITAL BLOCK
PEARLS • To block just one finger, the subcutaneous digital block technique can be used.
• If dorsal anesthesia is not required, a single- • Infiltrate along the radial and ulnar border of the digit proximally, at the webspace
injection volar technique is preferred by some. (Fig. 1.13).
This is done with a single injection over the
volar aspect, just proximal to the palmodigital INTRATHECAL BLOCK
crease. The needle can be moved to the radial
border webspace and then withdrawn slowly
and redirected to the ulnar side to allow for the
Step 1
injection of both sides with one needlestick. • Alternatively, a digital block can be performed using an intrathecal block technique
that involves injecting into the flexor tendon sheath.
• Injection is performed at the level of the palmodigital crease (Fig. 1.14).
SUBCUTANEOUS DIGITAL BLOCK
PITFALLS
Step 2
• There is a debate on dorsal versus volar
approach, with many preferring dorsal because • Insert the needle until it contacts the bone. Then pull back slowly while injecting
it is reportedly less painful. until a loss of resistance is felt—this is the plane between periosteum and tendon
• Volar-only techniques often still require a within the sheath (Fig. 1.15).
subcutaneous wheal injected on the dorsum
of the finger to block the dorsal digital nerves. POSTOPERATIVE CARE AND EXPECTED OUTCOMES
• Most of these blocks can be expected to provide adequate reduction of pain and
sharp sensation for the areas targeted.
STEP 1 PEARLS
• All patients should be educated on the common phenomenon of rapid dissipation of
• Intrathecal block offers anesthesia with one the local anesthetic, leading to a rebound pain response. Because of the duration of
injection and reportedly has a faster onset.
action of most anesthetics and the fact that most elective outpatient procedures are
A B
Digital crease
D
Flexor tendon
STEP 1 PITFALLS
• Because of the pressure within the flexor
sheath during injection, some patients report
increased and prolonged discomfort with the
intrathecal block technique.
STEP 2 PITFALLS
• Injection superficial to the tendon is often less
Flexor tendon sheath accurate; in some cases, no intrathecal injection
Flexor digitorum occurs because the injection is all performed in
profundus Volar digital nerve the subcutaneous space.
Flexor digitorum Volar digital artery
superficialis
POSTOPERATIVE PITFALLS
Proximal • Neuropraxia is uncommon, especially with
phalangeal bone these distal nerve blocks. Should they occur,
they will often resolve within 3 to 4 weeks.
Patient support and reassurance is usually the
only necessary treatment. In the rare event of
complete or near-complete palsy, additional
evaluation is warranted to rule out new
FIGURE 1.15
sources of compression.
• Toxicity from the local anesthetic, although
done midday, this phenomenon frequently occurs in the middle of the night. We incredibly uncommon with the small doses
recommend patients begin transitioning to oral pain medications at the first sign of described here, should always be considered if
a patient experiences central neurologic or
pain or a pins-and-needles feeling in the anesthetized area.
cardiac changes in the perioperative period.
See Video 1.1
EVIDENCE
Hung VS, Bodavula VKR, Dubin NH. Digital anesthesia: comparison of the efficacy and pain associated
with three digital nerve block techniques. J Hand Surg Br. 2005;30:581–584.
This is a randomized, controlled, single-blind study of 50 healthy volunteers, comparing time of onset,
pain from block, and method of preference of three different digital blocks. The metacarpal block
took significantly longer to block the digital nerves than the other two methods. Forty percent of
subjects felt discomfort for 24 to 72 hours after the transthecal digital block. Forty-three percent
of subjects chose the subcutaneous block as the preferred method. (Level I evidence).
Low CK, Vartany A, Engstrom JW, Poncelet A, Diao E. Comparison of transthecal and subcutaneous
single-injection digital block techniques. J Hand Surg. 1997;22:901–905. Randomized double-blind
study on 142 patients comparing transthecal digital block and subcutaneous digital block. No differ-
ence was found in effectiveness, distribution, onset, and duration of action. (Level I evidence).
Sonmez A, Yaman M, Ersoy B, Numanodlu A. Digital blocks with and without adrenalin: a randomised-
controlled study of capillary blood parameters. J Hand Surg Eur. 2008;33:515–518.
Twenty patients were randomized to digital block with 2% lidocaine and 2% lidocaine with 1:80,000 adrena-
lin. Po2 and Sao2 in the digits were not significantly different between the groups. No concerning issues
with digital perfusion were reported. Return of sensation in digits without adrenalin returned an average of
4.8 hours later, and with adrenaline occurred 8.1 hours later. (Level II evidence).
Strazar RA, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr
Surg. 2013;132(3):675–684.
This article published by Dr. Lalonde, a pioneer in WALANT hand surgery, discusses many different aspects
of reducing the pain associated with local anesthesia injection. Included in the article is a repeatable and
low-cost technique for buffering lidocaine/epinephrine solution to a physiologic pH.
CHAPTER 2
Fasciotomy for Compartment Syndrome
of the Hand and Forearm
KEY CONCEPTS
• Compartment syndrome occurs when pressure within a fibro-osseous space in-
creases beyond a level that is suitable for perfusion across tissues. The ischemia
caused by compartment syndrome affects nerves and muscles; irreversible damage
can occur within 6 hours for muscle and even less time for nerves.
• The most common causes of forearm compartment syndrome are fracture, injection injury,
extravasation injury, penetrating trauma, circumferential burns, and snake or insect bites.
• Continuous pressure examination is the most reliable method for diagnosing acute
compartment syndrome. Normal tissue pressures range from 0 to 8 mm Hg. A com-
partment pressure measurement over 30 mm Hg is typically an indication for urgent
fasciotomy; readings of 20 or more warrant close monitoring and possibly surgical
intervention.
• The forearm has four major compartments: superficial and deep volar, dorsal, and
lateral. The compartments of the hand with the most clinical significance and that
most often require release include the thenar, hypothenar, adductor pollicis, dorsal
interosseous, and volar interosseous.
• If fasciotomy is performed within 4 to 6 hours of compartment syndrome onset, the
patient may regain full function and sensation. If there is any concern for muscle
viability, return to the operating room approximately 48 hours after initial surgery for
examination and additional debridement.
• Fasciotomy of the forearm
• Fasciotomy of the hand
Arm incision
Volar radial Dorsal ulnar

Forearm incision
FIGURE 2.5 Incision markings for fasciotomy of the upper extremity.
4
CHAPTER 2
Fasciotomy for Compartment Syndrome
of the Hand and Forearm
INDICATIONS
• Compartment syndrome occurs when pressure within a fibroosseous space in-
creases beyond a level that is suitable for perfusion across tissues.
• The most common cause of forearm compartment syndrome is fracture, especially
distal radius fracture. Other causes of compartment syndrome include an injection
injury, an extravasation injury, a penetrating trauma, circumferential burns, and
snake or insect bites.
• Injection injuries involving air, water, or other hydrophilic liquids can potentially be
observed depending on the volume and clinical presentation.
• Injection of paint or other oil-based liquid requires early decompression and addi-
tional debridement as needed. Although seemingly benign, these injection injuries
tend to develop ischemia and deep space infections if left untreated.
• Ischemia-reperfusion occurs after prolonged tourniquet time and with the use of
compressive wraps and casts.
• Crush injury with resultant edema leads to increased pressure in the closed muscle
space and can also progress to compartment syndrome.
• Electrical injury, a type of burn injury, can also cause compartment syndrome when
the hands and upper limbs are damaged by a high-voltage current. Unlike thermal
damage caused by eschar compression, which requires escharotomy, the deep tis-
sue necrosis and swelling caused by electrical burns leads to increased compart-
ment pressure. This can only be treated with fasciotomy.
• In most cases, the upper extremities are the points of contact with the power
source and are likely to require amputation. Although the timing of debridement
does not reduce amputation rates, the boundary between healthy and damaged
tissue is often unclear initially. Early debridement is important to reduce second-
ary necrosis from infection.
• Multiple debridement procedures are often required to determine the extent of
damage and the need for amputation. It is necessary to return to the operating
room every 24 to 48 hours to reassess the viability of the tissue and repeat the
debridement.
• Immediate surgery is necessary if the patient has progressive neurologic dysfunc-
tion, vascular compromise, compartment syndrome, or systemic clinical deterio-
ration from suspected ongoing myonecrosis.
• The ischemia caused by compartment syndrome affects the nerves and muscles;
irreversible damage can occur within 6 hours for muscle and in even less time for
nerves.
• The diagnosis of compartment syndrome is generally a clinical one, based on findings
of nerve or muscle injury.
• Pain (out of proportion to injury, especially on passive stretch), paresthesia, paraly-
sis, pallor, pulselessness, and inability to regulate limb temperature (poikilothermia)
are common manifestations.
• Pain out of proportion to injury and paresthesias are the two earliest findings,
whereas pulselessness and pallor are often seen later or may not occur at all.
• The compartments are often firm to palpation, and overlying skin may become shiny
and even develop blisters (Figs. 2.1 and 2.2).
4.e1
4.e2 CHAPTER 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm
A B C
FIGURE 2.1 The thumb and index fingers are viable. There is a near circumferential eschar over the middle finger, which is alive. The ring finger and little
finger are necrotic. There is compartment syndrome over the hand, forearm, and upper arm.
FIGURE 2.2 Blister.
• For patients with electrical injuries, it is important to put forth the caveat of life
before limb because the heart and kidneys may be affected by electric shocks.
The patient’s general condition should be evaluated first, and limb salvage sur-
gery should be performed once the patient is stable from a trauma standpoint.
• Do not be deceived by the superficial appearance of skin burns after electrical
injury because deep tissue damage is often serious and harder to evaluate on
examination (Fig. 2.3).
• When an electric current passes through the body, the extent of damage to each
tissue type depends on its inherent resistance. Bone is the most resistant to
electric current, followed by fat, tendons, and skin. Muscles, blood vessels, and
nerves are the least resistant.
IMAGING
• Often, the diagnosis is clinically apparent, and therefore no additional imaging or
other workup is needed.
• Most commonly, the diagnosis in less clinically apparent cases is made by measuring
the intramuscular pressure (IMP). Many techniques have been described, including
arterial line transducer systems, slit catheters, and self-contained measuring systems.
CHAPTER 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm 4.e3
A B
FIGURE 2.3 Skin lesions are light.
• Single pressure measurement does not reflect pressure changes over time and has
limited significance for clinical diagnosis. Continuous pressure examination is the
current gold standard for the diagnosis of acute compartment syndrome.
• Normal tissue pressures range from 0 to 8 mm Hg. A compartment pressure measure-
ment over 30 mm Hg is typically an indication for urgent fasciectomy; readings of
20 or more warrant very close monitoring and possibly surgical intervention under the
right clinical circumstances. Additionally, some consider a difference of 20 mm Hg
between diastolic pressure and compartment pressure as an indication for fasciotomy
as well (hypotensive/septic patients).
SURGICAL ANATOMY
• The forearm has four major compartments—superficial volar, deep volar, dorsal, and
lateral (mobile wad) (Fig. 2.4 and Table 2.1).
• The interosseous membrane of the radius and ulna separates the forearm into volar
and dorsal compartments. The deep volar compartment is most susceptible and
most often affected by compartment syndrome, whereas the mobile wad (more
superficial) is least commonly involved. Pronator quadratus belongs to the deep
volar compartment, too. Some investigators consider it to be a separate subcom-
partment because it can be affected independently from other forearm muscles.
• When compartment syndrome occurs in the volar compartment, it can be devas-
tating to forearm function because the median nerve, anterior interosseous nerve
(AIN), and the ulnar nerve run within it. The median nerve is the most common
Median nerve
Flexor carpi radialis muscle

Palmaris longus muscle
Brachioradialis muscle
Flexor digitorum
Radial artery
superficialis muscle
Superficial branch of radial nerve Ulnar artery
Extensor carpi radialis muscle Ulnar nerve

and tendon
Flexor carpi ulnaris muscle
Flexor pollicis longus muscle Flexor digitorum profundus
Anterior interosseous artery muscle
Radius Anterior interosseous nerve

Extensor carpi radialis brevis Interosseous membrane
muscle and tendon Extensor pollicis longus
muscle
Abductor pollicis longus muscle
Antebrachial fascia
Extensor digitorum muscle
Ulna
Posterior interosseus artery
Extensor carpi ulnaris muscle
Extensor digiti minimi muscle
Posterior interosseus nerve

FIGURE 2.4
Table
Myofascial Compartments of the Upper Extremity and Their Contents
2.1
Compartment Muscle Artery Nerve
Arm Anterior Biceps, brachialis, coracobrachialis; Brachial Musculocutaneous
Posterior Triceps Profunda brachii Radial
Deltoid Deltoid — Axillary
Forearm Volar Pronator teres, flexor carpi radialis, palmaris Radial and ulnar Median, ulnar, and
Superficial longus, flexor digitorum superficialis, flexor Pos. interosseous anterior interosseous
Deep carpi ulnaris; — Pos. interosseous
Dorsal Flexor pollicis longus, flexor digitorum Radial
Superficial profundus, pronator quadratus;
Deep Extensor digitorum communis, extensor
Mobile wad digiti minimi, extensor carpi ulnaris;
Abductor pollicis longus, extensor pollicis
brevis, extensor pollicis longus, extensor
indicis proprius, supinator;
Brachioradialis, extensor carpi radialis
longus, extensor carpi radialis brevis;
Hand Thenar Abductor pollicis brevis, opponens pollicis, Digital Recurrent motor
Hypothenar flexor pollicis brevis; — Ulnar
Adductor Abductor digiti minimi, opponens digiti — Ulnar
Interosseous minimi, flexor digiti minimi; — Ulnar
Carpal tunnel Adductor pollicis; — Median
Digit Four dorsal and three palmar interosseous Digital Digital
muscles;
Flexor digitorum profundus, flexor digitorum
superficialis, flexor pollicis longus.
damaged nerve. AIN runs on the superficial side of the deep fascia and inner-
vates the deep flexor muscle.
• The dorsal compartment is not as frequently injured compared with the volar
compartment.
• The carpal tunnel is susceptible to compressive pressures and is often released
when other upper extremity fasciectomies are performed.
• The compartments of the hand that have the most clinical significance and most
often require release include the thenar, hypothenar, adductor pollicis, dorsal inter-
osseous, and volar interosseous.
• Digital compartments are bound by Cleland and Grayson ligaments, although the
clinical significance of these compartments in the setting of compartment syndrome
is debated.
• For high-pressure injection injuries, the surgical approach may need to be adjusted
to allow for adequate debridement of ischemic tissue in the area of injection.
Exposures
• Forearm
• Volar release is traditionally done via a curvilinear incision from the medial epicon-
dyle to the proximal wrist crease. This, however, places the distal flexor tendons
and median nerve at risk for exposure and desiccation. Therefore we advocate
for an alternative approach.
• We recommend two longitudinal incisions—one over the volar radial aspect (over
the flexor muscles) and the other over the dorsal ulnar aspect of the extensor
muscles. This approach decompresses the volar and dorsal compartments with-
out exposing the median nerve or distal forearm tendons (Figs. 2.5 and 2.6A–B).
• The more traditional dorsal release is performed via a single longitudinal incision
along a line between Lister tubercle and an area 4 cm distal to the lateral epicon-
dyle (incision is made in the space between extensor digitorum and extensor
carpi radialis brevis; Fig. 2.7). This incision facilitates dorsal release; however, a
more limited incision shown in Fig. 2.5 and Fig. 2.6A–B will provide adequate
exposure and minimize wound morbidity.
Arm incision
Volar radial Dorsal ulnar

Forearm incision
FIGURE 2.5
FIGURE 2.6 Incision design. (A) The curved incision in red across the forearm is incorrect, as it
could expose either the median nerve or the distal forearm tendons. The two longitudinal incisions
in green on the radial and ulnar side are correct.
EXPOSURES PEARLS • Hand

• The carpal tunnel is approached via a single incision between the thenar and
• Hypothenar compartment release should not
be done directly on the ulnar border, but in- hypothenar spaces, in line with the radial aspect of the ring finger (Fig. 2.8).
stead should be slightly radial to the border, • The thenar compartment is approached via an incision along the radial side of the
so that the scar is not on a direct pressure thenar eminence between glabrous and nonglabrous skin (Fig. 2.9).
area of the hand. • The hypothenar compartment is released via a longitudinal incision along the
• When decompressing the median nerve at the
ulnar aspect of the palm (Fig. 2.10).
carpal tunnel, avoid incising across the wrist
because this can increase the risk for wound • Dorsal hand compartments are released by two longitudinal incisions parallel and
dehiscence, with swelling and subsequent ex- radial to the index and ring finger metacarpals (Fig. 2.11). This facilitates decom-
posure of the median nerve and flexor tendons. pression of all four dorsal interosseus compartments (Fig. 2.12).
• Finger
• Decompression can be done with a midaxial incision along the noncontact (radial
EXPOSURES PITFALLS
for index and thumb; ulnar for middle, ring, and small) side of the finger (Figs. 2.13
It is not necessary to make release incisions distal
and 2.14).
in the midvolar forearm to expose the median
nerve or distal flexor tendons because this could
cause desiccation and necrosis of these vital
structures. Avoid these exposure approaches
whenever possible (Fig. 2.15A–B).
Skin incision, dorsal forearm

FIGURE 2.7
FIGURE 2.8 Carpal tunnel release.
FIGURE 2.9 Thenar decompression.

FIGURE 2.10 Hypothenar decompression. The incision should not be performed directly on the
ulnar border but instead should be slightly radial to the border.
FIGURE 2.11 Two longitudinal incisions parallel and radial to the index finger and ring finger metacar-
pals on the dorsal side.
FIGURE 2.12 Dorsal decompression.

Skin incision, finger

FIGURE 2.13
FIGURE 2.14 Incision design and finger release.
FIGURE 2.15 Avoid distal incisions in the volar forearm.

STEP 1 PEARLS
FASCIOTOMY OF THE FOREARM
• If the muscle still appears white after opening
Step 1: Volar Forearm Release fascia, divide the epimysium as well.
• The incision (see Fig. 2.6B) is made to the radial side of the volar forearm, between • Before approaching the deep flexor muscles,
the brachioradialis (BR) and flexor carpi radialis (FCR). We prefer to check all the identify the median nerve and stay ulnar to it
compartments through one incision. A longitudinal incision on the dorsal ulnar side to avoid injury to the palmar cutaneous
branch.
can also be added if necessary (see Figs. 2.5 and 2.6A).
• After electrical injury, even if the superficial volar
• The incision is made through skin and subcutaneous tissues (Fig. 2.16A), and the forearm is soft, exposure and release of the
deep fascia investing the muscles of the forearm is divided sharply. deep compartment is often performed because
• Subcutaneous flaps can be elevated to permit mobilization of the incision site and this compartment can be injured from the
improve exposure in all directions. electrical energy conducted through bone.
• Check the superficial and deep volar compartment first. Dissect between FCR and
palmaris longus to expose the deep flexors (flexor digitorum superficialis, pronator
quadratus, flexor pollicis longus, and flexor digitorum profundus) and decompress
as needed with fascial incisions (see Figs. 2.16B–C). STEP 1 PITFALLS
• It is critical to visualize the deep compartment flexor muscles, particularly after • Avoid exposure of median nerve and distal
electrical injury. flexor tendons (see Fig. 2.15A–B).
• The dorsal compartment can be examined simultaneously through this incision or • Traditional teaching of wide extensile expo-
through a dorsal incision. sure for forearm fasciotomy is shown in
Fig. 2.15A.
• Via the same incision, approach the muscles of the mobile wad (BR, extensor carpi • Fig. 2.15B shows the risk of this approach
radialis longus, and extensor carpi radialis brevis) and divide fascia to release that for volar fasciotomy, a nonhealing wound
compartment (see Fig. 2.16D). with resulting exposure and desiccation of
flexor tendons (black arrow pointing to
Step 2 flexor carpi radialis [FCR] tendon) and
median nerve (white arrow); this patient re-
• Release the tourniquet (if one was used) and obtain hemostasis. If muscle is nonvi- quired amputation.
able, stimulate it with electrocautery and look for fasciculations. If muscle has no
response to electrocautery, consider debridement of nonviable soft tissues back to
healthy, bleeding, fasciculating tissue.
Brachioradialis
FCR
A B
C D
FIGURE 2.16 (A) The junction approach from the lateral and superficial volar compartment. (B) Muscles of superficialis volar compartment appeared to
be alive. (C) Muscles of deep volar compartment appeared to be alive. (D) Muscles of lateral compartment appeared to be alive.
STEP 3 PEARLS
Step 3: Post Release
• Use mattress sutures to perform a partial or full (loose) skin closure if possible.
• If there is significant swelling, then leave most
of the incision open and perform a partial clo- • If skin closure is not possible, use a vessel loop to create a “Jacob’s ladder” or
sure over vital structures, such as the median similar construct to prevent the skin from retracting.
nerve and flexor carpi radialis tendons. • Place a bulky moist dressing over any open wounds and fit a removable splint in a
• Closure of the wounds immediately postrelease, functional position.
when the tissues are significantly swollen, risks
• Initiate regular dressing changes to prevent desiccation of exposed muscles and
additional ischemia. It is also technically difficult
because of the edema, which causes large tendons.
gaps between wound edges. Retention systems
can be used (e.g., staples and vessel loops;
Fig. 2.17) to prevent wound gaps from spread- FASCIOTOMY OF THE HAND
ing, which would make reconstruction more Step 1: Carpal Tunnel Release
challenging.
• Make an incision between the thenar and hypothenar spaces, in line with the radial
border of the ring finger.
• Dissect down to and through the palmar fascia and identify the transverse fibers of
the transverse carpal ligament.
• Divide the transverse carpal ligament longitudinally across the full distal and proxi-
mal extent of the ligament, similar to a standard carpal tunnel release.
Step 2: Thenar Decompression

• Deepen the incision until the abductor pollicis brevis is encountered.
• Divide the fascia over the abductor pollicis brevis.
Step 3: Hypothenar Decompression

FIGURE 2.17
• Deepen the incision until the abductor digiti minimi is visualized.
• Divide the fascia over the abductor digiti minimi.
STEP 1 PEARLS
• After releasing the carpal tunnel, close the skin Step 4: Finger Release
with interrupted mattress sutures to prevent • Decompression can be performed with a midaxial incision along the noncontact side
desiccation of the median nerve and flexor of the finger (see Fig. 2.14).
tendons.
Step 5: Amputation of Necrotic Fingers
STEP 2 PITFALLS • In this case, the necrotic ring and little fingers were amputated at the head of the
Use caution with the distal extension of the incision metacarpal (Fig. 2.18). A fillet dorsal skin flap was elevated for coverage of the head
so as not to expose the metacarpophalangeal joint. of the metacarpal.
Step 6: Dorsal Decompression

STEP 3 PITFALLS
• Incise along the index finger metacarpal to decompress the first dorsal interosseous,
Be careful not to divide the ulnar digital nerve to
the small finger. adductor pollicis, and second dorsal interosseous.
• Incise along the ring finger metacarpal to decompress the third and fourth dorsal
interossei.
STEP 4 PITFALLS
Be careful not to damage the digital nerve.
STEP 5 PEARLS
In the case of electrical injury, the amount of energy
dissipated determines the severity of the injury
and extent of tissue loss. Early decompression and
debridement can prevent ongoing ischemia
and tissue damage and, in some cases, prevent
the need for amputation.
STEP 6 PEARLS
To fully decompress the dorsal interossei, one
must incise the overlying muscle fascia, which
requires that the extensor tendons be mobilized
and retracted to adequately access this fascia in
each intermetacarpal space.
FIGURE 2.18 Amputation of ring and small fingers.
Step 7 STEP 6 PITFALLS

• Release the tourniquet (if one was used) and obtain hemostasis. Proceed with de-
Be cautious of the branches of the superficial radial
bridement of nonviable soft tissues back to healthy bleeding tissue. nerve and dorsal branches of the ulnar nerve.
Step 8: Post Release

• Place a few tacking sutures to secure soft tissue over the carpal tunnel and other
exposed critical structures.
• Place a bulky moist dressing over remaining open wounds and fit a removable splint
with the wrist in slight extension, fingers flexed to 70 degrees at the metacarpal-
phalangeal (MCP) joint, and extended at the intrinsic plus (IP) joints.
• Initiate regular dressing changes to prevent desiccation of exposed muscles and
tendons.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES

• Elevation of the extremity postoperatively is critical to reducing edema and improv-
ing pain control.
• Reexamine the extremity within 12 to 24 hours to evaluate the need for additional
debridement.
• If there is any concern for muscle viability, return to the operating room (OR) approxi-
mately 48 hours after initial surgery for examination and additional debridement.
• Wound care with regular moist gauze dressing changes (or petroleum-based dress-
ings) is important to prevent desiccation of any open wounds.
• Attempt closure of open wounds (whether primary wound closure or skin graft) within POSTOP PEARLS
3 to 5 days when tissues are still somewhat pliable to limit infection risk (Fig. 2.19A-C). If the patient can tolerate it, one may elevate
• If fasciotomy was performed within 4 to 6 hours of compartment syndrome onset, the area by putting a stockinette on the arm and
the patient may regain full function and sensation; however, any delay beyond 3 to slinging the arm on an IV pole. If this is attempted,
4 hours may result in some degree of permanent nerve and/or muscle damage. be sure to support the elbow with pillows.
FIGURE 2.19 (A-C) Three days after surgery.

EVIDENCE
Kistler JM, Ilyas AM, Thoder JJ. Forearm compartment syndrome: evaluation and management. Hand
Clin. 2018;34(1):53–60.
The authors introduced in detail the etiology, pathophysiology, anatomy, diagnosis, management, out-
comes, and complications of forearm compartment syndrome.
Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. J Am Acad Orthop
Surg. 2019;27(1):e1–e8.
The authors described in detail how electric current can cause damage to the human body after the
hand or upper limb is shocked. Clinical manifestations and principles of emergency surgical explora-
tion of electrical injuries are also mentioned.
Schmidt AH. Acute compartment syndrome. Injury. 2017;48(Suppl 1):S22–S25.
The authors introduced the current diagnosis of acute compartment syndrome. The clinical findings
and intramuscular pressure (IMP) measurement help determine the timing of the fasciotomy.
CHAPTER 3
Digit Amputations

This chapter includes the following video: Video 3.1 – Digit Amputation.
KEY CONCEPTS
• Amputation does not indicate failure of salvage; rather, it is part of the treatment
algorithm for restoring optimal function after extensive traumatic injuries.
• For injuries with a poor prognosis for return of function (e.g., joint destruction, need
for extensive soft tissue reconstruction), patients may prefer amputation to pro-
longed therapy with only moderate return of function. Digit amputation should also
be considered for any injury that damages a digit to the degree that vascularity, func-
tion, or soft tissue coverage cannot be restored. If possible, revascularization or
replantation should be considered first.
• For the thumb, it is important to preserve the carpometacarpal joint so that a toe
transfer remains an available option. In multidigit injuries, it is important to consider
using tissues from a digit requiring amputation to provide coverage for an adjacent
digit or hand wound.
• In general, revision finger amputations are done through the bony shaft distal to ten-
don attachment, rather than at joint level, to permit better contour of the amputation
stump and flexion of the joint. For metacarpal amputations, one must decide be-
tween a transmetacarpal amputation and a ray amputation.
• Revision digit amputation
• Transmetacarpal or ray amputation
5
6 CHAPTER 3 Digit Amputations
Flexor tendon
Palmar digital
arteries A1 pulley
and nerves
Superficial
palmar arch
FIGURE 3.2 Neurovascular structure of the hand and digits.

CHAPTER 3
Finger Amputations
INDICATIONS
• Digit amputation should be considered for any injury that damages a digit to the
degree that vascularity, function, or soft tissue coverage cannot be restored. If at all
possible, revascularization or replantation should be considered first.
• Amputation should also be considered after finger injuries that substantially destroy
structural and/or functional integrity beyond the ability to adequately reconstruct.
Ring avulsions or other traction injuries may leave the digit largely intact; however,
the underlying disruption of the digital vessels makes revascularization challenging
unless the vessels are anastomosed as distally as possible. In severe cases, trac-
tion injuries can cause complete amputation with avulsion of the extensor/flexor
tendons at the musculotendinous junction—these are very high energy injuries and
salvage is unlikely.
• Patient preference should also be considered after substantial trauma to digit(s). For
injuries in which the prognosis for return of function is poor (joint destruction, need for
extensive soft tissue reconstruction, etc.), patients may prefer amputation to prolonged
therapy with only moderate return of function. Additionally, patients may elect for a digit
amputation after a previous injury that has left them with a stiff, nonfunctioning digit.
• Necrosis of the digit, either because of thermal or ischemic injury, requires amputa-
tion. Regardless of the mechanism, wait several weeks for digit necrosis to fully
demarcate before finalizing an amputation to avoid incorporating developing ne-
crotic tissue into the amputation site.
• Neoplasm affecting either the structure or function of the digit may require amputa-
tion. Benign bone lesions, such an enchondromatosis, can substantially alter the
physical function of the digit, but the digit can be reconstructed after tumor ablation,
whereas malignant neoplasms such as melanoma or sarcoma require amputation to
achieve wide resection with negative margins. The goal is to preserve functional
length with durable soft tissue coverage.
• For the thumb, it is important to preserve the carpometacarpal joint so that a toe
transfer remains an available option.
• In multidigit injuries, it is important to consider using tissues from a digit requiring
amputation to provide coverage for an adjacent digit or hand wound.
• Create soft tissue flaps for viable and potentially sensate coverage of other in-
jured sites.
• Use bone, tendon, vessel, or nerve for grafting in the reconstruction of other in-
jured digits.
• Amputation does not indicate failure of salvage; rather, it is part of the treatment algo-
rithm for helping patients return to optimal function after extensive traumatic injuries.
Contraindications
• Replantation or revascularization should be attempted over amputation in those with
thumb amputations, multiple digit amputation, and/or loss of function in the contra-
lateral upper extremity.
• Replantation or revascularization should also be done in children because of their
great capacity for recovery.
• Check perfusion of the finger, looking at capillary refill, color, and turgor. Check that
refill takes approximately 2 seconds. This is most easily done by compression and
release at the nail bed if available (especially in patients with a darker skin tone).
6.e1
6.e2 CHAPTER 3 Finger Amputations
• If the finger feels soft and compressible, vascular inflow may have been lost, re-
sulting in this loss of turgor.
• Evaluate sensation.
• Check the response to a sharp stimulus at the fingertip; the sharp end of a broken
cotton swab or a sterile needle can be used.
• Examine two-point discrimination (although this is often difficult in the re-
cently injured patient). This can be done using a premade device, if available,
or by opening up a paper clip to the desired prong width or gently using the
tips of sharp Iris scissors opened to various widths. The objective is to test
at what width the patient is able to distinguish two points from one point of
pressure. On the volar fingertip, two-point discrimination is usually between
3 to 5 mm.
• Examine the structural integrity of each involved finger. Test the flexion of the distal
and proximal interphalangeal joints by blocking all adjacent joints. Finger extension
is most easily tested by placing the hand on a flat surface and asking the patient to
lift each finger off the surface.
IMAGING
• X-ray is generally the only modality used to evaluate traumatized digits when deter-
mining structural integrity and potential for long-term function if salvaged.
SURGICAL ANATOMY
• In general, revision finger amputations are done through the bony shaft distal to
tendon attachment, rather than at the joint level, to permit better contour of the
amputation stump and flexion of the joint.
• Knowledge of finger anatomy is important for maintaining attachments of flexor and
extensor tendons if possible; within the digit, flexor tendons insert at the volar me-
taphysis, whereas extensor tendons insert onto the dorsal epiphysis. Avoiding the
unnecessary violation of a proximal tendon insertion is essential (Fig. 3.1A–B).
• Common digital vessels bifurcate just proximal to the webspace. It is important to
take caution when performing revision amputation around the metacarpophalangeal
(MCP) joints because one can inadvertently injure the proper digital artery to an
adjacent digit if not careful (Fig. 3.2).
• For metacarpal amputations, one must decide between a transmetacarpal amputa-
tion and a ray amputation.
• For border digits, one often can do a transmetacarpal (neck or shaft) amputation,
with the distal remaining bone cut at a 45-degree angle oriented toward the
border surface to preserve hand curvature and shape.
• For central digits, and for border digits in patients unhappy with hand function/
EXPOSURES PEARLS appearance after border amputation, a complete ray amputation with removal of
• Put a clamp on the finger tourniquet as a re- the metacarpal is necessary.
minder to remove the tourniquet after surgery. • For index and middle fingers, one must keep the metacarpal base to preserve
In the chaotic environment of the emergency the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis
room, the surgeon may forget that the tourni- (ECRB) attachments, respectively.
quet is still on without a reminder.
• Ensure adequate time for the block to set in. It POSITIONING
is often easiest to place the block early, even
before thorough cleaning to ensure sufficient • With an adequate digital block, a revision finger amputation can often be performed
time. in the emergency department or in a small procedure room rather than in the operat-
ing room.
• Use of a finger tourniquet facilitates operating in a dry field. An extra glove can be
EXPOSURES PITFALLS used if no prefabricated finger tourniquet option is available (Fig. 3.3).
• In an operating room setting with general anesthesia, a standard arm tourniquet can
As discussed in Chapter 1 “Anesthesia of the
Hand”, long-acting local anesthetics can take 15 be used.
to 20 minutes to take full effect, especially for deep
soft tissue and bone. Do not make the mistake of EXPOSURES
injecting local anesthesia immediately before • With the digit anesthetized, thoroughly clean the hand using peroxide and saline.
beginning a procedure to avoid having to sit idly by
This will aid in visualization of skin color, perfusion, and the extent of deformity and
until the noxious stimuli fade.
soft tissue injury.
CHAPTER 3 Finger Amputations 6.e3
DIP joint Terminal tendon
Lateral band
Middle phalanx
Central slip
PIP joint
Proximal phalanx
Sagittal bands
MP joint
Juncturae tendinae
Extensor tendon
FDP
FDS
FIGURE 3.1 A-B, Finger anatomy.
REVISION AMPUTATION
Step 1
• In cases of traumatic amputation, there is often a zone of injury that extends beyond
the immediate amputation site. Begin the operation by sharply removing devitalized
skin from the periphery of the wound, as well any devascularized bone, tendon, or
interosseous muscle within the wound (Fig. 3.4A–B).
Flexor tendon
Palmar digital
arteries A1 pulley
and nerves
Superficial
palmar arch
FIGURE 3.2 Vessel anatomy.
FIGURE 3.3 Finger tourniquet.
STEP 1 PEARLS
The depth of the volar flap should be elevated • In general, all skin and soft tissue proximal to laceration sites should be preserved,
directly off the flexor sheath. It is important to keep even if traumatized, unless it is clearly no longer viable. This extra soft tissue length
the flap at full thickness because a thin flap could
will be needed to provide adequate durable coverage over the bony stump.
lead to hypersensitivity and pain at the healed
amputation site. • Bone will need to be resected proximal to the injury site to provide adequate soft
tissue to close over the bone. Therefore this tissue must be dissected off of the
bone with minimal injury to preserve viability.
STEP 1 PITFALLS • With sharp scissors or an elevator directly on the phalanx, elevate the soft tissue
Be judicious with your initial resection and take envelope off of the bone.
care to not overresect in the beginning stages • If the flexor or extensor tendon remains attached to the distal bone segment that
of the procedure. More bone and tissue can be will be excised, pull on the tendon, divide as proximally as possible, and allow it
removed later if necessary, but excessive resection to retract into the palm. This prevents the tendon from being tethered distally,
leads to unnecessarily short finger stumps.
which could restrict tendon excursion of the other fingers.
A B
FIGURE 3.4 (A-B) Amputation.
• With the damaged tissue excised, full-thickness flaps of volar skin and soft tissue are
elevated proximally. These flaps will eventually be used to cover the amputation site.
Step 2 STEP 2 PEARLS

• The neurovascular bundles are identified along the volar region of radial and ulnar If the nerve does not adequately retract after
borders of the injured digit. transection, attempt to tunnel the nerve end
• If soft tissue connections remain between the distal segment and the remaining into soft tissue or into bone to prevent painful
neuromas. All nerves will form a neuroma, but
digit, the neurovascular bundles may be in that soft tissue. Closely examine be-
nerves trapped in contact areas and not buried
fore transecting these soft tissue connections. may cause painful neuromas.
• In the finger, the nerve is volar to the artery; in the palm, the artery is volar to the
nerve.
• Digital arteries may be under vasospasm during initial injury; however, once the
smooth muscle of the endothelium relaxes, profuse bleeding can occur if the vessels
are not properly ligated with electrocautery or permanent suture.
• In amputated digits, the nerve should be placed on traction (Fig. 3.5) and then tran-
sected with sharp scissors so it can retract proximally away from the scar site.
Nerves trapped in the sutured skin cause debilitating pain, whereas nerves retracted
into the palm shield the neuroma from contact.
• In metacarpal-level amputations, management of the primary neurovascular bundles
is a more delicate matter because the common branches in the palm also feed the
adjacent digits and therefore must be preserved.
• First, identify the digital nerve distally in the finger and then follow it proximally to find
it within in the intermetacarpal space. Putting traction on the digital nerve in the finger
FIGURE 3.5 Nerve placed in traction.

STEP 3 PEARLS can help identify the branch-point in the webspace or the common nerve in the palm,
showing a safe transection point for the nerve to the finger being amputated.
Attempt to trim any bony spicules or radial/ulnar
prominence to avoid leaving the stump with • When approaching the metacarpal, approach directly over the bone and elevate
abnormally wide or prominent edges. soft tissue off to either side, protecting the neurovascular bundles.
Step 3
STEP 3 PITFALLS • The level of amputation is determined by the available soft tissue and the level of
If performing a metacarpal amputation, leave bony injury.
enough length/bone distally to preserve the • After trauma to multiple digits, one may need to use soft tissue from one digit to
intermetacarpal ligaments. Failure to do so will cover wounds on neighboring digits or the hand.
destabilize the remaining metacarpal. • Injuries like ring avulsions may require a more proximal amputation because of
soft tissue loss, even if the majority of the bone structure is intact.
• In the fingers, perform amputation through the phalangeal shaft if possible and avoid
leaving the condyle prominent distally.
• If possible, aim to preserve the attachments of flexor digitorum superficialis (FDS),
flexor digitorum profundus (FDP), and extensor digitorum communis (EDC) tendons.
• If amputation takes place through the joint, the traditional teaching is to denude the
cartilage along the distal aspect of the remaining phalanx and use a small rongeur
to remove the articular condyles. This is done to prevent continued generation of
synovial fluid. Experimental studies, however, have shown that articular removal is
unnecessary so we do not routinely remove the articular surface.
• Using a combination of rongeurs or, if available, a small oscillating saw, contour the
distal bone.
• For digits, do not leave sharp edges.
• For metacarpals, angle distal osteotomy of border digits to be approximately
45 degrees angled toward the hand or nearest border, providing natural curved
contour to match the rest of the hand (Fig. 3.6).
• For ray amputations, leave the base of index and middle finger metacarpals to
preserve the insertion of ECRL/ERCB.
FIGURE 3.6 X-ray demonstrating angled osteotomy.
Step 4: Closure
• No buried sutures are needed. Place interrupted nylons in the skin (Figs. 3.7 and
3.8A–B).
• Do not suture the flexor tendon to the extensor tendon or tack down the tendons
because this can substantially limit function of the hand.
• Because of the shared muscle belly of the digital flexor(s), a bound tendon can
lead to quadrigia, in which the remaining fingers cannot fully flex.
• Similarly, junctura are common among the extensor tendons, and an injured or
adhered extensor tendon can prevent full extension of adjacent digits.
• Consider loosely closing the skin flaps to permit drainage of any contaminated fluid
as the wounds heal (rather than tight closure of all wound margins).
• In children, only close with chromic suture or another rapidly dissolving suture
that does not need removal because compliance with suture removal may be a
challenge.
ELECTIVE AMPUTATION (TRANSMETACARPAL

OR RAY AMPUTATION)
If performing transmetacarpal or ray amputations to remove a nonfunctional digit after
revision finger amputation or for ischemia/malignancy, consider these additional steps.
Step 1
FIGURE 3.7 Wounds closed.
• Plan your incision. At the level of the metacarpophalangeal join, draw a curvilinear
teardrop incision along the volar aspect, and dorsally draw a narrow Y-shaped incision
STEP 4 PEARLS that extends further proximally (Fig. 3.9).
If there is a question of viability of remaining soft
tissues, examine again in approximately 48 hours Step 2
to determine whether additional debridement is
• Start with a volar incision and identify the digital neurovascular bundles to the finger
required or if it can be treated with local wound care.
(Figs. 3.10 and 3.11).
STEP 4 PITFALLS
• Avoid volar-based wound closure if possible
because this risks painful scars on the func-
tional surface of remaining fingers.
• Contour the digits by removing excess lateral
skin so that the tip of the digit is round.
A B
FIGURE 3.8 (A-B) Wounds healed/x-ray.
FIGURE 3.9 Incision design.
FIGURE 3.10 Identify neurovascular bundles. FIGURE 3.11 Identify neurovascular bundles.
STEP 2 PEARLS • After identifying a nerve, place slight traction and see if it pulls in the webspace;
Be cautious with the dissection around the if there is a tethering in the webspace, this is the proper digital nerve and it can
webspace. The common digital artery bifurcates be transected. If not, one may have the common digital nerve and need to ex-
more distally than the common digital nerve. plore further so as not to damage sensation of the adjacent digit.
Inadvertent damage to the common digital artery
• Identify the A1 pulley, divide it, and transect the flexor tendons to the digit, permit-
can harm blood flow to the adjacent digit.
ting them to retract into the forearm.
Step 3
• Cut down to bone and elevate any volar soft tissues that are tethered to bone,
protecting soft tissues on either side of the metacarpal (Figs. 3.12 and 3.13).
Step 4
• Turn to the dorsal side and make the Y incision overlying the bone.
• Cut down, divide the extensor tendon to that digit, and continue down to bone be-
fore using a key elevator to lift interosseous muscles off the metacarpal.
• Again, mobilize soft tissues to each side, protecting the neurovascular bundles,
and avoid unnecessary trauma to the muscles and intermetacarpal ligaments.
Step 5
• Divide the transmetacarpal ligaments, preserving as much length as possible.
• Use a saw to cut through metacarpal and remove the finger and metacarpal.
Step 6
• For third and fourth metacarpal amputations, use 2-0 Ethibond (or another braided
suture of choice) to bring transmetacarpal ligaments together and close down the
open space (Fig. 3.14).
• Be cautious not to overtighten this suture because it can over-reduce the adja-
cent fingers, leading to a crossover deformity.
• One can use buried absorbable suture to loosely bring soft tissues together, close
down dead space, and cover the permanent suture.
• Close overlying soft tissue with an interrupted nylon suture (Figs. 3.15A–B and 3.16).

• Patients with finger amputations are often discharged with only a soft dressing un-
less other more proximal injuries are also identified.
• After 48 hours, begin standard wound care with gentle cleansing and dressing
changes (our preference is Xeroform daily or bacitracin twice a day).
• With dressings in place, we encourage wrapping and elevation to control edema.
FIGURE 3.12 Cut down to bone. FIGURE 3.13 Cut down to bone.
FIGURE 3.14 Closure of the open space.
A B
FIGURE 3.15 (A-B) Wound closure.
FIGURE 3.16 X-rays.

• Once the wounds heal, patients are cleared to return to activities gradually. It is often
a much more rapid recovery than if complex reconstruction were performed.
• After metacarpal-level amputations, we often place the patient in an intrinsic-plus
volar splint while healing to prevent collapse of border metacarpals and abnormal
remaining finger cascade.
See Video 3.1
EVIDENCE
Wilkens SC, Claessen FMAP, Ogink PT, et al. Reoperation after combined injury of the index finger: repair
versus immediate amputation. J Hand Surg Am. 2016;41(3):436–440.
A retrospective study looking at the rate of reoperation of complex index finger injuries that underwent
repair versus primary amputation; 114 patients underwent 75 repairs versus 39 immediate amputations.
The rate of unplanned amputation was twice as high in the patients who underwent repair (44%) versus
primary amputation (21%).
Wang K, Sears ED, Shauver MJ, Chung KC. A systematic review of outcomes of revision amputation
treatment for fingertip amputations. Hand (NY). 2013;8:139–145.
This article is a review of outcomes after revision amputation for fingertip injuries. The authors reviewed
38 studies and concluded that near-normal sensation could be restored with satisfactory motion. Return
to work took an average of 7 weeks.
Whitaker LA, Graham WP III, Riser WH, Kilgore E. Retaining the articular cartilage in finger joint
amputations. Plast Reconstr Surg. 1972;49:542–547.
This article presents an experiment in cats that evaluated disarticulation amputation versus cartilage
removal at a distal amputation site. Inflammation and remodeling occurred more quickly in the
disarticulation model with longer recovery time in cases where the cartilage had been denuded.
Yuan F, McGlinn EP, Giladi AM, Chung KC. A systematic review of outcomes after revision amputation
for treatment of traumatic finger amputation. Plast Reconstr Surg. 2015;136:99–113.
This is a systematic review of treatment for revision amputation injuries. The mean static two-point dis-
crimination was 5 mm, with total active motion 93% of normal (slightly better after revision amputation
compared with local flap coverage). Seventy-seven percent of patients reported cold intolerance.
Ninety-one percent reported satisfactory or good/excellent overall function regardless of treatment.
CHAPTER 4
Proximal Upper Extremity Amputations

This chapter includes the following videos: Video 4.1 – Midforearm amputation;
Video 4.2 – Regenerative peripheral nerve interface.
KEY CONCEPTS
• The goal of upper extremity amputation is to provide a stable, functional limb with
durable soft-tissue coverage that facilitates the use of a prosthesis.
• Upper extremity amputation is most common after unsalvageable trauma, including
crushed/mangled extremity, amputation with prolonged ischemic time, electrical
burns, complex vascular injury, and cold injury/frostbite. Less common indications
include unresectable sarcoma, necrotizing fasciitis, and elective amputation for
chronic posttraumatic pain.
• For acute injuries, determine whether replantation or limb salvage is possible. If not,
determine what tissue remains viable. If there is extensive soft-tissue loss, skin graft-
ing or a flap may be necessary to cover the stump site.
• All transected nerves will form neuromas because the axons are seeking a target to
innervate, whether through a nerve or into a muscle. Regenerative peripheral nerve
interface (RPNI) is indicated at the time of primary amputation for management of
peripheral nerves, with the goal of reducing the incidence of painful neuroma forma-
tion. RPNI should be delayed if infection or other gross contamination of the wound
bed is present.
• An interdisciplinary approach for upper extremity amputations is strongly recom-
mended; patients should be referred to their physiatrist, prosthetist, and therapist
early in the recovery process.
• Trans-radial forearm amputation
• Regenerative peripheral nerve interface
Brachioradialis m.
Brachial Biceps
Radial artery brachii m.
Flexor carpi Superficial branch, artery
radialis tendon radial nerve
Median
Ulnar artery nerve Ulnar
and nerve Palmaris Median nerve
Flexor digitorum Pronator
teres m. (cut) Flexor carpi longus m. nerve
superficialis m.
radialis m.
FIGURE 4.1 Key anatomic structures for trans-radial amputation.
7
CHAPTER 4
Proximal Upper Extremity Amputation
INDICATIONS
• The goal of upper extremity amputation is to provide a stable, functional limb with
durable soft-tissue coverage to facilitate the use of a prosthesis.
• Upper extremity amputation is most common after unsalvageable trauma, such as
a crushed/mangled extremity, amputation with prolonged ischemic time, electrical
burns, complex vascular injury, or cold injury/frostbite.
• Amputation is also used to remove unresectable sarcoma, such as tumors with ex-
tensive vascular involvement, osseous/articular destruction, or soft-tissue loss.
• Infection, especially necrotizing fasciitis, in which soft-tissue reconstruction could
not be accomplished after extensive debridement is another indication.
• Rarely, an elective amputation may be chosen by a patient who has chronic post-
traumatic pain and/or spasticity.
• Regenerative peripheral nerve interface (RPNI) is indicated at the time of primary
amputation for the management of peripheral nerves, with the goal of reducing the
incidence of painful neuroma formation. All transected nerves will form neuromas
because the axons are seeking a target to innervate, whether through a nerve or into
a muscle. To avoid potential painful neuromas, we recommend performing RPNI
after all primary upper extremity amputations.
• Targeted muscle reinnervation (TMR) provides a similar function with identical indi-
cations, but instead of free muscle grafts to individual peripheral nerves as with
RPNI, TMR uses nerve coaptations/transfers of nonfunctioning distal peripheral
nerves (radial, ulnar, median) to functioning peripheral nerve branches of proximal
muscle bodies (biceps, triceps, pectoralis, latissimus). We prefer RPNI to TMR be-
cause it is less complicated and does not sacrifice the function of proximal muscle
bellies.
• RPNI can also be used in a revision setting for the management of neuromas in a
chronically painful amputated limb.
• RPNI and TMR are currently being used experimentally for advanced control of
myoelectric prosthetics.
Contraindications
• Amputation should be avoided in patients who already have an amputation or dis-
ability of their contralateral upper extremity.
• Preoperative evaluation with a physiatrist or amputation psychologist is strongly rec-
ommended in cases of elective amputation. If any concerns are raised about a pa-
tient’s ability to cope or adapt after an amputation, it should be avoided.
• RPNI should be avoided when infection or other gross contamination of the wound
bed is present. In this scenario, delaying the RPNI procedure is recommended.
TRANSRADIAL FOREARM AMPUTATION

Clinical Examination
• In cases of acute injury, it is important to first decide if replantation or limb-salvage
is achievable. If not, one should assess the extremity and decide what is viable ver-
sus nonviable tissue. If there is extensive soft-tissue loss, then skin grafting or a flap
may be necessary to cover the stump site.
• In cases of malignancy, it is important to study the patient’s surface anatomy and
advanced imaging because this will dictate the necessary level of amputation.
7.e1
7.e2 CHAPTER 4 Proximal Upper Extremity Amputation
Imaging
• Standard anteroposterior (AP) and lateral radiographs should be obtained to identify
any fractures or foreign bodies.
• In cases of infection or malignancy, magnetic resonance imaging (MRI) with and
without contrast can be invaluable in determining the proximal extent of pathology
to avoid incorporating contaminated tissue into the amputation site.
Surgical Anatomy
• There are five main nerves and four arteries that must be identified, divided, and
ligated during a standard transradial amputation (Fig. 4.1):
• The superficial radial nerve (SRN) is found within the radial, most subcutaneous
tissue of the mid forearm. The smaller lateral and medial antebrachial cutaneous
nerves can also be found in this area.
• The radial artery is identified proximally under the brachioradialis. At the middle-
to-distal forearm, the radial artery runs between the flexor carpi radialis and
brachioradialis tendons, with no superficial muscular covering.
• The median nerve is found within the volar compartment. At the level of the mid
forearm, the median nerve courses between the muscle bellies of the flexor digi-
torum superficialis and profundus, ulnar to the flexor carpi radialis.
• The ulnar artery and nerve together comprise the ulnar neurovascular bundle.
This structure courses deep into the flexor carpi ulnaris (FCU) muscle belly within
the forearm, with the nerve traveling ulnar to the artery.
• The anterior and posterior interosseous arteries run longitudinally along the ante-
rior and posterior aspects of the interosseous membrane. Depending on the level
of amputation, a proximal or distal anastomosis may be encountered. The terminal
Ulnar Median nerve

artery
Level of bone division Radial
Ulnar artery
nerve
Radial
nerve
Ulna Radius
Brachioradialis m.
Brachial Biceps
Radial artery brachii m.
Flexor carpi Superficial branch, artery
radialis tendon radial nerve
Median
Ulnar artery nerve Ulnar
and nerve Palmaris Median nerve
Flexor digitorum Pronator
teres m. (cut) longus m. nerve
superficialis m. Flexor carpi
radialis m.
FIGURE 4.1 Forearm anatomy. From Thal ER, Weigelt JA, Carrico CJ, eds. Operative Trauma Management: An Atlas. 2nd ed. New York: McGraw-Hill,
2002:449.
CHAPTER 4 Proximal Upper Extremity Amputation 7.e3
branches of the anterior and posterior interosseous nerves are found just adjacent EXPOSURES PEARLS
to their corresponding artery.
In cases of infection or a mangled extremity, it is
not always possible to determine the ideal level
Positioning of amputation on initial presentation. Temporizing
• A transradial forearm amputation is performed in standard supine position using a measures such as serial debridement may be
hand table. performed to give the proximal tissue time to rest
and demarcate. Distal guillotine amputation may
• An unsterile tourniquet will suffice for standard forearm amputations. In cases requir-
be necessary in emergent situations, such as
ing more proximal amputation, however, a sterile tourniquet is necessary to avoid necrotizing fasciitis.
draping too close to the surgical field.
Exposures
• Discuss the optimal location/level for the bone cuts with the prosthetic team to en-
sure that a compatible prosthesis is available.
• If a tumor or infection is present, bone cuts are made at least 1 cm proximal to the
contaminated area. In cases of trauma, bone cuts are made at a level proximal
enough to ensure that the remaining, uninjured soft tissue can cover the amputation
site without excessive tension.
• Draw a fish-mouth incision with the proximal tail extensions along the radial and
ulnar borders of the forearm. The skin flaps should extend at least 2 cm distal to the
planned bone cuts (Fig. 4.2).
Procedure
Step 1: Volar Dissection
• Make the volar incision. Then, using electrocautery, start superficially and cut struc-
ture by structure until the flexor carpi radialis and palmaris longus are encountered.
• Identify the superficial radial nerve along the radial border and tag it with an epineu-
ral suture for the RPNI procedure.
• Next, identify the radial artery under the nerve and secure it with two opposing ves-
sel clamps. Sharply divide the artery between the clamps.
• Using nonabsorbable suture, stick tie the proximal artery stump to prevent postop-
FIGURE 4.2 Fish-mouth incision with skin flaps
erative bleeding. Stick tying is the preferred method because it incorporates the extending greater than or equal to 2 cm distal
surrounding soft tissue to keep the suture in place around the artery (Fig. 4.3). from the planned bone cuts.
• Find the median nerve in the midvolar forearm between the two digital flexor muscle
bellies and divide it sharply; tag the nerve for subsequent RPNI (Fig. 4.4).
STEP 1 PEARLS
• Use electrocautery to divide the FCU along its ulnar border. Identify the ulnar neuro-
• When performing RPNIs, complete your initial
vascular bundle deep to the FCU. Perform artery ligation and nerve division as
nerve transections with enough working length
previously discussed (Fig. 4.5). remaining.
• Isolate and secure the anterior interosseous artery with suture ligation. Sharply divide • The basilic, cephalic, and other large dorsal
the anterior interosseous nerve, which is typically immediately ulnar to the artery. veins will be encountered during superficial
dissection; manage them with suture ligation
Step 2: Osteotomy as necessary.
• Use a combination of electrocautery and a key elevator to subperiosteally expose
both the radius and ulna. STEP 1 PITFALLS
• If the skin flaps are too small, then additional
bone resection is necessary to facilitate wound
closure. It is always better to create slightly
larger skin flaps that can later be trimmed to
size.
• Only place suture through the epineurium of
the peripheral nerves. Damaging the deeper
nerve fascicles with needles or suture will act
as a noxious stimulus.
FIGURE 4.3 Dissection of radial artery and su- Median nerve
perficial radial nerve. FIGURE 4.4 Dissection of the median nerve.

• Confirm the planned osteotomy level in relation to surface landmarks. Mark the
planned osteotomy onto the radius and ulna using electrocautery.
• Use a small or medium-sized oscillating saw to perform horizontal osteotomies
through the radius and ulna.
• Use a small rasp to lightly chamfer the bone edges.
Step 3: Dorsal Dissection

• Identify the posterior interosseous artery immediately dorsal to the interosseous
membrane and secure it with suture ligation. Then, sharply divide the posterior in-
terosseous nerve.
• Finish the remaining dorsal compartment dissection with electrocautery.
Ulnar nerve and artery Step 4: Myoplasty and Closure

FIGURE 4.5 Dissection of the ulnar nerve and • Use a 0 braided suture to bring the dorsal and volar muscular compartments to-
artery.
gether, covering the bone stumps of the radius and ulna. Be sure to grab the
muscular fascia within this closure (Fig. 4.6B).
STEP 4 PEARLS • Use 3-0 absorbable braided suture to reapproximate the subcutaneous tissues.
• A drain can be placed within the deep or • Use 4-0 Nylon suture in an interrupted fashion for final skin closure.
superficial layers to prevent hematoma • Place a compressive wrap/bandage.
accumulation.
• In distal forearm amputations, myodesis can
be performed to stabilize the muscles. This Myodesis consists of suturing the transected muscle to the bone through drill holes.
theoretically maintains supination/pronation
strength because the muscles are sutured di-
rectly to bone through interosseous drill holes.
We prefer myoplasty because it provides more
robust coverage of the terminal amputation
stump (see Fig. 4.6A–B for a demonstration of
each method in the lower leg; similar concepts
apply to upper extremity reconstruction).
STEP 4 PITFALLS
The forearm is highly vascular. Postoperative
bleeding and hematoma can occur if small arteries
and veins are not identified and ligated. We
recommend relieving the tourniquet before closure
to facilitate ligation/cauterization of any remaining
vessels within the deep tissue.
The cut ends of antagonistic muscle groups and their fascias are sewn together for myoplasty.
FIGURE 4.6 (A–B) Myodesis versus myoplasty demonstrated in the lower leg. Similar concepts apply
for upper extremity amputation. From Greisberg JK, Vosseller JT, eds. Core Knowledge in Orthopae-
dics: Foot and Ankle, 1st ed. Elsevier, 2014:213.
REGENERATIVE PERIPHERAL NERVE INTERFACE STEP 1 PITFALLS

Clinical Examination Do not harvest muscle tissue from the area just
proximal to the amputation; this muscle bulk is
• In patients who present for revision surgery of painful neuromas, evaluation of the
necessary to protect/pad the amputation stump
amputation site is important. Note any hyperactive scar formation, prior skin graft- and provides proper contour for the prosthetic
ing, or flap coverage that could make surgical dissection more difficult. socket.
• Tinel signs can indicate the location of neuromas, limiting the need for extensive
surgical dissection.
• If a primary amputation was performed by another surgeon, old operative reports are
useful to determine how the peripheral nerves were managed at the time of surgery
and if they were placed in a nonanatomic position.
Procedure
STEP 2 PEARLS
Step 1: Muscle Harvest
When a nerve carries both motor and sensory
• Regardless of amputation level (transradial, transelbow, transhumeral), RPNI re-
fascicles, an intraneural dissection should be
quires a 1 cm ! 3 cm rectangle of free, nonvascularized muscle tissue, roughly 3 to performed to isolate the individual fascicles. Within
5 mm thick, for each nerve or fascicle. the mid-to-distal forearm, both the ulnar and
• For primary amputation, muscle tissue is harvested from the amputated distal ex- median nerves have separate motor and sensory
tremity. In revision situations, other muscle autograft should be used. We prefer to fascicles.
harvest muscle tissue from the vastus lateralis as it has a large, easily accessible
muscle belly. Donor site morbidity is limited because of the functional redundancy
of the remaining quadriceps muscles (Fig. 4.7).
Step 2: Nerve Preparation

• When performing an amputation, identify, isolate, and sharply divide all major
nerves, with ample length remaining for manipulation around the wound (Fig. 4.8).
• In revision cases when amputation has previously been performed and neuroma has
developed, start distally by identifying and dissecting out the neuroma.
• Identify the neuroma and then dissect proximally, freeing 2 to 3 cm of the nerve.
• Sharply divide the nerve, then use loupe magnification to ensure that there are
healthy nerve fascicles that are free of scar tissue.
Step 3: Creating the Muscle–Nerve Interface

• Take a piece of free muscle graft. Place the nerve ending on top of the muscle graft
longitudinally.
Volar muscle
donor site
Radial sensory N.
Median N.
Free muscle
tissue
Ulnar N.
(sensory and motor N.)
FIGURE 4.8 Radial sensory, median, and ulnar nerves, exposed and
FIGURE 4.7 Harvesting brachioradialis muscle graft from the volar forearm. prepared for regenerative peripheral nerve interface (RPNI).
STEP 3 PEARLS • Use two to three interrupted, 6-0 permanent monofilament sutures to secure the
If there are plans for postoperative use of a epineurium and muscle together as a unit.
myoelectric prosthesis, the individual RPNIs • Fold the adjacent muscle flaps over the nerve, creating circumferential muscle
should be tunneled away from the direct weight- coverage around the nerve. Suture the two muscle flaps together with several 6-0
bearing portion of the limb and placed within the sutures (Fig. 4.9).
subcutaneous tissues.
• Repeat this process for each nerve/fascicle (Fig. 4.10).
• The individual RPNIs should be buried within the wound, away from the direct
weight-bearing portions of the stump.
• Routine wound closure is then performed (Fig. 4.11).
Free muscle graft
Transected peripheral Placement of Muscle graft is

nerve placed in center epineurial securing sutures rolled to cover nerve
of muscle graft ending and secured with sutures
FIGURE 4.9 Suturing the peripheral nerve into the free muscle graft.
Superficial
radial nerve
Ulnar nerve
Median nerve
FIGURE 4.10 Completed regenerative peripheral nerve interface (RPNI) to superficial radial, median,
and ulnar (motor and sensory fascicles) nerves.
FIGURE 4.11 Completed transradial amputation with regenerative peripheral nerve interface (RPNI)
and layered wound closure.

• A gauze dressing with elastic compressive wrap should be applied to the wound and
stump for the first week after surgery.
• We strongly recommend an interdisciplinary approach for upper extremity amputa-
tions; patients should be referred to their physiatrist, prosthetist, and therapist early
in the recovery process.
• Once the wound starts to heal, the patient can begin to wear shrinker/compressive
socks and initiate the process of prosthetic fitment.
• Neuroma development is common after upper extremity amputation, regardless of
the use of RPNI/TMR. In the event of neuroma development, a primary or revision
RPNI should be performed.
See Videos 4.1 and 4.2
EVIDENCE
Kubiak CA, Kemp SWP, Cederna PS, Kung TA. Prophylactic regenerative peripheral nerve interfaces to
prevent postamputation pain. Plast Reconstr Surg. 2019;144(3):421e–430e.
In this study, 90 patients underwent amputation at various levels within the upper and lower extremities.
RPNI was performed in 45 patients, whereas classic sharp ligation of peripheral nerves was per-
formed in 45 patients, who served as the control group. 51% of RPNI patients reported phantom
limb sensation compared with 91% in the control group. Painful neuromas developed in 6 out of
45 control patients, compared with 0 out of 45 RPNI patients (Level III Evidence).
Chow JA, Van Beek AL, Bilos ZJ, et al. Anatomical basis for repair of ulnar and median nerves in the
distal part of the forearm by group fascicular suture and nerve-grafting. J Bone Joint Surg Am.
1986;68(2):273–280.
An anatomic study of the internal fascicular anatomy of the median and ulnar nerves. In total, 45 cadav-
eric specimens were dissected and the common patterns of intraneural topography were described.
Initially intended to improve the accuracy of grouped fascicular nerve repair, this anatomy is vital to
accomplishing fascicular RPNI or TMR.
Resnik L, Ekerholm S, Borgia M, Clark MA. A national study of veterans with major upper limb amputa-
tion: Survey methods, participants, and summary findings. PLOS One. 2019;14(3):e0213578.
The largest national survey of U.S. veterans highlighting outcomes and prosthetic usage in those who
sustained either unilateral or bilateral upper extremity amputation. The rate of prosthetic use in unilat-
eral amputees was only 60%; of those, 52% of unilateral and 76% of bilateral amputees used their
prosthetic(s) for more than 8 hours every day. Phantom limb pain was reported in 83.4% of unilateral
amputees (Level IV Evidence).
CHAPTER 5
Finger Infections (Paronychia, Felons, Pyogenic
Flexor Tenosynovitis)
INDICATIONS
• Paronychia, felons, and flexor tenosynovitis (FTS) are some of the most common
infectious pathologies seen among hand surgeons. They are most often bacterial in
origin—with Staphylococcus aureus as the most common pathogen—and can be
pyogenic (pus-forming).
• Paronychia is an infection of the lateral or proximal nail fold and soft tissue, which
can also extend to the germinal and sterile matrix beneath the nail.
• A felon is a purulent infection that develops within the volar septate pulp tissue
of a finger or thumb.
• Pyogenic FTS is a purulent infection that occurs within the sheath surrounding
the flexor tendons.
• Pyogenic infections should be dealt with promptly to prevent tendon scarring and
necrosis, soft-tissue loss, proximal migration, and bacteremia.
• Rapid progression of pyogenic infections is common in patients with diabetes or IV
drug use and among those who are immunocompromised.
• A recent history of puncture or injury to the soft tissue is common, but not required,
for the development of pyogenic infections of the finger and hands.
• Bites are a common mechanism of hand infection. Cats specifically have sharp,
needle-like teeth, delivering bacteria (Pasteurella multocida)-laden saliva into
wounds, which then quickly seal over. Human bites from physical altercations are
also common, most frequently occurring on the dorsal ulnar hand at the level of the
metacarpophalangeal joints.
Contraindications
There are no contraindications to surgical management of pyogenic infections of the
fingers and hand. The adage “the sun never sets on an abscess” remains relevant, re-
gardless of the clinical setting. Even in critically ill patients, most finger infections can
be temporized by lancing at the bedside under a digital block.
• Clinical examination is the hallmark of diagnosis for felons, paronychia, and pyo-
genic FTS. Laboratory markers, such as white blood cell count (WBC) and erythro-
cyte sedimentation rate/C-reactive protein (ESR/CRP), are commonly within normal
limits and of little clinical utility.
• Patients with a finger infection will often report a recent history of swelling, erythema,
and worsening pain within the finger or hand.
• The common physical examination findings of pyogenic FTS are classically de-
scribed by Kanavel (Fig. 5.1):
• Fusiform swelling (also described as a “sausage digit”), with tense swelling along
the entire length of the digit
• Flexed posture
• Tenderness to palpation along the flexor tendon sheath
• Pain with passive digital extension
• Felons are characterized by tense swelling of the volar pulp and a well-defined area
of blanching overlying an obvious abscess (Fig. 5.2). As the infection worsens and
pressure increases, a type of localized compartment syndrome can develop within
the septa of the pulp tissue, leading to extreme pain.
8
CHAPTER 5 Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis) 9
FIGURE 5.1 Flexor tenosynovitis, with the classic flexed posture and FIGURE 5.2 Obvious purulence within the pulp tissue, the hallmark
fusiform swelling of the affected index finger. sign of a felon.
• Paronychia are initially characterized by unilateral swelling, erythema, and pain of

the lateral nail fold on one side. As the infection progresses, the swelling and ery-
thema will affect both lateral nail folds and extend proximally into the dorsal skin of
the digit (Fig. 5.3).
IMAGING
• X-rays are necessary to rule out associated osteomyelitis or bony destruction, sub-
cutaneous gas formation, or any retained foreign bodies.
• Ultrasound is useful when there is concern for proximal spread into the deep spaces
of the hand or forearm. Pain that spreads from the finger to the hand or forearm
should raise concern.
• Magnetic resonance imaging (MRI) is of little clinical utility for simple felons, paro-
nychia, and FTS and will only serve to delay treatment.
SURGICAL ANATOMY
• The flexor tendons of the fingers are contained by longitudinal sheaths, which are
reinforced by the pulley systems within each individual finger. The A1, A3, and A5
pulleys originate around the distal necks and interphalangeal (IP) joints of the meta-
carpal, proximal phalanx, and middle phalanx, respectively. The A2 and A4 pulleys
originate at the diaphysis of the proximal and middle phalanx, respectively, and
FIGURE 5.3 A patient with worsening thumb
function to prevent bow-stringing of the flexor tendons. pain, proximal nail fold swelling, and obvious
• The flexor sheaths of multiple digits may be connected via radial and ulnar palmar purulence beneath the nail.
bursa, although several anatomic variations have been described. The space of
Parona, which is located proximally at a level between the carpal tunnel and prona-
tor quadratus, often permits direct connections between bursa. The connections
permit communication between the flexor tendons of the thumb and small finger and
can facilitate seeding of the infection to the other digits. For example, a small finger
pyogenic FTS can spread to include the thumb as well, forming a so-called “horse-
shoe abscess” (Fig. 5.4).
POSITIONING
• Standard supine positioning with a hand table is used.
• The inflammation associated with infections can cause increased surgical site bleed-
ing, which makes it difficult to define normal anatomy. Use a digital or forearm-
based tourniquet as necessary. Do not exsanguinate before inflation because this
can force proximal extension of an underlying abscess. Instead, elevate the arm and
let gravity assist with venous drainage before tourniquet inflation.
10 CHAPTER 5 Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)
Tendon sheaths
Metacarpal heads
EXPOSURE PEARLS
Midaxial incisions should be placed on the radial
border of the thumb and small finger and on the
ulnar border of the index, long, and ring finger Ulnar bursa
to avoid scar formation and denervation of the
border/pinch surfaces. Radial bursa
EXPOSURE PITFALLS
Avoid making a lateral incision directly over the
neurovascular bundle, which runs parallel to
the distal phalanx. A midaxial incision should be
placed just dorsal to the bundle to permit access
to the volar pulp tissue, while keeping the nerve
and artery within the flap to preserve innervation.
The midaxial incision is centered over the lateral FIGURE 5.4 The proximal extensions of the ulnar and radial bursa that communicate with the flexor
joint crease when flexing the digits between the sheaths. (From Fig. 16.8 in Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6: Hand and
glabrous and nonglabrous skin. An incision dorsal Upper Limb. Elsevier; 2018.)
to the bundle can provide complete access to the
volar pulp tissue by dissection under the flap and
over the tendon sheath.
TREATMENT OF FELON INFECTIONS

STEP 1 PEARLS
Use a dental pick or freer elevator to palpate the
Exposures
underlying distal phalanx. If there is cortical erosion • The goal of surgical treatment of a felon is to completely release the internal septa-
on x-rays, or the bone is soft on examination, then tions within the volar pulp and debride any necrotic tissue.
biopsies should be taken with a rongeur and sent • This can be achieved with a midlateral incision, a volar midline incision, or an incision
for osteomyelitis analysis. directly over the area of purulence (Figs. 5.5 and 5.6).
Step 1
STEP 1 PITFALLS
• After making the incision, use blunt dissection to release all underlying septa and
Thorough debridement and irrigation is essential express all underlying purulent material (Figs. 5.7 and 5.8).
when treating a felon; however, do not remove
excessive amounts of fat from the pulp tissue • Use small curettes or a synovial rongeur to lightly debride any necrotic fat.
because this can lead to a thin, hypersensitive, and • Thoroughly irrigate the pulp tissue with sterile saline. The flexible tip of a standard
painful fingertip. angiocatheter on a large volume syringe can be used to precisely deliver fluid into
the wound.
STEP 2 PITFALLS Step 2

Do not reapproximate the wound with sutures Place sterile packing gauze within the wound. Leave a small tail of gauze at the wound
because this will encourage the wound to close exit to keep the wound open. This prevents rapid closure of the septa and allows the
prematurely, risking reformation of the felon.
wound to drain.
Felon
A
Midlateral incision
Volar midline incision
FIGURE 5.6 Midaxial incision on the ulnar border of the right index finger.
B C
FIGURE 5.5 Demonstration of the various septa that exist within the volar
pulp tissue and of the various incisions used to drain a felon. (From
Fig. 16.7 in Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6:
Hand and Upper Limb. Elsevier; 2018.)
Incision posterior to
digital artery and nerve
All septa divided
FIGURE 5.7 Pus draining from the wound immediately upon incision. FIGURE 5.8 Complete decompression, release of all
septa, and debridement of infectious material. (From
Fig. 78.6 in Azar, FM, Canale ST, Beaty JH. Campbell’s
Operative Orthopaedics. 13th ed. Elsevier; 2016.)
PYOGENIC FLEXOR TENOSYNOVITIS

Exposures
• There are two approaches to treating FTS. Traditionally, a long open midaxial ap-
proach has been used to expose a large area of the flexor sheath. This wide expo-
sure permits direct visualization and clearance of any necrotic or thick purulent
material.
• Preferably, a more limited approach can be taken through small incisions proximally
at the A1 pulley and distally at the A5 pulley. This approach necessitates flexible
catheter irrigation of the sheath (Fig. 5.9) and has the advantage of not violating the
tenuous inflamed volar tissue over the digit.
A B C
FIGURE 5.9 (A) Extensile midaxial incision along the ulnar border of the middle finger. (B, C) Minimally invasive approach for catheter irrigation.
(From Wolfe, SW, Pederson WC, Kozin SH, Cohen MS. Green’s Operative Hand Surgery. 7th ed. Elsevier: 2016.)
• We advocate use of the closed method in the majority of cases to preserve the soft
tissue over the finger, decrease healing time, and reduce the development of post-
operative stiffness and tendon adhesion.
STEP 1 PEARLS
Place the incision along the nonborder/pinch
Step 1: Incisions for Access to the Flexor Sheath
surface of the digit, such as the radial border of • Design a diagonal or Bruner incision over the A1 pulley. The incision should roughly
the small finger, or ulnar border of the index, long, align with the distal palmar crease on the middle, ring, and small fingers or the
or ring finger. proximal palmar crease on the index finger.
• Distally, at the level of the distal IP joint (DIP), create a 1 cm longitudinal incision
along the digital border of the finger, dorsal to the neurovascular bundle. This will
STEP 2 PITFALLS place the exposure between the A4 and A5 pulley (Fig. 5.10).
Take care to avoid disrupting the DIP joint capsule
with the distal dissection because this may Step 2: Exposing the Flexor Sheath
introduce infectious material into the DIP joint
• In the palm, use blunt dissection to spread down to the flexor sheath. Spread in a
space.
proximal/distal direction, parallel to the neurovascular (NV) bundles, to avoid injuring
FIGURE 5.10 Demonstration of all four Knavel signs and the planned proximal and distal incisions for
a minimally invasive irrigation.
the bundles that run on either side of the flexor sheath. If NV bundles are identified,
retract them away from the sheath (Fig. 5.11).
• Distally in the finger, spread in a plane parallel to the NV bundles. The NV bundles
will be volar to the incision site.
Step 3: Entering the Sheath

• In the palm, make a small longitudinal incision in the tendon sheath, just proximal to
the A1 pulley.
• In the finger, create a small window (around 0.5 cm) within the sheath distal to the
A4 pulley and proximal to the A5 pulley.
Step 4: Irrigating the Sheath

• Take the flexible end of a 14- or 16-gauge angiocatheter, which is readily available
on most anesthesia carts, and insert it into the sheath through the proximal incision.
• Connect the angiocatheter to a large volume (50cc) Luer lock syringe and irrigate
thoroughly using sterile saline. Watch for continuous outflow from the distal incision
site. A small self-retractor can be used proximally and distally to keep both incisions
open. FIGURE 5.11 The proximal palmar incision with
• Irrigate until the fluid is clear. Expect to use at least 500 cc for thorough irrigation blunt scissor dissection used to reach the
even if drainage runs clear before that amount is used (Fig. 5.12). entrance of the flexor sheath and A1 pulley.
Step 5: Finishing the Procedure STEP 3 PEARLS

• Loosely close with 5-0 interrupted monofilament suture (Fig. 5.13). Use needle aspiration before incising the sheath to
• Pack any open wounds with moist strip gauze to permit continued drainage of any obtain a sample for culture or be ready to acquire
fluid for testing after making an incision in the sheath.
remaining fluid and to prevent wound closure.
• Wrap the hand in a bulky soft dressing and place it in a volar slab splint to rest the
wounds. STEP 4 PEARLS
Although not as commonly available as
PARONYCHIA angiocatheters, pediatric feeding tubes are another
common tool used to irrigate the flexor sheath with
Exposures minimal invasiveness.
• Superficial infections between the lateral fold and nail can be decompressed with a
freer elevator or a 15-blade scalpel (Fig. 5.14). STEP 5 PITFALLS
• Obvious purulence under the nail causing nail displacement or infections that ex- If there is any concern about retained infectious
tend proximally often needs to be treated with partial nail removal, irrigation, and material, or if signs and symptoms of infection
debridement. worsen again postoperatively, then return to
the operating room (OR) for re-exploration and
additional irrigation and debridement, as necessary.
FIGURE 5.12 The incision of the A1 pulley is seen, with a

25Fr pediatric feeding tube entering the flexor sheath. FIGURE 5.13 Wounds closed.
Scapel blade
Swollen nail fold
Collection
of pus
FIGURE 5.14 Blunt dissection under the lateral nail

fold, releasing the underlying purulence. (From FIGURE 5.15 A longitudinal cut is made down the
Fig. 149.2 in Azar, FM, Canale ST, Beaty JH. length of the thumb nail, releasing the underlying
Campbell’s Operative Orthopaedics. 13th ed. purulence.
Elsevier; 2016.)
STEP 1 PEARLS Step 1: Nail Removal

• When the entire nail is affected, the whole nail • Slide the blunt end of a freer elevator between the affected lateral nail fold and fin-
should be removed. gernail to decompress the underlying abscess.
• Two longitudinal incisions can be created in • Use tenotomy scissors or a 15-blade scalpel to create a longitudinal cut in the nail,
the proximal nail fold, in line with the lateral roughly one-third to one-half the width of the nail, on the affected side (Fig. 5.15).
nail folds, to decompress any proximal migra-
• Starting at the distal end of the nail, use the sharp end of a Freer elevator, with the
tion of the paronychia (Fig. 5.17).
curve pointing up toward the nail, to slowly release the nail fragment from the under-
lying sterile matrix (Fig. 5.16).
• Finally, release the proximal nail from under the eponychium.
Step 2: Closure
• Leave the wound open to drain and heal by secondary intention.
• Splint the nail folds open with strip gauze to encourage continued drainage and
prevent premature wound closure.
A B C
D E
FIGURE 5.17 (A-E) Release of the proximal nail folds bilaterally, with the
eponychium then held open with strip gauze to prevent premature
FIGURE 5.16 The nail is then dissected free of the underlying sterile wound closure. (From Fig. 16.2 in Chang J, Neligan PC, Liu DZ, eds.
matrix and proximal nail fold, fully decompressing the paronychia. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018.)
• Use a finger-based or stack splint to protect the vulnerable fingertip and prevent
motion through the DIP joint.

• Postoperative management of felons, paronychia, and FTS are all similar.
• On the first postoperative day, the patient can begin with soaks and dressing
changes three times a day. Soaks can be performed in a 1:1 mix of peroxide and
warm water, a warm soapy solution, or dilute betadine–saline solution.
• Packing gauze should be removed after 36 to 48 hours. It is often too painful for this
gauze to be replaced in the wound; thus we do not recommend it.
• Stiffness often sets into the adjacent unaffected digits. We recommend starting hand
therapy soon after surgery to prevent loss of motion. Active and passive range-of-
motion (ROM) exercises should be performed during soaks.
• Felons, paronychia, and FTS are usually treated by an infectious disease specialist for
4 to 6 weeks with either IV or oral antibiotics. Repeat debridement is rarely required.
EVIDENCE
Draeger RW, Bynum Jr DK. Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg.
2012;20:373–382.
This study highlights the importance of antibiotics, timing of surgical intervention, and available
outcomes. It stresses the importance of earlier intervention for patients who present later and
with advanced infection or with concerning comorbidities.
Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor
tenosynovitis. J Hand Surg Eur Vol. 2015;40:720–728.
Systematic review of the literature on treatment of pyogenic flexor tenosynovitis. It identifies the
value of IV antibiotic treatment to avoid surgery in mild cases and highlights the benefits of closed
irrigation rather than open washout and the use of antibiotics in addition to washout.
Kanavel AB. An anatomical, experimental, and clinical study of acute phlegmons of the hand. Surg
Gyneco Obstet. 1:221–259.
These are the classic historical writings of Dr. Kanavel, where he first described the presentation of
pyogenic FTS. He also used plaster of Paris injections of cadaveric hands and used radiographs to
demonstrate many of the theoretical spaces within the hand where infection can accumulate. Many
of his described treatments are still relevant today.
CHAPTER 6
Splints and Orthoses
KEY CONCEPTS
• Think critically about the goals of the operation and consider whether immobilization
is necessary. If immobilization is required, determine how far distal or proximal the
orthosis should extend. For fractures or periarticular trauma, the first joints proximal
and distal to the injury typically require immobilization.
• Wrist motion can create substantial strain through the flexor and extensor tendons,
even if individual fingers are immobilized. Therefore many tendon repair protocols
advise immobilization of the wrist joint as well.
• Unnecessary immobilization of adjacent joints can cause stiffness that slows the
overall recovery process and may lead to permanent loss of motion. In particular,
splints that cross the elbow should be avoided unless there is an absolute need to
prevent forearm rotation, such as in forearm or distal radioulnar joint injuries.
• Once motion is initiated in the recovery period, it is important to recognize how an
orthosis can aid or inhibit passive and active motion. For example, a yoke splint is
commonly used for sagittal band injuries. This prevents flexion of only the affected
metacarpophalangeal (MCP) joint but enables free flexion and extension of all other
joints.
• Nonremovable splints are commonly applied to patients in the operating room.
These splints are left in place for several weeks after the procedure until patients are
no longer vulnerable to reinjury. By contrast, removable splints are commonly used
in the later stages of postoperative recovery.
Orthoses reviewed in this chapter:
• Finger-based splint
• Hand-based splint
• Forearm-based splint
• Gutter splint
• Dynamic splint
• Static progressive splint
FIGURE 6.11 Dynamic forearm-based orthosis.
16
CHAPTER 6
Splints and Orthoses
INTRODUCTION
This textbook describes over 120 surgical procedures of the finger, hand, wrist, and
forearm. For many of these procedures, splints or orthoses are used to immobilize or
support the operative sites. The goal of this chapter is to introduce the basic tenets of
upper extremity splinting and to present the common orthoses that can be used during
postoperative recovery.
BASIC PRINCIPLES OF ORTHOSES

• Think critically about the goals of your operation.
• First consider whether immobilization is necessary. Strict cast immobilization is
often applied immediately after fracture fixation, joint stabilization, tendon repair, or
free tissue transfer procedures to prevent displacement or reinjury of the repaired
structures. Nevertheless, this is increasingly unnecessary because of advances in
orthopedic implants and improved understanding of soft-tissue healing. For ex-
ample, modern locked plating provides more than adequate stability and rigidity to
permit early postoperative motion after extraarticular fracture fixation within the
wrist or hand. Similarly, advancements in the scientific understanding of tendon
healing and the publication of prospective trials evaluating postoperative rehabilita-
tion indicate that early mobilization is beneficial after acute flexor tendon repairs.
• If immobilization is required, consider how far distal or proximal the orthosis
should extend. For fractures or periarticular trauma, the first joints proximal and
FIGURE 6.1 From Dehn R, Asprey D. Essential
distal to the injury typically require immobilization. For example, a sugar-tong Clinical Procedures. 4th ed. Philadelphia, PA:
splint that immobilizes the elbow and wrist is often indicated for a displaced dis- Elsevier; 2020.
tal radius fracture treated with closed reduction (Fig. 6.1).
• Remember the tenodesis effect. Wrist motion can create substantial motion or
strain through the flexor and extensor tendons, even if individual fingers are im-
mobilized. Therefore many tendon repair protocols advise immobilization of the
wrist joint as well.
• Do not immobilize adjacent joints needlessly, because this causes unnecessary stiff-
ness that slows the overall recovery process or causes permanent loss of motion.
• Immobilization of the elbow is often unnecessary. Splints that cross the elbow
should be avoided unless there is an absolute need to prevent forearm rotation,
such as in forearm or distal radioulnar joint injuries. Elderly patients in particular
can develop permanent elbow stiffness after only a few weeks of immobilization.
• Historically, it was thought that forearm immobilization was required for carpal injuries
such as scaphoid fractures. More recent biomechanical studies, however, suggest that
forearm pronation/supination does not produce a significant displacement force.
Therefore we recommend the elbow be left free in most patients with scaphoid injuries.
• Pay close attention to the cascade of the metacarpal heads when fabricating
plaster splints. It is a common mistake to extend the plaster or fiberglass too
distally, past the small finger metacarpophalangeal (MCP) joint, when applying a
forearm-based splint. This provides needless immobilization of the small finger.
In combination with the swelling associated with a fracture or surgery, this can
lead to long-term loss of motion in the digit.
• Once motion is initiated in the recovery period, it is important to recognize how an
orthosis can aid or inhibit passive and active motion.
• For example, in many flexor tendon rehabilitation protocols, an orthosis is used
to prevent finger extension beyond neutral but still permit active-assisted or pas-
sive flexion (Fig. 6.2). FIGURE 6.2
16.e1
16.e2 CHAPTER 6 Splints and Orthoses
• Similarly, a yoke splint is commonly used for sagittal band injuries. This prevents
flexion of only the affected MCP joint but enables free flexion and extension of all
other joints (Fig. 6.3).
• Determine when the patient can transition to a removable splint.
• Nonremovable splints are commonly applied to patients in the operating room.
These splints are left in place for several weeks after the procedure until patients
are no longer vulnerable to reinjury.
• In contrast, removable splints are commonly used in the later stages of postop-
erative recovery. Velcro removable splints are often preferred by patients because
they are lighter and less bulky than nonremovable, circumferential casts or splints
and because they permit hand hygiene.
CATEGORIES OF ORTHOSES
Beyond the standard sugar-tong and forearm-based plaster splints, most upper
extremity orthotic devices are created by hand therapists. Although it is outside the
scope of this textbook to detail the steps of their fabrication, it is important that
every hand surgeon understands the various types of orthoses available and when
to use them.
Finger/Digit Based
FIGURE 6.3
A finger-based splint is used to immobilize the distal interphalangeal (DIP) or proximal
interphalangeal (PIP) joints of one or multiple fingers. Fig. 6.4 demonstrates our pre-
ferred method for nonoperative treatment of mallet fingers using a splint. This method
is advantageous over the traditional Stack/Stax splint because it causes less dorsal
skin irritation and is easier for patients to place independently.
Hand Based
• A hand-based splint immobilizes at least part of the hand and may extend distally to
include the thumb or digits but does not extend proximal to the wrist joint. Hand-
based splints are typically used for acute injuries, such as metacarpal or phalangeal
fractures, or in nonoperative management of patients who have chronic conditions,
such as arthritis.
• Fig. 6.5 portrays a hard, removable, hand-based thumb spica splint with the IP joint
free, which is often prescribed to patients with thumb carpometacarpal (CMC) arthritis.
A
Forearm Based
• Forearm-based orthoses encompass a broad range of immobilization devices that
extend proximal to the wrist and include the forearm. Forearm-based immobilization
can end at the level of the MCP joints, include a thumb spica extension, or extend
to the fingertips.
• A resting intrinsic plus position (Fig. 6.6) is necessary to prevent joint contractures,
especially for acute injuries such as fractures of the second to fifth carpometacarpal
joints or metacarpals. This places the wrist in 30 degrees of extension, the MCP
joints in 70 to 90 degrees of flexion, and the PIP/DIP joints in 0 degrees extension.
• Fig. 6.7 portrays a forearm-based thumb spica orthosis, which can be used after
CMC arthroplasty, scaphoid open reduction and internal fixation (ORIF), or other
procedures that affect the scaphoid or thumb.
• Fig. 6.8 shows a standard volar forearm-based splint that terminates at the MCP
joints and leaves the thumb free. This splint is provided to patients who undergo
wrist surgery, such as distal radius ORIF.
B • Fig. 6.9 demonstrates a forearm-based orthosis that extends to the fingertips, which
is often necessary for patients with inflammatory arthritis who have undergone MCP
FIGURE 6.4
arthroplasty with centralization of the extensor tendons and cannot yet initiate active
or passive motion.
Gutter
• A gutter splint is an orthosis that immobilizes only part of the hand and digits on
either the radial or ulnar border of the hand. Gutter splints can be hand-based or
CHAPTER 6 Splints and Orthoses 16.e3
A B
FIGURE 6.5
FIGURE 6.6 From Stender Z. Hand and wrist. In: Browner B, Fuller R, eds. Musculoskeletal Emer-
gencies. Philadelphia, PA: Saunders. 2012;148–183.
A B C
FIGURE 6.7
A B C
FIGURE 6.8
A B
FIGURE 6.9
forearm-based and are commonly used to stabilize CMC joint, metacarpal bone, or
MCP joint injuries.
• Radial gutter splints immobilize the index and middle fingers, whereas ulnar gutter
splints (Fig. 6.10) immobilize the small and ring fingers. Note that the thumb is usu-
ally free of immobilization in both ulnar and radial gutter splints.
Dynamic
• Dynamic splints use the power of elastic bands and springs—in combination with
pulleys and outriggers—to permit free movement in one direction while blocking or
limiting movement in a different direction.
• Fig. 6.11 shows a dynamic forearm-based orthosis that may be used by rheumatoid
arthritis patients who have undergone MCP joint arthroplasties with a concomitant ex-
tensor tendon centralization procedure. This splint permits full digital flexion, provides
CHAPTER 6 Splints and Orthoses 16.e5
A B
FIGURE 6.10
FIGURE 6.11
dynamic assistance with extension to avoid stressing the sagittal band reconstruction,
and prevents ulnar drift via the radially angled outriggers.
Static Progressive
• Static progressive orthoses apply constant, low-level force to stiff joints over the
span of days or weeks. They are used throughout the upper extremity to treat con-
tractures after injury or surgery.
• These splints typically consist of cords or straps and pulleys that provide a direct
line of pull to the digits or wrist in the direction of terminal motion loss. Fig. 6.12
shows a forearm-based static progressive splint used for a stiff PIP joint with loss of
flexion. The cord pulls the middle finger in a volar direction, whereas the extension
on the middle finger to include the proximal phalanx ensures the force is directed
only through the PIP joint.
EVIDENCE
McAdams TR, Spisak S, Beaulieu CF, Ladd AL. The effect of pronation and supination on the minimally
displaced scaphoid fracture. Clin Orthop Relat Res. 2003;411:255–259.
A biomechanical study of 10 upper extremities in which a waist fracture was created in the scaphoid.
Metallic markers were placed at the margin of the fracture, and then the extremities were placed into
a below-elbow cast. Computed tomography (CT) scanning was then performed in various forearm
positions and compared with uncasted controls. There was no significant displacement of the scaph-
oid fracture with below-elbow casting throughout pronation-supination, whereas the uncasted con-
trol group had unacceptable displacement with identical movement.
Clementsen SO, Hammer OL, Benth JS, et al. Early mobilization and physiotherapy vs late mobilization
and home exercises after ORIF of distal radial fractures. JBJS Open Access. 2019;4(3):e0012.1–11.
Level 1 evidence study in which 119 patients who underwent ORIF of an extraarticular distal radius
fracture were randomized into early mobilization and therapy within 48 hours postoperatively or de-
layed mobilization with splinting for 2 weeks. At 24 months postoperatively, there were no changes in
FIGURE 6.12
QuickDASH (Quick Disabilities of Arm, Shoulder, and Hand) scores, grip strength, or range of motion.
These results suggest that early transition from plaster splints to a removable orthosis is well toler-
ated by patients with little to no long-term effects.
ddsf
SECTION II
Hand Fractures and Dislocations

CHAPTER 7 Principles of Bone Fixation and Healing 18
CHAPTER 8 Kirschner Wire Fixation of Mallet Fractures 19
CHAPTER 9 Techniques for Fixing Extraarticular Phalangeal
Fractures 20
CHAPTER 10 Dynamic External Fixation of Fracture-Dislocation
of the Proximal Interphalangeal Joint 21
CHAPTER 11 Open Reduction and Internal Fixation of
Intraarticular Phalangeal Fractures 22
CHAPTER 12 Volar Plate Arthroplasty of the Proximal
Interphalangeal Joint 23
CHAPTER 13 Hemi-Hamate Arthroplasty 24
CHAPTER 14 Techniques and Fixation of Metacarpal
Fractures 33
CHAPTER 15 Open Reduction for Metacarpophalangeal
Joint Dislocation 34
CHAPTER 16 orrective Osteotomy of Metacarpal Fracture
C
Malunion 40
CHAPTER 17 Reconstruction of Acute and Chronic Ulnar
Collateral Ligament Injuries of the Thumb 41
CHAPTER 18 Techniques for Fixing Bennett and Rolando
Fractures 52
17
CHAPTER 7
Principles of Bone Fixation and Healing
KEY CONCEPTS
• Fracture healing requires coordinated interactions among multiple cell types, cytokines,
and growth factors. The healing process is influenced by the local mechanical and biologic
environment, as well as the surgical fixation device and reduction method. To optimize
fracture healing, the fracture must be reduced to a satisfactory position and stabilized.
• Fractures heal via primary (intramembranous) and secondary (endochondral) types
of healing. The degree of fracture stability will influence which type of healing pre-
dominates; more rigid fixation favors primary fracture healing.
• Secondary bone healing progresses in the following stages: hematoma stage, in-
flammatory stage, soft callus stage, hard callus stage, remodeling stage.
• Pins are used in percutaneous pinning of small bone fractures, commonly in hand
and wrist fractures. They are also useful for temporarily maintaining the reduction of
a fracture before implant placement.
• Screws can be used on their own to hold two fragments together or used in combi-
nation with plates.
• A variety of plates are available to provide absolute or relative fracture stability. Lock-
ing plates create angular stability between the implant and the bone. They are more
resistant to mechanical disruption than a conventional plating system.
Fixation techniques reviewed in this chapter:
• Pins
• Screws
• Cortical screws
• Cancellous screws
• Cannulated screws
• Self-tapping screws
• Headless compression screws
• Lag screws
• Position screws
• Plates
• Conventional
• Dynamic compression
• Locking
A B
C D
FIGURE 7.8 The lag screw generates interfragmentary compression.

18
CHAPTER 7
Principles of Bone Fixation and Healing
THE ESSENTIAL COMPONENTS OF FRACTURE HEALING

• Fracture healing is a complex and dynamic process that restores injured bones to
prefracture conditions.
• Fracture healing requires coordinated interactions among multiple cell types, cyto-
kines, and growth factors. The healing process is influenced by the local mechanical
and biologic environment, the surgical fixation device, and the reduction method.
• Maintaining adequate blood flow to the affected site is the primary determinant of
how well a fracture heals. To optimize fracture healing, the fracture must be reduced
to a satisfactory position and stabilized.
TYPES OF HEALING
Intramembranous Ossification (Primary Bone Healing)
• Intramembranous ossification is the process of direct bone formation without a car-
tilage intermediate. This type of ossification is responsible for primary bone healing
and normal bone remodeling.
• Primary bone healing is favored when anatomic reduction minimizes the fracture
gap and motion between two fracture surfaces is restricted through rigid internal
fixation.
• Intramembranous ossification begins with osteoprogenitor cells, a class of undifferen-
tiated mesenchymal cells located in the deep layers of periosteum, endosteum, and
marrow. These cells aggregate into membrane-like layers and proceed to differentiate
directly to osteoblasts without the formation of cartilage. The process concludes with
direct deposition of osteoid and subsequent mineralization.
• Throughout this process, no clinically visible callus can be appreciated on radio-
graphs.
Endochondral Ossification (Secondary Bone Healing)

• Endochondral ossification is a sequential process that is responsible for secondary
bone healing.
• Secondary bone healing of a fracture is favored when the fracture site has some
degree of mobility, unlike primary bone healing, which is favored by a rigid environ-
ment. Treatments that create favorable conditions for secondary bone healing in-
clude nonrigid fixation and casting immobilization.
• The majority of fracture healing takes place via secondary bone healing. This TYPES OF HEALING PEARLS
process begins with mature chondrocytes undergoing senescence and calcifica-
• Fractures heal via primary (intramembranous)
tion, leaving behind a scaffold of extracellular matrix. Blood vessels and osteo- and secondary (endochondral) types of healing.
blasts then invade this cartilage matrix, resulting in the deposition of immature The degree of fracture stability will influence
bone. which type of healing predominates.
• It is important to note that bone replaces cartilage in this process; cartilage is not • Both types of fracture healing require a similar
amount of time to restore mechanical integrity.
converted to bone.
• Rigid fixation strives for primary bone healing
that is more expedient in returning to function
STAGES OF SECONDARY BONE HEALING and induces less deformity at the fracture site.
The healing process begins at the time of the injury. Although secondary bone healing is
conceptualized here in stages, these processes overlap with each other in reality (Fig. 7.1).
Hematoma Stage
• A fracture causes local disruption of blood vessels, leading to the formation of a
hematoma.
18.e1
18.e2 CHAPTER 7 Principles of Bone Fixation and Healing
Inflammation stage
Soft callus stage
Hard callus stage

Remodeling stage
Biological activity (%)
1 week 3 weeks 6 weeks 3 months 3 years

Hematoma stage
FIGURE 7.1 Stages of secondary bone healing.
• The oxygen saturation inside a hematoma decreases significantly over the first 72
hours after a fracture. In response, hypoxia-inducible factor (HIF)-1 increases the
production of vascular endothelial growth factor (VEGF), resulting in angiogenesis
and revascularization of the affected area.
• In addition, local hypoxic conditions alter the gene expression of osteoprogenitor
cells, causing them to proliferate, secrete extracellular matrix, and differentiate into
chondrocytes.
• Several animal studies have shown that the removal of fracture hematoma during
early healing (2–4 days) leads to inferior healing, highlighting the critical role of the
hematoma in the healing process.
Inflammatory Stage
• The inflammatory stage is characterized by a strong cellular response to fracture
healing.
• Cellular debris inside the hematoma incites an inflammatory response mediated by
inflammatory cells including platelets, neutrophils, macrophages, and lymphocytes.
These cells release various cytokines to modulate the healing process. Some cyto-
kines elicit pain, encouraging the individual to immobilize the injured area.
• Among these cytokines, tumor necrosis factor (TNF)-alpha plays a vital role in coor-
dinating the inflammatory stage. A fracture-related hematoma contains a sevenfold
higher concentration of TNF-alpha compared with peripheral blood. Low levels of
TNF-alpha are associated with delayed fracture healing.
Soft Callus Stage

SOFT CALLUS STAGE PEARLS • This stage begins a few days to 6 weeks after the injury. The process is analogous
The local mechanical environment drives the to the formation of cartilage through endochondral ossification.
differentiation of progenitor cells into either • Fibroblasts and chondroblasts build connective tissue and cartilage, respectively.
osteoblastic (stable environment) or chondroblastic
The fibrocartilaginous callus fills the fracture gap, providing stability and supporting
(unstable environment) lineages of cells.
vascular ingrowth.
Hard Callus Stage

• The conversion of cartilage into woven bone defines the hard callus stage. This oc-
curs several weeks after a fracture and takes approximately 3 months.
• Woven bone is a disorganized matrix of collagen fibers that further strengthens the
callus and is visible on radiographs.
CHAPTER 7 Principles of Bone Fixation and Healing 18.e3
• For patients receiving nonoperative treatment such as casting or traction, the hard REMODELING STAGE PEARLS
callus stage is also accompanied by a clinically apparent reduction in pain and
Wolff’s law states that the growth and remodeling
increased stability at the fracture site. of bone is influenced by mechanical forces that are
applied to the bone. Placing moderate amounts of
Remodeling Stage mechanical stress on bone during the remodeling
• In this stage, woven bone is converted into lamellar bone through organized osteo- phase can trigger an adaptive response that
augments bone strength.
blast and osteoclast activity. This phase can continue for several years.
• The histology of fully healed bone is almost identical to the unbroken bone.
• During remodeling, bone responds to loading stress according to Wolff’s law.
FACTORS INFLUENCING FRACTURE HEALING

For a summary of factors influencing fracture healing, see Table 7.1.
Local Factors
• Viability of the fracture fragment depends on several factors:
• Fracture location and pattern. For example, metaphyseal fractures are associated
with faster healing.
• Presence of soft tissue attachments, which is associated with enriched blood
supply to the fracture site and better healing.
• Bone loss and comminution, which are associated with delayed healing.
Systemic Factors
• Smoking
• Smoking reduces local blood supply and inhibits the growth of new blood vessels
during the healing process. This increases the risk for nonunion and delayed union.
• Smoking almost doubles the risk for infection in patients receiving surgery.
• Smoking decreases fracture callus strength.
• Alcohol
• Alcohol inhibits osteoblast differentiation and has a dose-dependent adverse
effect on the functions of osteoblasts.
• Excessive intake is associated with osteomalacia and aseptic osteonecrosis of
the hip.
• Nutrition
• Vitamin D and calcium supplementation should be encouraged because vitamin D
deficiency is associated with nonunion.
TABLE
7.1 Factors Influencing Bone Healing
Local factors Systemic factors Medications
Location Age NSAIDs
Fracture pattern Traumatic brain injury Corticosteroids
Comminution or bone loss Diet and nutrition Bisphosphonates
Fracture gap Medical conditions (DM) Quinolones
Soft-tissue coverage Hormones Antineoplastics
Method of fixation HIV
Neurovascular injury Alcohol
Open fracture Smoking
Infection
Radiation
DM, Diabetes mellitus; NSAID, Nonsteroidal antiinflammatory drug.

• Protein malnutrition decreases callus strength. Amino acid supplementation can

facilitate callus mineralization.
• HIV
• HIV infection can lead to a relative TNF-alpha deficiency, which is associated with
poor fracture healing.
Medications
• Nonsteroidal antiinflammatory drugs (NSAIDs)
• Cyclooxygenase (COX)-2 activity is required for endochondral ossification during
the healing process.
• NSAIDs can prolong healing time by inhibiting COX-2.
• Corticosteroids
• Corticosteroids promote cell death of osteoblasts and osteocytes and inhibit
osteogenesis.
• They are associated with a higher nonunion rate.
• Quinolones
• Quinolones are associated with delayed fracture healing because of their harmful
effects on chondrocytes.
FIXATION METHODS AND MECHANICAL STABILITY

STABILITY AND FRACTURE HEALING Stability and Fracture Healing
PITFALLS
The degree of fracture stability influences the type of fracture healing (Table 7.2). Abso-
• Hypertrophic nonunion lute stability promotes primary bone healing, whereas relative stability facilitates sec-
• Related to excessive fracture instability in the
ondary bone healing with callus formation.
setting of adequate blood supply at the fracture
site.
• Atrophic nonunion Absolute Stability
• Caused by inadequate vascularity of fractured • Absolute stability is defined as rigid fixation with no motion between the fractured
fragments or poor healing environment owing fragments under physiologic loading.
to infection, open fracture, compromised
• Under these conditions, bone heals through primary healing without a callus.
nutrition, or smoking.
• Examples of absolute stability include a simple oblique fracture treated with an in-
terfragmentary screw and a simple transverse fracture treated with a dynamic com-
pression plate.
Relative Stability
• Relative stability is characterized by more elastic fixation, which permits micromo-
tion at fracture site under physical loading. Nevertheless, excessive motion must be
avoided because this increases the risk for hypertrophic nonunion.
• Fractures with relative stability will preferentially heal via secondary bone healing
with a callus.
• Examples of relative stability include nonoperative management such as a cast or
splint, external fixator, intramedullary nail, and bridge plate.
STRAIN THEORY
Strain is defined as the deformation of a material relative to its original form when a
force is applied. In the context of a fracture, strain is quantified as a change in
ΔL length of the fracture gap divided by the original length of the fracture gap (∆L/L)
L Strain =
L (Fig. 7.2).
ΔL
Strain and Fracture Healing
• A strain of less than 2% is associated with absolute stability and promotes primary
fracture healing.
• A strain of 2% to 10% is associated with relative stability and results in secondary
fracture healing with callus.
• A strain greater than 10% is associated with excessive instability at the fracture site
FIGURE 7.2 Conceptual diagram of fracture
and does not permit bone formation.
gap strain. L 5 Original length of fracture gap; • Multifragmentary fractures can tolerate more strain than simple fractures because
∆ L 5 change in length of fracture gap. the overall strain is distributed among many fracture gaps (Fig. 7.3A–B).
TABLE
7.2 Relationship Between Fixation Method and Fracture Stability
Suitable Fracture Type Fixation Methods
Absolute stability Simple fracture Rigid fixation
(Primary healing) Interfragmentary screw
Dynamic compression
plate
Tension band wire
Relative stability Comminuted fracture Nonrigid fixation
(Secondary healing) Casting
External fixation
Intramedullary nail
Bridging plate
Simple fracture
Strain = 30%
A 1.3 L
Comminuted fracture
L L L
Strain = 10%
B 1.1 L 1.1 L 1.1 L

FIGURE 7.3 (A–B) Relationship between strain and fracture type. Comminuted fractures have a
lower strain because the displacement can be distributed among multiple fracture gaps. L 5 Length
of fracture gap.
Applying the Theory

• A simple transverse or oblique fracture is best reduced anatomically and fixed by a
compression screw or plate. This produces absolute stability and avoids high strain.
• Optimal healing of multifragmentary fractures requires a callus to fill in all the fractures
gaps, a process that is facilitated by relative stability. Nevertheless, multifragmentary
fractures intrinsically have a low strain because of the distribution of mechanical
stress over many fracture gaps. Therefore options with indirect reduction and less
rigid fixation, such as a nail, bridge plate, or external fixator, are better choices be-
cause they provide slightly higher strain and promote relative stability.
FIXATORS FOR HAND AND WRIST SURGERY

Pins
PINS PEARLS
• Pins can be threaded or smooth and are available in several sizes. The threaded pin
minimizes sliding when engaging with the fragment and provides more stability than a At least two pins should be used. To prevent sliding
or rotation of the fragment, the pins should not be
smooth pin; however, this property also makes the threaded pin more challenging to
placed in parallel (Fig. 7.4A–C).
remove.
A B C
FIGURE 7.4 (A–C) Pinning fixation for a distal radius fracture.
• Pins are useful for temporarily maintaining the reduction of a fracture before implant
placement. They are also used in percutaneous pinning of small bone fractures,
commonly in hand and wrist fractures.
• Pins have less mechanical stability compared with plates and screws and therefore
do not provide significant contributions to weight bearing or strength.
Screws
• Screws are typically named according to their design, size, and choice of application.
• The design can be cortical, cancellous, cannulated, self-tapping, headless, or
compression.
• Cortical screws are fully threaded, with shallower threads than those in cancellous
screws. The distance between threads, known as the screw’s pitch, is shorter in
cortical screws compared with cancellous screws. The blunt-ended tip of the
cortical screw necessitates tapping before screwing. The cortical screw is used to
secure both cortices during interfragmentary fixation or to fix plates to long bones.
• Cancellous screws have a deeper thread and larger pitch than cortical
screws. They are commonly used for fixation of the metaphyseal region,
which contains a larger proportion of cancellous bone. Cancellous screws
can be fully threaded or partially threaded; the latter can function as a lag
screw to compress the fracture site (Fig. 7.5A–B).
• The cannulated screw contains a hollow shaft. This feature enables the
screw to insert over a guide pin or guide wire after a satisfactory position is
confirmed. Cannulated screws are commonly used to fix fractures that re-
quire great precision and do not permit frequent change in position, such as
femoral neck fractures and pediatric fractures.
• Self-tapping screws have shallow threads with a sharp cutting flute that
facilitates insertion. They can be inserted without tapping the screw track
because of their ability to self-cut. The majority of locking plate systems use
self-tapping screws.
• Headless compression screws have a larger pitch at the distal threads than
the proximal threads. This unequal pitch causes the screw to move forward
at different rates in the proximal and distal fragments, resulting in compres-
sion of the fracture site. Because these screws must be buried in the bone
to achieve maximal compression, they are suitable for fracture fixations
where the screw head will not be exposed outside the bone, such as with
femoral condyle fractures or scaphoid fractures (Fig. 7.6A–B).
Deep and
partially threaded
A B
FIGURE 7.5 (A–B) Deep and partially threaded cancellous screws for fixation of a medial malleolar fracture.
Unequal pitch
A B
FIGURE 7.7 Screw fixation for a fourth metacarpal
FIGURE 7.6 (A–B) Headless compression screws for fixation of a scaphoid fracture. spiral fracture.
• Dimension of outer thread diameter: The most common dimensions for screws SCREWS PITFALLS
are: 1.5, 2, 2.4, 2.7, 3.5, 4.5, and 6.5 mm. • The head of an isolated screw should be counter-
• Application includes cortex or cancellous bone, bicortical or monocortical, lag sunk in the near cortex. This increases the con-
compression, position screw, or locking screw. tact area between the screw head and the bone,
• Screws can be used on their own to hold two fragments together (Fig. 7.7) or used and reduces the risk of stress-related cracks.
• Drilling with a dull drill bit may cause thermal
in combination with plates.
necrosis, which is detrimental to fracture healing.
Lag Screws
• Lag screws generate interfragmentary compression and promote absolute stability
of fracture fixation.
Course
• First, drill a gliding hole with a drill bit slightly larger than the outer diameter of the
cortex screw (Fig. 7.8A–B). Next, a drill sleeve is inserted into the gliding hole to
A B
C D
FIGURE 7.8 Placing a lag screw. (A) An oblique fracture gap. (B) Drilling a gliding hole. (C) A drill
sleeve is inserted into the gliding hole. A smaller drill bit is used to accurately center the opposite
cortex. (D) A lag screw is used to pull the far cortex and compress the gap.
LAG SCREWS PEARLS

accurately center the threaded hole in the opposite cortex. The opposite cortex is
• It is essential to first drill a gliding hole in the drilled with a smaller drill bit corresponding to the inner diameter (core) of the screw
near cortex, then insert the drill guide into the (see Fig. 7.8C).
hole to align the far cortex accurately.
• If the surgeon drills through both cortices • The thread only engages with the cortex opposite to the fracture line (far cortex), not
simultaneously and proceeds to make a big with the cortex close to the screw head (near cortex).
gliding hole in the near cortex, this may result • When the screw head contacts the near cortex and can no longer move forward, the
in a misaligned screw direction. distal thread continues to engage the opposite cortex. This pulls the opposite cortex
toward the proximal direction when driving, creating compression between the two
fragments (see Fig. 7.8D).
LAG SCREWS PITFALLS
Position Screws
To generate optimal compression, a lag screw
• A position screw is a fully threaded screw that engages in both cortices. Therefore
should be positioned perpendicular to the fracture
plane. If the fixation direction is not perpendicular, when the screw is turned, the two fracture fragments are held at their current position.
interfragmentary compression can generate A defined gap between the fragments is maintained without generating compression.
additional sliding forces that may compromise • Position screws can be used instead of lag screws when difficulties occur with ex-
the anatomic reduction (Fig. 7.9). posure and drill direction.
• The surgeon must compress the fracture gap with clamps to achieve anatomic re-
duction before drilling.
POSITION SCREWS PEARLS
Unlike the lag screw, the position screw does not Course
need to be placed perpendicular to the fracture
• First, drill a hole through both the far and near cortex with the same axis. Use a drill
plane. Nevertheless, completing an anatomic
reduction before placing a position screw is bit that corresponds to the inner diameter of the screw.
recommended. • Tapping the screw may be advisable, but this depends on the bone quality.
• A position screw advances to thread both cortices and maintains reduction, with or
without a gap.
Conventional Plates
• The conventional plate has screw holes that are countersunk by screw heads. This
compresses the plate onto the bone and minimizes prominence. The preload and
friction between the two surfaces promote stability.
FIGURE 7.9 Incorrect positioning of a lag screw.
Functions of Various Plates
• A variety of plates are available to serve different functions and are designed to
provide absolute or relative stability.
• A neutralization or protection plate protects a simple fracture that was reduced

anatomically and fixed by lag screws. It is commonly used for smaller bones that
are not primary weight bearing, such as the clavicle (Fig. 7.10).
• A compression plate promotes axial compression through the eccentric place-
ment of screws and is suitable for transverse fractures that require compression,
such as radial (Fig. 7.11) or ulnar shaft fractures.
• A buttress plate supports the large articular fragment to prevent gliding, such as
the volar Barton or radial column fracture (Fig. 7.12) of the distal radius.
• A tension band plate or tension band wire reduces tensile forces and augments
compressive forces at fracture sites in eccentrically loaded bones. Tension band
wires are often applied to fractures associated with joint motion, such as the
olecranon (Fig. 7.13) or patellar fracture.
• A bridging plate is a long plate inserted through small incisions at each end of the
fracture site, obviating the need to expose the entire fracture site. Bridging plates
are recommended for extensive and comminuted fractures (Fig. 7.14), for which
other approaches may cause massive disruption of soft tissues.
FIGURE 7.10 Lag screw fixation of a clavicular fracture.The black arrow points to a lag screw.
FIGURE 7.11 Dynamic compression plate fixation of a transverse radial shaft fracture.
FIGURE 7.12 Buttress plate fixation of a radial column fracture.
A B
FIGURE 7.13 Tension band wire fixation of an olecranon fracture. The yellow arrows represent the force direction and location. (A) Without fixation,
joint motion will create tensile forces that exacerbate fracture gap displacement. (B) After tension band wire fixation, tensile forces at the eccentric
cortex are converted to compressive forces at the fracture site.
A B
FIGURE 7.14 Long bridging plate fixation of a comminuted fracture of the radius. (A) Before fixation. (B) After fixation with long bridging plate.
The yellow dotted lines represent the distal and proximal incisions.
Compression distance
FIGURE 7.15 A dynamic compression plate contains holes with sloped edges on the side
distal to the fracture site. In this image, the screw on the right was inserted away from the sloped
edge, locking the plate without moving it. Next, the screw on the left is inserted on the other side of
the fracture, with the screw head contacting the slope. When this screw is tightened, its movement
down the slope will create a compressive force.
Dynamic Compression Plate

• Dynamic compression plates (DCPs) contain oval-shaped screw holes with sloped
edges on the side that is distal to the fracture site (Fig. 7.15). When a spherical screw
head is placed eccentrically on the inclined aspect of the screw hole, tightening of
the screw causes the screw head to slide down the slope of the hole toward the
fracture site. This movement generates fracture compression.
• Once the compression is deemed adequate, the remaining screws can be placed in
a central fashion without contacting the sloped edge of the screw hole.
• A new advancement in DCP technology is the limited contact DCP, which is de-
signed to have less contact area on the bone. This reduces the harmful effects of
pressure and friction in poorly vascularized bone (Fig. 7.16A–B).
Locking Plates
• Locking plates are often applied through a minimally invasive approach that mini-
mizes soft tissue disruption. Locking plates facilitate secondary fracture healing with
callus formation.
B
FIGURE 7.16 (A) Dynamic compression plate. (B) Limited contact dynamic compression plate.
Biomechanics of Locking Plates

BIOMECHANICS OF LOCKING PLATES
PITFALLS • The locking screw head has a thread that engages with the reciprocal thread of the
• A conventional screw should be inserted first. plate hole (Fig. 7.17). The system creates angular stability between the implant and
This closes the gap between the plate and the the bone.
bone. Otherwise, the gap will persist and can • Unlike a conventional plate, tightening of the locking screw does not require the
lead to entrapment of tendons and soft tissue. plate to be directly contacting the bony surface. The stability of the fixation is there-
• Locking screws should always be inserted af-
fore not dependent on the preload and friction between bone and plate.
ter conventional screws. Once a locking screw
has been inserted, additional conventional • The load transfer occurs through the locking system, which is similar to an external
screws placed in the same segment would fixator but underneath the soft tissue.
create undesirable tension forces within the • Because the plate is not required to directly contact the bony surface, periosteal
plate and bone (Fig. 7.19A–B). blood flow in the underlying cortex is preserved. This feature appears to promote
healing and lowers the risk for infection.
• Locking plates are more resistant to mechanical disruption than a conventional plat-
ing system. To disrupt a locking plate, a bending or rotating force would have to be
strong enough to pull out the entire screw-plate construct together. By contrast, a
conventional plating system could be disrupted by a single loose screw that subse-
FIGURE 7.17 Conceptual diagram of a locking plate. quently loosens the other screws downstream. (Fig. 7.18A–B).
Common Indications for Locking Plates

COMMON INDICATIONS FOR LOCKING
PLATES PITFALLS Common indications for locking plates include:
• Reduction must be achieved before the place- • Planning indirect fracture reduction
ment of a locking plate. If not, the poorly reduced • Dealing with osteoporotic fracture
alignment and fracture gap will persist after plat- • Bridging severely comminuted fractures
ing. This may result in malunion or nonunion. • Dealing with periprosthetic fractures that need to be managed with monocortical
• The intramedullary fixator is more appropriate
than a locking plate for diaphyseal fractures of screws (Fig. 7.20)
weight-bearing bones, such as femoral shaft
fractures.
A B
FIGURE 7.18 (A) The angular stability in a locking plate prevents load concentration at a single screw-bone interface, resulting in a much greater force
needed to pull out the whole construct. Blue arrows indicate direction of applied force. Black arrows indicate tensile forces. (B) In conventional plates,
the load solely concentrates at the nearest screw, and continues to the next one if failure occurs.
A B
FIGURE 7.19 (A) Locking plate secured by locking screws. (B) Inserting conventional screws after locking
screws will press the plate onto the bone, causing plate deformities. Additionally, this could loosen the
locking screws and lead to further trauma in fracture fragments. Black arrows represent tensile forces.
FIGURE 7.20 For periprosthetic fractures, an intramedullary prosthesis prevents screws from getting
through both cortices. Monocortical screws in a locking plate can contribute angular stability.
EVIDENCE
Arens S, Eijer H, Schlegel U, Printzen G, Perren SM, Hansis M. Influence of the design for fixation im-
plants on local infection: Experimental study of dynamic compression plates versus point contact
fixators in rabbits. J Orthop Trauma. 1999;13(7):470–476.
The authors conducted a randomized, prospective study in experimental rabbits to compare infection
resistance after local bacterial challenge in two different designs for fixation implants: the conven-
tional dynamic compression plate (DCP) and the point contact fixator (PC-Fix). Under sterile condi-
tions, specially manufactured titanium DCP or PC-Fix of identical dimensions were fixed to rabbit tib-
iae. After wound closure, different concentrations of Staphylococcus aureus, between 2  10(4) and
2  10(8) colony-forming units (CFU), were inoculated percutaneously at the implant site. The im-
plants, underlying bone, and surrounding soft tissues were removed under sterile conditions and
quantitatively evaluated for bacterial growth. Infection was defined as positive bacterial growth at
the bone-implant interface. They found a higher infection resistance associated with the PC-Fix
design, which seems to be related to the reduced contact area at the bone-implant interface
(Level V evidence).
Le AX, Miclau T, Hu D, Helms JA. Molecular aspects of healing in stabilized and non-stabilized frac-
tures. J Orthop Res. 2001;19(1):78–84.
In this study, the authors tested the hypothesis that alterations in the mechanical environment regulate
mesenchymal cell differentiation and thus the formation of a cartilage or bony callus at the site of in-
jury. They produced stabilized and nonstabilized tibial fractures in a mouse model, then used molecu-
lar and cellular methods to examine the stage of healing. Using the “molecular map” of the fracture
callus, they divided the analysis into three phases of fracture healing: the inflammatory or initial phase
of healing, the soft callus or intermediate stage, and the hard callus stage. Their results show that
stabilizing the fracture, which circumvents or decreases the cartilaginous phase of bone repair, corre-
lates with a decrease in IHH signaling in the fracture callus. These data support the hypothesis that
mechanical influences affect mesenchymal cell differentiation to bone (Level V evidence).
Claes LE, Augat P, Suger G, Wilke HJ. Influence of size and stability of the osteotomy gap on the
success of fracture healing. J Orthop Res. 1997;15(4):577–584.
The authors investigated the influence of the size of the fracture gap, interfragmentary movement, and
interfragmentary strain on the quality of fracture healing. A simple diaphyseal long-bone fracture was
modeled by means of a transverse osteotomy of the right metatarsus in sheep. In 42 sheep, the
metatarsus was stabilized with a custom-made external ring fixator that was adjustable for gap size
and axial interfragmentary movement. The sheep were randomly divided into six groups with different
gap sizes (1, 2, or 6 mm) and strain (approximately 7% or 31%). After 9 weeks of healing, the ex-
planted metatarsus was evaluated to determine bending stiffness and was radiographed to measure
the callus formation. Increased size of the gap (from 1 to 6 mm) resulted in a significant reduction in
the bending stiffness of the healed bones. Larger interfragmentary movements and strains (31%
compared with 7%) stimulated larger callus formation for small gaps (1–2 mm) but not for larger gaps
(approximately 6 mm) (Level V evidence).
CHAPTER 8
Kirschner Wire Fixation of Mallet Fractures
KEY CONCEPTS
• A mallet finger is caused by disruption of the terminal extensor tendon distal to the
distal interphalangeal (DIP) joint and is categorized as either bony (mallet fracture) or
nonbony (tendinous).
• Although the majority of mallet fractures can be treated nonoperatively, there are
several indications for managing these fractures with an extension block pinning
technique:
• Large displaced bone fragment
• Loss of congruity of the DIP joint, articular gap greater than 2 mm
• Palmar subluxation of the distal phalanx
• If mallet fractures are left untreated, the extension force generated through the exten-
sor mechanism is delivered entirely to the proximal interphalangeal (PIP) joint. Over
time, this can lead to hyperextension of the PIP joint and a swan-neck deformity.
• Seymour fractures are displaced physeal fractures of the distal phalanx with an as-
sociated nail bed injury. They are considered to be an open fracture because a nail
bed laceration is present. Therefore early administration of antibiotics, irrigation/
debridement, nail bed repair, and fracture reduction are indicated to decrease the
risk for infectious complications.
• Nail bed disruption can lead to soft-tissue interposition, such as the torn portion of
the nail bed in the fracture site. Interposed soft tissue should be removed because
this can complicate fracture reduction and healing.
• Failure to recognize and correct the nailbed laceration may result in nail plate defor-
mity, physeal arrest, and chronic osteomyelitis. Removing the nail plate and carefully
examining the nail bed is an essential step for managing this injury.
• Extension block technique for mallet fracture
• Kirschner wire fixation of Seymour fracture and nail bed repair
A B
FIGURE 8.12 (AB) Insertion of extension block pin for mallet fracture.
19
CHAPTER 8
Kirschner Wire Fixation of Mallet Fractures
Seymour Fractures and Nail Bed Repair

INDICATIONS
• Seymour fracture is defined as a displaced physeal fracture of the distal phalanx
with an associated nail bed injury. This pediatric fracture pattern is typically caused
by a crush injury and can be classified as a Salter-Harris I or II fracture.
• The Seymour fracture is considered to be an open fracture because a nail bed lacera-
tion is present. Therefore early administration of antibiotics, irrigation/debridement,
nail bed repair, and fracture reduction are indicated to decrease the risk for infectious
complications.
Contraindications
• Because soft tissue such as the germinal matrix may be trapped within the physeal
fracture site, closed reduction is contraindicated because this approach impairs
recognition and removal of interposed tissue.
• A Seymour fracture should be suspected for distal phalangeal fractures with the fol-
lowing clinical presentations: (1) subungual hematoma or blood oozing from under-
neath the nail plate, (2) laceration over or proximal to the eponychial fold (Fig. 8.1), FIGURE 8.1 Laceration over the eponychial fold
(3) a nail plate that is superficial to the eponychium, and (4) nail plate avulsion. reflects the possibility of associated nail bed injury.
• The flexor digitorum profundus tendon inserts into the metaphysis (distal to the
Seymour fracture), which is distal to the extensor tendon’s insertion on the epiphysis
of the distal phalanx (proximal to the Seymour fracture). This creates an imbalance IMAGING PEARLS
between the flexor and the extensor tendons at the level of the fracture, resulting in • The lateral view is more reliable in identifying
a flexed distal phalanx (Fig. 8.2). the displacement between the epiphysis and
• Although Seymour fracture may appear similar to a pediatric mallet finger, the injury metaphysis and is necessary to confirm the
diagnosis of Seymour fracture (Fig. 8.3).
patterns are distinct. Pediatric mallet finger is an avulsion fracture that enters the • Seymour fracture lines are present along the
distal interphalangeal (DIP) joint, whereas the insertion of the extensor tendon re- physis or travel away from the joint surface.
mains intact in a Seymour fracture and the fracture line does not enter the DIP joint.
IMAGING
Finger radiographs, including posteroanterior (PA) and lateral view, are recommended.
SURGICAL ANATOMY
The flexor digitorum profundus tendon inserts into the metaphysis, which is relatively
distal to the extensor tendon’s insertion on the epiphysis of the distal phalanx.
PROCEDURE
FIGURE 8.2 The imbalance between the flexor
Step 1: Remove the Nail Plate and the extensor tendons at the fracture level
After digital anesthesia, the patient’s hand should be draped and prepped in the usual results in a flexed posture of the distal phalanx.
sterile fashion. Next, gently remove the nail plate and expose the nail bed (Fig. 8.4).
Step 2: Expose the Nail Bed Laceration and Fracture Site

• Thoroughly inspect the entire nail bed for lacerations. The distal phalanx fracture site
may be visible through the disrupted nail bed.
• Debridement and saline irrigation can elevate the impacted soft tissue (Fig. 8.5).
19.e1
19.e2 CHAPTER 8 Kirschner Wire Fixation of Mallet Fractures
A B
FIGURE 8.4 The nail plate was then removed gently, and the nail
FIGURE 8.3 (AB) Displaced distal phalangeal physeal fractures are easier to recognize bed was exposed for a thorough inspection. The white arrow
on lateral views compared with posteroanterior (PA) views. shows a laceration of the nail bed.
Step 3: Fracture Fixation and Nail Bed Repair

• Reduce the fracture under direct visualization.
• Percutaneous insertion of an intramedullary 0.045-inch (1.1-mm) Kirschner wire
(K-wire) can fixate the fracture through the DIP joint (Fig. 8.7).
• Repair nail bed lacerations using interrupted absorbable sutures (5-0/6-0 chromic
catgut; Fig. 8.8).
• The removed nail plate (after aggressive cleaning) can be reinserted under the eponych-
ium to cover the restored nail bed and stabilize the reduction, similar to a splint (Fig. 8.9).

FIGURE 8.5 The fracture site can be seen • Place the patient in a volar finger splint to stabilize the distal phalanx.
through the disrupted nail bed. Saline irrigation • The patient should immediately initiate proximal interphalangeal (PIP) and metacar-
and debridement are performed next. pophalangeal (MCP) range of motion exercises. Remove the pins after 4 weeks. The
nail will fall off by itself.
STEP 2 PEARLS
Extension Block Technique
• The eponychium can be incised and retracted
proximally to permit clear visualization of the base INDICATIONS
of the nail bed (germinal matrix; see Fig. 8.4). • A mallet finger is caused by disruption of the terminal extensor tendon distal to the
• During exposure, take care to prevent iatro-
distal interphalangeal (DIP) joint and is categorized as either bony (mallet fracture) or
genic injury to the insertion of the terminal ex-
tensor tendon at the distal phalanx epiphysis. nonbony (tendinous).
• The majority of mallet fractures are treated nonoperatively, with good success.
• Indications for this technique are limited to specific situations in which reduction of
STEP 2 PITFALLS the fracture is essential to avoid posttraumatic arthritis or instability:
• Nail bed disruption can lead to soft-tissue inter- • A large displaced bone fragment (one-third or more of the articular surface of the
position, such as the torn portion of the nail distal phalanx)
bed in the fracture site (Fig. 8.6). Interposed • Loss of congruity of the DIP joint and an articular gap greater than 2 mm
soft tissue should be removed because this can • Palmar subluxation of the distal phalanx
complicate fracture reduction and healing. • If mallet fractures are left untreated, the extension force generated through the ex-
• Failure to recognize and correct the nail bed lac-
eration may result in nail plate deformity, physeal tensor mechanism is delivered entirely to the PIP joint, rather than distributed along
arrest, and chronic osteomyelitis. Removing the the entire finger. Over time, this can lead to hyperextension of the PIP joint and a
nail plate and carefully examining the nail bed is swan-neck deformity.
an essential step for managing this injury.
Contraindications
• A comminuted or small avulsed fragment cannot be directly compressed with dorsal
STEP 3 PEARLS
blocking pins.
To avoid dislodging the nail plate during dressing • Fractures that are older than 5 weeks are a relative contraindication because the
changes, a 4-0 chromic suture can be used to
presence of scar tissue impairs closed reduction.
stabilize the nail plate to its nail fold.
• Inexperience with performing this technique can lead to iatrogenic nail bed injury.
CHAPTER 8 Kirschner Wire Fixation of Mallet Fractures 19.e3
FIGURE 8.6 Nail bed disruption can lead to soft-tissue interposition, such as the torn portion of nail
bed in the fracture site, complicating fracture reduction and healing.
FIGURE 8.7 An intramedullary Kirschner wire was percutaneously inserted to fixate the fracture
through the distal interphalangeal (DIP) joint.
FIGURE 8.9 The removed nail plate was reinserted under the
eponychium to cover the nailbed. A chromic suture was used to
FIGURE 8.8 The nail bed laceration was repaired. stabilize the nail plate to its nail fold.
A B
FIGURE 8.10 Flexed distal interphalangeal (DIP) FIGURE 8.11 (A) Lateral and (B) posteroanterior
joint on physical examination, with inability to radiographs of mallet fracture in the fourth digit.
actively extend the joint. (Courtesy Dr. Steven Haase, Michigan Medicine.)
STEP 1 PEARLS
• Make sure the extension block wire is firmly
anchored in cortical bone, so that it will not The patient will have a flexed DIP joint that is swollen and tender on examination. The
migrate inward or loosen. patient will also be unable to actively extend the DIP joint (Fig. 8.10).
• If the fracture is subacute (partially healed), the
fragments can be gently mobilized by manipu- IMAGING
lation with an additional percutaneous wire,
being careful not to lacerate the extensor • PA and lateral radiographs are necessary to evaluate the size of the avulsed frag-
mechanism (Fig. 8.13). This will make reduc- ment, joint congruity, and alignment (Fig. 8.11A–B).
tion easier in Step 2. • Tendinous mallet finger will demonstrate normal bony anatomy on radiograph.
STEP 1 PITFALLS
SURGICAL ANATOMY
• Mallet fractures are an avulsion fracture at the dorsal base of the distal phalanx.
If the extension block wire enters from a too
volar position on the middle phalanx head, it will • With larger dorsal avulsion fragments, the distal attachment sites of the collateral liga-
block extension of the DIP joint, which makes the ments may become involved. This can lead to palmar subluxation of the distal phalanx.
correction of subluxation difficult.
PROCEDURE
STEP 2 PEARLS Step 1: Insertion of Extension Block Pin
Be careful not to lacerate the extensor mechanism • Hold the DIP joint in flexion to pull the avulsed fragment as distally as possible.
or cause comminution of the fragment. • Guided by fluoroscopic imaging, a 0.045-inch (1.1-mm) K-wire is inserted percutane-
ously through the terminal extensor tendon just proximal to the avulsed fragment,
STEP 2 PITFALLS holding it in place (Fig. 8.12A–B). In children (or smaller adults), a 0.035-inch (0.9-mm)
K-wire may be more appropriate.
• When the DIP joint is extended, the dorsal fin-
ger skin may become pinched beneath the ex-
tension block pin. A relaxing incision distal to Step 2: Reduction
the wire will release the pressure on the skin • While applying longitudinal traction, the distal phalanx is translated in a volar-
and avoid ulceration. to-dorsal direction by compression at the base of the bone.
• For subacute fractures, it may be difficult to
• To complete the reduction, the DIP joint is then extended to a neutral position
achieve complete reduction because of scar
tissue (fibrous nonunion) interposed between (Fig. 8.14A–B).
the fracture surfaces.
Step 3: Insertion of the DIP Joint Transfixation Pin
• Another 0.045-inch (1.1-mm) K-wire is placed intramedullary from distal to proximal
across the DIP joint while maintaining reduction (Fig. 8.15A–B).
• If excellent reduction and joint congruency are achieved, it is not necessary to have
the DIP in full extension.
CHAPTER 8 Kirschner Wire Fixation of Mallet Fractures 19.e5
A B
FIGURE 8.13 Insertion of additional percutane-
FIGURE 8.12 (A–B) Insertion of extension block pin.
ous wire can facilitate mobilization of the fracture
fragment.
A B
FIGURE 8.14 (A–B) Reduction of the mallet fracture. The thin arrow represents longitudinal traction; the thick arrow
represents volar-to-dorsal force on the distal phalanx to reduce the fracture.
A B
FIGURE 8.15 (A–B) Insertion of the distal interphalangeal (DIP) transfixation pin.
• After confirming satisfactory reduction using fluoroscopy, the wires are cut and
capped (Fig. 8.16). A protective finger-based splint is applied.

• The pins are removed 4 to 6 weeks postoperatively, once the fracture is healed.
Trabecular bridging on x-ray and a nontender fracture site are good indicators of
fracture healing.
• After pin removal, extension exercises can begin immediately. The finger is still pro-
tected with a removable volar DIP joint splint for another 2 to 3 weeks.
• Progressive flexion exercises are introduced in the weeks after pin removal, advanc-
ing slowly to full active flexion.
• Residual deformity and dorsal prominence occur in up to 80% of cases. Further-
more, a lack of terminal extension may persist.
EVIDENCE
Asano K, Inoue G, Shin M. Treatment of chronic mallet fractures using extension-block Kirschner wire.
Hand Surg. 2014;19:399–403.
This retrospective study reviewed the outcomes of 11 patients who presented with chronic (older than
4 weeks) mallet fractures. The average duration from injury to surgical treatment was 56 days. All
were treated with extension block pinning using the Ishiguro technique; all patients went on to bony
FIGURE 8.16 Kirschner wires are cut and union. Patients were followed for a mean of 8 months. By Crawford criteria, outcome was excellent
capped after reduction is confirmed. or good in 8 patients (73%). The authors conclude this technique may benefit younger patients with
chronic mallet fractures.
Reyes BA, Ho CA. The high risk of infection with delayed treatment of open Seymour fractures: Salter-
STEP 3 PEARLS Harris I/II or juxta-epiphyseal fractures of the distal phalanx with associated nailbed laceration.
Make sure that the longitudinal wire does not J Pediatr Orthop. 2017;37(4):247–253.
cross the PIP joint, so that the PIP can be mobilized The authors divided all the patients into groups based on the timing and completeness of treatment.
quickly after surgery, avoiding development of Appropriate treatment was defined as irrigation and debridement, fracture reduction, and antibiotic
significant stiffness. administration. Acute treatment was defined as management within 24 hours of the injury. A total of
35 Seymour fractures met the inclusion criteria. In total, 31% (11 of 35) received acute, appropriate
treatment; 37% (13 of 35) received acute, partial treatment; and 31% (11 of 35) received delayed
STEP 3 PITFALLS treatment. No infections occurred in the acutely, appropriately treated group (infection rate 0%, 0 of
11); two infections occurred in the acutely, partially treated group (15%, 2 of 13); and five infections
Carefully monitor the advancement of the occurred in the delayed treatment group (45%, 5 of 11).
longitudinal wire at the fracture site. Take care that Han HH, Cho HJ, Kim SY, Oh DK. Extension block and direct pinning methods for mallet fracture:
this wire does not disrupt an otherwise excellent A comparative study. Arch Plast Surg. 2018;45(4):351–356.
reduction as it passes across the DIP joint. The authors treated patients with the extension block method (EBM) and the direct pinning method
(DPM) and then compared the results. Twenty-one patients were treated with the EBM and 20 pa-
tients were treated with the DPM. The result showed the DPM proved to be superior to the EBM in
that it produced more significant improvements in extensor lag and range of motion.
Lin JS, Popp JE, Samora JB. Treatment of acute Seymour fractures. J Pediatr Orthop. 2019;39(1):e23–e27.
The authors retrospectively investigated the treatments, outcomes, operative indications, and antibiotic
choice for acute Seymour fractures to better define optimal management. Among the 65 Seymour
fractures, 58 cases (89%) were initially managed in the emergency department. They concluded that
most injuries would achieve good outcomes with management in the emergency department alone.
CHAPTER 9
Techniques for Fixing Extraarticular Phalangeal
Fractures

This chapter includes the following videos: Video 9.1 – Closed Reduction With Kirschner
Wire Fixation of Extraarticular Phalangeal Fractures; Video 9.2 – Open Reduction and Inter-
nal Fixation of Extraarticular Phalangeal Fractures.
KEY CONCEPTS
• Extraarticular phalangeal fractures with angulation more than 10 degrees, shortening
greater than 2 mm, or significantly comminuted fractures are best treated with re-
duction and fixation.
• Percutaneous pinning enables quick fixation of simple fractures and avoids the need
for the dissection and periosteal stripping required for internal fixation.
• Rigid internal fixation is becoming increasingly common, given the possibility of
early active range of motion postoperatively. Plates and screws are used when the
phalangeal bones are so comminuted that percutaneous Kirschner wires (K-wires)
will not be able to achieve adequate reduction. Because the extensor tendons are
bound intimately around the phalanges, however, the exposure of the bone and
hardware placement will cause tendon adhesions that limit digit motion. Tenolysis
and/or proximal interphalangeal joint capsulotomy are required in a substantial num-
ber of patients who receive dorsal plating.
• Providing stable fixation of extraarticular phalanx fractures with either percutaneous
pinning or internal fixation should lead to a union rate of 90% or greater.
• Closed reduction with K-wire fixation of extraarticular phalangeal fractures.
• Open reduction and internal fixation of extraarticular phalangeal fractures.
FIGURE 9.7 Exposure of extraarticular fracture of the proximal phalanx.
20
CHAPTER 9
Treatment of Extraarticular Phalangeal Fractures
INDICATIONS Rotation of
• Reduction and fixation should be performed for all fractures that cannot be reduced injured finger
with closed methods or for those that remain unstable with loss of reduction after
successful closed reduction.
• Fractures with angulation more than 10 degrees or shortening greater than 2 mm and
significantly comminuted fractures are best treated with reduction and fixation. Frac-
tures with any rotational deformity or fingers that cross over each other with attempted
finger flexion must be reduced and fixed to preserve normal hand function.
• Rigid internal fixation is becoming an increasingly common option for fractures as
opposed to percutaneous pinning, given the possibility of early active range of mo-
tion postoperatively. Nevertheless, because the extensor tendons are bound inti-
mately around the phalanges, the exposure of the bone and hardware placement will
cause tendon adhesions that limit digit motion. Plates and screws are used when the
phalangeal bones are so comminuted that percutaneous Kirschner wires (K-wires)
will not be able to achieve adequate reduction.
• Percutaneous pinning enables quick fixation of simple fractures and avoids the need
FIGURE 9.1 Note the rotational difference of the
for the dissection and periosteal stripping required for internal fixation.
injured small finger compared with the remaining
• In complex traumatic injuries where multiple digits require fixation, such as multidigit fingers.
amputation, pinning can provide quick stabilization, permitting time-sensitive micro-
surgery to proceed efficiently.
Contraindications
• Avoid rigid internal fixation in patients with soft-tissue defects that cannot be covered
at the time of surgery because hardware infection is likely. Percutaneous fixation
would be preferred in this scenario because pins can be removed readily if needed.
• Note any rotational or angular deformity of the finger. This can be a subtle finding
and will be more easily noticed when evaluating the fingertip posture by comparing
the alignment of the fingernails (Fig. 9.1).
• Depending on the location of the fracture, a complex balance between flexion and
extension forces throughout the digit will determine the deforming force.
• Fractures of the proximal phalanx will often have an apex volar displacement pattern
because the interossei muscles pull the proximal fragment into flexion and the
central slip pulls the distal fragment into extension.
• Fractures of the middle phalanx will displace in an apex volar direction when the
fracture is distal to the flexor digitorum superficialis (FDS) insertion or in an apex
dorsal direction when the fracture is proximal to the FDS insertion (Fig. 9.2A–B).
• Open fractures will require thorough debridement and careful assessment of the soft
tissue injury, with repair of structures as indicated.
IMAGING
• Standard radiographs are taken in three views (posteroanterior, oblique, and lateral;
Figs. 9.3 and 9.4).
• Computed tomography is usually not helpful or required for extraarticular phalanx
fractures.
SURGICAL ANATOMY
• The extensor mechanism incorporates both longitudinal and transverse compo-
nents, covering most of the dorsal and lateral sides of the digit.
20.e1
20.e2 CHAPTER 9 Treatment of Extraarticular Phalangeal Fractures
MCP joint PIP joint

EDC
(EIP, EDM)
Intrinsic DIP joint
muscle
FDS
A
MCP joint PIP joint

EDC
(EIP, EDM)
Intrinsic DIP joint

muscle
FDS
B
FIGURE 9.2 Key anatomic landmarks and tendon insertion sites. DIP, Distal interphalangeal; EDC,
extensor digitorum communis; EDM, extensor digitorum minimi; EIP, extensor indicus proprius;
FDS, flexor digitorum superficialis; MCP, metacarpophalangeal; PIP, proximal interphalangeal.
FIGURE 9.3 Preoperative x-rays.

CHAPTER 9 Treatment of Extraarticular Phalangeal Fractures 20.e3
Terminal tendon
Terminal tendon Middle phalanx
Triangular ligament
Conjoined lateral
band
Conjoined lateral
band
Proximal phalanx
Central slip Central slip
Lateral slip
Lateral band
A B
FIGURE 9.5 Surgical anatomy. FIGURE 9.6 Incision design.
EXPOSURES PEARLS
• Divisions of thin, transverse fibers of the exten-
• The central slip inserts at the dorsal base of the middle phalanx and serves to extend sor mechanism, such as the interval between
lateral band and central slip, or the transverse
the proximal interphalangeal (PIP) joint.
retinacular ligament, do not require repair.
• The lateral bands are formed at the sides of the finger, with extensions projecting off • A small portion of the sagittal band may also be
the common extensor tendon proximal to the central slip and additional contribu- divided for exposure, but major disruptions should
tions from the interosseous muscles and lumbricals (radial side only). They recon- be repaired to prevent displacement of the exten-
verge distally to form the terminal tendon, which inserts at the dorsal epiphysis of sor tendon with metacarpophalangeal flexion.
• Extensive longitudinal splits in the extensor
the distal phalanx (Fig. 9.5).
tendon should be repaired at closure.
EXPOSURES
• When placing internal fixation, dorsal, dorsolateral, or midaxial incisions may be EXPOSURES PITFALLS
used for proximal and middle phalangeal fractures. • At the base of the middle phalanx, be mindful
• The interval between lateral band and central slip may be incised; this does not of protecting the central slip insertion to the
require repair at closure (Fig. 9.6). periosteum during tendon splitting.
• The extensor tendon may be split longitudinally at the midline (middorsal) over • Likewise, take care to protect the very thin, flat
terminal tendon as it inserts onto the dorsal
the proximal phalanx; long splits should be repaired at time of closure. base of the distal phalanx.
• With a lateral approach, the transverse retinacular ligament is divided to provide
access; this does not require repair at closure.
• Over the middle phalanx, the triangular ligament can be incised longitudinally to
provide access between the two lateral bands.
• Deep to the extensor mechanism, the periosteum is incised and stripped minimally
to expose the fracture site (Fig. 9.7).
CLOSED REDUCTION WITH KIRSCHNER WIRE FIXATION OF

DISTAL PHALANGES
Step 1
Reduction is performed with gentle manipulation. If the fracture is open, debridement
and irrigation of the fracture site is required, along with nail bed repair. FIGURE 9.7 Fracture site exposed.
FIGURE 9.8 Kirschner wires inserted.

The tuft of the distal phalanx is immediately • Retrograde insertion of the K-wire is the most common method applied.
beneath the nail matrix, and the tip of the distal • The wire is inserted in the tuft of the bone distally and advanced across the fracture
phalanx is thin and narrow. A common error is to site while the fracture is held in reduction manually.
place the K-wire too volarly on the hyponychia, • In most cases, the wire should be advanced until it abuts the cortical bone at the
missing the distal phalanx entirely. The entry point
base of the distal phalanx. For added stability, the wire can be advanced across the
should be just volar to the nail bed and hyponychia.
distal interphalangeal (DIP) joint with minimal additional morbidity (Fig. 9.8).
• To prevent rotational displacement of the fracture around a single wire, a second
STEP 2 PITFALLS wire can be placed across the fracture, ideally at a slightly divergent angle relative to
When placing a second K-wire across the fracture the first wire.
site, be sure not to accidentally distract the fracture
and disturb the reduction. Step 3
• The distal end of the K-wire can be cut and buried beneath the skin, or it can be left
protruding for easier removal later.
• Wires left buried present less risk for infection during the postoperative period but
typically require a small incision under local anesthesia to remove the wire later.
CLOSED REDUCTION WITH KIRSCHNER WIRE FIXATION OF

MIDDLE AND PROXIMAL PHALANGES
STEP 1 PEARLS
The reduction often cannot be accomplished in
Step 1
a single effort. A second reduction clamp can be • Reduction is obtained by manipulation of the digit, incorporating traction or other
used to maintain a provisional reduction and the maneuvers as indicated. Complex fractures may require a combination of these
fracture can be further manipulated to perfect the techniques.
reduction. • Simple transverse fractures with apex-volar angulation are typically reduced by first
applying traction with gentle manipulation to reduce any displacement and align the
STEP 1 PITFALLS dorsal cortex. Then, the finger can be passively brought into flexion, reducing the
Residual apex-volar deformity in proximal angular displacement of the fracture.
phalangeal fractures is easily overlooked because • Long oblique or spiral fractures may require traction to eliminate shortening plus the
the other digits may obscure the fracture in the use of a reduction clamp for rotational control.
lateral view. Confirm reduction of the fracture in
multiple directions using intraoperative fluoroscopy. Step 2
• K-wires of 0.045 in (1.1 mm) diameter are used in most adult phalangeal fractures.
• K-wires of 0.035 in (0.9 mm) or smaller diameter may be used in pediatric cases or
in fractures with smaller, more delicate bone fragments.
• Ideal entry points and trajectory for K-wires are identified under fluoroscopic control.
A B
STEP 2 PEARLS
• K-wires can be started on the near cortex per-
pendicular to the bone, with care taken not to
C D completely penetrate the first cortex. Once a
small divot is made in the cortical bone, the
FIGURE 9.9 Kirschner wires diverge proximal to fracture site. wire position can be changed to the more
acute angle often required for phalangeal fixa-
tion. The wire is driven in place at high speed
to core the proximal bone without bending the
wire to establish a new pin trajectory. This
• Insert K-wires antegrade (starting proximal and aiming distal) or retrograde (starting technique prevents the K-wire from “skiving
distal and aiming proximal) while holding the fracture reduced. off” the bone and injuring adjacent structures.
• The far tip of the K-wire should always be
• For stable fixation, a minimum of two K-wires is recommended. For maximum stabil- docked into cortical bone to prevent pin migra-
ity, K-wires should ideally be placed so that they cross and then diverge from each tion overtime.
other proximal to the fracture. Avoid placing K-wires in parallel because this creates
a biomechanically weak fixation (Fig. 9.9A–B).
• For middle phalanx fractures, retrograde transarticular pinning across the DIP joint STEP 2 PITFALLS
should be considered. Pinning the DIP joint for a short period of time results in • Whenever possible, the PIP and MCP joints
minimal morbidity. Pins can enter from the tuft of the distal phalanx or from the side should be left free to participate in gentle early
of the fingertip, depending on fracture characteristics (Fig. 9.10A–B). motion, even with the K-wires in place.
Although transarticular pinning of the DIP for
• For proximal phalanx fractures, two longitudinal or crossed K-wires are used to re- short periods of time is relatively safe, pinning
sist bending or rotation of the fracture during healing. These can often be placed other joints may lead to joint contractures with
with an extraarticular antegrade approach, entering from the radial and ulnar as- significant morbidity.
pects of the proximal phalanx base, avoiding pins across the metacarpophalangeal • Avoid making multiple passes back and forth
(MCP) joint. Alternatively, these may be placed in a retrograde, extraarticular fashion with any given K-wire, because this will make
the bone channel larger around the wire and
(Fig. 9.11A–B). decrease that wire’s effectiveness.
• When multiple fracture fragments exist, a stepwise approach should be taken. Sys- • Similarly, avoid repeated transarticular drilling
tematically, each fragment should be reduced back to the unfractured diaphysis or into adjacent phalanges, because this can
metaphysis and held in place with orthogonal K-wire fixation (Fig. 9.12A–B). create a large defect in the articular surface.
• The larger fragment or the easier-to-reduce fragment is stabilized first to establish a Heat-induced necrosis of the bone is avoided by
drilling the bone at low speed, with precision.
foundation for other fragments to fit in place.
A B
FIGURE 9.10 Pins enter from tuft of distal phalanx.
A B
FIGURE 9.11 Retrograde, extraarticular Kirschner wire placement.

A B
C D
FIGURE 9.12 Orthogonal Kirschner wire fixation.

After checking the alignment of the finger with visual inspection and checking reduction Do not cut or bend K-wires so that they lay
of the fracture with fluoroscopy, K-wires are trimmed and/or bent, and protective pin immediately adjacent to the skin. Postoperative
caps are applied. swelling will result, and pins can quickly erode into
adjacent soft tissues if cut too short.
OPEN REDUCTION AND INTERNAL FIXATION

Step 1: Reduction
• The fracture site should be cleaned of clot, debris, and any foreign material to permit
STEP 1 PEARLS
anatomic reduction of fracture fragments.
• Open fractures should be debrided with meticulous care to prevent deep infection. • Preserving periosteal attachments can help
maintain better blood supply to bone fragments.
Small cortical bone fragments that have been devitalized of any soft tissue can be • Temporary K-wires should be placed outside
removed if necessary. The bone is cleaned and used as bone graft to fill in the defect the primary surgical field to prevent interfer-
or to replace the original void. ence with plate and screw placement.
• Reduction is accomplished by gentle distraction and/or direct fracture manipulation. • In petite fingers that can be difficult to grasp,
• Reduction can be maintained by use of various reduction clamps and/or temporary longitudinal traction can be applied with the
use of a bone tenaculum through the skin,
K-wires. grasping the affected phalanx.
Step 2: Fixation
• Phalangeal fixation is typically performed with 1.5- to 2.0-mm diameter screw sets.
Smaller screws (1.0- to 1.3-mm diameter) may be indicated for smaller hands, small
fracture fragments, or for lag screws, where larger screws might be too big.
• A screw can be placed in the track of the reduction K-wire when the K-wire is re-
moved. Determine the size of the K-wire that will permit the replacement of a screw
without additional drilling.
Lag Screws
• Lag screws provide interfragmentary compression and are ideal for long oblique or
spiral fractures.
• The near cortex is drilled with a drill bit that has the same diameter as the external
diameter of the screw, creating a gliding hole (e.g., for a 1.3-mm screw, use a 1.3-mm
drill bit).
• The far cortex is drilled with a drill bit that matches the core diameter of the screw,
creating a threaded hole when the self-tapping screw is inserted (e.g., for a 1.3-mm
screw, use a 1.0-mm drill bit). Some instrumentation sets include a special drill guide
that fits into the gliding hole to assist with this step.
• Some surgeons choose to reverse this process, drilling both cortices with the
smaller drill bit first, then overdrilling the near cortex with the larger caliber drill bit.
We do not advocate for this approach because the screw holes for both cortices
may not align. It is preferable to overdrill the proximal cortex, then insert the drill
guide into the gliding hole to drill the opposite cortex, which will ensure that the
entire bone track is aligned with the screw.
• Measure screw length and insert the screw. The screw will slide through the near
cortex and engage the far cortex with the screw threads. Because most screws de-
signed for this application are self-tapping, a separate tapping step is not required.
• As the fully threaded screw is tightened in this lag configuration, the fracture site is
compressed between the head of the screw and the distal threads
• Three or more lag screws are ideal to obtain multidirectional stability. Short oblique
fractures may only accommodate two screws (Fig. 9.13A–B).
Plate Fixation
• Given the small size of the phalanges, compression plating is not practical.
• Plates conceptually fall into three other (noncompression) categories.
• Bridging plates: Plates that span an area of comminution to prevent collapse dur-
ing bony healing.
• Tension band plates: Plates placed dorsally across a fracture with apex-dorsal
STEP 2 PEARLS deformity serve to redirect the deforming forces into compressive forces at the
For complicated fractures, plates with screws in volar cortex.
more than one plane (three-dimensional [3D] plate, • Neutralization plates: Plates used to reinforce lag screws by providing additional
H-plate, or Z-plate) can aid in stability. These plates stabilization against bending at the fracture site. Unlike fractures in larger long-
can fix several fragments from multiple directions. bones, phalangeal fractures often do not need neutralization plates if two or three
lag screws can be placed with good purchase.
STEP 2 PITFALLS
• Phalangeal plates may incorporate holes in more than one plane or ovoid holes that
can be adjusted for rotation and position.
• The phalangeal cortex is often too thin to
• Fracture reduction occurs as previously described, and preliminary reduction can be
accommodate screw head countersinking.
• Screws placed dorsally cannot project beyond held in place with K-wires placed outside of the surgical field.
the volar cortex because the flexor tendons lie • The plate should be fixed to bone with a single screw on either side of the fracture
immediately adjacent to the volar surface of for provisional fixation, alignment should be checked, and then the remaining screws
the phalanges. Multiple views should be taken should be inserted (Fig. 9.14).
using fluoroscopy to ensure that there is no
• Fractures that occur near the articular surfaces provide a limited amount of bone to
screw prominence. This is especially important
at the head of the proximal and middle pha- place screws. In this scenario, locking screws can be used to provide more rigid
lanx, where the large articular condyles can fixation (Fig. 9.15).
hide a prominent screw. • The thin plates used for phalangeal fractures should be bent carefully or twisted to
improve finger alignment or, alternatively, plates with ovoid holes will allow for ad-
justments in alignment before final screw tightening.
Step 3: Closure and Splinting

• Use the tenodesis effect to evaluate rotational alignment and finger cascade. With pas-
sive wrist flexion, the digits should extend because of extrinsic tendon attachments; with
passive wrist extension, the digits should flex toward the scaphoid tubercle (Fig. 9.16).
FIGURE 9.13 Lag screw compression.
FIGURE 9.14 Screws inserted.

FIGURE 9.15 Fluoroscopy showing locking screws in place.
FIGURE 9.16 Tenodesis effect.
• The extensor mechanism is repaired as indicated with nonabsorbable braided suture.

• Deflate the tourniquet and achieve good hemostasis before skin closure.
POSTOPERATIVE PEARLS
• The skin is closed using nonabsorbable sutures.
• When possible, the sutures to reapproximate
• A well-padded splint is applied to maintain the interphalangeal joints in extension,
the tendons should be passed from deep to
superficial to bury knots. This is especially im- the MCP joints in 70 degrees of flexion, and the wrist in slight extension.
portant when closing after a dorsal approach
because unburied knots can remain prominent POSTOPERATIVE CARE AND EXPECTED OUTCOMES
and cause irritation. • Patients should be seen in clinic within 1 to 2 weeks to have their splints removed
• Once pins are removed, buddy-taping or strap-
and to transition to a custom orthosis. This permits removal of the orthosis for hand
ping of the injured digit to an adjacent, unin-
jured digit can facilitate improvements in func- therapy exercises and pin care.
tional motion while maintaining alignment • Uninjured fingers can begin therapy immediately to avoid unwanted stiffness.
during final fracture healing. • Even with wires in place, the injured digit can typically participate in gentle active
range of motion, so long as the fixation is relatively stable. Because K-wires do not
FIGURE 9.17 Postoperative x-rays.
offer the same stability as plates and screws, an experienced hand therapist should POSTOPERATIVE PITFALLS
supervise early motion activities, and exercises should be carefully individualized to • Despite early active motion, adhesions be-
the patient. tween plates and extensor tendons are quite
• Pins are usually removed in 3 to 4 weeks. This is usually enough time for early bone common with dorsal plating. Tenolysis and/or
healing to have stabilized the fracture. PIP joint capsulotomy are required in a sub-
stantial number of patients.
• Earlier pin removal can be considered in children because healing is typically faster. • Delaying pin removal until 5 or 6 weeks is not
• After pin removal, the orthosis is still used for protection for an additional 3 to 4 generally recommended, especially if pins are
weeks. interfering with motion of the MCP and/or PIP
• After 6 to 8 weeks, fractures are typically sufficiently healed to begin weaning out of joints. This will lead to joint contractures that
the orthosis. Fracture healing is determined radiographically based on bone bridging may be impossible to overcome, even with
appropriate hand therapy.
across the fracture site and clinically when no motion or pain is felt at the fracture
site with clinical examination (Fig. 9.17).
• Providing stable fixation of extraarticular phalanx fractures with either percutaneous
pinning or internal fixation should lead to a union rate of 90% or greater.
See Video 9.1
EVIDENCE
Bannasch H, Heermann AK, Iblher N, Momeni A, Schulte-Monting J, Stark GB. Ten years stable inter-
nal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no
increase of complications in the treatment of open compared with closed fractures. J Trauma.
2010;68:624–628.
This study reviewed the radiographic and clinical outcomes and complications of internal fixation for
365 metacarpal and phalangeal fractures. Bony union was achieved in 91.2% of patients. In the func-
tional analysis, 85.2% of patients had excellent to acceptable outcomes, and 14.8% had unsatisfac-
tory results. The presence of multiple fractures and soft tissue injury were associated with worse
functional outcomes. There was no significant difference in infection and nonunion rates between
open and closed fractures (Level IV evidence).
Curtin CM, Chung KC. Use of eight-hole titanium miniplates for unstable phalangeal fractures. Ann
Plast Surg. 2002;49:580–586.
This retrospective study reports on 13 patients with 16 unstable phalangeal fractures after a variety of
traumatic injuries. Most were open fractures with complex soft-tissue injuries. The fractures were
treated by open reduction and internal fixation with an eight-hole miniplate. For range of motion, six
patients had good to excellent results with total active motion greater than 180 degrees, although
three of these six patients required hardware removal and tenolysis. The remainder of patients in-
cluded two with poor results, two loss to follow-up, and three thumb fractures with acceptable range
of motion. Immediate postoperative stability was obtained in all cases, but there were significant
complication rates (Level IV evidence).
Eberlin KR, Babushkina A, Neira JR, Mudgal CS. Outcomes of closed reduction and periarticular pin-
ning of base and shaft fractures of the proximal phalanx. J Hand Surg Am. 2014;39:1524–1528.
This retrospective study reviewed 43 patients with 50 fractures of the shaft or base of the proximal pha-
lanx that were treated with periarticular pinning. This technique uses the radial and ulnar corners of
the proximal phalanx base as entry points for two K-wires, which are driven antegrade across the
fracture; the wires are not necessarily crossed. All patients were followed for an average of 17 weeks,
and clinical union was achieved in an average of 35 days. Sixty-three percent of patients had an ex-
cellent result, 17% had a good result, and 17% had a fair result. Digital stiffness needing tenolysis
was identified in three patients. Two patients had pin site infections. The author concluded that peri-
articular pinning is an acceptable treatment for extraarticular fractures of proximal phalanx (Level IV
evidence).
El-Saeed M, Sallam A, Radwan M, Metwally A. Kirschner wires versus titanium plates and screws in
management of unstable phalangeal fractures: A randomized, controlled clinical trial. J Hand Surg
Am. 2019;44(12):1091.e1–9.
A randomized controlled trial comparing K-wire percutaneous pinning versus plate fixation for unstable
extraarticular fractures of the proximal or middle phalanx in 40 adult patients. Quick Disabilities of
Arm, Shoulder, and Hand (DASH) score, total active motion (TAM), grip strength, and visual analogue
scale (VAS) were measured. Mean follow up was 6.8 months. There were no differences between the
two groups with respect to grip strength, QuickDASH scores, pain, or rate of healing—which, on av-
erage, occurred in both groups by 3 months postoperatively. TAM was greater in the plating group
(250 degrees) versus the K-wire group (218 degrees). The conclusion of the study is that for unstable
phalanx fractures, rigid fixation with plating results in greater total active digit motion compared with
percutaneous K-wire fixation (Level II evidence).
CHAPTER 10
Dynamic External Fixation of Fracture-Dislocation
of the Proximal Interphalangeal Joint
KEY CONCEPTS
• Dynamic external fixation of the proximal interphalangeal (PIP) joint is primarily used
to treat intraarticular fractures of the middle phalanx with significant comminution or
joint surface impaction, fractures with disruption of the volar or dorsal articular lip,
and metaphyseal fractures with limited bone stock for internal fixation.
• A dynamic fixator can also be used for unstable dislocations or fracture-dislocations
of the PIP that cannot maintain reduction with conservative treatments such as
blocking splints.
• The PIP joint develops posttraumatic stiffness rapidly. Dynamic external fixators are
beneficial because they both permit continued flexion/extension of the PIP and
maintain a reduction through ligamentotaxis.
• Dynamic fixators must be cared for diligently by the patient, with pin care performed daily
to prevent infection. Young children, patients with mental illness, or patients who are
otherwise unable to participate in daily hygiene are not candidates for dynamic fixators.
• The fixator device usually remains in place for 6 weeks. Reasons for earlier removal
include pin site irritation or infection. Well-tolerated devices can remain in place for
up to 8 weeks.
• After healing is complete, the joint may still appear irregular on x-ray, but congruent
joints tend to remodel over time.
Rubber
bands
K3
K2
K1
FIGURE 10.9 Proximal and distal hooks of the dynamic external fixator are connected by rubber bands.
21
CHAPTER 10
Dynamic External Fixation of Fracture-Dislocation
of the Proximal Interphalangeal Joint
INDICATIONS
• Dynamic external fixation of the proximal interphalangeal (PIP) joint is primarily used
to treat intraarticular fractures of the middle phalanx with significant comminution or
joint surface impaction, fractures with disruption of the volar or dorsal articular lip,
and metaphyseal fractures with limited bone stock for internal fixation.
• Additionally, a dynamic fixator can be used for unstable dislocations or fracture
dislocations of the PIP that cannot maintain reduction with conservative treatments
such as blocking splints.
• The PIP joint develops posttraumatic stiffness rapidly. Dynamic external fixators are
beneficial because they permit continued flexion/extension of the PIP while main-
taining a reduction through ligamentotaxis.
Contraindications
• Dynamic fixators must be cared for diligently by the patient, with pin care performed
daily to prevent infection. Young children, patients with mental illness, or patients
who are otherwise unable to participate in daily hygiene are not candidates for dy-
namic fixators.
• Patients with active infection or surrounding soft-tissue loss are not candidates for
dynamic fixators.
• Subacute fractures: After roughly 2 weeks, fracture callus begins to develop, and
indirect reduction will be difficult or impossible to achieve through externally applied
traction force alone. In these cases, open reduction is indicated.
As with any injury of the phalanges, rotational and angular malalignment or shortening
should be noted. Subtle rotational deformity can be identified by comparing the rota-
tional alignment of the nail to the adjacent fingers.
IMAGING
• Plain radiographs should be taken in posteroanterior (PA), oblique, and lateral views
(Fig. 10.1A–C).
• Fractures that disrupt the volar rim of the middle phalanx can create PIP instability,
leading the middle phalanx to translate dorsally. This can create a subtle finding on
a lateral radiograph, described as the “beak sign” or “V sign,” as detailed by the
white lines in Fig. 10.1C. The formation of the beak sign signifies point loading be-
tween the articular surface of the proximal and middle phalanx, which can lead to
rapid joint degeneration if not treated.
• Computed tomography (CT) is rarely needed for phalanx fractures but can provide
a more detailed assessment of articular comminution when plain radiographs are
unclear.
SURGICAL ANATOMY
• The PIP joint is a hinge joint that is stabilized by bony architecture and soft tissue
restraints.
• The proximal phalanx head consists of two concentric condyles. The concave sur-
face of the base of the middle phalanx fits to the condyles. This bony structure
provides stability during flexion and extension.
21.e1
21.e2 CHAPTER 10 Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint
A B C
FIGURE 10.1
• Collateral ligaments restrict radial and ulnar deviation; each has two parts (proper
and accessory ligaments). The proper collateral ligament originates from a sulcus on
the lateral surface of the head of the proximal phalanx and inserts on the volar lateral
aspect of the middle phalanx. The accessory collateral ligament originates from the
proper collateral ligament and runs in a volar direction to attach to the volar plate
(Fig. 10.2).
• The volar plate and accessory collateral ligaments provide stability during extension.
The proper collateral ligaments provide stability during flexion.
• Fragmentation of more than 40% of the volar articular surface of the middle phalanx
typically results in PIP instability and/or subluxation. (Fig. 10.3).
PROCEDURE
• When using dynamic fixators, the reduction force is primarily applied through liga-
mentotaxis, meaning that the forces of the volar plate, PIP joint capsule, and
collateral ligaments exert on the articular fragments when longitudinal traction is
applied. (Fig. 10.4)
• Many different techniques have been developed for dynamic external fixation of the
PIP joint. The following technique describes the fixator commonly called the Suzuki
frame.
Proper Central
collateral tendon
ligament
Unstable
Proximal phalanx 50%
Middle Proximal Middle phalanx
phalanx phalanx 30%
Stable
Volar plate
Accessory collateral ligament

CHAPTER 10 Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint 21.e3
K3
K2
Middle Proximal K1
phalanx phalanx
Volar plate

FIGURE 10.5
Step 1: Reduction STEP 1 PEARLS

• A true lateral view of the PIP joint is obtained with fluoroscopy. An in-office digital block with subsequent examination
• The middle phalanx is most often affected in these injuries and, as such, is a poor under fluoroscopy can be used to confirm fracture
reference for achieving a true lateral image. Instead, the two condyles of the reducibility before committing to operative intervention
proximal phalanx should be used. A true lateral image will have both condyles with dynamic fixator placement.
perfectly superimposed (Fig. 10.5).
• Longitudinal traction is applied through the finger and a true lateral image is ob-
STEP 2 PEARLS
tained. Dynamic/live fluoroscopy is then used, and the PIP is taken through flexion
and extension to ensure that reduction can be maintained. Use of a longer K-wire or a smooth thin Steinmann
pin for K1 is often useful to provide extra wire
Step 2: Insertion of Proximal and Distal Kirschner Wires length on either side of the digit, which will be bent
into position in later stages. Standard K-wires may
• While maintaining a true lateral x-ray of the PIP joint, the first Kirschner wire (K-wire; not provide enough length to create these bends.
0.045 in [1.1 mm], labeled “K1”) is inserted at the center of rotation (COR) of the
proximal phalangeal head, perpendicular to the axis of the bone.
STEP 2 PITFALLS
• The next wire to be inserted is the distal K-wire (0.045 in [1.1 mm], labeled “K3”),
which is placed in the distal part of the middle phalanx. Correct placement of the K1 pin is the critical step
• There is no center of rotation with which the K3 wire must be placed; however, of the operation. A K-wire placed outside of the
COR will lead to uneven reduction force across the
perpendicular placement of the wire within the middle phalanx is still required. PIP joint and prevent PIP motion.
• These wires are advanced through the opposite side of the digit until the lengths of
both sides are equal (Fig. 10.6).
STEP 3 PEARLS
Step 3: Bending of K-Wires A needle driver is clamped in place where the
intended bend is to be made, and a Frazier suction
• The proximal K-wire (K1) is bent on both sides of the digit 90 degrees and aimed
tip or additional needle driver is used to bend the
distally. At the terminal end of the wires, further bends are made to create a hook for wire. An additional needle driver should be used
the rubber bands to seat into. by an assistant to grasp and stabilize the wires
• The distal K-wire (K3) is also bent on either side of the digit to form a similar recess proximally while the surgeon bends the wire into
for the other end of the rubber band (Figs. 10.7 and 10.8). shape.
Step 4: Rubber Band Setting STEP 3 PITFALLS

• The proximal and distal hooks are connected by rubber bands, and adequate trac- Pay close attention to the adjacent digits; the
tion is obtained by adjusting the number of bands or the size/strength of the bands wires should not stick out so far laterally that they
(Fig. 10.9). displace the surrounding digits. Similarly, avoid
• PIP congruency and stability is checked under physical examination and fluoro- bending the wires so close to the affected finger
that they impinge on the injured digit when there is
scopic control through a full range of motion (ROM), and traction is adjusted as
postoperative swelling.
necessary.
STEP 4 PEARLS
• Orthodontic elastic bands or other small rubber
bands can be appropriately sterilized for this
procedure.
• If no sterile rubber bands are available, one
may simply have to place nonsterile rubber
bands on at the end of the case, once any in-
cisions are closed and sterility is no longer a
concern.
FIGURE 10.7
FIGURE 10.8
STEP 5 PEARLS Step 5: Adding a Third K-Wire

This third wire should be thinner than the other • Many constructs will require a third K-wire, placed distal to the fracture but proximal
wires (0.035 in [0.9 mm] or smaller), so it can be to the distal K-wire (typically 0.035 in [0.9 mm], labeled “K2”).
bent easily around the limbs of the proximal wire • The purpose of this wire is to control the tendency of the base of the middle phalanx
(K1) without undue torque on the fixator or the
fracture. to dorsally subluxate, which could lead to the “V sign” seen on lateral radiographs.
• In the sagittal plane, the K2 wire should be placed slightly volar to the level of K1 to
effectively resist against dorsal translation of the middle phalanx. The K2 wire can
then be bent around the K1 wire.
Early motion will help maintain mobility, encourage
joint surface remodeling, and enhance the health • After 48 to 72 hours of rest, the patient can begin active motion.
of the cartilage surfaces. • The patient should begin pin care at home starting on the first postoperative day.
Sterile saline or a 50:50 mix of sterile saline and 3% hydrogen peroxide can be
applied to a cotton swab to gently clean the pin sites.
CHAPTER 10 Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint 21.e5
Rubber
bands
K3
K2
K1
• Dressing around the pin sites should be thin to
avoid obstructing active motion.
• Patients need to be careful that the fixator
does not abrade or ulcerate adjacent digits,
especially if sensation is altered because of
nerve injury.
FIGURE 10.11
• Within the first 7 days, the patient’s alignment should be checked on physical ex-
amination and radiographs, and occupational therapy is started.
• The fixator device usually remains in place for 6 weeks. Reasons for earlier removal
include pin site irritation or infection. Well-tolerated devices can remain in place for
up to 8 weeks.
• After healing is complete, the joint may still appear irregular on x-ray, although con-
gruent joints tend to remodel over time (Fig. 10.10).
• With difficult intraarticular fractures, normal postoperative motion is not always ex-
pected, but select patients may obtain near-normal function, and average motion
obtained approaches 90 degrees in published series (Fig. 10.11).
EVIDENCE
Ellis SJ, Cheng R, Prokopis P, et al. Treatment of proximal interphalangeal dorsal fracture-dislocation injuries
with dynamic external fixation: A pins and rubber band system. J Hand Surg Am. 2007;32:1242–1250.
This study reports the results of dynamic external fixator (Suzuki frame) treatment of unstable fracture-
dislocations of the PIP joint. Of 14 patients treated, 8 were available for follow-up at an average of 26
months. The average range of PIP joint motion at final follow-up was 88 degrees, and average grip
strength was 92% of the uninjured hand. Five patients had a small step-off deformity or arthritis
(Level IV evidence).
Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic distraction external fixation for unstable
fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2008;33:19–25.
This retrospective study reviewed the outcome of Suzuki frame fixation for 34 unstable fracture-dislocations
and pilon injuries of the PIP joint. All patients were followed for an average of 16 months. At the final
follow-up, the average ROM was 88 degrees at the PIP joint and 60 degrees at the distal interphalangeal
joint. Pin-track infections were identified in eight cases. There were no patients with septic arthritis,
osteomyelitis, or loss of reduction. The preoperative level of activity was achieved in all cases (Level IV
evidence).
Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of commi-
nuted intraarticular fractures and fracture-dislocations in the hand. J Hand Surg Br. 1994;19:98–107.
This paper demonstrates operative technique of the dynamic traction system, postoperative care, and
case reports. In the case reports, outcomes of seven severely injured joints were presented, and all
patients were followed for an average of 13.1 months. At the final follow-up, the ROM averaged
80 degrees at the PIP joint (Level IV evidence).
CHAPTER 11
Open Reduction and Internal Fixation of
Intraarticular Phalangeal Fractures
KEY CONCEPTS
• Open reduction and internal fixation is indicated for intraarticular phalangeal frac-
tures that are displaced or those that shorten or angulate after successful reduction.
• When there is significant soft-tissue loss over the phalanges or interphalangeal
joints, treatment with Kirschner wire (K-wire) pinning is preferred. Pinning causes
less soft tissue disruption, and pins are easier to remove in the case of a deep
wound infection.
• Intraarticular fractures of the middle phalangeal base should be scrutinized for joint
subluxation. If greater than 50% of the volar articular rim is fractured, there is typi-
cally joint instability. Meanwhile, fracture of 30% to 50% of the articular surface can
cause more subtle beaking or development of a V-sign, which also signifies joint
instability.
• The extensor mechanism covers most of the dorsal and lateral sides of the digit at
the level of the proximal interphalangeal (PIP) joint. The central slip inserts onto the
epiphysis of the middle phalanx, with lateral bands running adjacent as they go on
to consolidate at the terminal tendon. Incisions and exposures must be performed
with precision to avoid damaging these structures. Otherwise, extensor tendon scar-
ring and adhesions will result.
• Patients with multiple fractures or injuries to the same hand/extremity benefit from
rigid internal fixation, even if their injury appears stable and reduced. Rigid internal
fixation permits early active motion and faster recovery compared with nonoperative
treatment.
• Protective splinting of the digit is continued until fracture union, which takes about
6 weeks. After confirming union, the splint can be weaned and strengthening exer-
cises started.
Unstable
Middle phalanx
30%
Stable
FIGURE 11.4 Instability of the volar middle phalanx PIP fracture begins with articular involvement of
30% or greater. PIP, Proximal interphalangeal.
22
CHAPTER 11
Open Reduction and Internal Fixation
of Intraarticular Phalangeal Fractures
INDICATIONS
There are a number of indications for this procedure, including:
• Displaced fractures or fracture-dislocations, which are irreducible by closed
reduction techniques.
• Fractures that displace, shorten, or angulate after successful reduction. Because of
the intraarticular extension of these fractures, any loss in reduction will likely lead to
an articular step-off. Any articular step-off, or gap in the articular surface greater
than 1 mm, should be treated surgically.
• Intraarticular fractures of the middle phalangeal base should be scrutinized for joint
subluxation. If greater than 50% of the volar articular rim is fractured, there is typi-
cally joint instability. Meanwhile, fracture of 30% to 50% of the articular surface can
cause more subtle beaking, or development of a V-sign, which also signifies joint
instability. A
• Patients with multiple fractures or injuries to the same hand/extremity benefit from
rigid internal fixation, even if their injury appears stable and reduced. Rigid internal
fixation permits early active motion, which helps accelerate recovery compared with
nonoperative treatment and splinting.
Contraindications
• When there is significant soft-tissue loss over the phalanges or interphalangeal
joints, treatment with Kirschner wire (K-wire) pinning is ideal over plate and screw
fixation. Pinning causes less soft-tissue disruption. In addition, pin removal is easier
in the case of a deep wound infection.
• Intraarticular fractures typically cause swelling, tenderness, and difficulty with range
of motion (Fig. 11.1A–B).
• Even in cases where range of motion is preserved, examine closely for angular or
rotational deformity resulting from the fracture displacement.
B
IMAGING FIGURE 11.1

• Standard posteroanterior and lateral radiographic views should be obtained to char-
acterize the fracture (Fig. 11.2A–B).
• One or more oblique views can provide additional information.
SURGICAL ANATOMY
• The proximal interphalangeal (PIP) joint is a ginglymoid (hinge) joint. The concentric
condyles of the proximal phalanx and the concave surface of the middle phalanx are
congruent with each other and provide some innate stability, which is further rein-
forced by the strong collateral ligaments and the volar plate.
• Fractures of the volar rim of the middle phalanx can create instability of the PIP. A
sometimes-subtle finding of a so-called “beak sign” can be seen on lateral radio-
graphs, as detailed by the dashed red lines in Fig. 11.3. In these injuries, there is loss
of congruent articular contact between the proximal and middle phalanx, leading to
A B
point-loading of the volar articular surface. Failure to recognize and treat this will
lead to rapid destruction of the PIP joint. FIGURE 11.2
22.e1
22.e2 CHAPTER 11 Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures
Unstable
Middle phalanx
30%
Stable
FIGURE 11.4
• Instability of volar middle phalanx PIP fractures can begin with articular involvement
of 30% or greater (Fig. 11.4).
• The extensor mechanism covers most of the dorsal and lateral sides of the digit at
the level of the PIP joint. The central slip inserts onto the epiphysis of the middle
FIGURE 11.3
phalanx, with lateral bands running adjacent as they go on to consolidate at the
EXPOSURES PEARLS terminal tendon. Incisions and exposures must be performed with precision to avoid
needless damage to these structures. Otherwise, extensor tendon scarring and ad-
To avoid an increased risk of avascular necrosis,
be sure to maintain the attachments of collateral hesions will result.
ligament, volar plate, and other tissues to small
fracture fragments.
EXPOSURES
Dorsal or Dorsolateral Approach
• This approach can be used to repair dorsal fracture fragments and provides access
EXPOSURES PITFALLS to one or both sides of the joint for condylar fractures.
• When working on the dorsal aspect of the PIP • A linear or curvilinear incision is made over the PIP joint. This can be designed as a
joint, be careful to preserve the attachment of middorsal line, a lazy “S,” or a zigzag incision.
the central slip to the dorsal base of the mid-
• Most condylar fractures can be visualized by incising the interval between the lateral
dle phalanx.
• When incising through joint capsule, it is of band and the central slip; this can be done on one or both sides of the joint to help
critical importance to remember that the artic- with visualization of the joint surface (Fig. 11.5).
ular surface is immediately deep to the cap-
sule. Overaggressive dissection, or burying of
the knife blade, will result in certain damage
to the articular cartilage.
Central slip
Lateral band
FIGURE 11.5
CHAPTER 11 Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures 22.e3
• Immediately deep to the extensor mechanism is the joint capsule. If the capsule EXPOSURES PEARLS
remains intact, attempt to define this layer because it will require separate closure.
When releasing the collateral ligaments, it is best
• With the capsule defined, create a capsulotomy along the vertical/long axis of the finger. to work from within the joint and release outward
• For better visualization of the proximal extension of condylar fractures, division of toward the ligament insertion. This ensures
the transverse retinacular ligament may provide better visualization of the shaft of that the immediately adjacent neurovascular
the proximal phalanx. bundle is safe from the knife blade and protects
against accidental laceration of the ligament in its
• In rare cases, to visualize the center of the PIP joint, the central tendon can be split
midsubstance.
down its midline.
Volar Approach EXPOSURES PITFALLS

• The volar approach can be used for cases that have a volar fragment, such as a • If the volar plate is to be detached from the mid-
large avulsion fragment associated with the volar plate of the PIP joint. dle phalanx, leave a small remnant behind to re-
• A palmar Bruner-style incision is created over the center of the PIP joint (Fig. 11.6). attach at the end of the procedure. Otherwise, it
• A flap of skin and subcutaneous tissue is elevated; the radial and ulnar neurovascu- may be necessary to reattach with bone tunnels
lar bundles should be identified and protected. or anchors, which is technically challenging.
• Be mindful of protecting the neurovascular bun-
• The flexor sheath is opened between the A2 and A4 pulleys, incising through the C1, dles when the collateral ligaments are released;
A3, and C3 pulleys. It is important to leave a cuff of pulley remaining for later repair. they are quite vulnerable during this step.
• The flexor tendons are retracted and the volar plate is exposed (Fig. 11.7). • Additional mobilization of the neurovascular
• The volar plate may be detached at its distal or proximal aspects, depending on the bundles is often needed to avoid a stretch
configuration of the fracture and the exposure required. injury to these structures when the shotgun
exposure is used.
• To fully expose both joint surfaces, the collateral ligaments are released from the
volar plate and from the base of the middle phalanx. This allows the joint to be hy-
perextended 180 degrees, exposing both joint surfaces. This is sometimes referred STEP 1 PEARLS
to as the “shotgun” exposure (Fig. 11.8).
Minimize stripping of the periosteum and other soft
tissue attachments from small fracture fragments
to preserve the blood supply. If using a volar
PROCEDURE approach, take care to leave dorsal structures
Step 1: Reduction intact, and vice versa.
• Anatomic reduction is required for all periarticular injuries. Failure to reduce the ar-
ticular surface will lead to rapid joint degeneration. STEP 1 PITFALLS
• Any clots and debris are removed from the fracture area for precise reduction.
• The condylar (metaphyseal) bone is fragile, so
• A combination of pointed reduction clamps, dental picks, and longitudinal traction
be gentle when using clamps to avoid creating
may be used to gain fracture reduction. additional comminution.
• In some injuries, the middle phalanx articular surface can be impacted deep into the • Be cautious when placing K-wires for provisional
metaphyseal bone. In these scenarios, a small corticotomy can be created distal to the fixation so that they do not interfere with the
fracture and a dental pick can be used to tamp the articular surface back into place. planned internal fixation. Avoid placing K-wires
near the flat surfaces where a plate will lie.
• Use K-wires to hold the reduction in place (Fig. 11.9).
Volar rim fragment

FDP
FIGURE 11.6 FIGURE 11.7 FIGURE 11.8

Screw
Fracture
site
FIGURE 11.10
FIGURE 11.9
STEP 2 PEARLS
FIGURE 11.11
Countersinking is not required for these screws
and may lead to loss of screw purchase if the bone
is too thin or too soft at the metaphysis.
Step 2: Fixation
• Small articular fragments are typically fixed with lag screws or bicortical screws.
STEP 2 PITFALLS • Bicondylar fractures, or complex articular fractures with complete transverse disrup-
• Do not place screws or a plate directly over or tion of the neck or shaft of the phalanx, may require plate fixation. Newer minifrag
through the collateral ligament(s) because this plating systems can be set with locking screws to create a fixed-angle construct
will restrict the ligaments’ function, causing which can better maintain a tenuous reduction.
joint stiffness. If fixation is needed at the foot-
print of the collateral ligament, then it can be • Proximal phalangeal condyle fractures are typically fixed with 1.3- to 1.5-mm
split in-line with its fibers, or its insertion can diameter screws. For smaller fragments, 1.0-mm screws may be used.
be partially released. • The screw is typically advanced from the mobile fracture fragment to the more stable
• When using fluoroscopy, take a live shot and (larger) fragment of bone (Fig. 11.10).
fully pronate/supinate the hand/finger to • Fragments should be fixated with two screws to prevent loosening or rotation; how-
ensure that there is no screw prominence
through the far-cortex. Evaluation of the static ever, tiny bone fragments may not have enough space to insert two screws.
anteroposterior and lateral views alone can de- • The reduction, position, and length of the screws are confirmed under radiologic
ceive the observer into believing there is no assistance (Fig. 11.11).
screw prominence—when in fact there is—as • Range of motion of the finger is checked for smooth motion and stability.
a result of the complex three-dimensional • Buttress plating of articular rim fragments can be used when fragments are too small
structure of the phalanges.
or comminuted to permit screw fixation.
CHAPTER 11 Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures 22.e5
A B A B
Step 3: Closure STEP 3 PITFALLS

• If the central slip was split for exposure, it should be repaired with a braided nonab-
• Overtightening or excessive repair of the extensor
sorbable suture. mechanism, volar plate, or collateral ligaments
• If the extensor mechanism was split between the central slip and lateral bands, this will lead to profound stiffness. Loose repair is
does not require repair (nor does the transverse retinacular ligament if violated). preferred because stiffness—not instability—is
• If the volar approach was used, reattach the volar plate back to its remaining stump, the usual outcome after a PIP injury.
• Check the finger position in the splint carefully.
usually on the middle phalanx. If the collateral ligaments were released entirely, they
In particular, hyperextension needs to be
should be loosely sutured back into place. Partial collateral ligament release does avoided at the PIP joint, or instability may re-
not require repair. sult because of improper healing of the volar
• The skin is closed with nonabsorbable sutures. A forearm-based intrinsic plus gutter plate after a volar approach.
splint is applied to rest the soft tissues. Unless the fracture fixation is tenuous, the
remaining fingers and thumb can be left free.

• In patients with rigid fixation, gentle active motion exercises can be started within a
week.
• Protective splinting of the digit is continued until fracture union, which takes about
6 weeks. The splint is removed for range-of-motion exercises.
• After confirming union, the splint can be weaned and strengthening exercises started.
• The restored joint usually recovers near-full range of motion and strength
(Figs. 11.12A–B and 11.13A–B).
See Video 11.1
EVIDENCE
Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal
interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am. 2006;31:1349–1354.
This study reports the outcomes of open reduction and internal fixation for nine patients with unstable
fracture-dislocations of the PIP joint. The fractures were fixed with miniscrews using a volar ap-
proach. Average follow-up period was 42 months after surgery. The range of motion of the PIP joint
at final follow-up averaged 70 degrees. Flexion contracture was an average of 14 degrees at the PIP
joint. Two patients had pain during heavy activity, but the others reported no pain in the injured finger
Lee JY, Teoh LC. Dorsal fracture dislocations of the proximal interphalangeal joint treated by open
reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg
Br. 2006;31:138–146.
This study reports on a series of 10 patients with unstable fracture-dislocations of the PIP joint. Open
reduction internal fixation was performed from a dorsal approach, using miniscrews. Patients were
followed for an average of 8.7 months. All patients had good-to-excellent results, with an average
PIP joint active range of motion of 85 degrees (Level IV evidence).
Shewring DJ, Miller AC, Ghandour A. Condylar fractures of the proximal and middle phalanges. J Hand
Surg Eur. 2015;40:51–58.
This retrospective study reports the treatment of 74 patients with phalangeal condylar fractures. Al-
though 12 patients were initially treated nonoperatively, five of these ultimately required fixation be-
cause of fracture displacement during follow-up. The remaining 62 patients were treated operatively
with a single screw via a lateral approach. Fixation was easiest within the first week, but delays of up
to 2 weeks had little effect on final results. Patients with unicondylar fractures that were fixed within a
week had the best results, with very little loss of range of motion. Patients presenting late, and those
with bicondylar fractures, fared less well (Level IV evidence).
Federer AE, Guerrero EM, Dekker TJ, et al. Open reduction internal fixation with transverse volar plat-
ing for unstable proximal interphalangeal fracture-dislocation: The seatbelt procedure. Hand (N Y).
2020;15(2):201–207.
Seventeen patients with PIP dorsal fracture-dislocations with large (>40%) articular volar rim fragments
underwent open reductions and internal fixation with a horizontal plate through a volar approach.
A 7-months mean follow-up demonstrated no recurrent instability, the average arc of motion was
70 degrees, and only two patients required hardware removal for irritation.
CHAPTER 12
Volar Plate Arthroplasty of the Proximal
Interphalangeal Joint
Kevin C. Chung

This chapter includes the following video: Video 12.1 – Volar Plate Arthroplasty of
the PIP Joint.
KEY CONCEPTS
• Volar plate arthroplasty of the proximal interphalangeal (PIP) joint is indicated for
fracture dislocations of the PIP joint that are unstable and in which the volar lip (but-
tress) of the middle phalanx base cannot be salvaged or reconstructed by other
means.
• Volar plate arthroplasty can be used for acute or chronic cases, but ideally the ar-
ticular surface of the head of the proximal phalanx is preserved. Acute injuries will
present with tenderness and swelling of the digit. Range of motion (ROM) will be
limited. Chronic injuries may present with stiffness and pain, often after what was
believed to be a trivial “finger jam” injury.
• In cases with subtle subluxation, the middle phalanx shifts relatively dorsal to normal
joint alignment, and a “V sign” can be seen at the dorsal side of the joint on plain
radiographs.
• The volar plate is firmly attached at its distal edge to the volar lip of the middle pha-
lanx. Its proximal attachments (checkrein ligaments) are ordinarily loose and flimsy
in the nonpathologic state. These attachments allow the volar plate free excursion
with flexion of the joint, but effectively prevent hyperextension.
• When the comminution of the middle phalanx volar lip involves more than 40% of
the articular surface, the PIP joint generally becomes unstable because of loss of the
collateral ligament and the volar plate stabilizers.
• Wide exposure of the joint is needed for this operation (“shotgun” exposure); by hyper-
extending almost 180 degrees, the whole joint surface can be exposed.
• The damaged, volar portion of the middle phalanx base is shaped into a smooth,
symmetric surface that is to be resurfaced by the volar plate.
Middle
phalanx
Volar plate
Checkrein
ligaments Collateral
ligament
Proximal
phalanx
FIGURE 12.3 The volar plate attaches to the proximal phalanx via the checkrein ligaments.
23
CHAPTER 12
Volar Plate Arthroplasty of the Proximal
Interphalangeal Joint
Kevin C. Chung
INDICATIONS
• Indications for this procedure include fracture dislocations of the proximal interpha-
langeal (PIP) joint that are unstable and in which the volar lip (buttress) of the middle
phalanx base cannot be salvaged or reconstructed with other means.
• Volar plate arthroplasty can be used for acute or chronic cases. Ideally, the
articular surface of the head of the proximal phalanx is preserved.
• Acute injuries will present with tenderness and swelling of the digit. Range of motion
(ROM) will be limited.
• Chronic injuries may present with stiffness and pain, often after what was believed
to be a trivial “finger jam” injury (Fig. 12.1).
IMAGING
• Plain radiographs in three views (posteroanterior, oblique, and lateral) should be
obtained. A properly aligned lateral view is especially important for identifying any
subluxation (Fig. 12.2A).
• In cases with subtle subluxation, the middle phalanx shifts relatively dorsal to normal
joint alignment, and a “V sign” can be seen at the dorsal side of the joint, highlight-
ing the incongruity of the joint surfaces (see Fig. 12.2B).
SURGICAL ANATOMY
• The volar plate is firmly attached at its distal edge to the volar lip of the middle pha-
lanx. Its proximal attachments (checkrein ligaments) are ordinarily loose and flimsy
in the nonpathologic state. These attachments (volar plate and the accessory
FIGURE 12.1 Small finger presents with pain and stiffness.
23.e1
23.e2 CHAPTER 12 Volar Plate Arthroplasty of the Proximal Interphalangeal Joint
B
FIGURE 12.2 (A–B) Plain radiographs demonstrate subtle subluxation of the middle phalanx.
collateral ligaments) permit free excursion of the volar plate with flexion of the joint,
but effectively prevent hyperextension (Fig. 12.3).
• When the comminution of the middle phalanx volar lip involves more than 40% of
the articular surface, the PIP joint generally becomes unstable because of loss of the
collateral ligament and the volar plate stabilizers (Fig. 12.4).
EXPOSURES
• A V-shaped incision is made on the volar side of the PIP joint and the center of the
incision is located on the PIP flexion crease.
• The skin flap with subcutaneous tissue is elevated. The radial and ulnar neurovas-
cular structures are identified and protected.
• The sheath from the A2 to A4 pulley is exposed, incised, and reflected as a rectan-
gular flap (Fig. 12.5A).
• The volar plate is exposed by retracting the flexor tendons (see Fig. 12.5B).
CHAPTER 12 Volar Plate Arthroplasty of the Proximal Interphalangeal Joint 23.e3
Middle
phalanx
Volar plate
Checkrein
ligaments Collateral
ligament
Proximal
phalanx
FIGURE 12.3 Volar plate is attached at its distal edge to the volar lip of the middle phalanx.
Proximal phalanx
Accessory
collateral ligament
Proper
collateral ligament
Volar plate
FIGURE 12.4 Comminuted middle phalanx volar lip creates instability of PIP joint. PIP, Proximal in-
terphalangeal.
A3
VP
A B
FIGURE 12.5 (A) The sheath from the A2 to A4 pulley is exposed, incised, and reflected as a rectan-
gular flap. (B) The volar plate is exposed by retracting the flexor tendons. (Fig. 73.19A–B, from
Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)
STEP 1 PEARLS PROCEDURE

The volar plate flap should be designed with Step 1: Incision of the Volar Plate and Joint Exposure
adequate width to provide stability to the
reconstruction. Also, it needs to be designed with • Longitudinal incisions are made along the radial and ulnar edges of the volar plate,
symmetry between the radial and ulnar sides of the which is separated from the collateral ligaments, elevating it as a proximally-based
flap to avoid an angular deformity. flap.
• Distally, the volar plate may already be avulsed with the fracture fragment(s). If not,
a transverse incision is made at the most distal aspect of the volar plate, detaching
it from the base of the middle phalanx (Fig. 12.6).
• Wide exposure of the joint is needed for this operation (the “shotgun” exposure). The
collateral ligaments are identified and the accessory collateral ligaments attaching to
the volar plate are released (Fig. 12.7) distally from the middle phalanx in a stepwise
fashion, checking periodically to see if enough has been released to open the joint
fully. If possible, the proper collateral ligaments are kept in place.
• By hyperextending almost 180 degrees, the whole joint surface can be exposed
(Fig. 12.8A–B).
Step 2: Preparation of the Joint and the Volar Plate

• Loose fracture fragments, including those attached to the distal volar plate, are
excised.
• The damaged, volar portion of the middle phalanx base is shaped into a smooth,
symmetric surface that is to be “resurfaced” by the volar plate (Fig. 12.9). The depth
Middle phalanx
Incisions
Collateral ligament

Volar plate
Proximal phalanx
FIGURE 12.7 Accessory collateral ligaments are identified and re-

leased. (Fig. 73.19C, from Azar F, Canale ST, Beaty JH, eds. Camp-
FIGURE 12.6 Incision markings for volar plate. bell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)
A B
FIGURE 12.8 (A–B) Exposure of the whole joint surface by hyperextending almost 180 degrees.
Central tendon Drill holes Collateral

for sutures ligament stump
Volar
plate Bone Flexor digitorum
resection superficialis tendon
Drill hole
Collateral
ligament stump
Volar plate Reshaped
FIGURE 12.9 The damaged, volar portion of the middle phalanx base
is shaped into a smooth, symmetric surface that is to be “resurfaced”
portion
by the volar plate. (Fig. 67.52E, from Azar F, Canale ST, Beaty JH, eds. FIGURE 12.10 Reshaped volar portion of the middle
Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.) phalanx base.
of the step-off between the healthy dorsal articular surface and this reshaped volar
portion of the middle phalanx base should be equal to the thickness of the volar
plate (Fig. 12.10).
Step 3: Reduction
• A 3-0 or 4-0 nonabsorbable suture is placed in the volar plate flap using a locking,
grasping suture pattern such as a Bunnell stitch or Krackow stitch (see Fig. 12.10).
• The sutures are passed through the base of the middle phalanx using Keith needles
or a similar method (Fig. 12.11).
• The needles should be inserted so that the volar plate is correctly brought into the
resurfaced area, abutting the residual healthy articular surface, so that a smooth
articular contour is achieved.
• The needles should be directed toward the dorsum of the finger, where the suture
can be tightened, pulling the volar plate into the articular defect (Fig. 12.12).
Keith needles
Proximal
phalanx
Volar plate
FIGURE 12.11 Sutures are passed through middle phalanx base using Keith needles.
Proximal Middle
phalanx phalanx
Volar
plate
FIGURE 12.12 Sutures are tightened to pull the volar plate into the FIGURE 12.13 Joint reduction and range of motion are assessed.
articular defect.
STEP 3 PEARLS • The joint reduction and ROM are assessed under direct vision and radiographic
• If the PIP joint cannot reach full extension after guidance. The sutures can be tied over a button, or preferably the extensor tendons
insertion of the volar plate, the volar plate are dissected off the sutures and the sutures are tied over the periosteum to avoid
should be mobilized further by partial, step skin troubles (Fig. 12.13).
wise release of the checkrein ligaments until
full extension is possible. Step 4: Fixation and Closure
• If lateral instability is identified, the lateral
sides of the volar plate may be sutured to the • Congruent reduction and stability through the entire ROM is confirmed under fluo-
adjacent collateral ligaments to improve lateral roscopic imaging (Fig. 12.15).
stability (Fig. 12.14). • The tourniquet is deflated, hemostasis is achieved, and skin is closed (Fig. 12.16).
• Transarticular pinning of the PIP joint in slight flexion for 3 weeks may be performed
to maintain accurate reduction during the early healing period. Preferably, the PIP
STEP 3 PITFALLS
joint is kept flexed at 30 degrees of flexion via a blocking splint for 3 weeks and
When the sutures are tied over the periosteum, active motion is initiated 1 week after surgery.
be mindful to avoid entrapping any portion of the
extensor mechanism.
• The PIP joint fixation is continued for 3 weeks after surgery.
• For cases using extension block pinning, active flexion is begun within a week.
• Full active flexion and extension is started when the block splint is removed at
3 weeks.
• The pullout suture is removed after 6 weeks in cases when a button is used.
• Dynamic splinting can be used after 6 weeks to help achieve full extension.
• Gradual improvements in ROM may be seen even up to 1 year after surgery.
See Video 12.1
Volar plate is split to

reconstruct collateral
ligaments
FIGURE 12.14 Volar plate is split to reconstruct

collateral ligaments. (Fig. 73.19G, from Azar F,
Canale ST, Beaty JH, eds. Campbell’s Operative
Orthopaedics, 14th ed. Elsevier; 2020.) FIGURE 12.15 Fluoroscopy confirms reduction and stability.
FIGURE 12.16 Skin closure.
EVIDENCE
Deitch MA, Kiefhaber TR, Comisar BR, Stern PJ. Dorsal fracture dislocations of the proximal interpha-
langeal joint: Surgical complications and long-term results. J Hand Surg Am. 1999;24:914–923.
This is a retrospective study that compares the outcomes and complications of two treatments for
acute dorsal fracture dislocations of the PIP joint: open reduction and internal fixation (ORIF) and
volar plate arthroplasty. Twenty-three patients were treated with volar plate arthroplasty, and 33 were
treated with ORIF. Redislocation occurred in 3 volar plate arthroplasty patients and 3 ORIF patients.
Seventy-four percent of patients had little or no pain. There were no statistically significant differ-
ences in the grip strength and ROM between ORIF and volar plate arthroplasty (Level III evidence).
Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of the proximal interphalan-
geal joint. J Hand Surg Am. 2000;25:429–437.
This study shows the outcome of volar plate arthroplasty for 17 fracture dislocations of the PIP joint.
The average follow-up period was 11.5 years. All patients had no pain with activity. Total active ROM
averaged 85 degrees in patients having arthroplasty within 4 weeks of injury, and 61 degrees in
patients having the procedure more than 4 weeks after injury. Joint narrowing was recognized in four
patients. The authors concluded that volar plate arthroplasty supplies satisfactory function and
pain-free motion (Level IV evidence).
Tyser AR, Tsai MA, Parks BG, Means Jr KR. Biomechanical characteristics of hemi-hamate reconstruc-
tion versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal
interphalangeal joint. J Hand Surg Am. 2015;40:329–332.
This biomechanical study compares stability and ROM after hemihamate reconstruction versus volar
plate arthroplasty using 18 PIP joint fracture dislocation models of cadaver hands. Dorsal displace-
ment of the middle phalanx averaged 0.01 mm in the hemi-hamate reconstructed joints and
averaged 0.03 mm in the volar plate arthroplasty joints (Level III evidence).
CHAPTER 13
Hemi-Hamate Arthroplasty
INDICATIONS
Indications include:
• Unstable proximal interphalangeal (PIP) joint fracture–dislocations in which more
than 50% of the palmar base of the middle phalanx is fractured or greater than
30 degrees of PIP joint flexion is required to maintain stability.
Loss of collinearity of the small finger
• Fracture of the palmar base that results in loss of the cup-shaped geometry and
buttressing effect of the volar lip. Hemi-hamate arthroplasty restores joint congru-
ity and stability and permits early motion.
• Comminuted lateral plateau fractures of the base of the middle phalanx.
• Joint salvage after failed treatment of complex fracture–dislocations of the PIP joint.
Contraindications
• Concentric PIP joint reduction can be maintained with open reduction and internal
fixation (ORIF) of a large, noncomminuted volar lip fracture.
• Loss of integrity of the dorsal cortex of the middle phalanx to permit fixation of the
graft.
• Damage to the cartilage surface and head of the proximal phalanx that prohibits a
smooth articulation with a reconstructed middle phalanx.
• If a patient has preexisting arthritis, they may be a better candidate for arthrodesis
or arthroplasty.
• Injured or arthritic hamate carpometacarpal articulation.
A
Small finger missing from
• The PIP joint is inspected for stability in both an extended and flexed position.
natural finger cascade
• If greater than 30 degrees of flexion is required to maintain stability, then recon-
stitution of the middle phalanx articular surface is indicated.
• Examine the sagittal alignment with the finger extended, looking for collinearity of
the proximal phalanx and middle phalanx.
• Evaluate coronal plane alignment, assessing for lateral deviation that suggests
asymmetric compression of the articular surface (Fig. 13.1).
• Record active and passive range of motion of the affected finger.
IMAGING
• Standard radiographs (anterior-posterior, oblique, and later) are obtained to evaluate
the cortical and articular surfaces. The base of the middle phalanx and the proximal
phalanx head should be evaluated (Fig. 13.2).
• A computed tomography (CT) scan can be helpful in determining more detailed
anatomy. In noncomminuted circumstances, ORIF may be favored over arthroplasty
in acute or subacute cases (Fig. 13.3).
B
SURGICAL ANATOMY
FIGURE 13.1 Right small finger proximal inter-
phalangeal (PIP) joint fracture–dislocation result-
• The PIP is composed of the bicondylar articular head of the proximal phalanx and
ing in (A) loss of collinearity in the coronal plane. the concave base of the middle phalanx. A box of ligamentous structures aids the
The red arrow shows that the axis of the middle stability of the joint. The volar plate forms the floor, the radial and ulnar collateral
phalanx does not align with axis of proximal ligaments serve as the sides, and the extensor mechanism is the lid.
phalanx. (B) There is also disruption of the natu- • The PIP joint is a hinge joint, where the middle phalanx actually glides more than
ral finger cascade where the small finger is not
seen because of loss of PIP joint flexion (white
rotates on a fixed point. Stability during initiation of flexion relies on an intact articu-
arrow indicates where small finger should be lar surface and the volar lip of the middle phalanx. Fracture or loss of this volar
visualized). stability can lead to dorsal subluxation. Additionally, a dorsally subluxated middle
24
A B C
FIGURE 13.2 Anteroposterior (AP), oblique, and lateral views of this left middle phalanx fracture-dislocation show loss
of proximal interphalangeal (PIP) joint articular surface continuity. (A) The AP view shows a comminuted fracture of the
radial plateau of the middle phalanx with loss of height (red arrow). (B) The oblique view demonstrates the loss of joint
congruity and loss of the buttressing effect of the volar lip (blue arrow). (C) The lateral view demonstrates the dorsal
subluxation or “V sign” (green angle) and approximately 50% destruction of the volar lip (yellow bracket).
A B
FIGURE 13.3 A Severe impaction of the middle phalanx articular surface can be clearly seen (blue
arrow) as well as comminution of the volar cortex and articular surface (red arrow).
phalanx will lose its gliding motion and lever at the fracture site, leading to a hinge
motion and loss of flexion (Fig. 13.4).
• The rationale of this procedure is based on the anatomy of the hamate and the base
of the middle phalanx. The distal dorsal surface of the hamate has a central ridge
between its articulations with the bases of the ring and small metacarpals. This
26 CHAPTER 13 Hemi-Hamate Arthroplasty
Proximal phalanx
Accessory
collateral ligament
Proper
collateral ligament
Volar plate
FIGURE 13.4 Dorsal subluxation occurs with avulsion fractures when the insertions of the collateral liga-
ments are retained on the volar fragment.
Middle
phalanx
Metacarpal IV Metacarpal V
A
B C
B
PIP joint
Hamate
Lateral view Volar view Dorsal view

FIGURE 13.5 The hemi-hamate donor graft is harvested such that the hamate ridge (depicted by
line B) is centered on the recipient middle phalanx so that it articulates with the bicondylar shape of
the head of the proximal phalanx. Therefore, the line marked by B is not always centered on the
width of the graft (line A). The depth of the hemi-hamate donor graft (line C) is critically important
because it must be large enough to reestablish the volar lip to prevent subluxation.
bicondylar articular surface of the distal hamate has a contour similar to the base of
the middle phalanx. The dorsal lip has a cup-shaped architecture that has matched
FIGURE 13.6 The Bruner incision is designed
from the metacarpophalangeal (MCP) joint to
anatomy for replacement of the volar lip of the middle phalanx (Fig. 13.5).
the distal interphalangeal (DIP) joint to provide
adequate exposure. POSITIONING
• The patient is placed supine with the arm extended on a hand table.
• A tourniquet is placed on the upper arm.
EXPOSURES PEARLS EXPOSURES
The A3 pulley may already be damaged from the • To expose the injured PIP joint, a volar Bruner incision is designed from the distal
injury and can be excised.
interphalangeal (DIP) to the metacarpophalangeal (MCP) joint (Fig. 13.6).
• The skin and subcutaneous tissue are incised, and a flap is raised on the flexor
sheath protecting the neurovascular bundles.
• The A3 pulley is divided on its lateral edge to expose the flexor tendons. The A2 and
A4 pulleys are preserved. Preserved joint surface
• The tendons are retracted away, exposing the volar plate (Fig. 13.7).
PROCEDURE
Step 1: Shotgun Exposure of the PIP Joint Damaged
articular
• Detach the volar plate distally from the base of the middle phalanx. surface
• Sharply release the lateral portions of the volar plate by separating it from the acces-
sory collateral ligaments.
• Retract the volar plate proximally to expose the joint.
FIGURE 13.7 The proximal interphalangeal (PIP)
• While protecting the neurovascular bundles, divide the collateral ligaments to permit
joint has been shot-gunned to expose both joint
the joint to be hyperextended and “shot-gunned,” exposing the articular surfaces of surfaces. The purple triangle indicates the dam-
the proximal and middle phalanges (see Fig. 13.7). aged portion of the middle phalanx articular sur-
• The proximal phalanx is inspected for any major articular wear that would prohibit face (red arrow). The proximal articular surface is
hemi-hamate arthroplasty reconstruction. well preserved, and the blue arrow shows the
small valley of the bicondylar head that will articu-
late with the ridge of the hemi-hamate donor graft.
Step 2: Preparation of Fracture Site
• Irrigate and debride all comminuted fracture fragments. The residual articular dam-
STEP 1 PEARLS
age is often irregular.
• A volar box resection that includes all the damaged articular surface is designed. A Mobilization of the volar plate in a distal to proximal
manner allows it be draped over the hamate graft
box design is easier to both resect and fill with a contoured graft piece. Resecting
at the end of surgery.
only the damaged area will make graft fitting difficult.
• Ideally, leave the radial and ulnar margins (if uninjured) around the box to create
a notch for future inset. STEP 1 PITFALLS
• A power saw or osteotome is used to make parallel cuts, resecting the damaged • Avoid excessive manipulation of the tendons
articular surface (Fig. 13.8). because this can create postoperative adhe-
• Measure the dimensions of the defect (length, width, and depth; see Fig. 13.5). sions leading to poor mobility outcomes.
• Always be cognizant of the location of the
• Make note of the location of the proximal articular ridge with respect to the neurovascular bundles.
defect.
• If the articular ridge does not equally bisect the box defect, cut a plastic ruler
STEP 2 PEARLS
template to match the length and width dimensions and mark the location of the
ridge along the width. • Making parallel and symmetric cuts aids in
measurement and contouring of the graft.
• The depth (or horizontal cut) can be slightly
Step 3: Hemi-Hamate Graft Harvest tapered distally (i.e., become more shallow). This
• Locate the fourth and fifth metacarpal interval with fluoroscopy (Fig. 13.9). ensures that when the hemi-hamate graft is in-
• Make a 3-cm transverse incision over the interval. set, the graft recreates the volar lip and follows
the natural contour of the articular surface.
• If using a saw, irrigate to prevent thermal
osteonecrosis.
STEP 2 PITFALLS
During preparation of the fracture site, it is important
not to fracture the dorsal cortex of the middle
phalanx. The dorsal cortex is used for fixation of the
replacement piece.
STEP 3 PEARLS
A small trough is made proximal to the horizontal
cut. This trough aids in the placement of a curved
osteotome to make a volar osteotomy parallel to
the dorsal cortical surface.
FIGURE 13.8 A box-shaped defect has been created (red arrow) in the middle phalanx. The condyle STEP 3 PITFALLS
on the radial side has been preserved to allow ease of graft inset (blue arrow). The ulnar condyle was The cuts should be designed 1 mm larger in all
too heavily injured to preserve. The green dotted line shows the location of the ridge on the proximal dimensions to ensure that a large graft is harvested.
phalanx. This line does not equally bisect the box defect, and this must be considered when harvest- The piece can then be trimmed to provide perfect inset.
ing the hemi-hamate graft.
4th MC 5th MC
Hamate
A B
FIGURE 13.9 Identifying the fourth and fifth metacarpal (MC) interval guides placement of the dorsal hand incision.
• Retract and protect the longitudinal sensory nerves and veins.

• Retract the extensor digiti minimi ulnarly and extensor digitorum communis radially
and expose the joint interval and hamate (Fig. 13.10A).
• Use the template previously created to mark the dimensions of the graft (and to
match the location of the hamate ridge that will articulate with the central groove of
the proximal phalanx; see Fig. 13.10B–C). The dorsal aspect of the hamate will serve
as the volar lip of the middle phalanx.
• Close the capsule over the joint and close the wound.
Metacarpal Hamate
A B C
FIGURE 13.10 (A) Retract the extensor digiti minimi ulnarly (blue arrow) and extensor digitorum communis (red arrow) radially and expose the joint inter-
val. The dimensions are marked as described, and a small trough is made proximal to the graft (green arrow). (B–C) The two lateral cuts are made first,
followed by the volar cut. The trough made proximal to the graft facilitates placement of a curved osteotome to make this volar cut parallel to the dorsal
cortex.
FIGURE 13.12 Three bicortical

screws are securing this graft to the
dorsal cortex. The lateral view
B shows a well-contoured articular
surface and recreation of the volar
FIGURE 13.11 The hemi-hamate graft is inset flush into the box recess previously created. The red arrow lip (red arrow). Additionally, there is
highlights the hamate ridge that will articulate with proximal phalanx recess (blue arrow). no “V sign” dorsally, which indicates
resolution of dorsal subluxation.
STEP 4 PEARLS
Step 4: Hemi-Hamate Graft Inset
• The hamate graft is fashioned to fit the predesigned, previously made box recess A properly placed hemi-hamate graft is angulated
to reconstitute the volar lip (Fig. 13.14).
(Fig. 13.11).
• Contour the graft as needed so that it is well seated.
• The graft must be inset so that it recreates the volar lip, which prevents dorsal STEP 5 PEARLS
subluxation. • The tendon sheath (A3 pulley) can be inter-
• Using fluoroscopy, the hamate is secured with multiple 1-mm screws to the dorsal posed between the tendons and volar plate as
an added layer of soft tissue if the volar plate
cortex (Figs. 13.12 and 13.13).
is thin or damaged.
• The graft is fitted visually to fill the defect. Be-
Step 5: Closure cause the hemi-hamate has more bone sub-
• The tourniquet is released, and hemostasis is obtained with bipolar cautery. stance, it will often appear larger on the x-
• The finger is reduced from the shotgun position to its anatomic position. The re- rays, when in actuality it is a good fit with the
cartilaginous construct of the volar cortex of
leased volar plate is laid distally over the newly secured hamate graft as the flexor
the middle phalanx.
tendons naturally resume their anatomic position.
• Movement and stability of the finger is manually tested in the operating room.
• The Bruner incision is closed with interrupted 4-0 nylon.
• The patient is placed in a dorsal splint with the wrist neutral and finger immobilized
in 20 degrees of flexion.

• The splint is removed at 1 week.
• Active PIP joint flexion is started with an extension block splint that prevents full PIP
joint extension. Active and passive motion is started for the MCP and DIP joints.
• Radiographs are obtained at 2 weeks and 6 weeks to evaluate the graft position and
bone healing (Fig. 13.15).
• Unrestricted use of the hand is allowed at 12 weeks.
FIGURE 13.13 Three-month follow-up shows excel-

lent bony healing and reconstitution of joint congruity.
Incorrect
Correct
FIGURE 13.14 The graft should be inset such that it recreates the volar lip (black arrow) and the contour follows the natural curve of the articulation.
B
E
FIGURE 13.15 Post-operative radiographs after right small finger PIP joint hemi-arthroplasty demonstrates
near full extension and approximately 90 degrees of flexion.
EVIDENCE
Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional
reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am.
2009;34:1232–1241.
The authors retrospectively evaluated 33 patients at an average of 4.5 years after hemi-hamate arthro-
plasty for both acute and chronic PIP joint fracture–dislocations. Patients had an average PIP range
of motion of 70 degrees and DIP motion of 54 degrees. The average visual analogue (VAS) functional
score was 1.4 and Disabilities of the Arm, Shoulder, and Hand (DASH) score was 5. Ten patients
complained of increased pain with cold temperatures. Only one patient required revision surgery. The
authors concluded that hemi-hamate arthroplasty restores PIP function after both acute and chronic
PIP joint fracture–dislocations (Level V evidence).
Frueh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalan-
geal joint reconstruction: a systematic review. J Hand Surg Eur Vol. 2015;40:24–32.
This article is a systematic review of hemi-hamate arthroplasty. The review was performed according to
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and
initial selection was performed by two independent reviewers. Thirteen articles on hemi-hamate auto-
graft were included in full-text analysis. Results of 71 cases were summarized: (1) Number of patients
treated; (2) degree of joint involvement; (3) delay to surgery; (4) follow-up time; (5) functional outcome
(range of motion, grip strength); and (6) complications and donor site morbidity. Mean follow-up was
36 months and mean proximal interphalangeal joint range of motion was 77 degrees. Overall compli-
cation rate was around 35%. Up to 50% of patients showed radiographic signs of osteoarthritis. Nev-
ertheless, few of those patients complained about pain or impaired finger motion. The authors con-
clude that hemi-hamate arthroplasty is reliable for the reconstruction of acute and chronic proximal
interphalangeal joint fracture–dislocation with joint involvement greater than 50%. Longer-term
follow-up studies are required to evaluate its outcome, especially regarding the rate of osteoarthritis
(Level III evidence).
Burnier M, Awada T, Braun FM, et al. Treatment of unstable proximal interphalangeal joint fractures
with hemi-hamate osteochondral autografts. J Hand Surg Eur Vol. 2017;42(2):188–193.
This retrospective study included 19 patients (average age of 39 years) with an isolated fracture of the
base of the middle phalanx (10 chronic, 9 acute) that involved more than 40% of the articular surface
who underwent hemi-hamate arthroplasty. Outcomes were measured at a mean follow-up of
24 months. The mean active flexion at the PIP joint was 83 degrees with a mean fixed flexion of
17 degrees. The mean active DIP joint motion was 41 degrees, mean QuickDASH was 11, and
mean grip strength was 82% of the contralateral side (Level III evidence).
CHAPTER 14
Techniques and Fixation of Metacarpal Fractures

This chapter includes the following video: Video 14.1 – Open Reduction and Internal
Fixation of Metacarpal Shaft Fractures.
KEY CONCEPTS
• Most metacarpal fractures do not require operative treatment. Nondisplaced frac-
tures or minimally displaced fractures without clinical deformity that meet accept-
able radiographic parameters can be treated with a brief period of immobilization
and early motion. Surgery may be indicated for metacarpal fractures that have recur-
rent or residual displacement after an attempt at reduction, especially if the fracture
displacement results in disturbance in form or function of the hand.
• Posteroanterior radiographs provide the best evaluation of shortening, whereas lateral
views are best for identifying angulation.
• Provisional reduction can be obtained with a variety of methods, including reduction
clamps, bone forceps, or temporary Kirschner wires.
• Operative fixation with an intramedullary device may be preferred to permit early
rehabilitation and return to sport. Treatment with lag screws and/or a plate construct
can also be used. Lag screw fixation should ideally include screws with two different
orientations: screws perpendicular to the fracture line provide better compression,
whereas screws perpendicular to the long axis of the bone resist axial shear better.
• Bridging plates are useful for maintaining bone length in situations where collapse
might otherwise occur.
• Most patients should recover near-normal motion and strength, with excellent union
rates and radiographic outcomes.
• Percutaneous intramedullary fixation of metacarpal head and neck fractures
• Open reduction and internal fixation of metacarpal shaft fractures:
• Lag screws
• Compression plates
• Bridging plates
• Tension-band wiring
• Neutralization plates
FIGURE 14.27 Compression plate fixation of metacarpal fractures.
33
CHAPTER 14
Techniques and Fixation of Metacarpal Fractures
Closed Reduction with Kirschner Wire Fixation of

Metacarpal Neck and Shaft Fractures
INDICATIONS
• Surgery may be indicated for fractures that have recurrent or residual displace-
ment after an attempt at reduction, especially if the fracture displacement results
in disturbance in form or function of the hand.
• Specific indications for surgery include rotational deformities, angular deformities,
shortening, multiple fractures, and open fractures.
Rotational Deformity
Even small amounts of rotational deformity (10 degrees; Fig. 14.1) can cause overlap
Rotational
(“scissoring”) of the digits; therefore this deformity must be corrected to preserve deformity
proper hand function.
Angular Deformity
Angular deformity is typically apex-dorsal (Fig. 14.2). Because of compensatory mo-
tion at the carpometacarpal (CMC) joints, residual angulation of metacarpal fractures
is tolerated better in the thumb, ring, and small fingers than in the index and middle
fingers.
FIGURE 14.1 Clinical assessment of rotational
In particular, the small finger metacarpal neck fracture (often called a “boxer’s deformity of a fourth metacarpal fracture demon-
fracture”) is a common fracture that typically heals with negligible morbidity, despite strating “scissoring.”
significant residual angulation, as long as there is no rotational deformity.
Surgical correction should be considered for shaft angulation of:
Angular deformity Dorsal
• Index and middle: More than 5 to 10 degrees
• Ring: More than 20 degrees
• Small: More than 30 degrees
• Thumb: More than 30 degrees
Surgical correction should be considered for neck angulation of: Volar
• Index and middle: More than 10 to 15 degrees
• Ring: More than 20 to 30 degrees
• Small: More than 40 to 70 degrees (wide variation in recommendations) FIGURE 14.2 Apex-dorsal angular deformity.
Shortening
Shortening is better tolerated than angular and rotational deformity, but loss of more
than 5 mm of length may cause symptoms of pain, weakness, and a noticeable
extension lag.
Multiple Fractures
If adjacent metacarpals are injured, fracture instability is dramatically increased beyond
what is seen for a single fracture, owing to loss of additional supporting structures.
Open Fractures
Percutaneous Kirschner wire (K-wire) fixation may be preferable for open fractures with
contamination or soft tissue defects requiring supplementary coverage to avoid exposure
of hardware in an open wound.
• Metacarpal neck fractures can also be treated with intramedullary fixation (see
“Percutaneous Intramedullary Fixation of Metacarpal Head and Neck Fractures”).
• Long oblique or spiral metacarpal shaft fractures may be more easily treated with lag
screws (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”).
33.e1
33.e2 CHAPTER 14 Techniques and Fixation of Metacarpal Fractures
Contraindications
• Note that most metacarpal fractures do not require operative treatment. Nondisplaced
fractures or minimally displaced fractures without clinical deformity that meet accept-
able radiographic parameters can be treated with a brief period of immobilization and
early motion. Stable displaced fractures with satisfactory alignment after closed
reduction can also be treated nonoperatively.
• General contraindications for surgery:
• Medically unfit: Highly comorbid patients or patients with active hemodynamic
compromise or systemic infections should have medical issues addressed before
considering operative treatment.
• Patient preference: Low-demand patients can have satisfactory functional results
even with substantial deformity and may prefer to be treated nonoperatively.
• Specific contraindications for closed reduction and K-wire fixation include:
• Comminution: K-wire fixation may not adequately maintain length and rotational
stability in fractures with long comminuted segments, which can be better
treated with bridge plating constructs (see Open Reduction and Internal Fixation
of Metacarpal Shaft Fractures).
A • Bone loss: Fractures with segmental bone loss also require a lengthy and rota-
tionally stable construct and can be better treated with bridge plating.
• Early return to athletic activity: Exposed pins can migrate or cause infection and
are not ideal for athletes seeking to return to early vigorous activity.
• Noncompliance: Because of concerns for pin site infection, patients who will not
reliably return for follow-up should be treated with other means.
• Swelling and wounds on the dorsal surface should be noted. Swelling may obscure
fracture displacement, and wounds may indicate the presence of an open fracture
or associated soft tissue injury that may be prone to osteomyelitis if the bone is not
debrided of contaminants (Fig. 14.3A–B).
• Malrotation can be assessed by simultaneously flexing the digits. Digits normally
converge slightly and point toward the scaphoid tuberosity. Fig. 14.4 shows a ring
finger that is not pointing toward the scaphoid tuberosity, labeled “S.”
• Subtle malrotation may be identified by close examination of the fingertips in mild
flexion. Fig. 14.5 shows a ring finger that is pronated relative to the other digits.
B • Limitations in range of motion should be identified, including any weakness, me-
chanical blocks, or extension lag. A mechanical block to motion may be present in
FIGURE 14.3 Swelling of the (A) dorsal and juxta-articular fractures or be indicative of intra-articular extension. The presence of
(B) volar hand. mild-to-moderate extension lag (20–30 degrees) at the metacarpophalangeal (MCP)
joint is common but often improves over time.
IMAGING
• Plain radiographs should be obtained in three views (posteroanterior [PA], oblique,
and lateral; Fig. 14.6A–C).
FIGURE 14.4 Assessment of fourth metacarpal

rotational deformity. S, scaphoid tuberosity. FIGURE 14.5 Subtle rotational deformity in ring finger.
.
CHAPTER 14 Techniques and Fixation of Metacarpal Fractures 33.e3
STEP 1 PEARLS
• Subacute (partially healed) fractures may ben-
efit from percutaneous manipulation with the
tip of a K-wire or dental pick to loosen any
early bony callus.
• Rotational alignment needs to be assessed,
corrected, and maintained during reduction and
fixation. Holding the injured digit and neighbor-
ing digits in a composite fist can help maintain
rotational alignment during this process.
A B C
FIGURE 14.6 (A) Posteroanterior [PA], (B) oblique, and (C) lateral radiograph of a second metacarpal
fracture. STEP 2 PEARLS
• Longitudinal K-wires:
• Wires can be placed extra-articular to the
• PA view gives the best evaluation of shortening. Metacarpal heads of middle, ring, metacarpophalangeal (MCP) joint if the
and small fingers are usually arranged in a line. entry point is at the collateral ligament
recess (metacarpal head/neck).
• The lateral view provides the best evaluation of angulation.
• Consider mini-open techniques with limited
• Computed tomography (CT) may be useful in the evaluation of subtle or complex dissection in some cases to avoid damage
fracture patterns, or if intra-articular extension is suspected. CT is typically unneces- to cutaneous nerves and/or extensor
sary for diaphyseal fractures. tendons.
SURGICAL ANATOMY
• Dorsal cutaneous nerves are at risk of injury or irritation, especially with wires placed STEP 2 PITFALLS
near larger, more proximal nerve branches. • Longitudinal K-wires
• The metacarpal shaft is comprised of heavy cortical bone with a narrow medullary canal. • Wires placed through the head of the meta-
carpal will transfix the extensor mechanism
In contrast, the cortical bone is thinner at the neck (metaphysis) of the metacarpal.
and often lead to extensor tendon adhe-
• Of all the metacarpals, the ring finger is the narrowest, making it a challenging target sions. These tendon adhesions can typically
for percutaneous fixation techniques. be managed with postoperative therapy but
may occasionally require reoperation.
PROCEDURE • Transverse K-wires
• At least two K-wires are needed in the dis-
Step 1 tal fragment to avoid palmar rotation of the
• Longitudinal traction, plus external pressure at the fracture site, can reduce most distal fragment.
metacarpal shaft fractures, which typically have an apex-dorsal configuration. • Fractures reduced indirectly can shorten
• The Jahss maneuver (Fig. 14.7) can help with reduction of metacarpal neck fractures over time. This K-wire configuration is best
suited for length-stable fracture patterns
intraoperatively. This maneuver uses dorsally-directed force applied to the flexed
(i.e., transverse or short oblique patterns
proximal interphalangeal (PIP) joint to reduce an apex-dorsal metacarpal neck frac- with minimal translation at the fracture site).
ture. Alternatively, this maneuver can be performed with the PIP joint extended to
relax the intrinsic muscles and further facilitate reduction.
Step 2
• Fixation is usually performed with 0.045-inch (1.1-mm) K-wires. Two configurations
of wires can be used: longitudinal or transverse.
• Longitudinal K-wires:
• They are typically placed from distal to proximal (Fig. 14.8A–D).
• Wires may be left exposed distally or advanced to exit the skin proximally.
• At least two wires are required for rotational stability.
• Alternatively, a single longitudinal wire can be used to prevent angular displacement,
and postoperative buddy-straps can be used to control rotational displacement in
stable fracture patterns.
• Transverse K-wires:
• They are typically placed from index-to-middle or small-to-ring metacarpals (Fig. 14.9).
• Uses a healthy neighboring metacarpal as a stable foundation to immobilize the
adjacent fracture indirectly. FIGURE 14.7 Jahss maneuver.
A B C D
FIGURE 14.8 Postoperative (A) posteroanterior [PA], (B) oblique, (C) lateral radiographs, and (D) intraoperative fluoroscopic image demonstrating K-wire
fixation of a fourth metacarpal fracture.
Step 3
• K-wires are cut to an appropriate length to accommodate a pin cap (a protective
covering for the end of the wire).
• Alternatively, K-wires can be cut beneath the surface of the skin and removed with
a minor procedure at a later date (not common).
• A protective splint is applied, with ample padding around the K-wire exit sites. This
initial splint is typically a forearm-based intrinsic-plus splint for the operative digit
and at least one neighboring digit.

• Patients are typically seen in 7 to 10 days to initiate mobilization exercises for all
uninvolved digits and joints.
• Even joints adjacent to the fracture should be able to be gently mobilized with the
K-wires in place.
• Long-term immobilization (over 4 weeks) is to be avoided because it will lead to
unwanted stiffness.
• A removable orthosis is used to protect the pin sites and permits the hand to rest in
a safe position (intrinsic-plus) between therapy sessions.
• Alternatively, for very young patients or others with poor compliance, casting for the
FIGURE 14.9 Transverse K-wire technique.
first few weeks can provide protection during the early stages of healing.
• Remove K-wires in the clinic once fracture healing is underway. Typically, this can
occur around 4 weeks postoperatively or when the fracture site is nontender or
STEP 3 PEARLS minimally tender to palpation.
• Strategies to prevent inadvertent K-wire migra- • Excellent union rates, range of motion, and grip strength are generally expected.
tion into the hand: Biomechanical strength and radiographic outcomes for complex fractures may be
• Place a bend in the wire a few millimeters slightly inferior to the other techniques described in this chapter.
above the level of the skin. The wire should
be far enough from the skin surface so that
postoperative swelling will not cause im- Percutaneous Intramedullary Fixation of Metacarpal Head
pingement. and Neck Fractures
• During insertion, position the K-wires so
that the distal tip is abutted against cortical INDICATIONS
bone—either the cortex of the metacarpal • See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft
base or the shaft on the opposite side of
Fractures” for a detailed discussion of the following indications:
the fracture line. This will prevent inward
migration of K-wires. • Rotational deformity
• Padding and dressings should be designed • Angular deformity
to minimize skin tension and motion at pin • Shortening
sites. The repetitive pistoning of skin around • Multiple fractures
pin entry points contributes to the introduc-
• For athletes, operative fixation with an intramedullary device may be preferred to
tion of bacteria at these sites.
permit early rehabilitation and return to sport. Treatment with lag screws and/or a
plate construct can also be used (see “Open Reduction and Internal Fixation of POSTOPERATIVE PEARLS
Metacarpal Shaft Fractures”). Radiographic signs of consolidation at the fracture site
• Long oblique or spiral metacarpal shaft fractures may be more easily treated with lag may not be visible for several months, so decisions
screws (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”). about pin removal should not be dependent only on
radiographic findings. When fracture site palpation is
Contraindications minimally painful, there is typically enough healing
present to remove pins and begin gentle mobilization.
• For general contraindications to surgery, see “Closed Reduction with Kirschner Wire
Fixation of Metacarpal Neck and Shaft Fractures.”
• There are a few specific contraindications for percutaneous intramedullary fixation:
• Comminution/bone loss: Intramedullary fixation is unlikely to adequately maintain POSTOPERATIVE PITFALLS
metacarpal length in fractures with comminution or segmental bone loss, which Wires exiting percutaneously near the MCP joint
can be better addressed with bridge plating constructs (see “Open Reduction need to be protected by limiting MCP extension
and Internal Fixation of Metacarpal Shaft Fractures”). postoperatively. Excess tension on these wires
• Malrotation: Intramedullary devices generally confer limited rotational stability. can lead to bending of the wires and/or pin site
infections.
Fractures with substantial rotational deformity are better treated with the other
fixation techniques in this chapter.
• Skin defects over the dorsal metacarpal head can provide direct access to the
fracture and should be treated with internal fixation and flap closure.
• Rotational alignment should be carefully assessed.
• For details of the clinical examination, see “Closed Reduction with Kirschner Wire
Fixation of Metacarpal Neck and Shaft Fractures.”
IMAGING
• For details of the imaging, see “Closed Reduction with Kirschner Wire Fixation of
Metacarpal Neck and Shaft Fractures.”
SURGICAL ANATOMY
• The dorsal sensory branch of the ulnar nerve passes directly over the base of the
small finger metacarpal and is at risk for exposures or punctures in this area.
• The terminal branches of the superficial radial nerve are vulnerable to injury at the
base of the thumb and/or index metacarpals.
• The finger extensor tendons cross over the bases of the middle, ring, and small
finger metacarpals on their way to the digits (Fig. 14.10).
• The metacarpal bases serve as insertion points for the wrist extensors: EXPOSURES PEARLS
• Extensor carpi radialis longus (ECRL) on the dorsal base of the index finger metacarpal For the small finger, this approach can be made at
• Extensor carpi radialis brevis (ECRB) on the dorsal base of the middle finger the ulnar border of the metacarpal base, making it
metacarpal easier to avoid the finger extensors.
• Extensor carpi ulnaris (ECU) on the dorsal-ulnar base of the small finger metacarpal
EXPOSURES PITFALLS
EXPOSURES Percutaneous techniques (without open dissection)
Intramedullary fixation techniques make use of small incisions at the base of the frac- risk damage to sensory nerves and extensor
tured metacarpal (Fig. 14.11). tendons with the introduction of K-wires at the
Using small retractors and blunt dissection, the overlying extensor tendons and metacarpal bases.
sensory nerve branches can be swept aside and protected, enabling safe access to the
metacarpal base (Fig. 14.12).
STEP 1 PEARLS
It may be desirable to measure the diameter of
PROCEDURE the intramedullary canal on a preoperative x-ray,
particularly if the implant size must be determined
Step 1 in advance.
• Closed reduction is used to correct any fracture displacement. The Jahss maneuver
(Fig. 14.13) is ideal for this. See “Closed Reduction with Kirschner Wire Fixation of
Metacarpal Neck and Shaft Fractures” for additional details. STEP 1 PITFALLS
• Fluoroscopic images are taken to verify reduction of the metacarpal and determine Poor size-matching of the implant to the
the diameter of implant needed to match the size of the intramedullary canal. The intramedullary canal will result in inadequate
implant can be placed directly over the metacarpal while taking a PA fluoroscopic fracture stability if the implant is too small or fracture
distraction/comminution if the implant is too large.
image. Its diameter should fill the diaphysis of the metacarpal.
EDC
EIP EDM
ECRL ECU
ECRB
FIGURE 14.10 Extensor tendon anatomy.
FIGURE 14.11 Percutaneous skin incisions from intramedullary fixation of fourth and fifth metacarpal
fractures.
FIGURE 14.12 Fluoroscopic image of canal entry device for intramedullary metacarpal stabilization.
FIGURE 14.13 Closed reduction of metacarpal fracture under fluoroscopic visualization.

• Once the base of the metacarpal is exposed, the fixation device is inserted into the
• If no starter awl is available, the sharp end of a
medullary canal, headed distally toward the fracture. large K-wire (0.062 inch [1.6 mm] or larger)
• Options for fixation include multiple K-wires as well as commercially available de- can be used for this purpose. Gentle manual
vices. If using K-wires, thin wires are preferred (e.g., 0.035 inch [0.9 mm]) because twisting of this wire can be used to make a
they are more flexible for navigating the medullary canal. controlled, small cortical opening in the bone.
• Creating the initial cortical opening with an oblique
• Commercial devices may contain a starter awl to make this initial hole in the cortical
trajectory (proximal-to-distal) helps to introduce
bone. Often, this awl incorporates a channel or cannula for introducing the intramed- the fixation device into the medullary canal.
ullary fixation device (Fig. 14.14A–B).
STEP 2 PITFALLS
Step 3
• Once the fracture is reduced, the intramedullary fixation device is advanced across Be sure not to penetrate the opposite cortex when
making the starter hole. If using a power drill, be
the fracture site and into the metacarpal head. Ideally, the device should stop at the very cautious because the metaphyseal region at
level of the subchondral bone without penetrating the cortex (see Fig. 14.13). the dorsal metacarpal base has a thin cortex.
• Most commercially available devices are designed to advance with manual pressure.
A handle is often provided to drive in the intramedullary device (Fig. 14.15). Cannu-
STEP 3 PEARLS
lated screw systems may include a thin guidewire that can be advanced into the
metacarpal and across the fracture site to facilitate screw insertion. • Advance the device carefully under fluoroscopic
guidance to avoid penetration of the distal cor-
• Some devices rely on a locking peg at the base to control rotation around a single tex at the metacarpal head or neck. Accidental
large intramedullary rod. This peg is covered with a silicone cap to protect the exten- perforation of the joint can lead to intra-articular
sor tendons during the healing period; these devices are designed to be removed damage and postoperative stiffness.
after fracture healing is complete (Fig. 14.16). • Either fully threaded or partially threaded
• When using smaller devices without locking pegs, at least two divergent rods or screws can be used for most fractures. Partially
threaded screws should be used if there is
wires are required to control rotation. Round-tipped K-wires can be pre-bent into a comminution at the fracture site because fully
gentle curve and used for this purpose (Fig. 14.17A–B). threaded screws or those with variable pitch
can cause overcompression and shortening.
Step 4
• Once fully advanced, the intramedullary device is truncated at the metacarpal base.
STEP 3 PITFALLS
Locking pegs are applied if indicated; other devices or K-wires may simply be bent
It is possible to malrotate the fracture while
and cut. Some commercial devices may supply specialized bending and/or cutting
advancing an intramedullary screw with a tight
tools for this purpose. fit. The digit should be held in the desired rotation
• If hardware removal is planned at a later date, the device should be left protruding while advancing the screw, particularly as the final
slightly from the bone to make removal easier. few turns are applied.
• Some surgeons elect to leave K-wires in permanently, in which case the wires can
be cut flush with the cortex of the metacarpal base.
A B
FIGURE 14.14 Fluoroscopic images of (A) canal entry device for intramedullary stabilization of fifth
metacarpal and (B) passage of guidewire into canal.
FIGURE 14.15 Commercially available handle for intramedullary device insertion.
A B
FIGURE 14.16 Postoperative (A) posteroanterior [PA] and (B) lateral radiographs of intramedullary
wires with locking pegs.
A B
FIGURE 14.17 (A) Preoperative and (B) postoperative radiographs of a fifth metacarpal fracture stabi-
lized with multiple intramedullary K-wires.
• Motion of the fingers should be checked with passive and/or active maneuvers to POSTOPERATIVE PEARLS
verify that the extensor tendons are gliding freely without interference.
Removal of hardware can be difficult because
the bone has often healed around the curved
POSTOPERATIVE CARE AND EXPECTED OUTCOMES intramedullary device. A secure grasp of the end
• The hand is protected with an intrinsic-plus splint for the first several weeks, but of the rod/wire with heavy pliers works best; small
early motion out of the splint is important, starting 4 to 7 days after surgery. needle-drivers or hemostats do not have enough
• Buddy-taping can help with maintaining rotational stability and improving motion mechanical advantage to be successful.
during the healing period.
• In about 6 weeks, most patients have very little fracture pain and have restored their POSTOPERATIVE PITFALLS
preoperative motion. At that point, they can wean from their splint and begin Removal of hardware needs to be performed gently
strengthening. without excessive torque to avoid fracture of the
• Uncomplicated union with restoration of full range of motion and grip strength and metacarpal base.
excellent subjective outcomes are expected for most fractures.
• If hardware removal is planned, it should be performed after fracture healing is complete.
Open Reduction and Internal Fixation

of Metacarpal Shaft Fractures
INDICATIONS
• See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft
Fractures” for a detailed discussion of the following indications:
• Rotational deformity
• Angular deformity
• Shortening
• Multiple fractures
• Fractures irreducible by closed means are another indication.
• Other indications are unstable fracture patterns:
• Spiral or long oblique fractures
• Multiple metacarpal fractures
• Comminuted fractures
• Fractures with segmental bone defects
• Open fractures with adequate soft tissue coverage
• A polytrauma patient may require the procedure.
• An athlete requiring early rehabilitation may require the procedure.
Contraindications
• See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft
Fractures” for general contraindications for surgery.
• Specific contraindications for open reduction and internal fixation include:
• Inadequate soft tissue envelope: Open fractures with wound contamination or
large skin defects requiring supplementary soft tissue coverage should be treated
with alternate means, such as closed reduction with K-wire fixation or external
fixation, to minimize hardware exposure and infection risk.
• Open reduction, particularly with plate and screw fixation, should be avoided in
patients with poor skin integrity at risk for wound healing complications.
• Closed reduction and percutaneous K-wire or intramedullary fixation should be
strongly considered in patients with systemic risk factors for wound healing com-
plications (e.g., systemic inflammatory disease, diabetes, smoking).
Refer to “Closed Reduction with K-Wire Fixation of Metacarpal Neck and Shaft Fractures”
for a discussion of the clinical examination.
IMAGING
• Refer to “Closed Reduction with K-Wire Fixation of Metacarpal Neck and Shaft
FIGURE 14.18 Radiograph of third metacarpal
fracture. Fractures” for a discussion of the radiographic evaluation of metacarpal fractures
(Fig. 14.18).
• Fracture configuration will directly influence the type of fixation considered.
• Transverse fractures are typically fixed with compression plating.
EXPOSURES PEARLS • Long oblique (spiral) fractures are typically fixed with interfragmentary compres-
• Be alert for small subcutaneous veins; they are sion screws (lag screws).
often paired anatomically with nerves. • Short oblique fractures, where there is limited space for interfragmentary screws,
• Nerves tend to lie a little deeper than the may benefit from a combination of lag screws and compression/neutralization
veins, in the deep subcutaneous tissue, but
plating techniques.
superficial to the fascia.
• Offset or “stagger” the incisions in each layer • Comminuted fractures generally require a bridging plate to span the fracture, in
(skin, subcutaneous tissue, and fascia) to avoid addition to other techniques such as lag screws or cerclage wires.
a continuum of scar extending from skin to
deeper structures. In other words, do not make SURGICAL ANATOMY
the skin incision directly over your incision in
• Distal branches of the superficial radial nerve and the dorsal sensory branch of the
the fascia/paratenon and do not incise
paratenon directly over your periosteal incision. ulnar nerve are at risk for injury on the dorsum of the hand (Fig. 14.19).
This permits uninjured tissue to be interposed • Juncturae tendinum interlink the extensor tendons at the level of the metacarpal
between the layers of scar (Fig. 14.23). necks and may need to be divided during fracture exposure. Repair may be consid-
• Elevate the periosteum and interosseous fascia ered but is probably not necessary in most cases (Fig. 14.20).
as a single unit, preserving this layer for closure
• Interosseous muscles originate from the metacarpal shafts; the fascia covering
over the hardware after fixation is complete.
these muscles is contiguous with the periosteum on the dorsum of the bones.
EXPOSURES
EXPOSURES PITFALLS
• The dorsal approach is essentially universal.
• Avoid making an incision directly over an ex-
• A skin incision is made longitudinally and slightly off-center along the dorsum of the
tensor tendon to decrease the chance of post-
operative tendon adhesions. metacarpal (Fig. 14.21).
• Do not completely strip the extensor tendons • For fixation of adjacent metacarpal fractures, a single incision can be made between
of their surrounding fatty areolar tissue the metacarpals so that both fractures can be exposed.
(paratenon) because this can also result in • Subcutaneous tissue is gently dissected to avoid damage to cutaneous nerves.
tendon adhesions.
• Extensor tendons are retracted, and periosteum is incised to expose the fracture
• Do not strip away more periosteum or muscle
than is necessary to achieve good reduction/ (Fig. 14.22).
fixation because this can reduce the blood
supply for fracture healing.
PROCEDURE
Step 1: Reduction
STEP 1 PEARLS
• Fracture edges need to be cleaned of debris and fracture hematoma to accurately
For most fracture configurations, the Auerbach assess the reduction.
bone reduction instrument (Fig. 14.24; Stryker
• Provisional reduction can be obtained with a variety of methods, including reduction
Corp., Kalamazoo, MI) works nicely.
clamps, bone forceps, or temporary K-wires.
Superficial branch of Dorsal cutaneous branch

the radial nerve of the ulnar nerve
FIGURE 14.19 Nerve anatomy in the dorsal hand.
Juncturae
tendinum
FIGURE 14.20 Juncturae tendinum.

FIGURE 14.22 Dorsal exposure of second metacarpal.

FIGURE 14.21 Dorsal hand skin incision.
Incision
line
Skin
Subcutaneous
tissue
Fascia
Bone
FIGURE 14.23 Staggering of layers in exposure of metacarpal.
FIGURE 14.24 Auerbach bone reduction instrument.
STEP 1 PITFALLS Step 2: Fixation

• Care must be taken not to strip more perios- Metacarpal fixation is typically performed with 2.0- to 2.4-mm diameter screw sets,
teum than necessary to achieve adequate vi- although smaller screws (1.5- to 1.7-mm) may be preferred for smaller hands or for lag
sualization of the fracture edges. Excessive screws, where 2.0-mm screws may be too large.
periosteal stripping will compromise the blood
supply and healing potential of the bone. Lag Screws
• Even if reduction appears anatomic, check the
posture and alignment of the finger carefully • Lag screws provide interfragmentary compression and are ideal for long oblique
before performing fixation. Once the bone has fractures.
been fixed with a plate and/or screws, it is • The near cortex is drilled with a drill bit that has the same diameter as the external
very difficult to revise the reduction.
diameter of the screw, creating a gliding hole (e.g., for a 1.5-mm screw, use a 1.5-mm
drill bit).
• The far cortex is drilled with a drill bit that matches the core diameter of the screw,
creating a threaded hole when the screw is advanced (e.g., for a 1.5-mm screw, use
a 1.1-mm drill bit). Some instrumentation sets include a special drill guide that fits
into the gliding hole to assist with this step.
• Some surgeons choose to reverse this process, drilling both cortices with the
smaller drill bit first, then overdrilling the near cortex as needed.
• A countersink can be used on the proximal screw hole to minimize the prominence
of the screw head, particularly if it is to be buried under a neutralization plate.
• Measure screw length and insert the screw. A fully threaded screw should be used.
The screw will slide through the near cortex and engage the far cortex with the screw
threads. Because most screws designed for this application are self-tapping, a
separate tapping step is not required.
• As the screw is tightened in this lag configuration, the fracture site is compressed
between the head of the screw and the distal threads (Fig. 14.25).
• Three or more lag screws are ideal (Fig. 14.26A–D).
• Lag screws may not be appropriate if the fracture length is less than twice the bone
diameter, and short oblique fractures may only accommodate two screws.
FIGURE 14.25 Lag screw technique.
Compression Plates
• Compression plates have ovoid holes so that compression can be generated at the
fracture site (Figs. 14.27 and 14.28).
• A screw hole adjacent to the fracture should be drilled first. The plate should be
pulled toward the fracture as a screw is inserted and tightened so that the screw is
positioned eccentrically in the hole.
• The ovoid hole on the opposite side of the fracture should be drilled next. This
hole is drilled eccentrically on the side of the hole distant from the fracture.
Many instrumentation sets have specialized drill guides to facilitate this step. By
tightening the second screw, axial compression is generated at the fracture site
(Fig. 14.29).
• Screws are then placed in the remaining holes. These screws serve to reinforce the
fixation but do not generate additional compression.
A B C
FIGURE 14.26 (A) Preoperative and postoperative (B) posteroanterior [PA] and (C) lateral photograph
and (D) clinical photograph showing lag screw fixation of a third metacarpal fracture.
FIGURE 14.27 Compression plating clinical photograph.
FIGURE 14.28 Compression plating radiograph.
FIGURE 14.29 Compression plating technique.
Bridging Plates
• This plate construct spans an area of comminution or bone loss and provides rela-
tive stability. Bridging plates are useful for maintaining bone length in situations
where collapse might otherwise occur (Fig. 14.30).
• At least three screw holes should be filled on each side of the fracture, spanning as
much of the metacarpal as possible to confer maximal stability.
• If bone loss is present, intercalary bone graft can be placed in the defect.
STEP 2 PEARLS
• Lag screw fixation should ideally include
screws with two different orientations: screws
perpendicular to the fracture line provide bet-
ter compression, whereas screws perpendicu-
lar to the long axis of the bone resist axial
shear better.
• Lag screw fixation alone may not confer suffi-
cient stability in fragile or osteoporotic bone or
when fewer than three screws are used. The
construct should be supplemented with a neu-
tralization plate in such scenarios.
• Plates with staggered holes permit more points
of fixation over a smaller exposure and may be
FIGURE 14.30 Bridge plating.
desirable for fractures located proximally or
distally in the metacarpal with limited bone
available for fixation on one side of the fracture
Tension-Band Wiring (Fig. 14.32).
This construct counteracts the forces that typically cause an apex-dorsal deformity in
metacarpal fractures. The deformity results from eccentric forces on the fracture site, STEP 2 PITFALLS
causing distraction of the dorsal side of the fracture (tension side) and compression of • Lag screws should not be placed within two
the volar side. Tension-band wiring converts tension forces on the dorsal side of the screw diameters of the edge of a fracture. Do-
fracture into compression forces, preventing angular displacement (Fig. 14.31). ing so may lead to additional comminution of
the bone.
Neutralization Plates • Volar gapping at the fracture site can occur
with improperly contoured compression plat-
This plate construct is used to reinforce lag screws or another compressive fixation. ing. Compression plates must be bent into a
The plate is applied after the lag screws have been placed and provides stability in- gentle curve, slightly more than the natural
stead of additional compression. dorsal curve of the metacarpal, to compress
the volar cortex (Fig. 14.33).
• Carefully check for residual malalignment or rotational deformity.
• Passive motion (tenodesis effect): With passive wrist flexion, the digits should
extend because of the extrinsic tendon attachments, and with passive wrist ex-
tension, the digits should flex toward the scaphoid tubercle. This permits the
surgeon to evaluate for any residual rotational malalignment.
• Active motion: An awake patient can demonstrate flexion actively, but this can be
simulated in an anesthetized patient by applying pressure to the volar forearm at
the musculotendinous junction, which causes the fingers to flex and enables
judgment of alignment (Fig. 14.34).
• Repair periosteum and fascia to cover the plate and/or screws.
• Repair juncturae tendinum if possible.
• Deflate tourniquet and achieve hemostasis before skin closure.
• Close skin in layers.
• Apply a well-padded volar splint to immobilize the wrist and MCP joints. Including the
interphalangeal (IP) joints is not necessary but may improve comfort for the patient.

• Reliable patients with rigid fixation can start early active finger motion of all joints
within 1 week to improve tendon gliding and tissue edema.
• Even in suboptimal conditions, the IP joints should be mobilized within 1 week to
FIGURE 14.31 Tension band wiring. (Fig. 6,
avoid joint contractures. from Weinstein LP, Hanel DP. Metacarpal frac-
• A removable forearm-based orthosis that maintains MCP joint flexion and IP joint tures. Journal of the American Society for Surgery
extension can be used for protection during the first several weeks. of the Hand. 2002;2(4):168–180.)
• Once fracture healing is evident around 6 weeks, the splint can be weaned and
strengthening exercises initiated.
• Most patients should recover near-normal motion and strength, with excellent union
rates and radiographic outcomes.
See Video 14.1
EVIDENCE
Avery DM, Klinge S, Dyrna F, et al. Headless compression screw versus Kirschner wire fixation for
metacarpal neck fractures: A biomechanical study. J Hand Surg Am. 2017;42(5):392.e1–392.e6.
This biomechanical study compared two fixation techniques for metacarpal neck fractures. Fifteen
fingers stabilized with two crossed 1.1-mm K-wires were compared with 16 matched fingers that
underwent intramedullary stabilization with a 3.5-mm headless compression screw. In axial loading,
the intramedullary screw construct demonstrated greater stiffness (178.0 N/mm vs 111.6 N/mm for
Plate with
staggered K-wires) and load to failure (467.5 N/mm vs 198.3 N/mm). The intramedullary screw also demon-
holes strated greater load to failure in 3-point bending (401.2 N/mm vs 205.3 N/mm). These findings
suggest that intramedullary screw fixation of metacarpal neck fractures provides superior stability
to fixation with two crossed K-wires.
Beck CM, Horesh E, Taub PJ. Intramedullary screw fixation of metacarpal fractures results in excellent
functional outcomes: A literature review. Plast Reconstr Surg. 2019;143(4):1111–1118.
This meta-analysis evaluated clinical outcomes across 9 studies including 169 metacarpal fractures treated
FIGURE 14.32 Staggered hole plate applied to
with intramedullary screw fixation. On average, patients achieved MCP joint flexion of 86 degrees and
third metacarpal fracture.
grip strength of 96% compared with the contralateral side by final follow-up (average 11 months). On
average, return to daily activities occurred at 8.1 weeks and a 100% radiographic union rate was
reported, taking on average 5.2 weeks. There were no major complications and few minor complications
(5.3%), mostly consisting of hardware removal. The authors concluded that excellent outcomes can be
expected after intramedullary screw fixation of metacarpal neck and shaft fractures.
Dreyfuss D, Allon R, Izacson N, Hutt D. A comparison of locking plates and intramedullary pinning for
fixation of metacarpal shaft fractures. Hand (N Y). 2019;14(1):27–33.
FIGURE 14.33 Effect of plate contouring. This single-center retrospective cohort study compared outcomes of 39 metacarpal fractures treated
with one or two K-wires from 2013 to 2015 with 35 fractures treated with a locking plate and screws
from 2016 to 2017. After follow-up of at least 12 months, fingers treated with the locking plate con-
struct demonstrated significantly less total active motion loss (14 degrees vs. 29 degrees for K-wires)
and improved grip strength (93% of contralateral hand vs. 83%). Patients treated with K-wires had
significantly shorter operative time (41 minutes vs. 58 minutes for locking plate and screws) and time
to radiographic healing (50 days vs. 59 days). Fixation with locking plates and screws was favored by
the authors because it enabled earlier mobilization with improved clinical outcomes compared with
K-wire techniques.
Eisenschenk A, Spitzmüller R, Güthoff C, et al. Single versus dual Kirschner wires for closed reduction
and intramedullary nailing of displaced fractures of the fifth metacarpal neck (1-2 KiWi): A randomized
controlled trial. Bone Joint J. 2019;101-B(10):1263–1271.
This multicenter randomized controlled noninferiority trail compared two fixation techniques in patients
with acute displaced fifth metacarpal neck fractures. Patients were treated with either a single 1.6-mm
intramedullary K-wire (n 5 146) or two 1.2-mm intramedullary wires (n 5 144). There were no signifi-
cant differences in Disabilities of the Arm, Shoulder and Hand (DASH) scores, pain, functional range of
motion, radiologic measurements, or complications. The authors concluded that either approach can
be used, but the single wire approach is less technically demanding.
Hoang D, Vu CL, Jackson M, Huang JI. An anatomical study of metacarpal morphology utilizing CT
scans: Evaluating parameters for antegrade intramedullary compression screw fixation of metacarpal
fractures. J Hand Surg Am. 2020. Online ahead of print.
This anatomic study investigated metacarpal morphology based on measurements from 100 CT scans
of the hand. Cortical thickness, intramedullary canal size and length, and optimal entry points for intra-
medullary constructs in each of the metacarpals were characterized. The ring finger was found to have
the narrowest intramedullary canal, measuring 2.8 mm in the coronal plane and 3.5 mm in the sagittal
FIGURE 14.34 Intra-operative assessment of plane at the diaphyseal isthmus. At the metacarpal head, the optimal entry point for intramedullary
wrist motion cascade. headless compression devices was found to be 3.5 to 3.8 mm volar to the dorsal cortex. This entry
point could be most safely achieved in the thumb, middle, and little finger without violating the
carpometacarpal joints.
POSTOPERATIVE PITFALLS Hooper RC, Chen JS, Kuo CF, Chung KC. Closed metacarpal neck fractures: A review of resource use
Low-demand or elderly patients may have very in operative and nonoperative management. Plast Reconstr Surg. 2020;146(3):572–579.
little pain at the fracture site despite minimal This database study compared resource use and cost of operative and nonoperative treatments for
bone healing. Clinical examination of the fracture closed metacarpal neck fractures. Four treatment groups were compared: closed reduction and
site, which would normally serve to limit activity percutaneous pinning (CRPP; n 5 1094), open reduction and internal fixation (ORIF; n 5 684),
in younger patients, cannot be used as reliably in closed treatment with or without reduction (n 5 11,215) and no intervention (n 5 33,852). Opera-
these patient groups and delayed fixation failure tive treatment resulted in higher overall costs ($2406/patient in the CRPP group, $3092/patient
may occur. Consider delaying weight-bearing and in the ORIF group) compared with nonoperative treatment ($546/ patient in the closed treatment
strength training until radiographic evidence of group, $261/patient in the no intervention group). Nevertheless, nonoperatively treated patients
healing becomes apparent. required significantly more clinic visits (1.7 visits/patient compared with 1.2 in the operative
groups) and incurred a substantial proportion of overall healthcare costs because of the high
volume of these injuries.
Vasilakis V, Sinnott CJ, Hamade M, Hamade H, Pinsky BA. Extra-articular metacarpal fractures: Closed
reduction and percutaneous pinning versus open reduction and internal fixation. Plast Reconstr Surg
Glob Open. 2019;7(5):e2261.
This retrospective cohort study compared outcomes of two techniques in the treatment of single-finger
closed extraarticular metacarpal fractures. Forty-four patients underwent closed reduction and per-
cutaneous pinning (CRPP) with K-wires, whereas 26 patients underwent open reduction and internal
fixation (ORIF) with a plate and screws or lag screws. Patients treated with ORIF were immobilized
for a shorter duration (19.7 days vs. 30.7 days for CRPP patients), but there were no differences in
total clinic visits or hand therapy referral rates. The two groups did not differ in terms of total active
motion, QuickDASH scores, or stiffness rates. Both techniques were found to have excellent clinical
outcomes and few complications, with ORIF permitting earlier postoperative mobilization.
Yalizis MA, Ek ETH, Anderson H, Couzens G, Hoy GA. Early unprotected return to contact sport after
metacarpal fixation in professional athletes. Bone Joint J. 2017;99-B(10):1343–1347.
This retrospective case series investigated outcomes of 16 professional athletes with nonthumb meta-
carpal fractures who underwent open reduction and internal fixation with a plate and screws. Average
time to return to unrestricted professional play was 2 weeks, and 46 of 48 athletic performance
metrics measured were unaffected after return to play.
CHAPTER 15
Open Reduction for Metacarpophalangeal
Joint Dislocation
INDICATIONS
Indications for this procedure include:
• Complex (or irreducible) metacarpophalangeal (MCP) joint dislocation.
• Concomitant fractures that require open reduction internal fixation.
• The index finger is the most common site of this injury.
• Most dislocations are dorsal and occur during forced hypertension of the MCP joint.
• The involved joint will be painful and swollen; range of motion (ROM) will be
decreased (Fig. 15.1A–C).
• There may be sensory changes because of traction on the neurovascular bundle.
• Simple dislocations typically have a hyperextended appearance, with the proximal
phalanx base and metacarpal head remaining in close contact (Fig. 15.2A).
• Complex dislocations often appear less displaced than simple dislocations.
• Complex dislocations usually have more separation between the joint surfaces, and
the proximal phalanx base may be displaced dorsal and proximal to the metacarpal
head (“bayonet” deformity; see Fig. 15.2B). In these cases, the finger does not ap-
pear grossly hyperextended (see Fig. 15.1) but may be shortened, with an easily
identifiable bump in the palm corresponding to the metacarpal head (Fig. 15.3).
IMAGING
• Plain radiographs of the hand should be obtained in three views (Fig. 15.4A–C).
• The affected joint may appear hyperextended or it may be in a so-called “bayonet”
position; the joint space will be widened if there is soft tissue interposed in the joint.
• Identify the position of the sesamoids, if present. If they are within the joint, it shows
that the volar plate is entrapped in the intraarticular space.
• Additional views, such as a reverse oblique or Brewerton view, may be useful for
detecting additional details, including subtle fractures of the metacarpal head.
SURGICAL ANATOMY
• With dorsal dislocations, the volar plate remains attached to the proximal phalanx.
Simple MCP Joint Dislocation

• Volar plate remains draped over the metacarpal head (not interposed in the joint
space; see Fig. 15.2A).
• Excessive hyperextension or traction during reduction may draw the volar plate into
the joint and convert the injury into a complex, irreducible dislocation.
• Proper reduction includes flexing the wrist (relaxes the flexors) and applying pres-
sure to the dorsal base of the proximal phalanx in distal and volar directions. This
will slide the proximal phalanx over the metacarpal head.
Complex (Irreducible) MCP Joint Dislocation

• The volar plate is either transposed between the joint surfaces or trapped dorsal to
the metacarpal head (see Fig. 15.2B).
• The metacarpal head becomes locked volarly as it “button-holes” between ligamen-
tous and tendinous structures.
34
CHAPTER 15 Open Reduction for Metacarpophalangeal Joint Dislocation 35
A B C
FIGURE 15.1 Complex dislocation of the index finger results in a swollen digit held in extension. No-
tice that there is no substantial metacarpophalangeal (MCP) joint hyperextension in complex disloca-
tions (red arrow).
Metacarpal head
Proximal
phalanx
Reducible
(simple)
FIGURE 15.3 The head of the metacarpal can be seen and palpated
Metacarpal just beneath the skin.
Volar
plate
Volar plate
Proximal phalanx
Irreducible
(complex)
Metacarpal A B C
B
FIGURE 15.2 (A) With simple dislocations, the volar plate remains FIGURE 15.4 (A) Anteroposterior, (B) oblique, and (C) lateral views show the meta-
draped over the metacarpal head and the metacarpophalangeal carpophalangeal (MCP) joint dislocation of the index finger (white arrows). The ra-
(MCP) joint is held in substantial hyperextension. (B) In complex diographs demonstrate increased joint space, loss of congruity, and subtle soft-
dislocations, the volar plate can be drawn entirely dorsally. tissue swelling.
36 CHAPTER 15 Open Reduction for Metacarpophalangeal Joint Dislocation
Palmar view of MCP joint of index finger Palmar view of MCP joint of 5th digit
Ulnar side Radial side
of proximal of proximal
Ulnar side Radial side phalanx phalanx
of proximal of proximal
phalanx phalanx
Natatory
ligament Natatory
displaced ligament
distally Metacarpal displaced Metacarpal
head distally head
“button-holing” “button-holing”
Superficial Superficial
transverse transverse
metacarpal metacarpal
ligament ligament
displaced displaced
proximally proximally
Flexor tendon Lumbrical Abductor digiti Flexor tendon

displaced to displaced to minimi muscle displaced to
ulnar side radial side displaced to radial side
ulnar side
A B
FIGURE 15.5 Artistic representation of an (A) index finger and (B) small finger metacarpophalangeal (MCP) joint
dislocation with displacement of surrounding ligamentous and tendinous structures that form a so-called “noose”
around the metacarpal head.
• In the case of index finger dislocation, the metacarpal head is typically pinched
between the lumbrical radially and the flexor tendons ulnarly (Fig. 15.5A). With small
finger MCP dislocations, the head is trapped between the flexor tendons radially and
the abductor digiti minimi tendon ulnarly (see Fig. 15.5B).
• In both cases, there is additional entrapment of the head between the displaced
natatory ligament and the superficial transverse metacarpal ligament.
• Together, these structures act as a “noose” around the neck of the metacarpal, pre-
venting closed reduction.
EXPOSURES PEARLS EXPOSURES
• Dislocations that are not acutely treated may • A dorsal, volar, or combined approach may be used to treat MCP joint dislocations.
be difficult to reduce. Both dorsal and volar ex-
posures may be required for these cases. • The location of an associated fracture may guide whether a dorsal or volar approach
• Care must be taken when making the skin in- is more suitable for fixation.
cision, as the radial neurovascular bundle will • The volar approach provides better visualization of the neurovascular structures if
be tented over the metacarpal head of the in- needed, but the dorsal approach has a lower risk for neurovascular injury.
dex finger (or ulnar neurovascular bundle of
the small finger; Fig. 15.8). Dorsal Approach
• A curvilinear incision is made on the dorsal aspect of the MCP joint (Fig. 15.6).
• To expose the joint capsule, the extensor mechanism is split.
• For the thumb, index, and small fingers, split between the two extensor tendons.
• Thumb: between extensor pollicis brevis and extensor pollicis longus.
• Index: between extensor digitorum communis and extensor indicis proprius.
• Small: between extensor digitorum communis and extensor digiti minimi.
• For middle and ring fingers, split the tendon in the midline.
• Beneath the torn dorsal capsule, the base of the proximal phalanx with attached
volar plate can be identified dorsal to the metacarpal head.
Volar Approach
• An oblique palmar incision is used from the proximal to the distal palmar crease. This
may be extended onto the digit with a Bruner incision (Fig. 15.7).
Extensor digiti minimi
Extensor digitorum communis
FIGURE 15.6 For a dorsal approach, the joint is exposed via a lazy-S skin incision and incising longitudi-
nally between extensor tendons (or splitting a single extensor tendon over the middle or ring finger).
Metacarpal head
FIGURE 15.7 For a volar approach, the joint is exposed via an oblique palmar incision directly over the
palpable metacarpal head.
• Identify and protect the neurovascular bundles, which may be displaced centrally
from their usual position(s).
• The prominent metacarpal head is easily recognized and found just deep to the skin
within the subcutaneous tissue.
• The proximal phalanx and attached volar plate are often obscured by the metacarpal head.
DORSAL APPROACH
Step 1: Expose Joint STEP 1 PEARLS
• The dorsal joint capsule is thin and typically torn. Incise any remaining joint capsule • It is critical to distinguish the articular surface
of the metacarpal head from the volar plate,
to expose the dislocation.
which may be stretched tightly over the sur-
• With careful dissection and gentle distraction, identify the dorsally displaced proxi- face of the metacarpal head. Both surfaces
mal phalanx, the volar plate, and the metacarpal neck. The metacarpal head may be may look shiny and white.
entirely hidden from view. • Inspect for osteochondral lesions that were not
identified on preoperative imaging.
Step 2: Perform Reduction
• While flexing the wrist to loosen tension on the extrinsic flexors, the proximal pha-
lanx is gently pushed distally and volarly. STEP 2 PEARLS
• If the volar plate is interfering with reduction, it can be leveraged over the metacarpal • In cases where the metacarpal head is firmly
head using a blunt periosteal elevator, such as a Freer. trapped underneath a tight volar plate, the vo-
• If necessary, gently place narrow Hohmann retractors around the neck of the meta- lar plate may be split longitudinally, allowing
the radial and ulnar halves to pass to either
carpal to hold back the lumbrical and flexor tendons, allowing the metacarpal head side of the head as it reduces.
to become unstuck from its noose and reduce properly. • When incising the volar plate, the underlying
articular surface of the metacarpal head must
Step 3: Evaluate Joint Congruity be protected from the scalpel blade—a Freer
elevator interposed between these two struc-
• Confirm a stable joint through full ROM under both direct vision and fluoroscopic
tures is helpful.
guidance.
38 CHAPTER 15 Open Reduction for Metacarpophalangeal Joint Dislocation
Neurovascular bundle Metacarpal head
A B
FIGURE 15.9 Repair the longitudinal incision to FIGURE 15.8 During the volar approach, care must be taken to protect the neurovascular bundles
prevent subluxation of the extensor tendons (red (red arrow), which are often displaced centrally and superficially from their native position by the
arrow). metacarpal head (blue arrow).
STEP 4 PEARLS
The dorsal capsule can be left unrepaired if • After reduction, use fluoroscopy to check for any subtle shear fractures of the meta-
obliterated from the injury. carpal head. If present, these will require fixation, often with small wires or screws.
STEP 2 PEARLS Step 4: Close

Inspect for osteochondral lesions that were not • The dorsal capsule of the MCP joint is repaired with 4-0 absorbable suture.
identified on preoperative imaging. • The longitudinal incision in the dorsal extensor hood is repaired with nonabsorbable
4-0 suture (Fig. 15.9).
• The skin is closed.
STEP 3 PEARLS • Immobilize the MCP joint in 10 to 30 degrees of flexion with a dorsal blocking splint.
Alternatively, a blunt elevator can be used as a lever
between the metacarpal head and tendons (that
are creating the noose) to guide the metacarpal VOLAR APPROACH
head dorsally. Step 1: Release the A1 Pulley
If not completely torn by the traumatic injury, release the A1 pulley for complete
STEP 3 PITFALLS visualization.
Dividing the volar plate may still be necessary, but
this is more difficult to do from the volar approach; Step 2: Identify Tendons and Volar Plate in Relation to Metacarpal
proceed cautiously. Head
• Identify the structures that are entrapping the metacarpal head. Fig. 15.10 shows an
index finger metacarpal dislocation entrapped between lumbrical (radial) and flexor
tendons (ulnar).
• The volar plate may be visible behind the metacarpal head, or it may be completely
hidden in complex dislocations (Fig. 15.11).
Step 3: Perform Reduction

• Have an assistant gently retract the constricting tendinous structures.
• Flex the wrist.
• Grasp the affected digit while simultaneously placing the thumb on the volar aspect
of the metacarpal head.
• Apply pressure to the volar aspect of the metacarpal head to reduce it dorsally, while
simultaneously pushing the proximal phalanx distally and volarly. Feel the proximal
FIGURE 15.10 The metacarpal head (white ar-
row) is entrapped by the lumbrical on the radial phalanx roll over the metacarpal head as it returns to a reduced position.
side (red arrow) and flexor tendons on the ulnar • If needed, a Freer elevator can be used to gently coax the proximal phalanx and the
side (blue arrow – not visualized in this image) attached volar plate into reduction.
A B C
FIGURE 15.11 In complex metacarpophalangeal (MCP) FIGURE 15.12 Fluoroscopically obtained images showing (A) anteroposterior,
joint dislocations, the volar plate (red arrow) is visual- (B) oblique, and (C) lateral views of a well reduced index finger metacarpophalan-
ized dorsal to the metacarpal (white arrow) and geal (MCP) joint dislocation (black arrows).
reflected into the field with a blunt elevator.
Step 4: Evaluate Joint Congruity and Close

• Check the reduction of the MCP joint under fluoroscopic guidance (Fig. 15.12A–C).
• The volar plate does not need to be repaired because the reduced joint is often
stable and the volar plate will scar down during recovery.
• Close the skin.
• Immobilize the MCP joint in 10 to 30 degrees of flexion with a dorsal blocking splint.

• After a few days of rest but within the first week, active ROM is started.
• The splint is weaned around 6 weeks, and light independent activity is permitted.
• Heavy activity, including sports, is allowed at 12 weeks.
• Posttraumatic arthritis may result in cases with intraarticular fracture. Chronic dislo-
cations have poorer functional results despite successful open reduction.
EVIDENCE
Afifi AM, Medoro A, Salas C, Taha MR, Cheema T. A cadaver model that investigates irreducible meta-
carpophalangeal joint dislocation. J Hand Surg Am. 2009;34:1506–1511.
Using a cadaver model of dorsal MCP dislocation, this study demonstrated how the anatomy around
the MCP joint may contribute to irreducibility of these injuries. For successful reduction, they found
that a split of the volar plate was required in all cases. Division of the deep transverse metacarpal
ligament did not aid in reduction (Level V evidence).
Barry K, McGee H, Curtin J. Complex dislocation of the metacarpo-phalangeal joint of the index finger:
a comparison of the surgical approaches. J Hand Surg Br. 1988;13:466–468.
This cadaver study compared the volar and dorsal approaches to reduction of MCP joint dislocation.
Reduction could be achieved by either approach, and no difference in joint stability between ap-
proaches was found. Using the volar approach, there was some vulnerability of the radial neurovas-
cular bundle. The dorsal approach was felt to be safer; however, the volar plate had to be longitudi-
nally divided to achieve reduction (Level III evidence).
Rubin G, Orbach H, Rinott M, Rozen N. Complex dorsal metacarpophalangeal dislocation: Long-term
follow-up. J Hand Surg Am. 2016;41(8):e229–e233.
This retrospective case series of five patients (mean of 13 year follow-up) and literature review evalu-
ated long-term outcomes of complex dorsal MCP joint dislocations. The authors found that the litera-
ture indicates that complications after dorsal MCP joint dislocations are related to multiple failed
closed reduction attempts, associated fractures, and prolonged immobilization. Their small series
suggested that patients do well with open reduction on the day of injury (via volar or dorsal ap-
proach) and long-term outcomes are satisfactory.
CHAPTER 16
Corrective Osteotomy of Metacarpal
Fracture Malunion
KEY CONCEPTS
• Corrective osteotomy is indicated for metacarpal malunion with angular, rotational,
or shortening deformity that results in functional results. Inquire about functional
limitations, including weakness, pain, muscle cramping, or muscle fatigue.
• The involved digit will usually have decreased prominence of the metacarpal head (loss
of “knuckle”). The metacarpal head may be palpable in the palm as a tender nodule.
• The osteotomy should be planned out carefully, using measurements from accurate,
well-positioned radiographs.
• Angular deformities are corrected with either a closing wedge or opening wedge
osteotomy. Rotational deformities are addressed with a derotational osteotomy. A
combination of a wedge osteotomy and a derotational ostomy are sometimes re-
quired to correct complex malunions.
• The correction of angular and/or rotational deformity can be confirmed with intraop-
erative fluoroscopy, as well as active and passive maneuvers, such as tenodesis
effect. Final fixation should consist of lag screws or plate fixation.
• An opening wedge osteotomy will require bone grafting. Dorsal plating can be con-
figured to provide some compression of the interposition bone graft or can serve as
a tension band. Larger bone grafts may even accommodate a screw to be lagged to
the plate.
• Rest and elevation are advised for the first 3 days postoperatively. Thereafter, patients
with stable fixation can start early active finger motion to avoid extensor tendon adhe-
sions and joint stiffness.
Bone graft
FIGURE 16.6 A bone graft is needed to fill the void created by opening wedge osteotomy.
40
CHAPTER 16
Corrective Osteotomy of Metacarpal
Fracture Malunion
Shepard P. Johnson and Kevin C. Chung
INDICATIONS
• One indication is metacarpal malunion with angular, rotational, or shortening deformity,
which results in functional deficits.
• Acceptable limits of each deformity are debatable (suggested indications for pri-
mary surgery are reviewed in Chapter 14 Techniques and Fixation of Metacarpal
Fractures), but indication for surgery is dictated by functional deficits that may be
improved by corrective osteotomy.
Angular Deformity
• Angulation typically occurs in the sagittal plane (dorsal angulation); angulations up
to 15 to 30 degrees generally are well tolerated.
• Angulation in the coronal plane (radial/ulnar) is less well tolerated because small
degrees of malunion may lead to angulation of the digit, which interferes with the
function of the adjoining fingers.
Malrotation Deformity
• Rotational deformity is not tolerated as well as angular deformity.
• Malrotation deformity commonly leads to overlap of the digits (so-called “scissoring”).
• Five degrees of malrotation at the metacarpal level can cause 1.5 cm of digit overlap
distally.
Shortening
• Greater than 6 mm of shortening can lead to an unacceptable extensor lag.
• Extensors can accommodate for some shortening because of their range of excursion.
• Every 2 mm of metacarpal shortening results in a 7-degree extensor lag.
Contraindications
Contraindications include metacarpal malunions on radiographic examination that have
no functional deficit. Patients often adapt to minor deformities even when they are
greater than the standards, indicating the need for primary operative intervention.
• Assess hand function in the context of a patient’s occupation, activities of daily liv-
ing, and recreational interests. Many patients can adapt to minor deformities without
difficulty.
• Inquire about functional limitations, including weakness, pain, muscle cramping, or
muscle fatigue.
• Examine the hand for pseudoclawing (hyperextension of the metacarpophalangeal
[MCP] joint with flexion of the proximal interphalangeal [PIP] joint), which is often
related to apex-dorsal deformity of the metacarpal neck or shaft. Because of the
flexed posture of the metacarpal, patients will attempt to hyperextend at the MCP
joint, which causes reciprocal flexion of the PIP joint.
• The involved digit will usually have decreased prominence of the metacarpal head
(loss of “knuckle”). The metacarpal head may be palpable in the palm as a tender
nodule.
• Check for a decrease in grip strength and pain with grip.
40.e1
40.e2 CHAPTER 16 Corrective Osteotomy of Metacarpal Fracture Malunion
A B C
FIGURE 16.1 (A) Anteroposterior, (B) oblique, and (C) lateral views demonstrate an apex dorsal mal-
union of the small finger metacarpal (red arrow). In the oblique view, the compensatory small finger
metacarpophalangeal joint hyperextension can be appreciated (blue arrow).
• Check range of motion, noting any extension lag, flexion lag, or overlapping (scis-
soring) of the digits during motion.
• Compare length and arc of motion to the contralateral hand for guidance on operative
goals.
IMAGING
• Radiographs of hands should be obtained in three views (posteroanterior [PA],
oblique, and lateral; Fig. 16.1A–C).
• Shortening is best evaluated on the PA view by examination of the relationship of the
metacarpal heads. The middle, ring, and small metacarpal heads are typically colinear.
• Angular deformity is best assessed on the lateral view.
SURGICAL ANATOMY
FIGURE 16.2 Before performing a closing • Distal branches of the superficial radial nerve and the dorsal sensory branch of the
wedge osteotomy, Kirschner wires (K-wires) are ulnar nerve have a possibility of injury on the dorsal side of the hand (see Fig. 14.19).
placed perpendicular (red angles) to the dorsal
• Juncturae tendinum may need to be divided for exposure (see Fig. 14.20).
cortical surface in the metacarpal proximal and
distal to the malunion. The saw cuts are then • Interosseous muscles originate from the metacarpal shafts and are covered with
performed with precision by aligning the angle of fascia that is continuous with the metacarpal’s dorsal periosteum.
the saw parallel with the K-wires.
EXPOSURES
The metacarpal is usually exposed with a dorsal approach, which is presented in detail
in the Chapter 14 Techniques and Fixation of Metacarpal Fractures section on “Open
Reduction and Internal Fixation.”
PROCEDURE
Step 1: Perform an Osteotomy to Correct Malunion Deformity
FIGURE 16.3 The Kirschner wires are used as
• The osteotomy should be planned out carefully, using measurements from accurate,
joysticks to reduce and hold the fracture. Leav-
ing periosteum on the volar side of the metacar- well-positioned radiographs.
pal also aids in stabilizing the reduction. • Angular deformities are corrected with either a closing wedge or opening wedge
osteotomy.
Closing Wedge Osteotomy

• To aid in resecting a precise wedge, use fluoroscopy and preplace Kirschner wires
(K-wires) as guides on either side of the malunion. The K-wires should be perpen-
dicular to the dorsal cortical surface of the metacarpal (Figs. 16.2–16.4).
FIGURE 16.4 Fixation is obtained with a 2.0 to • Measure the angle between the two K-wires. This angle serves as a guide to the
2.4 mm plating system. osteotomy cuts.
CHAPTER 16 Corrective Osteotomy of Metacarpal Fracture Malunion 40.e3
• Perform osteotomy cuts with an oscillating saw immediately adjacent to the mal- STEP 1 PEARLS
union. Minimize the amount of bone removed by designing the proximal and distal
• Despite the removal of bone, closing wedge
saw cuts so that they converge at the far cortex. osteotomies do actually lengthen the metacar-
• The saw cuts can be executed with precision by maintaining a parallel trajectory pal as the angulation is corrected.
with the preplaced K-wire guides. • When possible, leave the volar periosteum in-
tact while making the osteotomy cuts. This will
Opening Wedge Osteotomy allow it to remain as a “hinge” on the volar
surface, providing some stability during the
• Using fluoroscopy, make a single osteotomy saw cut in the center of the malunion case and some assistance to early bone heal-
that symmetrically bisects the angle of the malunion (Figs. 16.5 and 16.6). ing postoperatively.
• Obtain and place bone graft in the defect created by osteotomy. • For derotational osteotomies, estimate the
amount of rotational deformity at the midpoint
Rotational Deformities of finger flexion (this is when the deformity is
the largest). As a guide, approximately 2 mm
• These are addressed with a derotational osteotomy. Use a step-cut osteotomy with of longitudinal bone resection will result in
excision of a small cortical strip of bone along the longitudinal limb to derotate the 20 degrees of rotational correction at the tip
malunion (Fig. 16.7). of the finger.
• An oscillating saw is used to make a hemi-transverse cut in the proximal and • A combination of a wedge osteotomy and a
derotational ostomy are sometimes required to
distal diaphysis (on opposite sides of the shaft), approximately 2.5 cm apart.
correct complex malunions.
• The distal cut is made on the side that the finger will be rotating toward (i.e.,
derotating back to normal position; see Fig. 16.7).
• Two parallel, dorsal longitudinal cuts (connecting the proximal and distal trans-
verse cuts) are made to remove a small strip of bone. Leave the volar cortex intact. STEP 1 PITFALLS
• Manually derotate the digit into normal alignment by closing the longitudinal The oscillating saw should be cooled with saline
defect with reduction forceps. This will often crack the volar cortex. while cutting to avoid overheating the bone
• Assess tenodesis of the digit to evaluate cascade (remove additional longitudinal surfaces, which can damage the bone and slow
healing.
bone if needed).
• Use two 2.0 mm interfragmentary lag screws to fixate.
FIGURE 16.5 The opening wedge osteotomy is

performed at the apex of the malunion (blue
arrow) to equally bisect the angle of the defor-
mity (marked by two equivalent red angles).
Bone graft
FIGURE 16.6 Fixation is obtained with a 2.0 to

2.4 mm plating system. A bone graft is needed
to fill the void created by the opening wedge os-
teotomy. If large enough, the graft can be fixated
to the plate with an orthogonally placed screw.
FIGURE 16.7 Derotational step-cut osteotomies are performed to address digital rotatory deformities.
The distal hemi-transverse cut (red arrow) is made on the side that the affected digit will derotate
toward (blue arrows). The proximal cut is made on the contralateral side (green arrow) approximately
2.5 cm proximal to the distal cut. The longitudinal cuts (purple arrow) are made to remove a bone
strip. For every 2 mm in width removed, approximately 20 degrees of correctional rotation is
achieved. The closing osteotomy is fixated with two 2.0 mm lag screws.
40.e4 CHAPTER 16 Corrective Osteotomy of Metacarpal Fracture Malunion
STEP 3 PEARLS
Step 2: Reduce Deformity to Achieve a Normal Alignment and Arc
of Digit Motion
• Use of locking screws may have some benefit
in patients with osteoporosis, where purchase • After completing the osteotomy cuts, the deformity is corrected. Use the preplaced
of nonlocking bicortical screws may be com- K-wires as “joysticks” to assist reduction (see Fig. 16.3).
promised. • Temporary or partial fixation should be employed to hold the osteotomy reduced
• An opening wedge osteotomy will require bone while alignment is checked. K-wires may be used for this step, so long as their posi-
grafting. Dorsal plating can be configured to
tion does not interfere with final hardware placement.
provide some compression of the interposition
bone graft or can serve as a tension band. • If available, specialty miniplates with oblong, horizontally oriented holes can be
Larger bone grafts may even accommodate a used. These plates facilitate temporary fixation while still permitting minor adjust-
screw to be lagged to the plate (see Fig. 16.6). ments in rotation of the distal segment.
• The correction of angular and/or rotational deformity can be confirmed with intraopera-
STEP 3 PITFALLS tive fluoroscopy or with active and passive maneuvers, such as tenodesis effect.
Multiple techniques for checking alignment are described in Chapter 14 Techniques for
Be careful that the plate fixation does not distract
at the osteotomy site. Prebending the plate can Fixation of Metacarpal Fractures, ORIF Step 3 (see Fig. 14.34).
assist with providing some compression; dynamic
compression miniplates can also be used (see Step 3: Fixation and Closure
Fig. 14.33). • Final fixation should consist of lag screws (1.7–2.0 mm) or plate fixation (2.0–2.4 mm;
see Fig. 16.4).
• In a malunion of the metacarpal neck or base, a T- or Y-shaped plate will provide
additional points of fixation close to the joint. At least two screws (four cortices) of
fixation are required on either side of the osteotomy.
• Rigidity of the plate/screw construct can be improved with locking screws, but these
are not routinely required.
• After completing the internal fixation, verify that any rotational and/or angular defor-
mity has been corrected by clinical and radiographic assessment (Fig. 16.8A–C).
A B
FIGURE 16.8 After completing the osteotomies, evaluate the arc of motion with tenodesis from (A)
wrist flexion and (B) wrist extension, and (C) use intraoperative fluoroscopy to check bony alignment
and contact, as well as hardware placement.
CHAPTER 16 Corrective Osteotomy of Metacarpal Fracture Malunion 40.e5
A B C D
FIGURE 16.9 Postoperative examination demonstrates excellent digit range of motion and alignment.
A B C
FIGURE 16.10 Postoperative radiographs demonstrate healing osteotomy and maintenance of hard-
ware position.

• Rest and elevation are advised for the first 3 days.
• Thereafter, patients with stable fixation can start early active finger motion to avoid
extensor tendon adhesions and joint stiffness.
• The correction of deformity is evaluated by radiographic and physical examination
at follow-up (Figs. 16.9A–D and 16.10A–C).
EVIDENCE
Karthik K, Tahmassebi R, Khakha RS, Compson J. Corrective osteotomy for malunited metacarpal
fractures: Long-term results of a novel technique. J Hand Surg Eur Vol. 2015;40:840–845.
This retrospective study reviewed the outcomes of 12 patients with 14 malunited metacarpal fractures.
The average follow-up period was 46 months. The mean dorsal angulation of the metacarpal was
43 degrees. Rotational deformity was recognized in all but three cases. All were treated with their
reported technique of closing wedge osteotomy. There was significant improvement in the Disabili-
ties of the Arms, Shoulders, and Hands (DASH) scores after surgery. By the Büchler criteria, the
outcome was excellent in all patients. The authors conclude that their technique is an easy and safe
method to correct malunited metacarpal fractures (Level IV evidence).
Jawa A, Zucchini M, Lauri G, Jupiter J. Modified step-cut osteotomy for metacarpal and phalangeal
rotational deformity. J Hand Surg Am. 2009;34A:335–340.
This retrospective case series of 12 patients evaluated the outcomes of rotational step-cut osteotomies
to correct digital rotatory deformities associated with metacarpal and phalangeal malunions. All
patients had successful resolution of deformities with bony union and maintained or improved digit
motion. The authors concluded that this technique allowed precise correction of rotational
deformities and the rigid fixation permitted early postoperative motion therapy.
Van der Lei B, de Jonge J, Robinson PH, Klasen HJ. Correction osteotomies of phalanges and
metacarpals for rotational and angular malunion: A long-term follow-up and a review of the
literature. J Trauma. 1993;35:902–908.
This retrospective case series reported on nine phalanges and six metacarpals that underwent corrective
osteotomy for rotational and angular malunions. The 15 patients were followed for a mean of 4.5 years. All
patients achieved bony union, and the preoperative range of motion was maintained in all except one patient.
Adequate correction of the deformity and high satisfaction was seen in 13 patients (87%; Level IV evidence).
CHAPTER 17
Reconstruction of Acute and Chronic Ulnar
Collateral Ligament Injuries of the Thumb
INDICATIONS
• A complete tear of the ulnar collateral ligament (UCL) of the metacarpophalangeal
(MCP) joint of the thumb necessitates this procedure.
• An avulsion fracture at the attachment site of the UCL with displacement greater
than 5 mm may also require repair/reconstruction.
• Acute injuries are best treated with repair; chronic injuries (more than 3–6 weeks old)
will likely require reconstruction.
• Studies on the long-term outcome of ligamentous repair, rather than reconstruction,
for chronic UCL injuries demonstrate durable outcomes; however, the majority of
patients eventually develop osteoarthritis.
• Other techniques for UCL repair, such as those using an internal brace and the Bio-
Tenodesis Screw System, are also options for surgical reconstruction.
Contraindications
• If significant metacarpophalangeal (MCP) arthrosis or arthritis is present, MCP joint
fusion should be done because ligament reconstruction is not a durable option and
will not provide pain relief.
• Acutely injured patients typically have tenderness and swelling on the ulnar side of
the MCP joint (Fig. 17.1).
• The integrity of the UCL is tested by applying valgus (radially directed) stress to the
MCP joint and comparing the injured thumb to the uninjured contralateral thumb.
The degree of laxity is measured, and the endpoint of the deviation is assessed.
• A complete UCL tear is present if there is more than 35 degrees of laxity, with the
MCP in either flexion or extension, or if there is more than 15 degrees of additional
laxity compared with the uninjured side. Typically, a soft endpoint is present when a
complete tear exists (see Fig. 17.1).
• Less than 10 to 15 degrees of increased laxity, combined with a firm endpoint, prob-
ably indicates only a partial tear, and open repair is not typically indicated.
• Crepitus or pain with joint loading may be a sign of arthritis with loss of healthy joint
cartilage.
IMAGING
• Standard radiographs should be obtained in posteroanterior, lateral, and oblique
views to assess if there is an associated avulsion fracture (Fig. 17.2). Stress testing
should not be done in the setting of displaced fractures. Fractures made up of
greater than 30% of the joint surface and with significant displacement/malrotation
should be treated surgically.
• In the lateral view, volar subluxation of the proximal phalanx may indicate an ac-
companying dorsal capsular tear of the MCP joint. Some subluxation may be
physiologic, so comparing it with radiographs of the uninjured side is important.
Pathologic subluxation may require additional capsular repair or imbrication at the
time of UCL repair.
• In chronic injuries, radiographs should be carefully scrutinized for the presence of
osteoarthritis of the thumb MCP joint.
41
42 CHAPTER 17 Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb
FIGURE 17.1 Clinical examination.
FIGURE 17.2 Imaging.
• Ultrasonography can differentiate between partial and complete injury in most

cases, especially in the hands of an experienced ultrasonographer. Furthermore, the
position and orientation of the torn ligament can be ascertained in most cases.
• Magnetic resonance imaging (MRI) may also be a useful adjunct, but these tests are
unnecessary if the clinical examination is conclusive.
SURGICAL ANATOMY
• Distal branches of the superficial radial nerve often lie in the operative field and are
at risk for injury.
• The thumb MCP joint is a diarthrodial ginglymoid joint that is movable in all planes
but primarily moves in a flexion-extension arc.
• The joint is stabilized by both static (volar plate, collateral ligaments) and dynamic
(intrinsic and extrinsic muscles) structures.
CHAPTER 17 Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb 43
Proper collateral ligament
Metacarpal bone
Proximal phalanx
Volar plate

FIGURE 17.3 Ulnar collateral ligament (UCL) anatomy.
Proximal phalanx
Dorsoulnar digital nerve
UCL: torn and displaced
Adductor aponeurosis
Thumb metacarpal
Adductor pollicis
FIGURE 17.4 Ulnar collateral ligament (UCL) tear.
• The UCL is composed of two distinct structures: the proper UCL and the accessory
UCL. The proper UCL arises from the lateral condyles of the thumb metacarpal head
and travels distally and volarly to insert on the lateral tubercle of the proximal pha-
lanx. The accessory UCL courses superficially from a more volar site on the meta-
carpal head to the volar plate and sesamoids (Fig. 17.3).
• When excessive valgus stress is applied, the UCL usually tears (or avulses) at its
distal attachment. If the radial deviation of the proximal phalanx continues, the
avulsed UCL displaces further, and the leading edge of the adductor aponeurosis
passes over and beyond the torn ligament. As the injured MCP joint reduces, the EXPOSURES PEARLS
torn UCL folds back upon itself, and the adductor aponeurosis becomes interposed
• Mark the adductor aponeurosis with a surgical
between the torn inverted ligament and its attachment site on the proximal phalanx. marker before incising it and leave an edge to
This anatomic occurrence is termed a Stener lesion (Fig. 17.4). sew to radially. This makes it easier to identify
• Stener lesions are reported to occur in the majority of complete UCL tears (64%– and repair this structure at the end of the case.
88%). Because the ligament is displaced from its point of attachment, normal heal- • If a tiny avulsion fragment is present, it should
be excised to avoid impingement in the joint.
ing cannot occur, even with prolonged immobilization. This is why operative repair
is indicated for most, if not all, complete UCL ruptures.
EXPOSURES PITFALLS
EXPOSURES Take time to carefully evaluate this anatomy; one
• A lazy-S incision is marked on the dorsal-ulnar aspect of the thumb MCP joint must avoid accidentally detaching the proximal
(Fig. 17.5A). Alternatively, the incision can be hidden within the skin fold when the portion of the collateral ligament as the adductor
thumb adducts (see Fig. 17.5B) The incision curves from volar distally to dorsal aponeurosis is incised and the joint capsule
opened.
proximally, remaining ulnar to the extensor pollicis longus (EPL) tendon.
FIGURE 17.5 (A) Lazy-S incision design. (B) Incision hidden within the crease of the thumb.
• Identify and protect branches of the superficial radial nerve within the subcutaneous
layer.
• The proximal border of the adductor aponeurosis is exposed.
• If there is a Stener lesion, a rounded mass of tissue will appear at the proximal edge
of the aponeurosis.
• The adductor aponeurosis must be incised longitudinally, ulnar to the EPL, to ex-
pose the joint capsule. The joint capsule is then opened longitudinally at the dorsal
edge of the collateral ligament, and the soft tissue and bone injury can be exposed
and evaluated (Fig. 17.6).
• Radially deviate the proximal phalanx and irrigate the joint to gain maximal visualization.
Ulnar collateral
ligament
FIGURE 17.6 Joint capsule exposed.

REPAIR OF ACUTE ULNAR COLLATERAL LIGAMENT STEP 1 PITFALLS

INJURY Be very careful when dissecting out the UCL, which
may appear distorted when it is first encountered.
Step 1: Preparation of the UCL and the Insertion Site Avoid accidentally damaging the ligament or
detaching it from the metacarpal.
• The UCL may be foreshortened, folded back on itself, or otherwise malpositioned. It
should be gently dissected free from surrounding debris and scar and unfolded to
its full length.
• The site for UCL reattachment on the proximal phalanx is exposed, any distal liga-
ment remnants are excised, and the surface of the bone is abraded with a curette or
rongeur. This will provide a cut edge of ligament to heal directly to the bone without
intervening tissue.
Step 2: Reattaching the Ligament

• This step may be accomplished with a suture anchor or transosseous sutures.
• Suture anchor method:
• Anchors preloaded with a 2-0 or 3-0 nonabsorbable suture are preferred.
• A drill guide is used to place the pilot hole for the anchor at the reattachment site.
• The anchor is deployed, making sure that it is fully countersunk into the bone
(Fig. 17.7). The position can be checked fluoroscopically.
• The attached suture is used to secure the UCL down to the bone, using a grasping
suture technique (Kessler- or Bunnell-style stitch; Fig. 17.8).
• Bone tunnel method when suture anchor is not available:
• A pair of parallel drill holes is created, beginning from the intended site of liga-
ment attachment, heading across the phalanx to the radial side, angled from
proximal to distal.
• This drilling can be accomplished with 0.045-in (1.14-mm) Kirschner wires (K-wires)
or a small drill bit. STEP 2 PEARLS
• A 3-0 nonabsorbable grasping suture is placed into the ligament stump.
The repair can be supplemented by suturing the
• The free ends of the suture are passed through the bone tunnels using Keith
distal end of the ligament to local tissue or to
needles, specialty K-wires, or other suture passing devices (Fig. 17.9). periosteum around the attachment site.
• The sutures are tied on the radial side of the proximal phalanx (Fig. 17.10).
• Alternatively, sutures can be tied over the skin using a button. If pull-out sutures
STEP 2 PITFALLS
are tied over the button, use Prolene suture because it can glide over structures
and be removed readily, unlike braided suture, which will not glide. One must be sure that the distal attachment point
of the ligament is correct. It should be attached to
• Alternatively, using a small counterincision for exposure, sutures can be directly the volar aspect of the ulnar side of the base of the
tied over the periosteum. This prevents any potential skin compromise from pres- proximal phalanx (see Fig. 17.3). Reattaching the
sure injury from the button. ligament at the wrong point may cause stiffness or
• Regardless of the method used for ligament repair, the MCP joint is temporarily instability of the MCP joint.
pinned by a percutaneous, transarticular K-wire to protect the repair.
Suture attached to anchor Ulnar collateral

ligament repaired
Ulnar collateral
ligament
FIGURE 17.7 Suture anchor deployed. FIGURE 17.8 Suture in place to repair the ulnar collateral ligament.
Keith needles
K-wire
Ulnar
collateral
ligament
FIGURE 17.9 Free ends of sutures passed through bone FIGURE 17.10 Sutures tied on the radial side of the proxi-
tunnels. mal phalanx.
Step 3: Closure
• Before closing, any large dorsal capsular tears should be repaired to reduce the
chance of joint subluxation later.
• The adductor aponeurosis is repaired with a 4-0 absorbable suture.
• Close skin in layers.
• A thumb spica splint is applied with the interphalangeal (IP) joint of the thumb left free.
STEP 1 PEARLS RECONSTRUCTION OF CHRONIC ULNAR COLLATERAL

If the PL is absent, a slip of the abductor pollicis LIGAMENT INJURY
longus, flexor carpi radialis, ECRL, or the proximal
aspect of the extensor pollicis brevis (EPB) can be Step 1: Preparation of the Attachment Sites and Graft
used as a tendon graft.
• In chronic cases, the joint must be carefully inspected for arthritis before proceeding
with ligament reconstruction.
• Both the proximal and distal ligament attachment sites need to be exposed and
prepared.
• In the chronic situation, residual ligament tissue will be insufficient for repair, though
the remaining ligament stumps can be used to identify the correct attachment points
for the graft and may be sutured to the tendon graft to reinforce the reconstruction.
• The palmaris longus (PL) graft is harvested through a transverse incision at the volar
wrist crease and a second proximal incision over the musculotendinous junction,
where the tendon is mobilized and divided. The tendon is withdrawn through the
wrist incision with traction on the distal cut end of the tendon. If the PL tendon is not
present, one can obtain a split segment of tendon graft from the extensor carpi ra-
dialis longus (ECRL) or extensor carpi radialis brevis tendon.
Step 2: Reattachment
• As with acute repair, chronic ligament reconstruction can be accomplished with ei-
ther suture anchors or bone tunnels.
• Suture anchor method:
• Temporary K-wire fixation of the MCP joint is performed in slight flexion, with the
joint in neutral or slight ulnar deviation.
• After preparing the sites, pilot holes are made at the proximal and distal attach-
ment sites (Fig. 17.11).
FIGURE 17.11 Pilot holes are made at the proxi- • Suture anchors preloaded with 2-0 or 3-0 suture are deployed at each location
mal and distal attachment sites. (Fig. 17.12A–B).
B
The suture attached to the anchor
FIGURE 17.12 (A) Sutures deployed.
• The PL is folded on itself, sutured together, and fashioned to the appropriate

length to span the two attachment sites (Fig. 17.13).
• The graft is secured in place proximally and distally with the sutures attached to
the suture anchors to firmly approximate the tendon graft down to bone at both
sites (Figs. 17.14 and 17.15).
• Bone tunnel method:
• This method requires passing the tendon graft through bone tunnels to recon-
struct the ligament between the anatomic attachment points of the native UCL.
The bone tunnel provides much more support for secure tendon-bone healing
(Fig. 17.16A–B).
• Holes may be created with K-wires, small drills, or burs.
• The tendon graft can be passed through the bone tunnels with the aid of a custom
tendon- or suture-passer or loops of stainless steel wire fashioned into narrow PL tendon graft
snares to grab the tendon and pull it through the bone. If these bone tunnels are FIGURE 17.13 Palmaris longus (PL) tendon graft.
used, the tendon graft may need to be trimmed to fit into the tunnel.
Step 3: Closure STEP 2 PEARLS

• The adductor aponeurosis is repaired with a 4-0 absorbable suture. The graft may be secured to residual ligament,
• Deflate the tourniquet and achieve good hemostasis before skin closure. periosteum, and joint capsule to augment the
• Close the skin in layers. repair.
• A thumb spica splint is applied with the IP joint of the thumb left free.
STEP 2 PITFALLS
• Set the tension of the graft appropriately. If the
• Immobilization in a full-time splint or cast is continued for the first 6 weeks. The K-
graft is made too tight, motion of the MCP joint
wire is removed at 4 weeks. is limited and may cause pain postoperatively.
• After 6 weeks of immobilization, range of motion exercises are begun, though radially • When creating multiple bone tunnels, be care-
directed stress is avoided. ful to avoid comminution or fracture of the
• Strengthening exercises are started at 8 weeks under the guidance of a hand therapist. small bone bridges between the tunnels/holes.
Holes that are big enough to accommodate
• Activities that directly stress the reconstruction, including lateral side pinch, are
passage of a tendon graft also put the bone at
permitted after 12 weeks. some risk for fracture.
• Patients can typically return to full activities, including contact sports, 4 months after
surgery.
• The reconstruction of the UCL is evaluated by radiographic and physical examination
at follow-up (Fig. 17.17A–E).
B
A
PL tendon graft
FIGURE 17.15 Graft secured. PL, Palmaris longus
FIGURE 17.14 Graft secured.
A B
FIGURE 17.16 Bone tunnel method.
• Although mild loss of pinch strength and mild loss of motion are typically reported,
most patients are satisfied after UCL reconstruction (see Fig. 17.17D–E).
Sensory disturbances after surgery may be RECONSTRUCTION OF CHRONIC ULNAR COLLATERAL
because of stretching of the cutaneous nerves LIGAMENT INJURY WITH MINI MITEK ANCHOR
during surgery, irritation from pin(s), or thumb
spica splints that apply pressure to the digital Step 1: Identification of the UCL
nerves. Most of these disturbances are temporary
• In chronic cases, the joint must be carefully inspected for arthritis before proceeding
and require only reassurance to the patient.
with ligament reconstruction or repair.
• The UCL should be identified and inspected. Occasionally, the ligament may be re-
STEP 1 PEARLS paired with the use of suture anchors if the ligament itself is stout. In this case, the
• Careful assessment of the quality and quantity UCL was torn from its proximal attachment off the metacarpal and thus the ligament
of the UCL should be done to see if the liga- itself was not frayed or degenerated (Fig. 17.18)
ment may be repairable.
• A suture anchor should be on hand if a UCL Step 2: Reattachment
suitable for repair is identified, even in a
Suture anchor method:
chronic situation.
• The MCP joint is held in slight flexion, with the joint in neutral or slight ulnar deviation
to take tension off the repair.
A B C
D E
FIGURE 17.17 Postoperative result.
FIGURE 17.18 Ligament torn off metacarpal, distal attachment to prox- FIGURE 17.19 Mini-mitek suture anchor placed at the proximal
imal phalanx intact; stout ligament without degeneration present. insertion.
• After preparing the site, a pilot hole is made at the proximal attachment site.
• Suture anchors preloaded with 2-0 or 3-0 suture are deployed to secure the UCL STEP 2 PEARLS
repair (Fig. 17.19). Additional ethibond suture is placed to repair the UCL (Fig. 17.20). • Ensure that the suture anchor is buried within
the bone to the laser line.
Step 3: Closure • Test the strength of the suture anchor by gen-
tly pulling on the sutures. A well-deployed su-
• The joint capsule is repaired with a 4-0 Vicryl suture. ture anchor will not pull out of the bone.
STEP 2 PITFALLS
Set the tension of the repair appropriately. If the
ligament is repaired with the MCP joint in too much
ulnar deviation, the repair will be overly tight and
limit MCP motion.
FIGURE 17.20 Ethibond suture used with ligament repaired.
POSTOPERATIVE PEARLS • Close the skin in layers.

• A thumb spica splint is applied with the IP joint of the thumb left free.
Sensory disturbances after surgery may be
because of stretching of the cutaneous nerves
during surgery or thumb spica splints that apply POSTOPERATIVE CARE AND EXPECTED OUTCOMES
pressure to the digital nerves. Most of these • Immobilization in a full-time splint or cast is continued for the first 4 weeks.
disturbances are temporary and require only • After 4 weeks of immobilization, range of motion exercises are begun, though radi-
reassurance to the patient.
ally directed stress is avoided.
• Strengthening exercises are started at 8 weeks under the guidance of a hand therapist.
• Activities that directly stress the reconstruction, including lateral side pinch, are
permitted after 12 weeks.
• Patients can typically return to full activities, including contact sports, 4 months after
surgery.
See Video 17.1
EVIDENCE
Katolik LI, Friedrich J, Trumble TE. Repair of acute ulnar collateral ligament injuries of the thumb meta-
carpophalangeal joint: A retrospective comparison of pullout sutures and bone anchor techniques.
Plast Reconstr Surg. 2008;122:1451–1456.
This retrospective study compared the outcome between pullout sutures and bone anchor techniques in
30 patients with complete rupture of the ulnar collateral ligament of the thumb. All were assessed at a
mean follow-up of 29 months. Average range of motion at the MCP joints was 97% of the contralat-
eral side in the anchor group and 86% in the button group. Pinch strength was average 101% of the
contralateral side in the anchor group and 95% in the button group. Tourniquet time for the anchor
group averaged 28 minutes compared with 43 minutes for the button group. Complications were
identified in 27% of patients in the button group and 7% in the anchor group (Evidence level III).
Samora JB, Harris JD, Griesser MJ, Ruff ME, Awan HM. Outcomes after injury to the thumb ulnar col-
lateral ligament—A systematic review. Clin J Sport Med. 2013;23:247–254.
This review compared nonoperative treatment with surgical repair and reconstruction of UCL injuries of
the thumb in a systematic review, which included 14 articles. Thirty-two nonoperative cases were
compared with 261 operative cases; 200 acute injuries and 93 chronic injuries were included. Pa-
tients were followed for a mean of 42.8 months. Nonoperative treatment often met with failure. Both
acute UCL repair and UCL reconstruction for chronic injury achieved excellent clinical outcomes. In
fact, there was no significant difference between the outcomes in the acute and chronic groups
(Evidence level III).
Weiland AJ, Berner SH, Hotchkiss RN, McCormack Jr RR, Gerwin M. Repair of acute ulnar collateral
ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand
Surg Am. 1997;22:585–591.
This study reported the outcomes of 36 patients with 37 complete tears of the UCL treated with suture
anchor repair. Postoperative range of motion in both the IP and MCP joints was decreased by an
average of 15 degrees and 10 degrees, respectively. Stress testing for radial deviation showed no
significant difference between the repaired thumb and contralateral thumb. No obvious complica-
tions arose. The authors feel that a suture anchor is a secure method for treatment of the UCL tear
of the thumb MCP joint (Evidence level IV).
Christensen T, Sarfani S, Shin AY, Kakar S. Long-term outcomes of primary repair of chronic thumb
ulnar collateral ligament injuries. Hand. 2016;11(3):303–309.
A retrospective review of long-term follow-up of patients undergoing ligamentous repair of chronic

UCL injuries. Assessed radiographs, postoperative outcome questionnaire DASH, and VAS sores.
Confirmed local tissue repair with durable outcomes but majority progress to osteoarthritis
(Evidence Level III).
Baskies MA, Tuckman D, Paksima N, Posner MA. A new technique for reconstruction of the ulnar
collateral ligament of the thumb. Am J Sports Med. 2007:35(8):1321–1325.
A cadaveric study looking at biomechanical outcomes on cadaveric systems. Compared tendon free
graft versus Bio-Tenodesis Screw System and found no difference between peak load failures of the
two reconstructions (Evidence Level III)
CHAPTER 18
Techniques for Fixing Bennett and Rolando
Fractures

This chapter includes the following video: Video 18.1 – Bennett Fracture Treated With
Metacarpal Corrective Osteotomy and Placement of Alloderm in the Carpometacarpal
Joint.
KEY CONCEPTS
• Bennett fractures are intraarticular fractures of the base of the thumb metacarpal that
classically have two main fracture fragments: a constant “Bennett” fragment of the
volar-ulnar thumb metacarpal, and the remaining thumb metacarpal, which displaces
radially and proximally because of unopposed pull from the abductor pollicis longus
(APL) and into flexion and adduction because of pull from the adductor pollicis.
• In modern practice, any complex periarticular fracture of the thumb metacarpal is
referred to as a Rolando fracture. Classically, a Rolando fracture is a Bennett fracture
with an additional intraarticular fracture through the dorsal-radial base of the thumb
metacarpal, creating a Y- or T-shaped intraarticular fracture pattern.
• There are three aspects to reduction of Bennett and Rolando fractures, which are
performed in the following order: longitudinal traction of the thumb, pronation of the
thumb, and abduction applied at the level of the thumb carpometacarpal (CMC).
• Closed reduction and percutaneous pinning is indicated for any Bennett or Rolando
fracture with articular step-off greater than 1 mm, fracture-dislocation of the thumb
CMC joint, or angulation/rotation greater than 10 degrees.
• Open reduction with internal fixation is indicated for open fractures of the thumb CMC
or fractures that cannot be reduced via closed methods. Internal fixation should be
avoided in open injuries with soft tissue loss, unless coverage can be provided acutely.
Adductor pollicis
muscle
Palmar oblique
ligament
Abductor pollicis
longus muscle
FIGURE 18.3 (B) In a Bennett fracture, the remaining thumb metacarpal is displaced by the unop-
posed pull from the abductor pollicis longus and the adductor pollicis.
52
CHAPTER 18
Techniques for Fixation of Bennett and Rolando
Fractures
INDICATIONS
• Closed reduction and percutaneous pinning is indicated for any Bennett or Rolando
fracture with articular step-off greater than 1 mm, fracture-dislocation of the thumb
carpometacarpal (CMC) joint, or angulation/rotation greater than 10 degrees.
• Open reduction with internal fixation is indicated for open fractures of the thumb
CMC or fractures that cannot be reduced via closed methods.
Contraindications
• The integrity of the thumb CMC joint is vital for normal thumb/hand function. There-
fore there are few contraindications to reduction and fixation of displaced Bennett
and Rolando fractures.
• Internal fixation should be avoided in open injuries with soft-tissue loss, unless cover-
age can be provided acutely. In this scenario, percutaneous pinning is chosen for
ease of hardware removal should a wound healing issue or infection arise.
• Swelling and tenderness are present on the proximal part of the thumb metacarpal
(Fig. 18.1).
• The thumb may appear shortened because of subluxation or dislocation of the CMC
joint or because of fracture comminution.
IMAGING
• A true thumb posteroanterior (PA) view (Robert’s view) and lateral view (Bett’s view)
are needed (Fig. 18.2).
• For a true PA view of the thumb CMC, the shoulder, forearm, and hand must be
internally rotated and hypersupinated so that the thumb lays flat against the cas-
sette/image sensor.
• Computed tomography is rarely needed but can help with the assessment of frac-
ture comminution and joint congruity in complex cases.
SURGICAL ANATOMY
Bennett Fracture
• Bennett fractures are intraarticular fractures of the base of the thumb metacarpal
that classically have two main fracture fragments:
• A constant “Bennett” fragment of the volar-ulnar thumb metacarpal
• The remaining thumb metacarpal, which displaces radially and proximally be-
cause of unopposed pull from the abductor pollicis longus (APL) and into flexion
and adduction because of pull from the adductor pollicis (Fig. 18.3).
• Classically, the anterior oblique “beak” ligament (AOL) has been thought to be the
primary ligamentous stabilizer of the constant fragment, keeping it reduced in posi-
tion. More recent research has demonstrated that the AOL is more of a capsular
thickening than a true ligament and that the ulnar collateral ligament of the thumb
CMC is the true ligamentous stabilizer of the constant fragment.
Rolando Fracture
• Classically, a Rolando fracture is a Bennett fracture with an additional intraarticular
fracture through the dorsal-radial base of the thumb metacarpal, creating a Y- or
52.e1
52.e2 CHAPTER 18 Techniques for Fixation of Bennett and Rolando Fractures
A B
FIGURE 18.1 Arrow indicates swelling at thumb metacarpal.
A B
FIGURE 18.2 (A) Left thumb posteroanterior (PA) and lateral imaging demonstrate an impacted
Rolando fracture of the left thumb.
Intermetacarpal
ligament Adductor pollicis
muscle
Anterior oblique
ligament
Capsule
Palmar oblique
ligament
Abductor pollicis longus
Abductor pollicis
longus muscle
A B
FIGURE 18.3
CHAPTER 18 Techniques for Fixation of Bennett and Rolando Fractures 52.e3
T-shaped intraarticular fracture pattern. Because of this, a volar-ulnar “constant”

fragment is still seen in Rolando fractures and can act as a stable base for the reduc-
Abduction
tion of additional fragments.
• In modern practice, any complex periarticular fracture of the thumb metacarpal is
referred to as a Rolando fracture.
• Similar deforming forces are seen in Rolando fractures, but the APL is often attached to
the dorsal-radial fragment and can act as a strong deforming force of this small fragment.
CLOSED REDUCTION
Traction
Step 1: Reduction
• There are three aspects to reduction of Bennett and Rolando fractures, which are Pronation
performed in the following order (Fig. 18.4):
• Longitudinal traction of the thumb
• Pronation of the thumb
• Abduction applied at the level of the thumb CMC
• This maneuver works because of ligamentotaxis of the CMC joint capsule and dor-
sal ligamentous complex on the fracture fragments, which often remain intact in
these injuries.
• The reduction is confirmed with fluoroscopy. If there is residual articular step-off
greater than 1 mm or persistent metacarpal subluxation, open reduction should be
performed (Fig. 18.5A–B).
FIGURE 18.4
Step 2: Kirschner Wire Fixation
• Often, an assistant can perform the initial fixation while the reduction is maintained STEP 1 PEARLS
or can hold the reduction while the surgeon places the Kirschner wire (K-wire). The tip/pulp of the thumb should be roughly
• A 0.045-inch (1.1-mm) K-wire is placed in retrograde fashion, from the metacarpal parallel with the adjacent fingers when positioned
into the trapezium, holding the reduction. to directly oppose each other. This can act as a
• The starting point for the K-wire is on the dorsal-radial aspect of the thumb meta- quick verification of alignment/reduction before
fluoroscopic images are taken (Fig. 18.6).
carpal, at the level roughly between the proximal and middle third of the metacarpal.
• The so-called “constant” fragment, if large enough, may then be captured by an
additional wire placed across the fracture line (Fig. 18.7). STEP 2 PITFALLS
• Rolando fractures are innately unstable because of increased comminution; there- • Branches of the superficial radial nerve may run
fore multiple K-wires are usually required (Fig. 18.8A–B). directly through the area of K-wire placement,
• In cases where the fragments are very small or numerous, direct capture with a and iatrogenic injury to these nerve branches
may lead to chronic pain. If placing several K-
K-wire will be impossible. In these cases, maintaining solid joint reduction with
wires, consider a so-called “mini-open” approach
an additional K-wire either into the trapezium or second metacarpal can provide with a small (less than 1 cm) incision, enabling
increased resistance against redisplacement (Fig. 18.9A–C). the subcutaneous tissues to be retracted away.
• The scaphotrapeziotrapezoid joint has a com-
plex three-dimensional shape and can easily
obscure a prominent K-wire. Several fluoros-
copy images should be taken and scrutinized
to ensure the transarticular thumb CMC K-wire
has not advanced too far proximally.
The pulp of the thumb is parallel

to the other digits.
Pronation of the
thumb
A B
FIGURE 18.7
A B
FIGURE 18.8
A B C
FIGURE 18.9
OPEN REDUCTION
Step 1: Incision and Dissection
• An incision is created along the radial border of the thumb metacarpal and thumb
CMC joint. Typically, the transition between the glabrous (non-hair-bearing) and
nonglabrous (hair-bearing) skin defines the interval (Fig. 18.10).
• Superficial dissection is taken down to the level of the metacarpal, and the thenar
musculature is gently elevated off the volar surface, exposing the joint capsule of the
thumb CMC joint.
• The joint capsule is further defined volarly and dorsally (Fig. 18.11A) and then
opened longitudinally in line with the incision, exposing the fracture site (see
Fig. 18.11B). Excessive dissection and stripping of fracture fragments should be
avoided.
Step 2: Reduction
• As with all periarticular trauma, the goal is to reestablish a congruent articular
FIGURE 18.10 surface with less than 1 mm of articular step-off.
A B
• The fracture site is manually opened, and a combination of irrigation, curettes, and STEP 2 PITFALLS
small-tipped rongeurs are used to remove any fracture hematoma that prevents an
With a Rolando fracture, attempting to reduce
exact reduction. articular fragments to the metacarpal shaft before
• A dental pick or small elevator can then be used to mobilize the fracture fragments reestablishing the articular surface will often make
into position, which can then be temporarily maintained with a pointed reduction anatomic reduction more difficult. The reduced
clamp (Fig. 18.12). working area will inhibit reduction of the remaining
fragments and reduce visualization of the articular
• A 0.045-inch (1.1-mm) or 0.035-inch (0.9-mm) K-wire can be used to temporarily
surface.
hold reduction of the individual fragments.
• In cases of a Rolando fracture with three or more articular fragments, reduction
should be systematic.
• Articular fragments are reduced back to each other first and held with temporary
K-wire fixation (Fig. 18.13A–B).
• With the articular surfaces reduced together, the consolidated articular surface
can then be reduced back to the metacarpal shaft.
• Confirm reduction with fluoroscopy.
A B
FIGURE 18.13
STEP 3 PEARLS
Step 3: Fixation
• Depending on the size of the fracture fragments, fixation can be performed with
K-wires can be used for definitive fixation of
Rolando fractures if enough metaphyseal bone is K-wires, 1.3-mm or 1.5-mm lag-screws, or mini fragment locking plates designed for
attached to the articular fragments. The primary the thumb metacarpal.
benefit of K-wire fixation is that the pins can be • Even if a plate construct or interfragmentary screws are used, a retrograde K-wire
removed easily in an outpatient setting, avoiding entering the metacarpal and crossing the thumb CMC joint into the trapezium
the need for more permanent internal fixation and
remains a valuable tool for stabilizing the CMC joint and maintaining reduction.
the potential for extensor tendon irritation.
Step 4: Closure
STEP 3 PITFALLS • If open reduction was performed, the thumb CMC joint is thoroughly irrigated to
The metacarpal base articular surface is concave, ensure no fracture fragments remain within the joint (Fig. 18.14A–B).
which can obscure identification of the intraarticular • The joint capsule should be repaired with 4-0 braided suture.
screw penetration. Multiple views on fluoroscopy • The subcutaneous tissues and skin are closed per surgeon preference.
and direct inspection of the joint surface should be
• Exiting K-wires are bent using a needle driver and Frazier suction tip and cut, then
performed to confirm accurate screw placement.
a protective cap is placed over the sharp end.
• Xeroform or other petroleum-impregnated gauze is placed around the pin sites.
• A forearm-based thumb spica splint or cast is placed to the thumb tip to ensure
complete immobilization of the thumb metacarpal and CMC joint.

• Radiographic examination is performed 2 weeks after surgery to confirm that the
reduction is maintained.
• Patients are maintained in a full-time splint or thumb spica cast for 4 to 6 weeks.
• If rigid internal fixation was placed, transition to a thumb spica cast with the inter-
phalangeal (IP) joint free may be initiated at 2 weeks postoperatively to encourage
motion and lessen the risk for tendon adhesion.
• If K-wires were placed, they are removed roughly 6 weeks after the operation de-
pending on radiographic healing.
• After pin removal, gentle mobilization of the CMC joint is started under the supervi-
sion of a hand therapist.
• Reduction with residual displacement of less than 1 mm leads to good radiographic
and clinical outcomes in Bennett fractures (Fig. 18.15A–E).
See Video 18.1
A B C
B D E

EVIDENCE
Kang JR, Behn AW, Messana J, Ladd AL. Bennett fractures: A biomechanical model and relevant
ligamentous anatomy. J Hand Surg Am. 2019;44(2):154.e1–154.e5.
An anatomical study that aimed to clarify the ligamentous stability of Bennett fractures. Six cadaver
upper extremities were dissected to expose to the thumb CMC joint. A Bennett fracture was simu-
lated by employing axially applied loading in a grip position. The proper ulnar collateral ligament of
the thumb CMC joint was found to be intact and fully attached to the Bennett constant fragment in
all six specimens, whereas the anterior-oblique ligament was found to be diminutive in comparison
and more often attached to the remaining metacarpal.
Livesley PJ. The conservative management of Bennett’s fracture-dislocation: A 26-year follow-up.
J Hand Surg Br. 1990;15:291–294.
This is a study with 17 patients to demonstrate the long-term outcome of conservative treatment for
Bennett fracture. The average follow-up period was 26 years. All patients had decreased range of
motion and grip strength. A characteristic deformity of the hand was shown in 12 patients. Sublux-
ation of the CMC joint and degenerative changes were revealed in radiographs (Level IV evidence).
Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S. Closed reduction transarticular
Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture
dislocation. J Hand Surg Br. 2003;28:142–147.
In this study, 32 patients with Bennett fractures were treated with either closed reduction and percuta-
neous pinning or open reduction and internal fixation. The patients were followed for an average of
7 years. The type of operation performed had no statistical impact on the clinical outcome or on the
prevalence of radiologic posttraumatic arthritis. Adduction deformity of the thumb metacarpal was
significantly more common in the percutaneous pinning group (Level III evidence).
Middleton SD, McNiven N, Griffin EJ, Anakwe RE, Oliver CW. Long-term patient-reported outcomes
following Bennett’s fractures. Bone Joint J. 2015;97:1004–1006.
This study reviewed the long-term outcomes of 143 patients after displaced Bennett fractures treated
with K-wire fixation. The average follow-up period was 11.5 years. The average satisfaction and Dis-
abilities of the Arm, Shoulder, and Hand (DASH) scores were 94% and 3.0, respectively. There were
no patients who required salvage procedures or a change in occupation or sports activities (Level IV
evidence).
ddsf
SECTION III
Wrist Fractures and

Carpal Instability
CHAPTER 19 Wrist Arthroscopy 54
CHAPTER 20 TFCC Repair 68
CHAPTER 21 Scapholunate Ligament Repair 80
CHAPTER 22 Scapholunate Ligament Reconstruction 93
CHAPTER 23 Lunotriquetral Ligament Reconstruction
Options using Tendon Grafts 113
CHAPTER 24 Scapholunate and Lunotriquetral Ligament
Reconstruction with Internal Brace and
Tendon Grafting 125
CHAPTER 25 Open Reduction and Internal Fixation of
Acute Scaphoid Fracture 131
CHAPTER 26 Treatment of Scaphoid Nonunion 142
CHAPTER 27 Salvage Procedures for Scaphoid Nonunion 161
CHAPTER 28 Open Reduction and Fixation of Acute Lunate
or Perilunate Dislocation With or Without
Fracture 175
CHAPTER 29 Ulnar Shortening Osteotomy for Ulnar
Impaction Syndrome 184
CHAPTER 30 Distal Radioulnar Joint Reconstruction Using
the Palmaris Longus Graft 185
CHAPTER 31 Procedures for Avascular Necrosis of the Lunate
(Kienböck Disease) 194
53
CHAPTER 19
Wrist Arthroscopy
INDICATIONS
Diagnostic
The diagnostic indications include the following:
• To identify or confirm pathology that is suggested by physical examination or non-
invasive radiographic imaging, such as x-ray or magnetic resonance imaging (MRI).
• To investigate the source of chronic pain that is thought to originate in the wrist and
has persisted despite conservative measures, such as corticosteroid injections or
occupational therapy (including splinting).
• To characterize partial and complete ligamentous and cartilaginous injury, and to
determine whether the patient will benefit from either arthroscopic or open operative
intervention.
Therapeutic
A therapeutic indication is to aid in the treatment of (1) distal radius and scaphoid frac-
tures, (2) debridement and shrinkage or repair of the scapholunate (SL) or lunotriquetral
(LT) interosseous (IO) ligaments and dorsal wrist capsule, (3) triangular fibrocartilage
complex (TFCC) repairs, (4) removal of foreign bodies, or (5) wrist irrigation in the case
of infection or debridement of synovitis in inflammatory conditions such as rheumatoid
arthritis (Table 19.1).
Contraindications
• Contraindications include any cause of visible swelling that distorts the normal
anatomy and/or significant capsular tears that might lead to extravasation of irriga-
tion fluid, neurovascular compromise, coagulopathy, or severe infection.
• Being unfamiliar with regional anatomy is a relative contraindication.
TABLE
19.1 Therapeutic Indications for Wrist Arthroscopy
Common Arthroscopic Procedures
Loose body removal
Synovectomy
Intraarticular adhesion release
Lavage of septic wrist joint
Debridement of chondral lesion; hypertrophic or torn ligament
Ganglion excision; volar and dorsal
Assisted reduction of distal radius and scaphoid fractures
Bone resection (radial styloidectomy; distal ulnar; proximal hamate)
Carpal bone excision (scaphoid; lunate; proximal row) and arthrodesis
TFCC repair
Treatment of carpal instability
TFCC, Triangular fibrocartilage complex.
54
• History and physical examination should cue the surgeon to the specific anatomic
structures that may have been injured.
• Anatomic snuff box tenderness suggests a scaphoid fracture.
• Pain distal to the Lister tubercle, between the third and fourth extensor compartments,
prompts suspicion of an SL ligament injury. LT ligamentous injury may be suspected
with pain over the 4-5 interval or with radial-ulnar compression of the wrist.
• Ulnar-sided wrist pain and tenderness over the ulnar head or prestyloid recess sug-
gests a possible TFCC injury.
• Diffuse wrist swelling and tenderness over the distal radius suggests a distal radius
fracture.
IMAGING
• Noninvasive imaging may be enough to identify an injury that would benefit from
either nonoperative or operative intervention.
• Plain x-rays can help identify dynamic or static wrist ligamentous injury, displaced
carpal bone fractures, fractures of the distal radius and ulna, and ulnar variance.
• MRI or magnetic resonance arthrography can be used to locate ligamentous pathol-
ogy with reasonable sensitivity and may demonstrate changes within the lunate or
triquetrum associated with an ulnar abutment.
SURGICAL ANATOMY
• Before beginning the procedure, several anatomic structures should be marked,
including the bony landmarks: the Lister tubercle, the articular margins of the carpal
bones, and the radius and ulna (Fig. 19.1).
• Tendons should be identified as they cross the wrist, including the extensor pollicis
longus (EPL), extensor digitorum communis (EDC), extensor digiti minimi (EDM), and
extensor carpi ulnaris (ECU; Fig. 19.2).
• Portal sites 3-4, 4-5, radial and ulnar midcarpal, 6R, and 6U are marked before inci-
sion. The name of the portal is defined by the interval in which it is located.
• The 3-4 portal refers to the wrist entry site between the third and fourth extensor
compartments just distal to the dorsal lip of the radius. The 4-5 portal is located
between the fourth and fifth extensor compartments, slightly more proximal than the
Radial midcarpal
Ulna midcarpal portal (MCR)
portal (MCU)
3-4 portal
6U portal
6R portal
4-5 portal
FIGURE 19.1 Markings for each portal are based on anatomic landmarks.
56 CHAPTER 19 Wrist Arthroscopy
EDM
MCU portal
MCR portal
6U portal
3-4 portal 6R portal
4-5 portal
Lister tubercle
ECU
EDC
ECRL/ECRB
FIGURE 19.2 Portals are named according to the anatomic compartments in which they are located.
POSITIONING PEARLS
ECRB, Extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi
• Isotonic and crystalloid solutions such as nor- ulnaris; EDC, extensor digitorum communis; EDM, extensor digitorum minimi; MCR, radial
mal saline (0.9% NaCl solution) or lactated midcarpal; MCU, ulnar midcarpal.
Ringer solution are preferable because they
can be rapidly absorbed into the tissues.
• Irrigation can be introduced through the sheath 3-4 portal, following the inclination of the radius. The 6R and 6U portals permit entry
of arthroscope or another separate inflow por- into the wrist on the radial and ulnar side of the ECU tendon, respectively. The radial
tal. Inflow by gravity is adequate for clearing
and ulnar midcarpal portals are located approximately 1 cm distal to the 3-4 and 4-5
the visual field and distending the joint space
and can also decrease the risk for fluid extrav- portals, respectively. These portals permit entry into the midcarpal joint.
asation into subcutaneous tissue.
POSITIONING
• A sterile traction device is used to suspend the hand with the elbow flexed at 90
degrees (Fig. 19.3).
• Finger traps suspend the index and long finger. Approximately 5 to 10 lbs of weight
is applied through the traction tower to distract the wrist.
• For better visualization of ulnar-sided pathology, the finger traps can suspend the
index and ring finger. For patients with fragile skin, additional finger traps can reduce
the force on the skin.
• A 1.9- to 2.7-mm angled arthroscope, along with a camera attachment, is essential to
permit adequate mobilization without injury to surrounding structures and articular
cartilage. The 1.9-mm scope is remarkably advantageous for the evaluation of small
joints such as the distal radioulnar joint, basal joint, and metacarpophalangeal joint.
Besides the standard 30-degree arthroscope, a 70-degree arthroscope is occasionally
FIGURE 19.3 A traction device is used to suspend useful.
the hand and enlarge the wrist joint space.
EXPOSURES
EXPOSURES PEARLS
• Extremity exsanguination with subsequent tourniquet control should be performed
Some surgeons prefer not to use extremity for all arthroscopic cases, except where infection or malignancy is expected.
exsanguination with a tourniquet, except when • The traditional portal is the 3-4 portal, located in the radiocarpal joint in the interval
bleeding tendency is expected. Because the
patient’s hand is held high during the operation, between the third and fourth extensor compartments. The marking for the 3-4 portal
fluid continuously distends the joint space with is performed by locating the Lister tubercle and traveling distally 1 cm beyond the
sufficient pressure to minimize bleeding. Others dorsal articular surface of the distal radius. This portal is generally in line with the
prefer a dry arthroscopy without infusion of fluid. radial border of the long finger metacarpal, just distal to the EPL tendon.
All are suitable techniques based on the surgeon’s • The 4-5 portal is located by identifying the EDC tendons of the fourth compartment
experience and preference.
and marking a position slightly more proximal than the 3-4 portal, in the interval
between the fourth and fifth compartment. This portal is typically in line with the mid
axis of the ring metacarpal.
• 6R and 6U are named according to their positions in relation to the ECU tendon, with
6R located radial and 6U located ulnar. 6R is typically a working portal, and 6U is
often used for inflow or outflow of fluid into and out of the wrist.
• The 1-2 portal is identified along the dorsal aspect of the anatomic snuff box. Take
care to avoid injury to the radial artery.
• The radial and ulnar midcarpal portals are made 1 cm distal to the 3-4 and 4-5 por-
tals, respectively. The radial midcarpal (MCR) portal is bounded radially by the ECRB
and ulnarly by the EDC. The EDC and EDM bound the ulnar midcarpal (MCU) portal
which is often more accessible than the radial midcarpal portal. EXPOSURES PITFALLS
• If a scaphotrapezial-trapezoid (STT) portal is desired, the incision is made ulnar to • Understanding the normal anatomy of the wrist
the EPL tendon. The exact location of this portal can be confirmed with an arthro- is essential to avoiding injury to structures.
scope in the radial midcarpal portal by passing a spinal needle into the STT space. • The portal placement must be precise to within
• A typical arthroscopic examination includes variable combinations of the 3-4 portal, 1 to 2 mm of the desired location to avoid
damage to articular surfaces.
4-5 portal, MCR portal, MCU portal, and 6R/U portals (see Fig. 19.1).
• When the wrist is swollen after acute trauma,
one should palpate bony landmarks to confirm
Arthroscopic Evaluation of Wrist portal location.
Step 1: Injection of Radiocarpal Joint and Preparation of the 3-4

Portal
• Axial traction is applied to the wrist via finger trap suspension through the index and
long finger. Approximately 10 lbs (4.5 kg) of traction is used, although 15 lbs (6.8 kg)
can be used in a more muscular patient or when arthritis has significantly narrowed
the joint space.
• An 18-gauge needle attached to a 10-cc syringe filled with saline should be used to
enter the radiocarpal joint via the 3-4 portal, remembering to enter at approximately
10 degrees of downward inclination toward the hand to match the dorsal-volar incli-
nation of the distal radius. The bevel of the needle should be parallel with the exten-
sor tendons to avoid inadvertent injury (Fig. 19.4). If not positioned correctly, one
may have difficulty with entry into the joint, impeded by either the scaphoid or the
radius. If the portal is not positioned perpendicular to the joint capsule, in the center
of the joint, movement of the scope and visualization of all anatomic structures of
the radiocarpal joint will be difficult.
FIGURE 19.4 The needle enters at approximately 10 degrees of inclination toward the wrist joint.
STEP 1 PEARLS • Entry into the joint can be determined by feeling a distinct “pop” through the dorsal
capsule. Further confirmation can be ascertained by injecting approximately 5 cc of
• The skin incision should be shallow to avoid
injury to important subcutaneous structures saline to distend the radiocarpal joint.
such as tendons and nerves. • An 11-blade scalpel, inserted parallel to the extensor tendons, is used to increase
• After a shallow skin incision, blunt dissection the size of the skin incision.
should be carried out to the level of the joint • Remembering the angle in which the needle entered the joint, a mosquito is used to
capsule, followed by arthroscope introduction bluntly dissect and increase the opening in the dorsal joint capsule (Fig. 19.5).
with blunt trocar to avoid injury to the extensor
tendons or the articular cartilage. • A blunt cannula is used to place the 2.7-mm arthroscope within the radiocarpal joint.
• Remember that the distal radius volar tilt will re-
quire the radiocarpal instruments to be inserted Step 2: Preparation of the 4-5 and 6R/U Portals
at approximately 10 degrees toward the hand. • The gravity-driven inflow of arthroscopy fluid can be provided by the 6U portal or
through the arthroscopic cannula. An 18-gauge needle is placed in the 6U portal for
STEP 2 PEARLS outflow. The outflow of fluid should be collected in a basin to avoid the pooling of
• The inflow through the arthroscope can push saline in the operative field.
debris away instead of pulling it towards the • Traditional working portals are the 4-5 portal or 6R portal (Fig. 19.6).
camera. • The interval between the fourth and fifth extensor tendons is palpated, and the ra-
• When creating a new portal, an 18- to diocarpal joint is entered with an 18-gauge needle. The portal is dilated using a
22-gauge needle can be inserted under direct
arthroscopic visualization. mosquito as previously described. The 6R/U portals are on the radial and ulnar side
• The 4-5 and 6R portals are positioned slightly of the ECU tendon; entry can be similarly accessed.
proximal to the 3-4 portal because of the incli-
nation of the radius. Step 3: Evaluation of Radiocarpal Joint
• Dry arthroscopy can be performed to confirm a • With the arthroscope in the 3-4 portal, the radiocarpal space is evaluated system-
diagnosis when an open operation is planned.
In this way, the structures will not be distorted atically from radial to ulnar in the order of articular surface, extrinsic ligament, and
by arthroscopy fluid. intrinsic ligament.
• The articular surfaces are examined first: radius, scaphoid, lunate, and triquetrum
(R, radius; S, scaphoid; L, lunate; Figs. 19.7 and 19.8).
• The extrinsic ligamentous structures are evaluated next: radioscaphocapitate ligament
(RSC), long radiolunate ligament (LRL), ligament of Testut (radioscapholunate ligament),
short radiolunate ligament (SRL), prestyloid recess, and TFCC (Figs. 19.9–19.11).
FIGURE 19.6 The traditional viewing portal is

FIGURE 19.5 A mosquito is used to bluntly dissect the 3-4 portal. Working portals are the
and increase the opening in the dorsal joint capsule. 4-5 or 6R portal.
A B
FIGURE 19.7 (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed (radiocar-
pal joint). R, Radius; S, scaphoid.
A B
FIGURE 19.8 (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed (radiocar-
pal joint). L, Lunate; R, radius.
S L
Long radiolunate
ligament (LRL)
Radioscaphocapitate
ligament
Ligament of Testut
R R
FIGURE 19.9 R, Radius; S, scaphoid. FIGURE 19.10 L, Lunate; R, radius; S, scaphoid.

Prestyloid recess
TFCC L
FIGURE 19.11 TFCC, Triangular fibrocartilage complex.

R
FIGURE 19.12 The dotted line indicates the scapholunate

interosseous ligament. L, Lunate; R, radius; S, scaphoid.
STEP 3 PEARLS • The RSC ligament is the radial-most structure, originating from the radial styloid. The
slightly wider LRL can be seen ulnar to the RSC ligament.
• Gently resting your middle and ring fingers on
the patient’s dorsal hand is essential for stabi- • The ligament of Testut is seen ulnar to the LRL and is primarily a neurovascular
lizing the arthroscope (Fig. 19.13). structure. It marks the SL interval and sagittal ridge, which should be redundant on
• Do not confuse the normal prestyloid recess probing. The SRL is next to the ulnar side.
with a peripheral TFCC tear. Most peripheral • The integrity of the TFCC can be assessed using a probe via the 6R/U portal.
tears are observed dorsal to the fovea. • The intrinsic ligaments can also be evaluated from the 3–4 portal: the SL IO ligament
and the LT IO ligament (Fig. 19.12).
• The extrinsic ulnar ligaments, including the ulnar lunate (UL) and ulnar triquetral (UT)
ligaments, are best visualized with the arthroscope in the 6R portal.
FIGURE 19.13 Gently rest your middle and ring fingers on the patient’s dorsal hand to stabilize the
arthroscope.
Step 4: Preparation of Midcarpal Portals and Evaluation

• Midcarpal evaluation should be performed after a thorough evaluation of the radio-
carpal joint.
• A needle can be placed in the radial midcarpal portal approximately 1 cm distal to
the 3-4 portal. Upon entering the joint, if there is arthroscopy fluid flowing out, one
should suspect an IO ligament injury because of fluid communicating through the
STEP 4 PITFALLS
ruptured proximal intercarpal ligaments.
• The ulnar midcarpal portal, approximately 1 cm distal to the 4-5 portal, can be con- • Remember the location of cutaneous nerves
when creating portals or placing percutaneous
firmed under direct visualization with an arthroscope in the radial midcarpal portal. Kirschner wires (K-wires) for provisional fixa-
• The proximal articular surfaces, including trapezium (Tzm), trapezoid (Tzd), capitate tion (Fig. 19.18).
(C), and hamate (H), are best appreciated through the midcarpal joints. Furthermore, • If thermal shrinkage is performed for soft tis-
the distal articular surfaces of the scaphoid (S), lunate (L), and triquetrum (T) are also sue debridement, it is crucial to monitor the
seen (Figs. 19.14–19.17). temperature of the fluid exiting the wrist to
avoid high-temperature injury.
• Widening of the SL and LT IO interval is best seen through the midcarpal portals.
Systematic Evaluation and Common Pathologies

Step 1: Radiocarpal Joint
See Table 19.2 and Figs. 19.19–19.27 for an overview of the procedure and pictures.
• Begin with the 3-4 portal, which is the primary viewing portal.
• Move from radial to central to ulnar.
Tzd
Tzm
A B
FIGURE 19.14 (A–B) The circle in the x-ray indicates the position in the joint where the scope is
placed (scaphotrapezial-trapezoid joint). S, Scaphoid; Tzd, trapezoid; Tzm, trapezium.
S L
A B
FIGURE 19.15 (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed.
C, Capitate; L, lunate; S, scaphoid.
A B
FIGURE 19.16 (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed.
C, Capitate; L, lunate; T, triquetrum.
C H
A B
FIGURE 19.17 (A–B) The circle in the x-ray indicates the position in the joint where the scope is
placed. C, Capitate; H, hamate.
• 4-5 and 6R portals can be used as the working portal.

• Change to the 4-5 or 6R portal as the viewing portal to easily access the ulnocar-
pal joint.
Step 2: Midcarpal Joint

See Table 19.2 and Figs. 19.28–19.32 for an overview of the procedure and pictures.
• Begin with the MCR portal, which is the primary viewing portal.
• Move from central to ulnar to radial.
• The MCU or STT portal can be used as the working portal.

• After routine arthroscopic evaluation and soft tissue debridement/thermal shrinkage,
the patient is instructed to remain in a soft dressing for 72 hours, after which the
patient may shower and keep the incisions clean.
• Range-of-motion and strengthening exercises are dictated by the treatment of the
specific pathology and will be described in separate chapters.
See Video 19.1
TABLE
19.2 Systematic Evaluation of Wrist Arthroscopy
Radiocarpal Joint
Common
Field of View Anatomic Structures Checkpoint Pathologies
1. Radial to 3-4 portal
Proximal scaphoid, radial styloid, and Arthritic change Fig. 19.19–20
radial facet
Volar extrinsic ligaments RSC, LRL, RSL (Testut)
2. Central to 3-4 portal
SL ligament Normal concave appearance Fig. 19.21

Tear or diastasis
Drive-through sign
3. Ulnar to 3-4 portal
Proximal lunate and lunate facet Arthritic change Fig. 19.22–23
LT ligament Fig. 19.24–25
Triquetrum
Radial attachment of the TFCC
TFCC and prestyloid recess Trampoline test Fig. 19.26–27
Hook test (fovea tear)
Palmer classification
4. Easily evaluated from the Ulnolunate and ulnotriquetral ligaments
4-5 or 6-R portal
Midcarpal joint
Common
Field of View Anatomic Structures Checkpoint Pathologies
1 Central to MCR portal
Convexity of the capitate Arthritic change
SL joint SL instability by Watson’s test Fig. 19.28–30
Widening interval (Geissler
grade)
2 Ulnar to MCR portal
Lunate, hamate, triquetrum surface Arthritic change Fig. 19.31
LT joint LT instability by ballottement Fig. 19.32
test
Widening interval (Geissler
grade)
Triquetrohamate joint space is normally
quite tight
3 Radial to MCR portal
STT portal as working STT joint Arthritic change
portal (Bubbles frequently collect here)
LRL, Long radiolunate ligament; LT, lunotriquetral; MCR, radial midcarpal; RSC, radioscaphocapitate ligament; RSL, radioscapholunate ligament; SL, scapholunate;
STT, scaphotrapezial-trapezoid; TFCC, triangular fibrocartilage complex.
Radioscaphocapitate
Superficial branch of Dorsal cutaneous branch ligament (RSC)
the radial nerve of the ulnar nerve
FIGURE 19.18 Remember the location of cutaneous nerves when creating por- FIGURE 19.19 Synovitis around radial styloid. R, Radius;
tals or placing percutaneous Kirschner wires for provisional fixation. S, scaphoid.
S
L
FIGURE 19.20 Synovitis and scaphoid FIGURE 19.21 Arrow indicates attenuated FIGURE 19.22 Arrow indicates lunate
articular wear. scapholunate ligament. L, Lunate; S, scaphoid. articular wear.
S
L
Lunate facet
TFCC
FIGURE 19.24 Demonstrates arthritis change

FIGURE 19.23 Arthritic change of lunate facet on the
of triquetrum. T, Triquetrum; TFCC, triangular
radius. L, Lunate; S, scaphoid.
fibrocartilage complex.
L L
TFCC
TFCC
Ulna head
FIGURE 19.25 Arrow indicates TFCC tear

from the radial attachment. L, Lunate; TFCC, FIGURE 19.26 Demonstrates TFCC central tear
triangular fibrocartilage complex. with ulna head exposure. TFCC, Triangular fibro-
cartilage complex.
S L
< 2 mm
FIGURE 19.27 Arrow indicates TFCC peripheral tear. TFCC, Tri- FIGURE 19.28 Shows Geissler grade 2 gapping (, 2 mm)
angular fibrocartilage complex. of the scaphoid and lunate. L, Lunate; S, scaphoid.
L
> 2 mm
S
L
FIGURE 19.29 Shows Geissler grade 3 gapping FIGURE 19.30 Illustrates Geissler grade 4 gapping of the scaphoid and lunate,
(. 2 mm) of the scaphoid and lunate. L, Lunate; drive-through sign. L, Lunate; S, scaphoid.
S, scaphoid.
H C
H
C
Step
off
FIGURE 19.32 Geissler grade 3 gapping (. 2 mm) of

FIGURE 19.31 Arrow indicates hamate articular wear. the lunate and triquetrum, with step off. C, Capitate;
C, Capitate; H, hamate. H, hamate; L, lunate; T, triquetrum.
EVIDENCE
Chung KC, Zimmerman NB, Travis MT. Wrist arthrography versus arthroscopy: A comparative study of
150 cases. J Hand Surg Am. 1996;21:591–594.
The authors used triple-injection wrist arthrography and arthroscopy to evaluate 150 patients with sus-
pected wrist ligamentous injuries. The diagnoses obtained by these two techniques were compared to
determine the differences between the two modalities. All of the patients in this study had both a clinical
diagnosis of ligamentous injuries of the wrist and normal findings on x-ray films. Intercarpal abnormalities
were found in 106 patients (71%) at wrist arthrography and in 136 patients (91%) at arthroscopy. There
was only 42% agreement (63 patients) between the arthrographic and arthroscopic diagnoses. Eighty-
seven patients (58%) had alterations of their arthrographic diagnoses after arthroscopy. For patients with
normal arthrographic findings (44 patients), 88% underwent arthroscopy because there was insufficient
correlation between the physical examination findings and the arthroscopic findings. Of the 44 patients
with normal arthrographic findings, 35 patients (80% of the subgroup) had injuries found at arthroscopy.
More than half of the patients had alterations in their arthrographic diagnoses after arthroscopy. The
authors concluded that in a patient with suspected ligamentous injury of the wrist, wrist arthroscopy
may be the most effective method for arriving at a definitive diagnosis (Level IV evidence).
Johnstone DJ, Thorogood S, Smith WH, Scott TD. A comparison of magnetic resonance imaging and
arthroscopy in the investigation of chronic wrist pain. J Hand Surg Br. 1997;22:714–718.
The authors conducted a prospective study wherein they evaluated 43 patients with chronic wrist pain
MRI and arthroscopy. Pathology within the wrist joint was detected in 30 cases with MRI and in 32
cases with arthroscopy. The sensitivity and specificity of MRI compared with arthroscopy were 0.8
and 0.7 for TFCC pathology, 0.37 and 1.0 for SL ligament, and 0 and 0.97 for LT ligament. They con-
cluded that MRI is not helpful in the investigation of suspected carpal instability and that the results
of MRI for TFCC injuries should be interpreted with caution (Level IV evidence).
Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears.
J Hand Surg Am. 1997;22:344–349.
This study examined the role of arthroscopic debridement alone for complete and incomplete intercarpal lig-
ament tears in 43 wrists. At an average of 27 months follow-up, 29 (66%) wrists with a complete SL liga-
ment tear and 36 (85%) wrists with a limited SL ligament tear had either complete symptom resolution or
improved symptomatology. Thirty-three (78%) wrists with a complete LT ligament tear and 43 (100%)
wrists with a limited LT ligament tear had complete symptom resolution or improvement. There were no
static intercarpal instability pattern changes on follow-up radiographs and grip strength improved 23%
postoperatively. These findings suggest that in a majority of patients, partial and complete intercarpal liga-
ment tears may be treated from a symptomatic standpoint by debridement alone. Long-term data are not
available (Level IV evidence).
CHAPTER 20
Repairing Tears of the Triangular Fibrocartilage
Complex
INDICATIONS
• Indications for repair include tears of the triangular fibrocartilage complex (TFCC)
that cause persistent pain and/or distal radioulnar joint (DRUJ) instability.
• Another indication for repair involves symptomatic TFCC injuries that are refractory
to conservative treatments (usually at least 6 weeks of immobilization).
• Peripheral tears of the TFCC are amenable to repair owing to better blood supply,
whereas tears of the relatively avascular central zone of the TFCC are not (Fig. 20.1).
• The Palmer classification system categorizes TFCC injuries as traumatic or degen-
erative. This chapter will focus on the treatment of Type 1 (traumatic) TFCC lesions
Radioscapholunate ligament Long radiolunate ligament
Radioscaphocapitate ligament Articular disc (fibrocartilage)
Radial collateral Disk-carpal ligaments

ligament (D-L) (D-T)
Ulnar collateral
ligament
Extensor
carpi ulnaris
Deep and superficial

radioulnar ligaments
Dorsal branch of anterior

interosseous artery Dorsal radioulnar capsule
FIGURE 20.1 Anatomy and vascular supply of the triangular fibrocartilage complex and surrounding structures.
(Fig. 50.18, from Standring S, ed. Gray’s Anatomy, 42nd ed, 2020:930–954.e3)
68
CHAPTER 20 Repairing Tears of the Triangular Fibrocartilage Complex 69
TABLE
20.1 Palmer Classification of Traumatic TFCC Injuries
Name Location/Pathology Treatment
1A Tear or perforation of central Rest/activity modification/immobilization
aspect of disk (fovea) Arthroscopic or open repair
1B Tear within the peripheral TFCC Arthroscopic or open repair
1C Distal detachment of TFCC from Conservative
carpus
1D Proximal detachment of TFCC Conservative
from carpus
TFCC, Triangular fibrocartilage complex.
A
Dorsal D
Palmar
C
Common TFC Tears
FIGURE 20.2 Palmer classification of traumatic triangular fibrocartilage complex tear. (Fig. 3, from
Carlsen B, Rizzo M, Noran S. Soft-tissue injuries associated with distal radius fractures. Operat
Teach Orthop 2009;19(2):107–18)
(Table 20.1). Type 1A (Fig. 20.2) lesions are treated with debridement but not with
repair because the central disk does not tend to heal. Types 1B, 1C, and 1D are all
candidates for arthroscopic or open repair. Type 1B lesions are the most common
and are the subject of this chapter.
Contraindications
• Chronic/degenerative lesions with associated changes of carpal chondromalacia or
other signs of arthritic wear are not good candidates for TFCC repair.
• Evaluate for ulnar positive status because a prominent ulna can contribute to TFCC
injury and stress a repair.
• Concomitant extensor carpi ulnaris (ECU) tendon subluxation or instability must be
identified before TFCC repair.
• Evaluate for ulnar styloid injury that can also be associated with TFCC injury and
resultant DRUJ instability.
• Many TFCC injuries can be repaired with arthroscopic techniques if proper equip-
ment is available; however, if ECU subluxation, ulnocarpal impaction, other carpal
ligament injury (e.g., lunotriquetral ligament injury), and/or large ulnar styloid frac-
ture segment is identified, an arthroscopic approach is likely contraindicated.
• TFCC injuries often present as ulnar-sided wrist pain.
• Acute injuries are associated with a fall, especially on an outstretched and pronated
hand, or with an aggressive traction or torque event.
• Patients may complain of clicking, popping, or locking during pronosupination.
• To look for a positive fovea sign, palpate the soft spot of the ulnar wrist, just distal
to the ulnar styloid and proximal to the pisiform, between the ECU and flexor carpi
ulnaris tendons. Substantial pain with deep palpation here is a positive fovea sign
(supporting the diagnosis of a peripheral TFCC tear).
70 CHAPTER 20 Repairing Tears of the Triangular Fibrocartilage Complex
• To complete an ulnocarpal stress test, with the patient’s elbow bent at 90 degrees,
the examiner puts their nondominant hand under the elbow and grips the palm/
carpus of the affected hand with a handshake-style grip. The examiner then maxi-
mally ulnarly deviates the patient’s hand, and, while holding this axial ulnar load, the
examiner puts the joint through passive pronation and supination. Reproduction of
symptoms is a positive test indicating likely TFCC pathology (a nonpainful click is
not considered positive).
• The ballottement test evaluates DRUJ stability (Fig. 20.3). Grasp the radius in the
examiner’s nondominant hand and the distal ulna with the dominant index finger
and thumb, then move the distal ulna volar and dorsal relative to the radius. Soft
endpoints, pain, and/or notable instability compared with contralateral all indicate
DRUJ instability.
• To look for a piano key sign, with the wrist in pronation, note the position of the ulnar
head. A notably prominent ulnar head that shifts down with volarly directed pressure
and then recoils to the dorsally displaced position indicates DRUJ instability (posi-
tive piano key sign).
IMAGING
• Although the TFCC cannot be seen on x-rays, it is important to evaluate standard
posteroanterior (PA), lateral, and oblique images. To properly assess ulnar variance,
FIGURE 20.3 Ballottement test. (Fig. 3, from the PA x-ray should be taken with the forearm in neutral rotation, elbow flexed to
Atzei, A, Luchetti, R. Foveal. TFCC tear classifi- 90 degrees, and shoulder abducted to 90 degrees. Obtain similar x-rays of the con-
cation and treatment. Hand Clin. 2011;27(3): tralateral side for comparison.
263–272.) • Indicators of possible TFCC injury (especially acute) include ulnar styloid fracture
and/or DRUJ incongruity.
• Other sources of ulnar-sided wrist pain or contributors to TFCC pathology include
ulnar positive variance, ulnar styloid nonunion, widened lunotriquetral interval
indicative of LT ligament injury, cystic changes in the lunate indicative of impac-
tion, and DRUJ arthritis.
• Triple injection arthrogram can be used in evaluation but has a moderately high false
negative rate. It has generally fallen out of favor as magnetic resonance imaging
(MRI) has improved.
• Modern MRI machines have sensitivity and specificity around 90% or better for
identifying TFCC injury; however, peripheral injuries have the lowest diagnostic ac-
curacy and findings may depend on the experience of the radiologist.
• The standard diagnostic modality is arthroscopy.
SURGICAL ANATOMY
• Identifying the area of the TFCC that is injured guides the surgical approach.
• The TFCC is composed of the triangular fibrocartilage (TFC, otherwise known as the
articular disk), meniscus homologue, radioulnar ligament (RUL), ulnotriquetral liga-
ment, ulnolunate ligament, ECU subsheath (not included in the figure image), and
ulnar joint capsule (Fig. 20.4).
• Injuries to the TFC are the most commonly discussed (and treated) component of
TFCC injuries.
• Nevertheless, evaluating the other components of the TFCC that contribute to
DRUJ stability is critical, especially when DRUJ instability is part of the presenting
problem.
• The TFCC attaches radially along the sigmoid notch of the radius and ulnarly along
the ulnar fovea (Fig. 20.5). Injuries that result in tearing of the TFCC in either of these
two attachment zones are appropriate for repair.
• The TFC attachment to the ulna has superficial and deep components (see Fig. 20.5)
that must be considered during the evaluation and repair of TFCC injuries.
• The superficial component attaches to the styloid.
• The deep component attaches to the ulnar fovea.
• Ulnar styloid nonunion in the setting of TFCC peripheral tear often war-
rants excision of the styloid segment before the TFCC repair/reanchoring
procedure.
Ulnolunate
ligament*
Ulnotriquetral
Scaphoid fossa ligament*
Lunate fossa
Articular disk* Ulnar

capsule*
Meniscus
homologue*
Prestyloid
recess
Ulnar styloid
Ligamentum
subcruentum
(runs deep,
inserts into
ulnar fovea)
Radius Ulna
Dorsal DRUL
superficial portion*
Dorsal DRUL
deep portion*
*Indicates a component of the TFC complex
(ECU subsheath not shown)
FIGURE 20.4 Anatomy of the foveal attachment of the triangular fibrocartilage complex (TFCC). Red
asterisk indicates the structure is a component of the TFCC. (Fig. 72.2, from Adams JE. Disorders of
the distal radioulnar joint. In: Miller, MD, Thomas, SR, eds. DeLee, Drez & Miller’s Orthopaedic
Sports Medicine, 5th ed. Elsevier:865–872)
Sigmoid notch
Ulna styloid
A
Lister’s TFC superficial limb
tubercle TFC deep limb
Fovea
R U
B
FIGURE 20.5 Anatomy of the triangular fibrocartilage complex and associated structures. (Fig. 6.4,
from Adams BD, Mitchell SA. The distal radioulnar joint and triangular fibrocartilage complex. In:
Trumble TE, Ghazi MR, Baratz ME, Budoff JE, Slutsky DJ, eds. Principles of Hand Surgery and
Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:117–143.)
Radial midcarpal
Ulnar midcarpal portal (MCR)
portal (MCU)
3–4 portal
6U portal
6R portal
4–5 portal
FIGURE 20.7 Skin markings. Courtesy W. Hugh

FIGURE 20.6 Markings for each arthroscopy portal are based on anatomic landmarks. Baugher, MD
POSITIONING AND EQUIPMENT PEARLS

Before beginning arthroscopy, consider where an
open incision would be needed to perform an open • For arthroscopic approaches to TFCC evaluation and repair, combinations of
repair, and confirm that easy access is available the dorsal 3 to 4, dorsal 4 to 5, and 6-R or 6-U portals are often used. Addition-
even with the arm still in the arthroscopy tower. ally, many surgeons will also use radial and ulnar DRUJ arthroscopy portals
(Fig. 20.6)
• Before repair (either during arthroscopy or after the open exposure), evaluate
EXPOSURES PEARLS
the lunate, triquetrum, and ulnar head for signs of impaction and associated
It is far easier to see, feel, and mark landmarks chondromalacia.
before beginning arthroscopy.
POSITIONING AND EQUIPMENT
EXPOSURES PITFALLS • The patient is placed supine on the operating room table.
• A standard arthroscopy setup is used, with elbow at 90 degrees and upper arm
Avoid positioning the hand/arm in the arthroscopy
tower in any way that obstructs access to the secured to the hand table.
6U/6R portal or to the open approach of choice.
EXPOSURES
• For arthroscopic repair, it is common to use a 1.5- to 2.5-cm longitudinal incision
volar to the ulnar styloid to properly expose the ulna/ulnar capsule before tying down
the sutures.
• When using this approach, protection of the ulnar sensory branches is critical.
• For open repair, two common approaches are either dorsal in the area of the fifth
extensor compartment (Fig. 20.7) or along the ulnar border of the wrist via a longi-
tudinal incision (Fig. 20.8).
• For both approaches, ulnar sensory nerve branches are at risk and must be pro-
tected.
• For the dorsal approach, designing proper capsular flaps is necessary to permit
durable repair/closure (Fig. 20.9A–B).
• For the ulnar border approach, a longitudinal incision through the capsule can be
repaired primarily. When using this approach, it is also important to avoid injury
to the ECU/ECU sheath.
INSIDE-OUT ARTHROSCOPIC REPAIR – TYPE 1B TEAR

Before any TFCC repair, perform a diagnostic arthroscopy.
• The location of the injury and surgical approach for repair are based on findings from
FIGURE 20.8 Longitudinal incision along the ul-
arthroscopy.
nar border of the wrist is an alternative approach There are several critical components for evaluating the TFCC injury:
for open repair. • Visualize the central disk and the radial attachment.
A B
FIGURE 20.9 (A) Extensor retinaculum markings. (B) Extensor retinaculum incisions to create flaps for repair. Courtesy W. Hugh
Baugher, MD.
A B
FIGURE 20.10 (A) Trampoline test. (B) Hook test. (Fig. 4, from Atzei, A, Luchetti, R. Foveal. TFCC tear
classification and treatment. Hand Clin. 2011;27(3):263–272.)
• Examine for lunate chondral injury.

• Perform the hook test and trampoline test to identify a peripheral TFCC injury
(Fig. 20.10A–B).
There are many techniques described for TFCC repair. One of the many ar-
throscopic techniques (inside-out with meniscal repair kit; Fig. 20.11A–F) passes the
needle from radial to ulnar to capture the TFCC with the suture. We present clinical
photos of an ulnar-based inside-out technique and an open repair from a dorsal ap-
proach that requires minimal additional equipment/expense and is usually performed
on a hand table, with no need for an arthroscopy tower or traction.

• With the arthroscope in the 3-4 or 4-5 portal to facilitate direct visualization, use the Leave adequate TFCC substance between the two
two cannulated needles to capture the TFCC. cannulated needles so that the suture has durable
• Needles are both placed from ulnar to radial, entering along the ulnar border of the wrist. purchase of the TFCC.
• Both are aligned to enter from the fovea/deep to the ulnar styloid and are passed
superoradially to capture the frayed ulnar margin of the torn TFCC.
• The needles must enter the TFCC along the ulnar side of the disc but stay sepa-
rated from each other.
Articular surface
of lunate bone Joint capsule
Tear in rim
Tuohy of TFC 2–0 PDS
needle suture
Tuohy needle penetrates

ulnar TFC
Radius Ulna
A Triangular fibrocartilage (TFC) B

over ulna
Tear in rim of TFC Tear in rim of TFC
Second point of
Second point of penetration
penetration
2–0 PDS
suture
2–0 PDS
suture
C D
Dorsal sensory
branch of ulnar n.
Ulna
Knot tied over

joint capsule
Arthroscopic view
2–0 PDS
suture Protected dorsal
sensory branch of
ulnar n. TFC tear
2–0 PDS suture
E F
FIGURE 20.11 (A–F) Arthroscopic inside-out repair. (Fig. 6, from McAdams TR, Swan J, Yao J. Arthroscopic treatment
of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med 2009;37:291–297.)
Step 2
• 2-0 or 0 PDS is passed in through one of the needles (Fig. 20.12A–B).
• A looped grasper is used via the second needle to pull the suture out and through
the second needle, capturing a segment of TFCC with the suture (Fig. 20.13A–B).
A B
FIGURE 20.12 (A) Suture passer inserted through trocar. (B) 0-PDS inserted through opposite trocar and suture passer
loop.
A B
FIGURE 20.13 (A) Polydioxanone suture secured with passer against trocar. (B) Passer and trocar withdrawn as a single unit.

• The suture is tied down over the capsule to secure the TFCC along the ulnar fovea/ Dissect adequately to avoid trapping other tissue
ulnar margin of the capsule. along the capsule or in the suture knot, particularly
• Use the scope to visualize/confirm the repair is well seated and durable to stress the dorsal ulnar sensory nerve.
(Fig. 20.14A–B).
STEP 3 PITFALLS
OPEN REPAIR – TYPE 1B TEAR Inadequate dissection and visualization of the
suture site puts the sensory nerve branches (and
Step 1 other soft tissues) at risk for injury or entrapment.
Complete exposure.
• After elevating the retinacular flaps (see Fig. 20.9A–B), the dorsal capsule will be
exposed (Fig. 20.15).
• Make a transverse incision through the dorsal capsule just distal to the ulnar head
(Fig. 20.16).
• Retract the dorsal capsule and elevate if off of the ulna to expose the ulnar head.
The ulna will be notably dorsally displaced once freed.
A B
FIGURE 20.14 (A) Prerepair. (B) Postrepair.
Extensor
digiti minimi
Dorsal
capsule
Extensor
carpi ulnaris
FIGURE 20.15 Dorsal capsule exposed. Courtesy W. Hugh Baugher, MD
Extensor
digiti minimi
FIGURE 20.16 Dorsal capsule incision. Courtesy W. Hugh Baugher, MD

Fovea
TFCC
FIGURE 20.17 Fovea. Courtesy W. Hugh Baugher, MD FIGURE 20.18 Placing the suture in the triangular fibrocartilage
complex (TFCC). The TFCC is being held within the pickups with
the suture being passed from proximal/underside of TFCC to distal.
It will then be passed back distal to proximal to complete the hori-
zontal mattress. Courtesy W. Hugh Baugher, MD

Suture in the TFCC.
When making the transverse capsule incision, use
• Identify and mobilize the TFCC, taking care to preserve all radial and volar/dorsal a hook to provide distal traction.
attachments that remain.
• Once the injured TFCC is mobilized, clear out any fibrinous debris and identify and
mark the fovea (Fig. 20.17). STEP 1 PITFALLS
• Make a distal transverse incision in the capsule, parallel and distal to the initial trans- Be sure to leave a small cuff of capsule on the
verse incision, to permit visualization of the carpus-facing side of the TFCC. ulna so that the repair can be performed; leaving
• Now with direct visualization of the proximal and distal aspects of the TFCC, place inadequate capsule on the ulna risks a weak
closure.
a #2 or #0 fiber-wire suture through the ulnar margin of the TFCC in a horizontal
mattress (Fig. 20.18).
STEP 2 PEARLS
Step 3 Confirm that the TFCC is adequately freed/
Create bone tunnels. mobilized before placing any sutures.
• Use two 0.045-mm Kirschner wires (K-wires) to create two separate bone tunnels
through the fovea and out the head of the ulna (Fig. 20.19). STEP 2 PITFALLS
Step 4 Inadequate freeing of the TFCC along both proximal

and distal aspects will make repair more difficult
Pass the suture. and likely restrict ability to achieve a tight repair.
• Use a bent 26-gauge wire as a suture retriever.
• Remove the K-wire, make a loop in the 26-gauge wire, pass the wire through the
bone tunnel, and pull the suture through (Fig. 20.20). Do the same for the other tun- STEP 3 PEARLS
nel/other arm of the suture in the TFCC. Leave an adequate bone bridge between the two
drill sites to avoid pull-through of the suture when
Step 5 securing.
Secure the TFCC.
• Manually mobilize the TFCC to confirm that it can reach and seat in the fovea. STEP 5 PEARLS
• With each suture through its respective bone tunnel, tie down the sutures and secure
Have an available assistant place traction on the
them over the ulnar head. TFCC and volar pressure on the ulna to aid in
• Confirm that the TFCC is now secured back to the ulnar fovea (Fig. 20.21A–B). facilitating maximal ulnar translation of TFCC and
proper ulnar reduction when securing the repair.
Step 6
Finish the repair. STEP 5 PITFALLS
• Repair the capsule using 3-0 Vicryl suture (Fig. 20.22). After the capsule is repaired,
If the TFCC is secured but the ulna has not been
test wrist range of motion to confirm that the repair is stable and motion is preserved.
properly reduced, this risks persistent instability or
• Repair the retinacular flaps using 3-0 Vicryl suture (Fig. 20.23). After the retinaculum repair failure.
is repaired, test wrist range of motion to confirm that the repair is stable and motion
is preserved.
Ulnar head
Wire loop
FIGURE 20.20 The suture has been pulled through one bone
tunnel (and is being retracted in the top-center of the image),
FIGURE 20.19 Bone tunnels. Courtesy W. Hugh Baugher, MD with the wire loop now through the second tunnel preparing to
pull the other side of the suture through. Courtesy W. Hugh
Baugher, MD
Extensor
digiti minimi
Extensor
digiti minimi
Extensor
carpi ulnaris
A B
FIGURE 20.21 (A–B) Securing the triangular fibrocartilage complex. Courtesy W. Hugh Baugher, MD
FIGURE 20.22 Capsule repair. Courtesy W. Hugh Baugher, MD FIGURE 20.23 Extensor retinaculum repair. Courtesy W. Hugh Baugher, MD
• Repair the skin per surgeon preference (we use 4-0 Monocryl in the deep dermis STEP 6 PEARLS
followed by 4-0 Monocryl running subcuticular).
The ulnar head will remain somewhat proud
dorsally until the capsule is repaired.
The patient is placed in a long-arm splint in the operating room. They return to clinic in
approximately 2 weeks to begin active range of motion therapy and otherwise are in a POSTOPERATIVE PEARLS
Muenster splint. After 6 weeks, start to wean them out of the splint. If the patient is still Because stability of the repair and range of motion
very stiff at 2 to 3 months postoperation, add passive range of motion to the therapy are tested in the operating room, patients can
protocol. begin active range of motion in the first 2 weeks
after surgery with low risk.
EVIDENCE
Luchetti R, Atzei A, Cozzolino R, Fairplay T, Badur N. Comparison between open and arthroscopic-
assisted foveal triangular fibrocartilage complex repair for posttraumatic distal radio-ulnar joint
instability. J Hand Surg Eur Vol. 2014;39(8):845–855.
Prospective study of 25 arthroscopic and 24 open TFCC repairs. All cases had a positive arthroscopy
hook test before repair. At 6 months, 44 of 49 patients had a stable TFCC. Both groups had signifi-
cant improvement in wrist pain, Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand
(DASH) score, and Patient-Rated Wrist Evaluation (PRWE). The DASH score was significantly better
(lower) in the arthroscopic group at 6 months; otherwise, there were no significant differences
between groups.
Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of
arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am.
2008;33(5):675–682.
Retrospective review of 36 arthroscopic and 39 open TFCC repairs with an average follow-up of nearly
4 years. Across all patients, 57% improved in pain and 17% underwent subsequent surgery for DRUJ
instability. Comparing groups, there were no significant differences in pain improvement or postoper-
ative complications, although there was a higher incidence of ulnar sensory nerve temporary irritation
in the open group.
CHAPTER 21
Scapholunate Ligament Repair
INTRODUCTION
• The scapholunate (SL) ligament is a commonly injured wrist ligament. A complete SL
ligament injury that is not treated can progress to pancarpal arthritis, as described
later, making the diagnosis and repair of SL ligament injuries important.
• The SL ligament is the primary stabilizer of the scapholunate joint. As a stabilizer,
the SL ligament prevents the scaphoid and lunate from moving independently at the
SL joint. If disrupted, the scaphoid tends to flex (volarly), whereas the lunate tends
to extend (dorsally) when viewed from a lateral radiograph.
• The secondary stabilizers of the SL joint are the scaphotrapeziotrapezoid (STT),
scaphocapitate (SC), and radioscaphocapitate (RSC; Fig. 21.1A–B). These are volar
structures and resist the scaphoid’s tendency to flex; in this way, they are secondary
stabilizers. The STT and SC are volar intrinsic ligaments, whereas the RSC is a volar
extrinsic ligament.
TT Td Td
C CH H C TC TT
Tm CT H CH Tm
HT
S T TH SC
T S
DIC TC
LT P RSC
L
SL L
DRC UT LRL
UC UL SRL
PRU
U U R
R
A B AIA RA
= secondary stabilizer of SL joint
FIGURE 21.1 (A) Dorsal. (B) Volar. Primary and secondary stabilizers of the scaphoid and lunate. Red asterisks indicate second-
ary stabilizers of SL joint. AIA, Anterior interosseous artery; C, capitate; CH, capitohamate ligament; CT, capitotriquetral ligament;
DIC, dorsal intercarpal ligament, H, hamate; HT, hamate-triquetral ligament; L, lunate; LRL, lunotriquetral ligament; P, pisiform;
PRU, palmar radioulnar ligament; R, radius; RA, radial artery; RSC, radioscaphocapitate; S, scaphoid; SC, scaphocapitate;
SL, scapholunate; SRL, short radiolunate ligament; T, triquetrum; TC, triquetral capitate ligament; Td, trapezoid; TH, triquetral
hamate ligament; Tm, trapezium; TT, trapeziotrapezoid ligament; U, ulna; UC, ulnocapitate ligament; UL, ulnolunate ligament;
UT, ulnotriquetral ligament.
80
• If an SL ligament injury is severe enough and does not spontaneously heal, the pri-
mary stabilizer is lost and the secondary stabilizers become stressed.
• Over time, loss of the secondary stabilizers permits scaphoid flexion and changes in
wrist biomechanics, leading to a spectrum of dysfunction known as scapholunate
advanced collapse (SLAC).
• The endpoint of SLAC is pancarpal arthritis; therefore timely identification and repair
of an SL ligament injury can prevent the development of pancarpal arthritis.
STAGING
• SL ligament injuries exist along a continuum, and different treatments exist for
different stages along this continuum.
• Table 21.1 presents a staging system that shows the progression from partial injury
(stage I) to arthritis (stage VI).
• The dorsal SL ligament is strongest and most important. Stage I indicates an incom-
plete SL ligament tear involving only the volar and proximal portions (Fig. 21.2) with
an intact dorsal aspect of the SL ligament. This is also known as predynamic be-
cause the scaphoid does not move with provocative testing or imaging.
• Stages II and III both have complete SL ligament disruptions and normal carpal align-
ment; however, the distinction is whether the SL ligament is reparable. Progression
from stage II to III is influenced by both time and the location of the tear. Complete
SL ligament injuries older than 6 weeks are usually irreparable and are generally de-
scribed as chronic injuries. Meanwhile, midsubstance tears are often harder to repair
over time than avulsion-type injuries.
• For complete SL ligament tears in both stages II and III, there may be widening of
the SL interval with stress views such as a clenched fist view, so these stages are
known as dynamic.
• The progression from stages II and III to IV and V reflects a loss of the secondary
stabilizers. With disruption of the primary stabilizer (SL ligament) and secondary
stabilizers (STT, SC, RSC), the scaphoid flexes and the lunate extends. Early on, the
scaphoid can be reduced to its normal alignment. With time, fibrosis can make reduc-
tion impossible, thereby distinguishing stages IV and V. (Of note, scaphoid flexion is
only considered “reducible” and therefore stage IV, if only mild force is needed to re-
duce the scaphoid. If tremendous force is required, current reconstruction techniques
will not maintain reduction, and therefore it is classified as not reducible, stage V).
• Eventually, abnormal wrist biomechanics leads to wrist arthritis through a predict-
able pattern known as SLAC wrist (stage VI).
TABLE
21.1 Staging System for Scapholunate Dissociation
Stage Definition
I Partial SL ligament injury (“predynamic”)
II Complete disruption that is reparable, with normal static scapholunate
alignment (“dynamic”)
III Complete disruption that is not reparable but has normal static scapholunate
alignment (“dynamic”)
IV Complete disruption that is not reparable, with static volar flexion of the
scaphoid that can be reduced to normal (“static”)
V Complete disruption that is not reparable, with volar flexion of the scaphoid that
cannot be reduced to normal, but the cartilage surfaces are intact (“static”)
VI Complete disruption that is not reparable, with volar flexion of the scaphoid
that cannot be reduced to normal, with cartilage degeneration (scaphol-
unate advanced collapse [SLAC])
SL, Scapholunate.
Adapted from: Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholu-
nate dissociation: Indications and surgical technique. J Hand Surg Am. 2006;31(1):125–134.)
82 CHAPTER 21 Scapholunate Ligament Repair
Scapholunate ligament
Scaphoid (1) Dorsal (3) Proximal portion (2) Palmar

portion portion
Lunate
Scaphoid Long radiolunate

tuberosity ligament
Radioscaphoid
ligament
Short radiolunate
ligament
Triquetrum
Radius
FIGURE 21.2 Key anatomic structures related to the scapholunate ligament.
The authors’ preferred operative technique will be presented for stages I and II.
Chapter 22 will review treatment for stages III to VI.
The Geissler arthroscopic classification is another system used to grade the severity
of SL ligament injuries (Table 21.2); however, it is not as complete as the aforemen-
tioned system.
INDICATIONS AND CONTRAINDICATIONS

• Patients with diagnosed SL ligament injuries who present with wrist pain should
generally receive treatment that is appropriate for the stage of their injury.
• The only exception is if a patient presents without pain and no obvious injury within
6 weeks; these patients are typically left untreated.
• This is guided by clinical experience because no randomized trials can offer guid-
ance on this recommendation.
TABLE Geissler System for Arthroscopic Grading of Scapholunate Ligament

21.2 Injury
Appearance of Ligament Appearance of Joint
Radiocarpal
Grade Radiocarpal Scope Scope Midcarpal Scope
I Attenuated No gap No step-off
(Normal concave ligament
appears convex)
II Attenuated, partial tear No gap Step-off 1
(Probe [~2 mm] cannot be
passed through joint)
III Complete tear Gap 1 Step-off 1
(Probe [~2 mm] can be
passed through joint)
IV Complete tear Gap 1 Step-off 1
(2.7-mm arthroscope can
be passed through joint)
• Patients present with radial-sided wrist pain, particularly with axial loading, power
grip, and with extremes of wrist extension and radial deviation.
• An SL ligament tear results in tenderness over the scaphoid in the anatomic snuff
box and distal to the Lister tubercle over the scapholunate interval.
• Many provocative tests exist to aid in diagnosis:
• The carpal shake test involves passively shaking the wrist into extension and
flexion by grasping the forearm. If this does not elicit pain or resistance to move-
ment, then carpal pathology is unlikely.
• The sitting hand test involves weight-bearing/loading the wrist as the patient rises
from the seated position to standing. If this elicits pain, then it is suspicious for
wrist pathology.
• The scaphoid shift test (Fig. 21.3A–B) is the bimanual examination of the scaph-
oid in relation to the radius. One hand is used to apply pressure dorsally over
the distal radius while the thumb presses on the distal pole of the scaphoid. The
examiner’s opposite hand is then used to passively move the hand from ulnar
to radial deviation. With SL ligament laxity or tear, the proximal pole of the
scaphoid subluxes dorsally out of its fossa, which can result in pain along the
SL interval. With release of pressure on the distal scaphoid, an audible and
palpable clunk can be appreciated with reduction of the scaphoid back into its
fossa.
• Resisted long finger extension is when the patient extends the long finger with
resisted extension and partial flexion of the wrist. This may elicit pain over the SL
interval, which lies directly under the long finger extensor tendon.
• To complete the SL ballottement test, after firmly stabilizing the lunate with one
hand, the opposite hand is used to translate the scaphoid dorsally and volarly.
Pain, crepitus, or mobility suggests disruption of the SL interval.
Distal pole of
scaphoid
Distal pole of
scaphoid
A B
FIGURE 21.3 (A) Photos of scaphoid shift test. (B) Illustration of scaphoid shift test. (Fig. 8.10, from Haase SC,
Chung KC. Fractures and dislocations of the wrist and distal radius. Chang J, ed. Plastic Surgery: Hand and
Upper Extremity. 2018. Elsevier: 170–187.)
A B C
FIGURE 21.4 (A–C) Standard wrist x-rays will only identify static scapholunate instability, showing a widened SL interval (arrow) or flexed
scaphoid.
IMAGING
• Standard wrist x-rays will only identify static SL instability, showing a widened SL
interval (Fig. 21.4A–C) or flexed scaphoid.
• Additional views are known as stress views and include clenched fist, posteroante-
rior (PA) maximal radial deviation, and PA maximal ulnar deviation (scaphoid view).
• Arthroscopic evaluation is the reference standard for diagnosis of SL injuries, par-
ticularly predynamic and dynamic injuries.
• The Geissler arthroscopic classification of SL ligament injuries can both diagnose an
SL tear and examine the articular surface for signs of degeneration (see Table 21.2).
SURGICAL ANATOMY
• The SL ligament can be found distal to the Lister tubercle and deep to the dorsal
wrist capsule between the second and fourth dorsal extensor compartments.
• The SL ligament is a U-shaped ligament consisting of palmar, proximal, and dorsal
fibers. The dorsal ligament is the strongest of the ligamentous complex (see Fig. 21.2).
• Wrist kinematics are governed by the primary (intrinsic) and secondary (extrinsic)
ligamentous stabilizers of the wrist. The primary stabilizer of the scaphoid and lunate
is the SL ligament. The secondary stabilizers of importance in scapholunate injury
include the volar STT, SC, and RSC ligaments (see Fig. 21.1).
• Predynamic scapholunate instability represents a partial ligament injury that results
in pain but cannot be appreciated on plain x-ray. Diagnosis can be confirmed by
arthroscopy, which may reveal attenuation, hemorrhage, or a partial tear of the
scapholunate ligament (see Table 21.1).
• With complete disruption of the scapholunate ligament and preservation of the
secondary stabilizing ligaments, dynamic instability can be appreciated. This
refers to an injury pattern in which the scapholunate interval widens with activa-
tion of extrinsic muscular forces across the wrist. With axial loading, such as
clenching the fist, radiographs will demonstrate an increase in the scapholunate
interval (Fig. 21.5).
• After complete scapholunate injury and attenuation or rupture of the secondary sta-
bilizing ligaments, static carpal malalignment results. This refers to fixed gapping of
Clenched fist radiograph

demonstrates widening of
scapholunate interval
FIGURE 21.5 Clenched fist radiograph shows scapholunate widening.
Scaphoid
Lunate
A B
Fixed scaphoid Wide scapholunate

(Signet ring) (Terry Thomas sign)
FIGURE 21.6 (A) Fixed scaphoid and wide scapholunate.
the scapholunate interval (4 mm; Terry Thomas sign) and flexion of the scaphoid
(Signet ring sign) with or without extension of the lunate (Fig. 21.6).
ARTHROSCOPIC DEBRIDEMENT AND PINNING OF

THE SL INTERVAL
Indications
• If an SL ligament injury is suspected based on clinical examination and imaging
studies, wrist arthroscopy can be performed to fully characterize the extent of the
S L
Healthy scapholunate ligament

FIGURE 21.7 The circle denotes arthroscopy field. L, Lunate; S, scaphoid.
wrist pathology. If plain x-rays, computed tomography (CT), and/or magnetic reso-
nance imaging (MRI) demonstrate static SL widening, scaphoid flexion, or extensive
wrist arthritis, a different procedure should be considered.
• For Geissler grade I and II injuries, debridement and pinning of the SL interval should
be performed. Geissler grade I and II injuries (see Table 21.1) both correspond to
stage I injuries (see Table 21.2).
• Comprehensive evaluation of the wrist ligamentous structures and articular surfaces
will guide treatment.
STEP 1 PEARLS Step 1: Arthroscopic Evaluation of the Wrist

• It is important to perform a systematic evalua- • Systematic wrist arthroscopic evaluation is performed, as described in Chapter 19.
tion of the wrist to identify and treat concomi- • The 3–4 portal is located in the interval between the third and fourth extensor com-
tant ligamentous and/or bony pathology. partments. Upon introducing the arthroscope, this portal can be used to view the SL
• The 6U portal has a higher risk for injuring the
dorsal cutaneous ulnar nerve than the 6R por- ligament from the radiocarpal joint (Fig. 21.7).
tal. A longer incision and blunt dissection down • The 6R or 6U portal can be used for outflow of arthroscopy fluid, if needed.
to the wrist capsule can avoid injuring this • The radial midcarpal portal, located 1 cm distal to the 3–4 portal, should be used to
structure. identify gapping of the SL ligament.
• Fig. 21.8 shows a Geissler grade I SL injury where there is fraying or hemorrhage
within the ligament. A grade I SL injury can be diagnosed from the 3–4 radiocar-
pal portal. All others are confirmed using the radial midcarpal portal.
• Fig. 21.9 shows the gap of a Geissler grade II SL injury as seen from the midcar-
pal portal. There is gapping or motion between the scaphoid and lunate that is
less than a probe width.
• Fig. 21.10 shows the gap of a Geissler grade III SL injury. The gap is more than a
probe width.
• Fig. 21.11 shows the gap of a Geissler grade IV SL injury. The gap is more than
the scope diameter.
• Attenuation and gapping of the SL interval should be documented.
• For Geissler grade I or II injuries, debridement and pinning of the scapholunate in-
terval should be performed.
• If a Geissler grade III to IV injury is identified, this corresponds to stage II1 injury (see
Table 21.2) and other treatment options should be considered. These options are
described later in this chapter or in Chapter 22.
S L
Type I
S L
FIGURE 21.8 Geissler grade I scapholunate injury can be diagnosed from the 3 to 4 radiocarpal portal. All others are
confirmed using the radial midcarpal portal. L, Lunate; S, scaphoid.
S L
< 1 mm
(less than probe width)
Type II
S L
FIGURE 21.9 Geissler grade II scapholunate injury. L, Lunate; S, scaphoid.

> 1 mm
(more than probe width)
Type III
S L
FIGURE 21.10 Geissler grade III scapholunate injury. L, Lunate; S, scaphoid.
> 2.7 mm (scope)
S L
C
Type IV
S L
FIGURE 21.11 Geissler grade IV scapholunate injury. L, lunate; S, scaphoid; C, capitate.

Scaphoid
Lunate
A B
FIGURE 21.12 (A) Illustration of scapholunate pinning. (B) Fluoroscopy confirms scapholunate pinning.
Step 2: Debridement of the SL Ligament and Pinning

of the SL Interval
• If a Geissler grade I or II is confirmed (see Table 21.1), this represents a stage I SL
injury (see Table 21.2). In the absence of other pathology, the SL ligament should be
debrided to healthy appearing tissue.
• After debridement, the SL interval can be pinned using a single 0.062-in (1.1-mm)
Kirschner wire (K-wire).
• The entry site of the K-wire should be positioned just distal to the radial styloid,
along the scaphoid waist.
• The wire should be passed from the scaphoid into the lunate, perpendicular to the
long axis of the forearm (Fig. 21.12A–B).
• The K-wire should be buried under the skin for future removal at 8 weeks.
OPEN SL REPAIR AND DORSAL CAPSULODESIS

Indications
• With complete SL ligamentous disruption, dynamic instability will be present.
Clenched fist radiographs will demonstrate gapping between the scaphoid and
lunate.
• If dynamic SL injury is suspected, wrist arthroscopy should be performed to charac-
terize the injury, identify concomitant injuries, and rule out articular wear.
• If complete SL ligament injury is confirmed by arthroscopy, the wrist should be
opened in preparation for SL ligament repair and dorsal capsulodesis.
• With identification of significant radioscaphoid arthritis, one should consider abort-
ing the soft-tissue repair/reconstruction in favor of performing a salvage operation,
such as a scaphoidectomy and partial wrist fusion.
Step 1: Markings
A standard dorsal exposure of the wrist is marked (Fig. 21.13).
STEP 2 PEARLS
Step 2: Exposure
Fluoroscopy can confirm the correct place for
• Sharp dissection is carried out through the skin and subcutaneous tissue to the
dorsal wrist capsulotomy.
extensor retinaculum (Fig. 21.14). The third compartment is identified and the exten-
sor pollicis longus (EPL) is protected.
• The extensor retinaculum is open longitudinally, and the fourth extensor compart-
ment is entered. Tendons are retracted ulnarly.
• The dorsal wrist capsule is entered on the radial side of the fourth extensor compart-
ment. The dorsal SL ligament lies deep to the floor of the extensor compartments.
Extensor retinaculum
FIGURE 21.13 Dorsal wrist marking for incision. FIGURE 21.14 Exposure of extensor retinaculum.
Step 3: Debridement of the Scapholunate Interval

• Scar tissue between the scaphoid and lunate is debrided to healthy-appearing
ligament.
• At this point, one needs to determine whether the ligament is amenable to repair.
STEP 4 PITFALLS Step 4: Repair of the Scapholunate Ligament

If the ligament is not tightly secured into the • If there is a midsubstance rupture, the ligament can be repaired using several inter-
cancellous trough, there will be no bone-ligament rupted 4-0 Ethibond sutures (Fig. 21.15).
healing. Raw cancellous bone will help the • If the ligament has been avulsed from either the scaphoid or lunate, it should be
ligament heal.
reattached using two Mitek mini suture anchors.
• Starting from the bone from which the SL ligament has avulsed, a 3-mm trough on
the dorsal surface of the bone is created using a rongeur or small bur.
• This should reveal healthy cancellous bone. The trough should be created at the site
of prior ligamentous attachment. If this is not readily apparent, the debrided ligament
should be placed on top of the bone to which it will be reattached. Its contact with
the bone should be marked for creation of the trough.
• The Mitek mini suture anchors are placed within the cancellous trough.
• The ligament should be sutured down to the cancellous trough with direct ligament-
to-bone apposition.
Step 5: Dorsal Capsulodesis

• The distal scaphoid is identified.
• The Mitek mini suture anchor entry point, in the center of the distal pole, is confirmed
visually and radiographically.
L
Repaired ligament
S
FIGURE 21.15 Scapholunate ligament repaired. L, Lunate; S, scaphoid.

FIGURE 21.16 Dorsal capsulodesis.
Dorsal capsule Bone anchor
S
S
Radius Radius
B
A
FIGURE 21.17 (A) Illustration of bone anchor tethering scaphoid to dorsal capsule. S, Scaphoid. (B) Close-up
photo of bone anchor tethering scaphoid to dorsal capsule.
• A curette can be used to remove the dorsal cortex, revealing a 3-mm area of cancel-
lous bone.
• Using the drill bit within the Mitek mini suture anchor kit, a hole is drilled in the distal
scaphoid (Fig. 21.16).
• The two-tailed suture from the suture anchor is passed through the radial-sided
dorsal capsule, directly overlying the distal scaphoid.
• The dorsal capsule is tied down to the cancellous bone of the distal scaphoid
(Fig. 21.17A–B).
Step 6: Closure
• The dorsal wrist capsule should be closed using 3-0 Vicryl suture.
• Hemostasis is obtained after releasing the tourniquet.
• The skin can be closed using 4-0 monocryl or 4-0 PDS suture.

• The patient is placed into a forearm-based, volar wrist splint at the conclusion of the
procedure.
• Sutures are removed at 2 weeks postoperatively and the incision is inspected.
• A custom, thermoplastic splint is designed and the patient is instructed to wear it at
all times, except when showering, during which the wrist should be protected.
• No strenuous activity or heavy lifting is permitted for 8 weeks.

• K-wires are removed 6 to 8 weeks after surgery. The pins should be buried to reduce
the risk for pin-tract infection.
• After removal of the splint at 8 weeks, active range of motion exercises are initiated.
There is no need for formal hand therapy. The goal of the procedure is to reduce
wrist motion and to promote healing of the reconstruction. Early active motion or
strenuous activity could lead to reconstructive failure. The patient should be coun-
seled preoperatively to expect a postoperative loss of flexion compared with the
contralateral side. The goal of the operation is to reduce wrist pain and prevent or
delay the progression of arthritis at the expense of some wrist motion.
EVIDENCE
Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate
dissociation: indications and surgical technique. J Hand Surg Am. 2006;31(1):125–134.
The authors present a concise review of SL ligament injuries and outline their thoughtful algorithm for
managing SL injuries along the entire spectrum.
Park IJ, Maniglio M, Shin SS, Lim D, McGarry MH, Lee TQ. Internal bracing augmentation for scaphol-
unate interosseous ligament repair: A cadaveric biomechanical study. J Hand Surg Am. 2020;45(10):
985.e1–985.e9.
The authors performed a biomechanical study to determine whether nonabsorbable suture tape can
augment SL ligament repair. They used 21 fresh frozen cadavers and compared native SL ligaments
with repaired SL ligaments and repaired ligaments with costabilizing suture tape along various bio-
mechanical metrics. Although the suture tape did not recreate native SL ligament strength, it was
significantly stronger than repair alone, suggesting that suture tape could enhance SL ligament
repair. Long-term results and clinical outcomes were not examined.
Bleuler P, Shafighi M, Donati OF, Gurunluoglu R, Constantinescu MA. Dynamic repair of scapholunate
dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg Am. 2008;33:281–284.
This study described the outcomes after extensor carpi radialis longus (ECRL) tenodesis for symptomatic
scapholunate instability in 20 wrists of 19 patients with static scapholunate instability. Preoperative evalua-
tion, in all patients, consisted of clinical and radiologic evaluation and arthroscopy for confirming the diag-
nosis of static scapholunate instability. The aforementioned technique involves the fixation of the ECRL
tendon on the dorsal aspect of the scaphoid by means of a cancellous screw and a special washer.
Eighteen of 19 patients were satisfied with the operation and all patients returned to work between
1.5 and 4 months after the surgery. Pain was reduced postoperatively based on a reduction in visual a
nalog score (VAS). This study is limited by short follow-up and the small sample size (Level IV evidence).
Nienstedt F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over
10 years. J Hand Surg Am. 2013;38:887–892.
Ten patients who underwent the modified Brunelli, three-ligament tenodesis, with a mean follow-up of
13.8 years were evaluated. Subjective outcomes including the Green and O’Brien scale were excellent
or good in seven of eight patients. DASH and modified Mayo scores averaged 9 and 83, respectively.
Mean total wrist motion and grip strength were 85% of the opposite normal side, at the final postopera-
tive visit. Six of eight patients were pain free; one patient had slight and occasional pain, and another
had chronic pain. The mean scapholunate gap was 5.1 mm preoperatively, corrected to 2.4 mm at sur-
gery and was 2.8 mm at final follow-up. Scapholunate angle was maintained at 63 degrees at final fol-
low-up. Progressive degenerative arthritis was present in only one patient at final follow up (Level IV evi-
dence).
Soong M, Merrell GA, Ortmann F IV, Weiss AP. Long-term results of bone-retinaculum-bone autograft
for scapholunate instability. J Hand Surg Am. 2013;38:504–508.
The authors report long-term outcomes of scapholunate interosseous ligament reconstruction with bone-
retinaculum-bone (BRB) autograft in patients with dynamic scapholunate instability. Of the 14 patients
initially treated with BRB reconstruction, only 6 returned for clinical examination and radiographs at an
average of 11.9 years of follow up (range, 10.7–14.1 y). Three were reached by telephone, and two
were lost to follow-up. Three of 14 patients underwent salvage procedures (two total wrist arthrodeses
and one proximal row carpectomy). On average, clinical and radiographic outcomes deteriorated mod-
erately from the interim report. Mayo wrist score averaged 83. Findings at repeat surgery in the failed
group included an intact graft without any apparent abnormalities, a partially ruptured graft (after a sub-
sequent reinjury), and a completely resorbed graft. The authors conclude that bone-retinaculum-bone
autograft reconstruction is a viable treatment option for reducible, dynamic scapholunate instability, but
some patients will develop arthritis requiring a salvage procedure (Level IV evidence).
Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears.
J Hand Surg Am. 1997;22:344–349.
This was a retrospective review in which authors performed arthroscopic debridement alone for iso-
lated scapholunate and lunotriquetral ligament tears. At an average follow-up of 27 months, 29 wrists
(66%) having a complete scapholunate ligament tear and 36 (85%) wrists having a limited scapholu-
nate ligament tear had either complete symptom resolution or improved symptomatology. Of the
wrists with complete lunotriquetral (LT) ligament tear or partial LT ligament tear, 78% and 100% had
complete symptom resolution, respectively. Static intercarpal instability was not apparent in any of
the wrists at final follow-up. Grip strength improved on average 23% (Level IV evidence).
CHAPTER 22
Scapholunate Ligament Reconstruction
INDICATIONS
• See Chapter 21 Scapholunate Ligament Repair.
• This chapter reviews reconstruction options for stage III and IV scapholunate liga-
ment injuries. Unlike stage I and II injuries, the ligament is not repairable because of
poor tissue quality, and thus reconstruction should be attempted.
Contraindications
• As discussed in Chapter 21, stage I and II injuries still have good ligament quality
after partial or complete injury. Therefore repair should be attempted.
• For stage V and VI injuries, where either irreducible malalignment of the carpus
(stage V) or cartilage loss with arthritis is present (stage VI), salvage procedures
should be pursued (Chapter 27 Salvage Procedures for Scaphoid Nonunion). Op-
tions include proximal row carpectomy, four-corner fusion, or wrist arthrodesis
(Chapter 53 Total Wrist Fusion).
See Chapter 21.
IMAGING
See Chapter 21.
SURGICAL ANATOMY
See Chapter 21.
EXPOSURES
See Chapter 21.
Stage III: Complete Disruption With Irreparable Ligament

but Normal Alignment: Bone-Tissue-Bone Reconstruction
INDICATIONS
• One indication is dynamic scapholunate dissociation in which the ligament cannot
be repaired primarily.
• Bone-tissue-bone (BTB) reconstruction can be performed for static, reducible insta-
bility through a ligament reconstruction; a three or four ligament tenodesis should be
considered.
• BTB reconstruction is contraindicated where there is evidence of radiocarpal or
midcarpal arthritis.
• Standard posteroanterior (PA), oblique, and lateral wrist radiographs will not show
scapholunate (SL) widening with dynamic SL instability.
• Clenched-fist views, when the wrist is loaded, will reveal gapping between the
scaphoid and lunate if the ligamentous injury is significant.
• Arthroscopy can be performed to confirm the diagnosis and to rule out articular wear
that would preclude reconstruction in favor of a salvage operation, such as wrist
fusion.
• The dorsal SL ligament is the strongest portion of the U-shaped ligament that also
has a proximal and volar component.
• Repair or reconstruction of the dorsal portion of the ligament is desired.
93
94 CHAPTER 22 Scapholunate Ligament Reconstruction
• Scaphoid stabilization with extensor carpi radialis longus (ECRL) tenodesis is also
an option for this stage of injury and may be more predictable.

A ligament-sparing approach to the wrist can be
performed. The design of this radially based triangular
Step 1: Debride the Scar Tissue Within the Scapholunate Interval
flap splits the fibers of the dorsal radiocarpal and • A 6-cm longitudinal incision is designed on the dorsal wrist, ulnar to the Lister
dorsal intercarpal ligaments (Fig. 22.4A–C). tubercle (Fig. 22.1).
• After incising the extensor retinaculum between the third and fourth compartments,
the extensor pollicis longus (EPL) is identified and retracted radially (Fig. 22.2).
• The wrist capsule is opened longitudinally to expose the SL interval.
• After exposing the SL interval, scar tissue should be debrided back to healthy bleeding
tissue (Fig. 22.3).
STEP 2 PEARLS Step 2: Reduce the Scaphoid and Lunate

• Because the scaphoid has assumed a flexed • If static, reducible instability is present, the scaphoid will need to be anatomically
position and the lunate is extended, the wires reduced to correct any dorsal intercalated segment instability (DISI) deformity.
should be placed from distal to proximal in the • Two 0.062-in (1.57-mm) Kirschner wires (K-wires) can be used to reduce the scaph-
scaphoid and proximal to distal in the lunate.
This will facilitate reduction. oid and lunate into preinjury anatomic alignment (Fig. 22.5).
• Stouter 0.062-in (1.57-mm) K-wires are used • Because the scaphoid is flexed and the lunate is extended with a DISI deformity, the
instead of 0.045-in (1.14-mm) wires. K-wires should be placed from distal to proximal in the scaphoid and proximal to
distal in the lunate.
Detached ECRL Tendon
EPL
Lunate
FIGURE 22.2 EPL identified. EPL, Extensor pollicis longus. FIGURE 22.3 SL interval debrided. SL, Scapholunate.
DIC
DRC
B C
FIGURE 22.4 (A–C) DIC, Dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament.
• Using the K-wire, the lunate should be flexed maximally toward the fingers to ensure
that it is neutral with respect to the long axis of the radius.
• The scaphoid can be extended to ensure that the flexed, pronated posture is
corrected (Fig. 22.6).
• To close the gap between the two bones, the wires are compressed.
Scaphoid
Lunate
FIGURE 22.5 Kirschner wires (K-wires) in the scaphoid and lunate to aid reduction.
FIGURE 22.6 Correction of the DISI deformity by extending the scaphoid and flexing the lunate. DISI, Dorsal intercalated segment
instability.
STEP 3 PEARLS Step 3: Use a Kirschner Wire to Temporarily Maintain Scapholunate

• The SL angle should be corrected and con- Reduction
firmed radiographically: normal scapholunate • Reduction is maintained by pinning the scapholunate interval. This can be achieved with
angle is 30–60 degrees and normal radiolunate
angle is 0–15 degrees. one 0.062-in (1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial
• Gapping between the scaphoid and lunate styloid. The wire should be directed perpendicular to the long axis of the forearm to
should be eliminated. capture the scaphoid and lunate. Reduction of the scapholunate gap and restoration of
the normal scapholunate angle (30–60 degrees) should be confirmed fluoroscopically.
STEP 5 PEARLS • A second 0.062-in (1.57-mm) K-wire can be driven across the scaphocapitate (SC)
interval to prevent midcarpal motion (Fig. 22.7).
• When harvesting the graft, it is important to
center your template over the capitohamate
ligament and preserve this attachment to both Step 4: Create a Trough in the Scaphoid and Lunate
the capitate and hamate. • Using a 5-mm osteotome, create a trough on the dorsal surface of the scaphoid and
• Alternatively, you can harvest BTB from the dis- lunate to accept the BTB graft.
tal radius over the Lister tubercle (Fig. 22.11); • The dimensions of this trough measured 12 mm long, 6 mm wide, and 6 mm deep
however, the capitohamate ligament is more
accessible because it is at the same operative (Fig. 22.8).
field, just distal to the SL interval. It is important
to remove a segment of bone from this BTB Step 5: Harvest Bone-Ligament-Bone Graft From Capitohamate
graft (Fig. 22.12). The goal is to reconstruct the • After measuring the defect created in the dorsum of the scaphoid and lunate, trans-
dorsal ligament and avoid bony fusion between pose this template onto the capitohamate (Fig. 22.9A–B).
the scaphoid and lunate.
• Using the 5-mm osteotome, harvest the BTB graft (Fig. 22.10).
Scaphoid
Lunate
FIGURE 22.7 Reduction of DISI deformity pinned in

place with Kirschner wires (K-wires) and confirmed on FIGURE 22.8 Create a trough in the scaphoid and lunate dorsal
x-ray. DISI, Dorsal intercalated segment instability. surface.
Capitate
Hamate
A B
FIGURE 22.9 (A) Transposing the template. (B) Removed trough of scaphoid and lunate.
Capitate
Hamate
FIGURE 22.10 BTB harvested from capitate and hamate. BTB, Bone-tissue-bone.
Harvest site BTB graft

SL trough
A
B
BTB construct
FIGURE 22.11 (A–B) BTB, Bone-tissue-bone; SL, scapholunate.
FIGURE 22.12 BTB graft. BTB, Bone-tissue-bone. FIGURE 22.13 Screws inserted into the harvested graft.
Step 6: Securing the Graft

• After contouring and placing the graft in the trough on the dorsum of the scaphoid
and lunate, 1.3-mm or 1.5-mm screws can be placed through each side of the graft
into the corresponding carpal bone (Fig. 22.13). Alternatively, if precise measure-
ments are obtained, then the graft can be press fit into the trough by gently tapping
the bone grafts into the slot with a bone tamp.
• The K-wire should be buried and left in place to maintain reduction of the SL interval
(Fig. 22.14).
Step 7: Closure
• After the tourniquet is deflated and hemostasis is ensured, the dorsal capsule and
extensor retinaculum can be closed using 3-0 or 4-0 Vicryl suture.
• The skin can be closed using 4-0 Monocryl or 4-0 PDS.
FIGURE 22.14 Final x-ray with Kirschner wires (K-wires) in place in the SL and SC to maintain reduc-
tion of the SL interval. SC, Scaphocapitate; SL, scapholunate.
Stage III: Complete Disruption With Irreparable Ligament

but Normal Alignment: Scaphoid Stabilization With ECRL
Tenodesis
INDICATIONS
• Indications include scaphoid dissociation, complete disruption of the SL ligament,
and intact secondary stabilizing ligaments.
• SL ligament is not amenable to direct repair.
• Dynamic instability is present as confirmed by clenched fist radiographs and diag-
nostic arthroscopy.
• There is no evidence of articular wear.
• BTB dorsal scapholunate reconstruction is also an option but may not lead to a
predictable result.
PROCEDURE
• The SL ligament is exposed using a 6-cm longitudinal incision, ulnar to the Lister
tubercle, as previously described.
• After the SL interval is identified, any scar tissue is debrided to healthy-appearing tissue.
Step 2: Pinning of the Scapholunate Interval

• After reduction of the SL interval is ensured, one 0.062-in (1.57-mm) K-wire can be
used to maintain reduction. The entry point for the K-wire is just distal to the radial STEP 3 PEARLS
styloid. The wire should be directed perpendicular to the long axis of the forearm to
The ECRL insertion, on the base of the index
capture the scaphoid and lunate. metacarpal, can be confirmed by fluoroscopy.
• A second 0.062-in (1.57-mm) K-wire can be driven across the SC interval to prevent
midcarpal motion (Fig. 22.15).
STEP 4 PEARLS
Step 3: Dissection and Separation of Extensor Carpi Radialis Longus • This reconstruction attempts to counteract the
Tendon flexion of the scaphoid and the strain on the
• The ECRL should be identified at its insertion into the base of the index metacarpal. secondary stabilizers, which are too weak and
cause instability in the SL interval.
• An ulnar-sided slip (50%) of the ECRL or the entire ECRL may be disinserted from
• Repositioning of the ECRL tendon insertion
the metacarpal. Our preference is to use the entire ECRL tendon (Fig. 22.16). acts as a dynamic tenodesis, theoretically
providing more wrist flexion than a traditional
Step 4: Insertion of Mitek Mini Suture Anchor static capsulodesis procedure.
• The distal pole of the scaphoid is identified and confirmed fluoroscopically. • Maintenance of normal scaphoid alignment
• A Mitek mini suture anchor is placed into the distal pole of the scaphoid after re- prevents the articular wear associated with a
flexed, pronated scaphoid.
moving a 3-mm rim of cartilage for insertion of the tendon into the cancellous bone.
Scaphocapitate pin ECRL Tendon
FIGURE 22.15 Kirschner wire (K-wire) driven across SC interval.

SC, Scaphocapitate.
FIGURE 22.16 ECRL tendon detached distally. ECRL, Extensor carpi

radialis longus.
STEP 4 PITFALLS The suture must be tied tightly to be sure that the tendon contacts the bone. The
wrist can be extended to ensure that there is no tension when tying down the suture
• Care is taken to avoid injury to the vascular
pedicle of the scaphoid along its dorsal ridge (Fig. 22.17).
(Fig. 22.20). • The ECRL is attached to the distal pole of the scaphoid via the suture anchor (Fig. 22.18).
• A common problem is that the tendon does • Fluoroscopic confirmation of SL alignment is obtained (Fig. 22.19).
not contact the cancellous bone, and healing
at the tendon/bone interface does not occur. It Step 5
is critical that the tendon is cinched down to
• The dorsal wrist capsule should be closed using 3-0 Vicryl suture.
the bone trough. Because FiberWire is used for
the mini anchor, breakage of the suture is • Hemostasis is obtained after releasing the tourniquet.
uncommon. • The skin can be closed using 4-0 Monocryl or 4-0 PDS suture.
Scapholunate Ligament Reconstruction Using the Internal

Brace (If the Suture Anchor Is Available)
INDICATIONS
• The indications are the same as for scaphoid stabilization with ECRL tenodesis.
• If the internal brace is available, we prefer this technique for SL and lunotriquetral
(LT) ligament reconstruction because of the ease of exposure, reduced trauma to the
Detached ECRL Tendon
Distal pole of
the scaphoid
FIGURE 22.17 Drilling for mini Mitek suture anchor placement in distal pole of the scaphoid.
Dorsal
FIGURE 22.18 Mini Mitek placed (black arrow) to stabilize ECRL tendon to distal pole of scaphoid.
ECRL, Extensor carpi radialis longus. Drill hole
Scaphoid
Radius
FIGURE 22.20 Avoid injury to the vascular pedicle

of the scaphoid along its dorsal ridge.
FIGURE 22.19 X-ray showing confirmation of scapholunate alignment.
bone via bone tunnels, and stout tendon/suture tape construct that stabilizes the
intercarpal ligaments.
PROCEDURE
• The scapholunate ligament is exposed using a 6-cm longitudinal incision, ulnar to
STEP 2 PEARLS
the Lister tubercle, as previously described (Fig. 22.21).
• The ECRB insertion, on the base of the middle
metacarpal, can be confirmed by fluoroscopy.
• The harvested ECRB should span 10 cm, from
Step 2: Dissection and Separation of ECRB Tendon the proximal pole of the scaphoid to the lunate
• The ECRB should be identified at its insertion into the base of the index metacarpal. to the distal pole of the scaphoid (Fig. 22.23).
• Harvest a 2-mm width of ECRB that measures 10 cm in length (Fig. 22.22). A thicker It should be whip-stitched at both ends with fi-
berloop for insertion into the forked eyelet of
tendon graft will not fit within the bone trough.
the anchor.
• The limb of tendon extending from the lunate
Step 3: Insertion of Kirschner Wires to the distal pole of the scaphoid helps correct
• Place 0.054-in K-wires from the internal brace kit into the proximal and distal poles scaphoid flexion.
of the scaphoid and lunate (Fig. 22.24A–B). Verify the position of the K-wire insertion • A harvested tendon graft more than 2 mm in
sites under fluoroscopy. width will be difficult to place inside the suture
anchor with suture tape.
• Overdrill your K-wires using the drill bit and guides in your internal brace kit.
FIGURE 22.21 Incision design ulnar to Lister tubercle.
FIGURE 22.22 ECRB identified and 2-mm-thick portion harvested. ECRB, Extensor carpi radialis brevis.
FIGURE 22.23 ECRB measuring 10 cm in length. ECRB, Extensor carpi radialis brevis.
Distal pole of
the scaphoid
Distal pole of
the scaphoid
Proximal pole of
the scaphoid
Lunate
Proximal pole of
the scaphoid
Lunate
A B
FIGURE 22.24 (A) Insertion of Kirschner wires (K-wires) into the scaphoid and lunate. (B) Fluoroscopy confirmation of K-wire
placement in the scaphoid and lunate.
FIGURE 22.25 Loaded forked eyelet with suture tape and tendon graft.
Residual hole
from K-wire
reduction
STEP 3 PEARLS
• Ensure that the K-wires have been buried up
to the laser line.
• If tendon graft is used in addition to suture or
suture tape for 3.5-mm anchors, drill with the
3.5-mm drill bit.
• Drill each suture anchor hole as each is placed
because the tendon graft may not be long
FIGURE 22.26 Final anchors placed. enough to reach all anchors. In this case, the
distal pole of the scaphoid anchor may need to
be drilled with the smaller drill bit to accom-
Step 4 modate just the suture tape. This will bring the
• Insert the tendon graft and then suture tape into the forked eyelet of the suture anchor. scaphoid into extension to avoid stressing the
In the proximal pole of the scaphoid anchor, one end of the tendon graft and suture tape SL internal.
should be placed in the forked eyelet to maximize the length of graft, and the suture tape
should span from proximal scaphoid to lunate to distal scaphoid (Fig. 22.25).
STEP 3 PITFALLS
• Next, place your lunate anchor, including the suture tape and tendon graft. The final
Care should be taken to avoid the vascular pedicle
anchor should be placed in the distal pole of the scaphoid and include both graft
to the scaphoid along the dorsal ridge (see
and suture tape (Fig. 22.26). Fig. 22.20).
Step 5
• The dorsal wrist capsule should be closed using 3-0 Vicryl suture. STEP 4 PEARLS
• Hemostasis is obtained after releasing the tourniquet. • Apply firm pressure to insert the suture anchors
• The skin can be closed using 4-0 Monocryl or 4-0 PDS suture. and ensure that the laser line is at or below the
surface of the bone.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Between each suture anchor placement, twist
the suture tape and graft to aid in loading of
The patient will remain splinted for 6 weeks to encourage healing before initiation of
the subsequent anchor eyelet.
range-of-motion (ROM) exercises.
Stage IV: Complete Disruption With Irreparable Ligament

and Reducible Rotary Subluxation of the Scaphoid—
Ligament Reconstruction With Flexor Carpi Radialis
Tenodesis
INDICATIONS
Indications include chronic SL instability with static malalignment, evidence of DISI, and
no evidence of degenerative change (Fig. 22.27A–B).
EXPOSURES
Dorsal
• An 8-cm longitudinal incision is centered over the Lister tubercle (Fig. 22.28).
• The extensor retinaculum is sharply incised, and then the EPL is identified and retracted
radially to expose the dorsal wrist capsule.
• The wrist capsule is opened to examine the SL interval (Fig. 22.29).
Volar
Three 1- to 2-cm incisions are made over the course of the flexor carpi radialis (FCR).
An oblique incision can be designed over the distal pole of the scaphoid (Fig. 22.30).
SL angle
30-60°
56°
A Normal
SL angle
>70°
92°
FIGURE 22.27 (A–B) SL, Scapholunate.

FIGURE 22.28 Dorsal incision design.
FIGURE 22.29 Examining the SL interval. SL, Scapholunate.
FIGURE 22.30 Volar incision design.
PROCEDURE
• The SL ligament is exposed using a longitudinal incision, ulnar to the Lister tubercle,
as previously described.
STEP 2 PEARLS
Step 2: Harvest a Slip of Distally Based Flexor Carpi Radialis Tendon Remember that the FCR tendon rotates 90 degrees
Using the distal-most 1-cm incision over the FCR, a 3-mm radial-sided slip of FCR is within its sheath. It is important to carefully dissect
split from the remaining tendon. This is then sharply dissected, using proximal discon- the fibers proximally to avoid inadvertent complete
transection of the tendon.
tinuous incisions, up to its musculotendinous junction (Fig. 22.31).
FIGURE 22.31 FCR harvest. FCR, Flexor carpi radialis.
Step 3: Create a Bone Tunnel Within the Scaphoid

• A 0.045-in (1.14-mm) K-wire is directed from the dorsal proximal scaphoid toward
the volar, radial corner of the scaphoid. The correct position of the wire should be
confirmed visually and fluoroscopically (Fig. 22.32).
• Using the K-wire as a guide, a 2.7-mm cannulated drill is directed dorsal to volar to
create the bone tunnel.
STEP 4 PITFALLS
Step 4: Pass the Flexor Carpi Radialis Through the Scaphoid Tunnel
Forcing a strip of FCR larger than 3 mm through Using a Hewson suture passer inserted from dorsal to volar, the distally based slip of
the bone tunnel could fracture the scaphoid.
FCR can be passed from volar to dorsal back through the bone tunnel (Fig. 22.33).
FIGURE 22.32 Preparation of scaphoid bone tunnel from the dorsal rim to the distal pole.
FIGURE 22.33 Passage of the FCR from volar to dorsal using a Hewson suture passer. FCR, Flexor
carpi radialis.
Step 5: Reduce the Scaphoid and Lunate

STEP 5 PEARLS
• If static, reducible instability is present, the scaphoid will need to be anatomically
Because the scaphoid has assumed a flexed
reduced to correct any DISI deformity. position and the lunate is extended, the wires
• Two 0.062-in (1.57-mm) K-wires can be used to reduce the scaphoid and lunate into should be placed from distal to proximal in the
preinjury anatomic alignment. scaphoid and proximal to distal in the lunate. This
• Because the scaphoid is flexed and the lunate is extended with a DISI deformity, the will facilitate reduction.
K-wires should be placed from distal to proximal in the scaphoid and proximal to
distal in the lunate (Fig. 22.34).
• Using the K-wire, the lunate should be flexed maximally toward the fingers to ensure
that it is neutral with respect to the long axis of the radius.
• The scaphoid can be extended to ensure that the flexed, pronated posture is corrected.
• To close the gap between the two bones, the wires are compressed. Reduction is
confirmed on fluoroscopy (Fig. 22.35).
Step 6: Use a K-Wire to Temporarily Maintain Scapholunate Reduction

• Reduction is maintained by pinning the SL interval. This can be achieved with one STEP 6 PEARLS
0.062-in (1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial • The SL angle should be corrected and con-
styloid. The wire should be directed perpendicular to the long axis of the forearm to firmed radiographically: normal SL angle is
capture the scaphoid and lunate. Reduction of the SL gap and restoration of the 30–60 degrees and normal radiolunate angle
normal SL angle (30–60 degrees) should be confirmed fluoroscopically. is 0–15 degrees.
• A second 0.062-in (1.57-mm) K-wire can be driven across the SC interval to prevent • Gapping between the scaphoid and lunate
should be eliminated.
midcarpal motion.
FIGURE 22.34 Appropriate placement of the Kirschner wires (K-wires) to aid in scaphoid and lunate
reduction.
FIGURE 22.35 Fluoroscopic imaging of SL reduction and DISI correction. DISI, Dorsal intercalated
segment instability; SL, scapholunate.
Step 7: Secure the FCR to the Lunate

• Using a bur, an approximately 2-mm-wide trough is made on the dorsum of the lu-
nate. A 1.8-mm suture anchor (Mitek mini quick anchor or similar) is used to secure
the FCR to the midportion of the lunate bone trough (Fig. 22.36A–B). Rather than
drilling a hole into the lunate, which may fracture the lunate, the bone trough helps
to seat the tendon into the lunate groove.
• The remaining tendon beyond the suture anchor is passed through the dorsal radiocar-
pal ligament and sutured to itself over the lunate using 3-0 Ethibond (Fig. 22.37A–B and
Fig. 22.38).
Step 8: Closure
• The dorsal wrist capsule is closed using 3-0 Ethibond suture (Fig. 22.39A–B).
• After closure of the capsule, the tourniquet is deflated and hemostasis is ensured. To
avoid ischemic rupture, the EPL tendon is transposed over the extensor retinaculum,
Scaphoid
Lunate Bone anchor

suture
Joystick Radiotriquetral
K-wires ligament
Radius
Distally
based FCR
Bone reduction clamp B

A
FIGURE 22.36 (A–B) Suture anchor is used to secure the FCR to the midportion of the lunate bone trough. FCR, Flexor carpi radialis.
A B
FIGURE 22.37 (A–B) Anchor inserted into the dorsal gutter of the lunate (yellow arrow).
FIGURE 22.38 Completed tenodesis with wrist capsule closed.
Joystick
K-wires
Bone anchor
suture
Radiotriquetral
ligament
Distally
based FCR
B
A
FIGURE 22.39 (A–B) FCR fixed through the dorsal capsule under the fourth compartment. FCR, Flexor carpi radialis.
within the subcutaneous tissue. The extensor retinaculum is then closed using 3-0
Ethibond suture (Fig. 22.39A–B).
• The skin can be closed using 4-0 Monocryl or 4-0 PDS.
• Fig. 22.40 demonstrates correction of SL gapping and prior DISI deformity.
Stage V: Complete Disruption With Irreducible

Malalignment and Intact Cartilage—Salvage Procedure,
Soft Tissue Reconstruction Not Indicated
INDICATIONS
This stage is uncommon because static irreducible carpal bone is associated with carti-
lage wear. Attempts at reconstruction are futile, with high failure probability if the ma-
lalignment of the carpus cannot be corrected; thus salvage procedures such as proximal
row carpectomy (PRC) or four-bone fusion are pursued.
Correction of
SL angle, no
DISI present
SL interval
restored
FIGURE 22.40 One-year postoperative x-rays.
Stage VI: Chronic Scapholunate Interosseous Ligament
Although ROM will decrease, the majority of patients Disruption With Cartilage Loss—Salvage Procedure, Soft
report a decrease in wrist pain after this procedure.
Tissue Reconstruction Not Indicated
POSTOPERATIVE PITFALLS INDICATIONS

• Despite reconstruction, some patients will • When static, irreducible instability or SL advanced collapse is present, soft tissue re-
progress to arthrosis and/or arthritis requiring construction is unlikely to provide a durable reconstruction and long-term pain relief.
a salvage operation such as a scaphoidectomy • The patient should be counseled about the risks and benefits of a salvage operation.
and partial wrist fusion. • Treatment options differ based on the location of articular wear.
• Using the Garcia-Elias staging system as a
guide to SLL injuries, treatment options tai- POSTOPERATIVE CARE AND EXPECTED OUTCOMES
lored to the injury can be identified.
• The patient is placed into a forearm-based, volar wrist splint at the conclusion of the
procedure.
• The incision is inspected 2 weeks postoperatively and the sutures are removed.
• A custom thermoplastic splint is designed and the patient is instructed to wear it at
all times, except when showering, during which time the wrist should be protected.
• No strenuous activity or heavy lifting is permitted for 8 weeks.
• K-wires are removed 6 to 8 weeks after surgery. The pins should be buried to reduce
the risk of pin tract infection.
• After removal of the splint at 8 weeks, active ROM exercises are initiated. There is no
need for formal hand therapy. The goal of the procedure is to reduce wrist motion and
promote healing of the reconstruction. Early active motion or strenuous activity could lead
to reconstructive failure. The patient should be counseled preoperatively to expect a
postoperative loss of flexion compared with the contralateral side. The goal of the opera-
tion is to reduce wrist pain and prevent or delay the progression of arthritis at the expense
of some wrist motion. Our goal is painless wrist motion for any wrist procedures.
• Fig. 22.41A–D demonstrates ROM at 13 months after reconstruction of left SL dis-
sociation with dorsal ECRL tenodesis.
• Notice a reduction in flexion arc, though all other wrist motions are similar to the
contralateral side.
• Fig. 22.42 demonstrates the 13-month radiographic appearance of the wrist after
ECRL tenodesis.
• Fig. 22.43A–D demonstrates wrist motion at 4 months’ follow-up after BTB reconstruction.
• Fig. 22.44 demonstrates preservation of the SL interval and no evidence of DISI
deformity at 4 months after BTB reconstruction.
A B
C D
FIGURE 22.41 (A–D) Four-month follow-up.
FIGURE 22.42 Preservation of the scapholunate interval and no evidence of DISI deformity at 4 months
after BTB reconstruction. BTB, Bone-tissue-bone; DISI, dorsal intercalated segment instability.
A B
C D
FIGURE 22.43 (A-D) Demonstrates wrist motion at 4 months’ follow-up after BTB reconstruction. BTB, Bone-
tissue-bone.
FIGURE 22.44 Demonstrates preservation of the scapholunate interval and no evidence of DISI defor-
mity at 4 months after BTB reconstruction. BTB, Bone-tissue-bone; DISI, dorsal intercalated segment
instability.
EVIDENCE
Konopka G, Chim H. Optimal management of scapholunate ligament injuries. Orthop Res Rev.
2018;10:41–54.
The authors provide a review of the anatomy and biomechanics of the wrist with surgical options
based on the Garcia-Elias staging system (Level IV evidence).
Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: A review of current concepts. Hand (NY).
2013;8(2):146–156.
This review provides a description of SL ligament injuries and an overview of treatment options.
CHAPTER 23
Lunotriquetral Ligament Reconstruction Options
Using Tendon Grafts
Isolated lunotriquetral (LT) ligament tears are rarely treated acutely. Therefore, the tradi-
tional treatment approaches have been to attempt ligament repair, ligament reconstruc-
tion, or LT fusion.
• Ligament repair is often not an available option for chronic injuries because the re-
maining ligamentous substance is inadequately substantive to repair.
• LT fusion has a relatively high complication and nonunion rate (up to 50%).
• LT reconstruction has traditionally been performed with a distally based extensor
carpi ulnaris (ECU) weave. Nevertheless, other techniques have been published,
including a weave using palmaris longus, dorsal capsulodesis using the dorsal ra-
diocarpal ligament, or our preferred technique, using an Arthrex InternalBrace.
• When opting for ligament reconstruction, we have come to favor the Internal-
Brace method because it provides an exceedingly strong construct without the
need for the cumbersome creation of bone tunnels.
• The disadvantage of this technique is the cost of the equipment that some fa-
cilities may not be able to absorb.
Some surgeons have advocated for the use of ulnar shortening osteotomy to treat
symptomatic LT ligament injury as long as imaging and arthroscopy confirm no joint
degeneration and no triangular fibrocartilage complex (TFCC) or scapholunate (SL)
ligament injury. We have used this approach as well.
INDICATIONS
• Symptomatic LT dissociation without evidence of wrist arthritis
• If volar intercalated segment instability (VISI) is seen on x-ray (see section on
“Imaging”), it should be passively correctable and confirmed with fluoroscopy
before pursuing reconstruction.
• Continued wrist pain with associated LT injury despite conservative management
• Ruled out concomitant or other reasons for ulnar-sided wrist pain
Contraindications
• Evidence of arthritic changes in the radiocarpal or midcarpal joints is a contraindica-
tion for the procedure.
• Another contraindication is VISI that cannot be manually reduced with traction and/
or manipulation.
• Notable ulnar positive variance is a relative contraindication to performing LT recon-
struction alone.
• The patient complains of ulnar-sided wrist pain that may have been preceded by
trauma.
• Common causes of ulnar-sided wrist pain include ulnar abutment syndrome, ECU
subluxation, distal radial ulnar joint (DRUJ) instability, TFCC pathology, pisotriquetral
arthritis, and hook of hamate fractures.
• Provocative maneuvers can help differentiate LT pathology from other causes of
ulnar-sided wrist pain.
• Palpate the LT interval; with the wrist in 30 degrees of flexion, the interval is found dor-
sally between the fourth and fifth compartments, one fingerbreadth distal to the DRUJ.
113
114 CHAPTER 23 Lunotriquetral Ligament Reconstruction Options using Tendon Grafts
• When conducting an LT compression test, radially directed pressure over the trique-
trum may elicit pain with LT instability (Fig. 23.1).
• The LT ballottement test is similar to the LT compression test, but here one hand
controls/stabilizes the wrist and lunate while the other applies radially directed force
on the triquetrum, driving it into the lunate.
• With the LT shear test, stabilizing the lunate centrally and directing the triquetrum
volarly and dorsally elicits pain, crepitus, and excessive mobility compared with the
contralateral side when LT instability is present (Fig. 23.2).
IMAGING
• Plain radiographs are often normal with LT dissociation. One may see a slight widen-
ing of the LT interval (Fig. 23.3) or a step-off or disruption of Gilula’s proximal arc
between the lunate and triquetrum.
• VISI may be present. This can be appreciated on lateral x-ray. The lunate flexes
with the scaphoid, making the SL angle too acute (,30 degrees, normal is 30 to
60 degrees; Fig. 23.4).
• Arthroscopy can be used to diagnose LT dissociation. Normally, the lunate (L) and
triquetrum (T) are tightly articulated, but with dissociation, a gap or step-off can be
seen on arthroscopy. A probe can be used to separate the lunate from the triquetrum
via the midcarpal portal (Fig. 23.5). This image demonstrates Geisler grade III insta-
bility, where a probe can be passed easily between the two bones.
• We advocate performing wrist arthroscopy to survey the entire wrist joint before
entertaining reconstruction.
• Concomitant injuries can be identified and the amount of gapping can help de-
cide on the reconstructive options, including assessing the articular wear that
may preclude ligament reconstruction.
SURGICAL ANATOMY
FIGURE 23.1 The LT compression test is performed • The LT ligament is a C-shaped ligament, but unlike the scapholunate ligament in
by using a radially directed force against the ulnar which the dorsal fibers confer the most support, the volar fibers of the LT ligament
border of the triquetrum. LT, Lunotriquetral. are strongest.
Slightly
widened
LT
SL angle < 30°
VISI
FIGURE 23.2 An LT shear test allows the exam-
iner to stress the LT interval by manually manip- FIGURE 23.3 X-ray demonstrating FIGURE 23.4 Illustration of the carpal relationship that
ulating the lunate and triquetrum to test for pain, slight LT interval widening (arrow develops in a volar intercalated segment instability
crepitus, or laxity compared with the contralat- points to widened LT interval). LT, (VISI) deformity, with the scapholunate (SL) angle more
eral side. LT, Lunotriquetral. Lunotriquetral. acute than normal.
CHAPTER 23 Lunotriquetral Ligament Reconstruction Options using Tendon Grafts 115
L T
Triquetrocapitate Triquetrohamate ligament
ligament
Ulnocapitate ligament
Ulnotriquetal ligament
Ulnolunate ligament
LT interval
FIGURE 23.5 Arthroscopic image from a midcarpal view show-
ing an LT step-off associated with Grade III instability. Arrow
points to the incongruous LT interval. L, Lunate; LT, lunotrique-
tral; T, triquetrum.
FIGURE 23.6 Illustration of the main volar secondary stabilizers of the LT in-
terval. LT, Lunotriquetral.
Dorsal intercarpal (DIC)
Dorsal radiocarpal (DRC)
FIGURE 23.7 Illustration of the main dorsal secondary stabilizers of the LT interval. LT, Lunotriquetral.
• Secondary stabilizers of the LT ligament include the ulnocarpal (ulnolunate, ulno-

capitate, and ulnotriquetral ligaments), midcarpal (triquetrohamate and triquetro-
capitate ligaments), and dorsal carpal (dorsal intercarpal and dorsal radiotriquetral/
radiocarpal) ligaments (Figs. 23.6 and 23.7).
Central wrist incision

Triquetrum
Freer in
Lunate LT Space
FIGURE 23.8 Incision used to approach the LT interval. LT, Lunotrique-

tral.
FIGURE 23.9 Dorsal exposure of the LT region of the wrist.
The freer is easily able to pass between the lunate and trique-
trum, indicating a torn LT ligament. LT, Lunotriquetral.
• With injury to the LT ligament and failure of the secondary stabilizers, the lunate and tri-
quetrum dissociate, permitting the scaphoid and lunate to flex together, resulting in VISI.
POSITIONING
EXPOSURES PITFALLS
• The patient is positioned supine, with arm extended on an arm board.
Branches of the dorsal ulnar sensory nerve should
• A sterile tourniquet is used on the upper arm.
be identified and protected. This nerve branches
off from the main ulnar nerve about 8 cm proximal
to the pisiform. It then passes dorsal to the flexor EXPOSURES
carpi ulnaris (FCU) and pierces the deep fascia • A 6- to 8-cm longitudinal incision is designed over the dorsal wrist between the
about 5 cm from the pisiform. It reaches the fourth and fifth compartments (Fig. 23.8).
dorsum of the hand after coursing in close relation
• After protecting the fourth and fifth compartment tendons, sharply enter the wrist
to the ulnar styloid process (Fig. 23.10).
and expose the LT interval (Fig. 23.9).
Dorsal branch of ulnar nerve
Pisiform
8 cm
FCU
A B
FIGURE 23.10 Illustration of the course of the dorsal sensory branch of the ulnar nerve. FCU, Flexor
carpi ulnaris
K-wire
joysticks
ECU slip
tendon
graft
T
ECU ECU L S
tendon
EDM
Ulna
Radius
FIGURE 23.11 Harvest of the distally based ECU tendon for

weave technique. ECU, Extensor carpi ulnaris. FIGURE 23.12 Harvest of ECRB graft for the InternalBrace technique. ECRB,
Extensor carpi radialis brevis brevis; ECU, Extensor carpi ulnari; L, lunate;
S, scaphoid; T, triquetrum.
PROCEDURE
Step 1: Excise the Scar Tissue Between the Lunate and Triquetrum
After exposure of the LT interval, debride the scar tissue (see Fig. 23.9).
Step 2: Harvest Tendon for Reconstruction

ECU Weave Technique
Identify a 3-mm slip of ECU tendon along the radial aspect of its insertion on the base
of the small finger metacarpal and separate it from the remaining tendon. This can be
dissected proximally to its musculotendinous junction (Figs. 23.11 and 23.12).
Arthrex InternalBrace Technique

• Identify the extensor carpi radialis brevis (ECRB) exiting the second extensor com-
partment heading toward the base of the third metacarpal. STEP 2 PEARLS
• Harvest a 2-mm wide segment of ECRB (Fig. 23.13). The ECU tendon strip width should not exceed
• The ECRB tendon is chosen for harvest because of its wide caliber, which should 3 mm to smoothly pass the tendon through the
not weaken the remaining tendon. Nevertheless, the ECU tendon can be harvested bone tunnels.
similar to the weave procedure.
ECRB tendon graft
FIGURE 23.13 Illustration of ECU tendon for weave and K-wire joysticks for LT reduction. ECU, Exten-
sor carpi ulnaris; K-wire, Kirschner wire; L, lunate; LT, lunotriquetral; S, scaphoid; T, triquetrum.
T L S
FIGURE 23.14 Illustration of K-wire manipulation to facilitate LT reduction. C, Capitate; K-wire,

Kirschner wire; L, lunate; LT, lunotriquetral; S, scaphoid; T, triquetrum.
Step 3: Reduction of the Lunate and Triquetrum

ECU Weave Technique and Arthrex InternalBrace Technique
• Evaluate the position of the lunate and triquetrum and confirm that a reduction can
be easily performed and maintained.
• To help with reduction (as needed), insert two 0.062-inch (1.6-mm) Kirschner wires
(K-wires), one into the lunate and one into the triquetrum, to act as joysticks to re-
duce the carpal bones (Fig. 23.14; see also Fig. 23.12).
• Place these wires out of the future bone tunnel path. For the InternalBrace, these
wires can also function as the procedure guidewires (see Step 4) rather than plac-
ing joysticks and guidewires.
• Because the lunate has flexed with the scaphoid, the lunate K-wire should be directed
from distal to proximal, with the wire somewhat flat (near the plane of the hand) and
distal so that the joystick can extend the lunate without obstruction from the radius.
• The K-wire inserted within the triquetrum should be placed from proximal to distal.
• Manipulate the wires toward being more perpendicular to the plane of the hand
to reduce any malalignment or dissociation (Fig. 23.15).
STEP 3 PEARLS • Confirm reduction.
With a VISI deformity, the lunate follows the
scaphoid into a flexed position and the triquetrum
is extended. Placement of the K-wires from distal
to proximal in the lunate and proximal to distal in
the triquetrum facilitates reduction.
FIGURE 23.15 Joystick in the lunate and triquetrum being manipulated to perform the LT reduction.
LT, Lunotriquetral.
• Place a 0.062-inch (1.6-mm) K-wire across the LT interval to maintain reduction.

• Direct the K-wire from the midportion of the triquetrum through the central axis
of the lunate. The starting point and trajectory can be confirmed fluoroscopically.
• Remove the joystick K-wires.
Step 4: Create Bone Tunnels

ECU Weave Technique
• There are two versions of this technique, one with a tunnel in the lunate and trique-
trum and another with only a tunnel in the triquetrum and a trough in the dorsal
lunate, with a bone anchor to secure the graft. Both are viable options, based on
available equipment. We prefer the trough approach, because drilling the tendon T
path in the lunate risks fracturing the cortex of the lunate when traction is placed on H L
the tendon. C
• The entry point for a 0.045-inch (1.1-mm) K-wire guide should be at the proximal,
volar, and radial aspect of the triquetrum. This K-wire should then be directed
toward its distal, dorsal, and ulnar corner. FIGURE 23.16 Drilling from proximal to distal f
• Once the position of the K-wire is confirmed radiographically, a 2.7-mm cannu- or the triquetrum bone tunnel. C, Capitate;
lated drill can be used to create the bone tunnel within the triquetrum (Fig. 23.16). H, hamate; L, lunate; T, triquetrum.
• If making a lunate tunnel, it is best directed from proximal ulnar lunate (aligned
with the tunnel in the triquetrum) to distal dorsal radial (Fig. 23.17C).
T
ECU
H
L
T
H
L
C
A B ECU
S
ECU T L FIGURE 23.17 Clinical photo of ECU graft be-
fore (A) and after (B) being passed through the
triquetrum bone tunnel, as represented in the
illustration (C). C, Capitate; ECU, extensor carpi
LT interval ulnaris; H, hamate; L, lunate; S, scaphoid;
C T, triquetrum.
H
C
T ECU
L
Lunate
trough
B
ECU
FIGURE 23.18 Clinical photo (A) and illustration (B) of the lunate tunnel and bone anchor to secure
the graft. C, 5capitate; L, 5lunate; T, 5triquetrum; H, 5hamate; ECU, 5extensor carpi ulnaris.
Dotted outline indicates the lunate trough in the clinical photo.
STEP 4 ECU WEAVE PEARLS • If a suture anchor is available, make a trough in the dorsal lunate rather than a
• Alternatively, the triquetrum K-wire can be tunnel through the bone.
placed distal to proximal, from the distal ulnar • Use a bur to create a 3-mm-wide, shallow trough on the dorsal aspect of the
corner toward the volar, radial corner of the lunate to secure the tendon graft.
bone.
• A small curette can be used as an alternative • The trough should have healthy-appearing cancellous bone to promote bone–
to the drill to avoid fracturing the triquetrum. tendon healing (Fig. 23.18A–B).

• Place a guidewire in the triquetrum and in the lunate, setting the location for the
tenodesis screw that will hold the tendon graft and suture tape.
• Aim to have guidewires in the midsubstance of the respective bones in the reduced
position (Fig. 23.19).
• Plan that the position of the guidewires will set the location of the drill hole for the
interference screws.
Step 5: Prepare and Place the Tendon Graft

ECU Weave Technique: Passing the Slip of ECU Through the Bone Tunnel
• Pass a fine 25-gauge wire from proximal to distal, through the triquetrum bone tun-
nel. The tendon is then sutured to the wire and pulled through the tunnel from distal
to proximal (see Fig. 23.17A–C).
• The same method is used to pull the tendon from proximal ulnar in the lunate
through the tunnel to the distal radial exit site.
L T
L T
FIGURE 23.19 X-ray of the InternalBrace guidewires in place in the lunate (L) and triquetrum (T).
Tendon graft
whip-stitched
with Fiberwire
FIGURE 23.20 Preparing the tendon graft for use with InternalBrace.
Arthrex InternalBrace Technique: Preparing the Tendon STEP 5 ECU WEAVE PITFALLS
• Use a fiber-wire suture to whip-stitch the graft, adding stability and creating a lower Do not force the tendon graft through the bone
profile tendon that can fit into the screw (Fig. 23.20). tunnel because this could fracture the carpal bone.
Instead, trim the tendon graft to fit.
Step 6: Secure the Tendon Graft/Weave
ECU Weave Technique STEP 6 PEARLS
• If using the lunate trough technique, secure the graft to the base of the trough with Fluoroscopy should be used at this point to confirm
that the lunate is in neutral position and has not
a suture anchor.
fallen back into VISI deformity. There should be no
• Within the trough, over the center of the lunate, place a 1.8-mm mini Mitek suture gapping between the lunate and triquetrum; this
anchor (or similar). should be confirmed visually and radiographically.
• Put the ECU under tension from radial to ulnar and suture the ECU slip to the lunate
(Fig. 23.21).
• Pull the graft over the lunate from radial to ulnar (either from the bone tunnel or from
the secured anchor in the trough) to create tension.
• Pass the remaining graft through the ulnar-sided dorsal capsule and suture it to itself
over the lunate using 3-0 nonabsorbable suture (Fig. 23.22).

• Prepare tenodesis screw placement by passing the weaved tendon graft and suture
tape through the screw.
• Place tenodesis screw with the graft and tape into the lunate and triquetrum to
secure the graft and tape as a replacement for the LT ligament (Fig. 23.23A–B).
ECU C
S
T
L
ECU
FIGURE 23.21 Illustration of tensioning and securing the FIGURE 23.22 Illustration of the final steps in securing the
ECU graft in the lunate trough with the bone anchor. ECU weave. C, Capitate; ECU, extensor carpi ulnaris; L,
ECU, Extensor carpi ulnaris; L, lunate; T, triquetrum. lunate; S, scaphoid; T, triquetrum.
Triquetrum Tendon graft + suture

tenodesis tape ligament reconstruction
screw placed
Lunate tenodesis
screw placed
A
Tendon graft + suture tape

Triquetrum ligament reconstruction
tenodesis
screw placed
Triquetrum
tenodesis
Lunate screw
tenodesis
screw
B Lunate tenodesis C
screw placed
FIGURE 23.23 Clinical photos of (A) the InternalBrace and ECRB graft being placed into the lunate and triquetrum with interference screws
and (B) the final appearance with the graft trimmed after proper tensioning with x-ray (C) of the construct in place with tenodesis screw in
the lunate and in the triquetrum. ECRB, Extensor carpi radialis brevis.
• The suture tape provides added strength to the repair until the tendon graft has
stiffened to provide permanent stability.
Step 7: Close the Capsule, Extensor Retinaculum, and Skin

• If a K-wire was used to pin across the LT interval, decide whether to leave it in place
for 8 weeks before extracting the pins in the operating room. Leaving K-wires out-
side the skin for more than 3 weeks risks pin track infection that may progress to
osteomyelitis of the carpal bone, a devastating complication.
• For the ECU weave technique, we almost always leave the pin for future extrac-
tion; therefore, we cut the pin to bury it under the skin.
• For InternalBrace, we often do not use an LT pin because of the stability of the
construct. If the pin is to be kept in place, we would recommend burying it.
• The wrist capsule should be closed with interrupted 3-0 Vicryl or Ethibond sutures.
• The skin can be closed with 4-0 Monocryl or 4-0 Polydioxanone (PDS).

• The patient is kept in a volar wrist splint for 8 weeks.
• Postoperative x-rays are performed.
• With the InternalBrace technique, if no LT pin was left in place, we will begin gentle
motion at 4 weeks.
• If a pin is in place (either technique), the LT K-wire is removed after 8 weeks and the
patient starts gentle range-of-motion exercises.
• The patient should expect wrist stiffness and loss of range of motion compared with
the contralateral side, especially in flexion; however, nearly all patients report a re-
duction or absence of pain after this procedure (Fig. 23.24A–B).
• Despite this ligamentous reconstruction, some patients will need to undergo a sal-
vage operation, such as a partial wrist fusion, because of the progression of wrist
arthritis.
See Video 23.1 and 23.2
FIGURE 23.24 Postoperative range of motion showing extension (A) and flexion (B) of the operative
right wrist compared with the uninjured left.
EVIDENCE
Shin AY, Weinstein LP, Berger RA, Bishop AT. Treatment of isolated injuries of the lunotriquetral liga-
ment in comparison of arthrodesis, ligament reconstruction, and ligament repair. J Bone Joint Surg
Br. 2001;83:1023–1028.
In this retrospective review, the authors compared outcomes in 57 patients at a mean follow-up of
9.5 years with LT ligament injury treated with arthrodesis, direct ligament repair, or ligament recon-
struction using a slip of the ECU tendon. The following outcomes were compared: written question-
naires; the Disabilities of the Arm, Shoulder, and Hand (DASH) score; range of movement; strength;
morbidity; and rates of reoperation. Before surgery, all patients were confirmed to have isolated LT
injury by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years, and the injuries
were subacute or chronic in 98.2%. Eight patients underwent LT reconstruction using a distally
based strip of the tendon of ECU, 27 had LT repair, and 22 had LT arthrodesis. The probability of
remaining free from complications at 5 years was 68.6% for reconstruction, 13.5% for repair, and
less than 1% for arthrodesis. Of the LT arthrodeses, 40.9% developed nonunion, and 22.7% devel-
oped ulnocarpal impaction. The probabilities of not requiring further surgery at 5 years were 68.6%
for reconstruction, 23.3% for repair, and 21.8% for arthrodesis. The DASH scores for each group
were not significantly different. Objective improvements in strength and movement and subjective
indicators of pain relief and satisfaction were significantly higher in the LT repair and reconstruction
groups than in those undergoing arthrodesis (Level III evidence).
van de Grift TC, Ritt MJ. Management of lunotriquetral instability: A review of the literature. J Hand
Surg Eur Vol. 2016;41(1):72–85. doi:10.1177/1753193415595167.
In this literature review, the available data supporting conservative treatment, progression to arthros-
copy, arthroscopic guidance of surgical treatment, and ligament reconstruction for isolated LT liga-
ment injury are all reviewed. The authors highlight areas where decision-making and treatment clarity
is lacking and describe the methodologic issues that limit broad usability of available data on this
condition.
Thompson RG, Dustin JA, Roper DK, Kane SM, Lourie GM. Suture tape augmentation for scapholu-
nate ligament repair: A biomechanical study. J Hand Surg Am. 2020;S0363–5023(20)30376.
This cadaveric study reported on the strength of the suture tape/InternalBrace construct across the SL
interval. The SL ligament was sharply transected, immediately repaired, and then directly stressed/
tested to failure. The suture tape technique had significantly higher load to failure than the direct
repair using two suture anchors (mean 135N vs. 68N).
CHAPTER 24
Scapholunate and Lunotriquetral Ligament
Reconstruction with Internal Brace and Tendon
Grafting
INDICATIONS
• In young individuals without arthritis, attempts at reconstruction rather than salvage
should be pursued to recreate the scapholunate and lunotriquetral ligaments.
• Internal brace and tendon grafting is an option to reconstruct various stages of
scapholunate (SL) ligament injury without articular wear, in particular in associa-
tion with lunotriquetral (LT) ligament dissociation. In cases with both SL and LT
ligament tears, proximal row carpectomy is a suitable option, but if the articular
surfaces are intact, it is preferable to stabilize the ligaments to preserve carpal
mechanics.
• Ulna shortening should be performed at the time of surgery if the LT tear and insta-
bility are secondary to ulnar positive variance to prevent retear of the reconstructed
ligament.
• Additionally, the triangular fibrocartilage complex (TFCC) should be examined care-
fully because LT tears are often associated with degenerative tears of the TFCC.
Contraindications
If SL injury has already led to scapholunate advanced collapse (SLAC) arthritis, or articular
wear is present at the LT joint, then salvage options, including proximal row carpectomy,
scaphoid excision, and four-corner fusion or wrist arthrodesis, should be explored. Other-
wise, these patients will likely experience pain and dysfunction as a result of their arthritis.
See Chapter 21 (Scapholunate Ligament Repair) and Chapter 23 (Lunotriquetral Liga-
ment Reconstruction using Tendon Grafts)
IMAGING
See Chapter 21 and 23.
SURGICAL ANATOMY
See Chapter 21 and 23.

• The patient is positioned supine on a stretcher with a tourniquet on the operative
extremity. EXPOSURES PEARLS
• The operative extremity is pronated on a hand table. Posterior interosseous nerve (PIN) neurectomy can
be performed at the time of surgical exposure by
EXPOSURES identifying and resecting the nerve in the floor of
the fourth extensor compartment.
See Chapter 21.
PROCEDURE
Step 1
• A 6-cm longitudinal incision is designed on the dorsal wrist, ulnar to the Lister
tubercle (Fig. 24.1).
125
126 CHAPTER 24 Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting
FIGURE 24.1 Incision design. FIGURE 24.2 Posterior interosseous nerve (PIN) identified.
S/L interval
L/T interval
FIGURE 24.3 Wrist capsule opened.
STEP 1 PEARLS
A ligament-sparing approach to the wrist can be • After incising the extensor retinaculum between the third and fourth compartments,
performed. The design of this radially based triangular the extensor pollicis longus (EPL) is identified and retracted radially.
flap splits the fibers of the dorsal radiocarpal and
dorsal intercarpal ligaments (Fig. 24.4). • A PIN neurectomy is performed to excise 3 cm of nerve (Fig. 24.2).
• The wrist capsule is opened longitudinally to expose the SL and LT intervals (Fig. 24.3).
• After exposing the SL and LT intervals, scar tissue is debrided back to healthy bleed-
STEP 2 PEARLS ing tissue.
• An adequate amount of tendon must be har-
vested to span from the proximal pole of the Step 2
scaphoid to the lunate and the triquetrum. • The extensor carpi radialis brevis (ECRB) is identified at its insertion into the base of
• Harvesting more than a 2-mm width of tendon
the middle metacarpal.
graft will make it difficult to place inside your
suture anchor with suture tape. • Harvest a 2-mm width of ECRB that measures 10 cm in length. The tendon graft
must be thin enough to fit within the drill hole of the screw (Fig. 24.5).
• Whip-stitch both ends of the graft with fiberwire loop (Fig. 24.6).
STEP 3 PEARLS
• If the wrist is in DISI, the scaphoid is in a Step 3
flexed position, and the lunate is extended, • If static, reducible instability is present between the scaphoid and the lunate, then
then the wires should be placed from distal to the scaphoid needs to be anatomically reduced to correct any dorsal intercalated
proximal in the scaphoid and proximal to distal segment instability (DISI) deformity.
in the lunate. This will facilitate reduction.
• If volar intercalated segment instability (VISI) is • Three 0.062-in (1.57-mm) Kirschner wires (K-wires) can be used to reduce the
present, the wires should be placed from distal scaphoid, lunate, and triquetrum into preinjury anatomic alignment.
to proximal in the lunate and proximal to distal • Care should be taken not to place the K-wires in the path of the suture anchors at
in the triquetrum. the proximal and distal poles of the scaphoid and the lunate and triquetrum.
• Stouter 0.062-in (1.57-mm) K-wires are used in- • To close the gap between the three bones, the wires are compressed.
stead of 0.045-in (1.14-mm) to aid in reduction.
• The SL angle should be corrected and con- • Assess the carpal alignment on intraoperative fluoroscopy.
firmed radiographically. A normal scapholunate
angle is 30–60 degrees and a normal radiolu- Step 4
nate angle is 0–15 degrees. • Place 0.054-in K-wires from the internal brace kit into the proximal and distal poles
• Gapping between the scaphoid and lunate, and of the scaphoid, lunate, and triquetrum.
lunate and triquetrum should be eliminated.
• Overdrill your K-wires using the drill bit and guides in your internal brace kit (Fig. 24.7A–B).
CHAPTER 24 Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting 127
DIC
DRC
FIGURE 24.5 Extensor carpi radialis brevis (ECRB)

harvested.
FIGURE 24.6 Whip-stitched fiberwire loop.
STEP 4 PEARLS
• Ensure that the K-wires have been buried up
to the laser line. If tendon graft is used in addi-
tion to suture tape, then drill with the 3.5-mm
drill bit for a 3.5-mm anchor. If suture or
suture tape is used without tendon graft, then
drill with a 2.5-mm drill bit for a 2.0-mm
anchor.
• Drill each suture anchor hole as the anchors
are placed because the graft may not be long
enough to reach all anchors. The goal is to
have the tendon and suture tape span from
scaphoid to lunate and triquetrum.
• The distal pole of the scaphoid anchor should
B C
be drilled with the 2.0-mm drill because this
anchor will only have suture tape spanning
FIGURE 24.4 (A-C) Ligament-sparing approach. DIC, Dorsal intercarpal; DRC, dorsal
from the lunate. This is also necessary be-
radiocarpal.
cause the anchor is 2.5 mm, not 3.5 mm. This
helps to prevent flexion of the scaphoid, similar
Step 5 to the dorsal capsulodesis technique, to keep
the scaphoid extended and prevent shearing
• Insert the tendon graft and then suture tape into the forked eyelet of the suture an- stress over the SL ligament repair.
chor. In the proximal pole of the scaphoid anchor, one end of the tendon graft is
placed into the forked eyelet to maximize the length of graft to span from proximal
STEP 4 PITFALLS
scaphoid to lunate to triquetrum. The suture tape is loaded in the center to create
two limbs, which will span from scaphoid to lunate (Fig. 24.9A–B). Care should be taken to avoid injuring the
• Next, place your lunate anchor, including both limbs of the suture tape and tendon vascular pedicle to the scaphoid along the dorsal
ridge (Fig. 24.8).
graft. When placing the triquetrum anchor next, only load one limb of suture tape
A B
FIGURE 24.7 (A–B) Kirschner wires inserted.
Dorsal
Drill hole
Scaphoid
Radius
FIGURE 24.8 Drill hole location.
FIGURE 24.9 (A–B) Suture tape loaded.

CHAPTER 24 Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting 129
Tendon graft
Suture tape
3 4
2 1
A B
FIGURE 24.10 (A–B) Suture tape inserted.
FIGURE 24.11 Final anchor placed.
along with the tendon graft. The other limb of suture tape from the lunate anchor will
be used without tendon graft in the distal pole of the scaphoid (Fig. 24.10A–B).
• The final anchor is placed in the distal pole of the scaphoid and includes only one
STEP 5 PEARLS
limb of suture tape from the lunate anchor (Fig. 24.11).
• Apply firm pressure to insert the suture an-
chors, and ensure that the laser line is at or
Step 6 below the surface of the bone.
• The dorsal wrist capsule is closed using 3-0 Vicryl suture and the EPL is placed over • Between each suture anchor placement, twist
the extensor retinaculum to prevent entrapment (Fig. 24.12). the suture tape and graft to aid in loading of
• Hemostasis is obtained after releasing the tourniquet. the subsequent anchor eyelet.
• Remember, only suture tape should extend
• Skin is closed using 4-0 Monocryl or 4-0 nylon sutures (Fig. 24.13).
from the lunate to the distal pole of the scaph-
• Patient is placed in a short arm splint. oid, and so you should drill this anchor last.
This aids in preventing flexion of the scaphoid.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • 3.5-mm by 8.5-mm anchors are placed in the
The patient remains splinted for 6 weeks to permit healing of the reconstructed proximal pole of the scaphoid, lunate, and tri-
quetrum. A 2.5-mm by 7-mm anchor is placed
ligament. Then range of motion exercises can be initiated.
in the distal pole of the scaphoid.
See Video 24.1
FIGURE 24.12 Extensor pollicis longus (EPL) placed over extensor

retinaculum to prevent entrapment. FIGURE 24.13 Wounds closed.
EVIDENCE
Schwartzenberger JJ, Clark C, Santoni BG, Garcia M, Stone JD, Nydick J. Poster 146: Scapholunate
ligament reconstruction using tendon autograft and 3.5 mm fork-tip interference anchors. Presented
at: 72nd Annual Meeting of the American Society for Surgery of the Hand; September 7-9, 2017;
San Francisco, CA.
The authors compare early clinical and radiographic outcomes of all-dorsal scapholunate reconstruc-
tion with internal brace versus three-ligament tenodesis. The all-dorsal reconstruction group had
significant correction of scapholunate and radioscaphoid angle (76.2 degrees and 65.5 degrees)
preoperatively to postoperatively (52.5 degrees and 47.8 degrees).
Lee SJ, Coyle R, Porter DA, Kremenic I. Poster No. P0218: Biomechanical testing of scapholunate
reconstruction with internal brace versus scapholunate repair. Presented at: AAOS 2018 Annual
Meeting; March 6-10, 2018; New Orleans, LA.
The authors compare the biomechanical properties of all-dorsal scapholunate reconstruction with
internal brace versus scapholunate repair with two suture anchors in a cadaveric model. The
ultimate strength of the internal brace averaged 82.0 N versus ligament repair averaged 41.7 N.
CHAPTER 25
Open Reduction and Internal Fixation of Acute
Scaphoid Fracture
INDICATIONS
• A scaphoid fracture is considered acute when presenting within 6 weeks of injury.
Fractures in which presentation is delayed have poorer healing potential and a
higher likelihood of progressing to nonunion with or without surgical intervention.
• The decision to pursue operative or nonoperative intervention depends on a number
of factors, including fracture location and pattern within the scaphoid, displacement
or deformity, associated ligamentous injury, and patient preferences.
• The duration of immobilization and union rates with nonoperative treatment differ
based on the location of the fracture.
• Distal pole fractures heal more quickly than waist or proximal pole fractures.
• Union rates for nonoperative treatment of nondisplaced distal pole fractures ap-
proach 100%, compared with 95% for waist fractures and only 70% for proximal
pole fractures. Therefore operative treatment should be considered for any frac-
ture displaced more than 2 mm or any proximal pole fracture, regardless of
displacement.
• Operative treatment of nondisplaced fractures will enable accelerated rehabilitation
and earlier return to work or athletic activity and may be preferred in laborers, ath-
letes, or highly active patients.
• Specific indications for operative treatment are reviewed in Table 25.1.
TABLE
25.1 Indications for Operative Treatment of Acute Scaphoid Fracture
Injury Characteristic Operative Indication
Fracture location • The volar approach is preferred for distal pole fractures.
(Fig. 25.1) • Scaphoid waist fractures can be stabilized through
either a dorsal or volar approach.
• The dorsal approach is preferred for proximal pole fractures.
Angular deformity Certain radiographic parameters are associated with carpal in-
stability and warrant operative treatment:
• Scapholunate angle . 60 degrees (Fig. 25.2)
• Humpback deformity, or lateral intrascaphoid angle (LISA) .
35 degrees (Fig. 25.3)
• Dorsal intercalated segment instability (DISI) in the subacute
or chronic fracture setting
Comminution/bone These fractures will lead to shortening and predispose to de-
loss generative wrist disease. They warrant operative treatment,
potentially with bone grafting of the fracture gap.
Perilunate injury Any scaphoid fracture occurring in the setting of a perilunate
fracture dislocation should be treated operatively because
these injuries are highly unstable.
Open fracture/ Surgical stabilization is warranted in settings requiring
polytrauma irrigation and debridement for open fracture and/or operative
treatment of other fractures.
Ipsilateral distal Fixation of the scaphoid and distal radius fracture can be per-
radius fracture formed concurrently through an extended volar approach.
131
132 CHAPTER 25 Open Reduction and Internal Fixation of Acute Scaphoid Fracture
Scaphoid Scaphoid Proximal

tubercle waist pole
fracture fracture fracture
FIGURE 25.1 Common locations of scaphoid fractures. (Fig. 5.2, from Trumble TE, Omori D.
Scaphoid fractures. In: Trumble TE, Rayan GM, Budoff JE, Baratz ME, Slutsky DJ, eds. Principles of
Hand Surgery and Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:100–116.)
Scapholunate
normal
∝ = 46° (30° to 60°)
DISI
∝ > 60°
LISA
VISI
∝ > 30°
FIGURE 25.2 Scapholunate angle. (Fig. 4.5, from Rosewasser MP, Zeltser DW. Carpal instability. FIGURE 25.3 Lateral intrascaphoid angle
In: Trumble TE, Rayan GM, Budoff JE, Baratz ME, Slutsky DJ, eds. Principles of Hand Surgery and (LISA). Yellow: outline of scaphoid. Red: per-
Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:70–99.) pendicular lines to each pole of the scaphoid.
Contraindications
• There are few true contraindications for surgery in displaced scaphoid fractures.
• Highly comorbid patients or patients with active hemodynamic compromise or systemic
infections should have medical issues managed before considering operative treatment.
• A strong patient preference for nonoperative treatment, particularly for nondisplaced
fractures, warrants an appropriate period of immobilization and close observation.
• History usually includes a fall onto an outstretched hand in a patient younger than
40 years of age (Fig. 25.4).
• The injury may also occur in the context of a high energy trauma with perilunate
dislocation.
CHAPTER 25 Open Reduction and Internal Fixation of Acute Scaphoid Fracture 133
FIGURE 25.4 Mechanism of scaphoid fracture. (Fig. 69.47, from Azar FM, Beaty JH, Canale ST, eds.
Campbell’s Operative Orthopaedics. 2017:3478–3575.e10.)
Abductor pollicis
longus
Extensor pollicis
brevis
Extensor pollicis
longus
Anatomic snuff box
FIGURE 25.5 Anatomic “snuff box.” (Fig. 7.99, from Magee DJ. Orthopedic Physical Assessment. FIGURE 25.6 Palpation of the scaphoid tubercle
6th ed. Saunders: 2014: 429–507.) for tenderness.
• The classic mechanism is an axial load onto an extended and ulnarly deviated wrist.
• The combination of snuff-box tenderness, scaphoid tubercle tenderness, and pain
with axial compression of the wrist is highly characteristic of a scaphoid fracture
(Figs. 25.5 and 25.6).
IMAGING
• The initial x-ray series should include standard posteroanterior (PA), oblique, and
lateral wrist x-rays (Fig. 25.7A–C) and a scaphoid view (see Fig. 25.7D).
• The scaphoid view brings the plane of the scaphoid from a flexed to a neutral posi-
tion through ulnar deviation at the wrist to better visualize the entire bone.
• Additional views that can be considered include a clenched fist PA, which increases
the axial load across the wrist and may make the fracture more apparent, and a
pronated oblique view.
• The incidence of false-negative plain x-ray diagnosis of acute scaphoid fracture is
10% to 30%. When initial x-rays are negative and there is a strong clinical suspicion
for scaphoid fracture, several diagnostic strategies can be used:
• The traditional approach has been to immobilize the patient in a thumb spica
splint and repeat x-rays in 2 weeks when the fracture line is more radiolucent.
A B C D
FIGURE 25.7 Radiographs demonstrating a fracture of the scaphoid waist: (A) posteroanterior [PA], (B) pronated oblique, (C) lateral, and
(D) scaphoid view.
This strategy has been found to be less cost-effective than immediate magnetic
resonance imaging (MRI) or computed tomography (CT), but it is still preferred in
many centers.
• MRI is the most cost-effective, sensitive, and specific imaging modality for iden-
tifying acute scaphoid fractures. Cortical disruption in the presence of bone mar-
row edema is diagnostic (Fig. 25.8). MRI is also useful for determining vascularity
when the timing of the injury is unknown and avascular necrosis is suspected.
• CT can diagnose occult scaphoid fractures when MRI is not available. CT dem-
onstrates excellent bony detail for preoperative planning but is less sensitive and
specific than MRI and exposes the patient to radiation.
SURGICAL ANATOMY
• Eighty percent of the scaphoid is covered by articular cartilage, leaving limited space
for the entrance of an arterial supply.
• The axis of the scaphoid lies 45 degrees radial to the axis of the wrist.
• Because it is the largest bone in the proximal carpal row, the scaphoid articulates
with the trapezium, trapezoid, capitate, lunate, and radius and serves as a mechan-
ical link between the proximal and distal carpal rows.
• Although there are multiple intrinsic and extrinsic ligaments that attach to the scaph-
oid, the scapholunate ligament is the most important intrinsic ligament, providing
stability and linking the bones of the proximal row. The most important extrinsic
FIGURE 25.8 Magnetic resonance imaging (MRI)
demonstrating an occult fracture of the
ligament is the radioscaphocapitate (RSC) ligament, which acts as a fulcrum for
scaphoid. rotation along the midaxis of the scaphoid (Fig. 25.9).
• Dorsally, the proximal pole of the scaphoid is relatively immobile because it is sur-
rounded by the dorsal rim of the radius, RSC ligament, long radiolunate ligament
(LRL) and scapholunate interosseous ligament (SLIL). On the other hand, the distal
pole of the scaphoid, located volarly, is mobile and susceptible to fracture at the
waist when subjected to an axial load.
• The dorsal groove courses the length of the scaphoid and provides attachment sur-
faces for ligaments and blood vessels. The dorsal blood supply (branch of the radial
artery), which delivers 70% to 80% of the blood supply, courses from distal to proximal
through the bone. Occasionally, there is a partial volar contribution to this blood supply.
• A palmar branch of the radial artery supplies the scaphoid tubercle, accounting for
20% to 30% of the scaphoid blood supply.
• Because of the distal-to-proximal course of the blood supply, proximal fractures
take longer to heal than distal fractures.
• This also explains why the scaphoid is at higher risk for avascular necrosis in proxi-
mal fractures (Fig. 25.10). Once avascular necrosis has developed, there is a high
likelihood of nonunion.
Trapezium
Capitate
Scaphoid
Scapholunate ligament
Radioscaphocapitate
Long radiolunate ligament ligament
Radiolunate ligament
Radius
FIGURE 25.9 Ligamentous anatomy of the scaphoid.
Dorsal carpal
branch
Superficial palmar
branch
Radial artery
EXPOSURES PEARLS
• Using the dorsal approach, the starting point is
Dorsal Volar
relatively easy to find and there are no other
FIGURE 25.10 Vascular anatomy of the scaphoid. carpal bones obstructing the long axis of the
scaphoid. With the volar approach, one must
navigate the trapezium to obtain the perfect
trajectory.
POSITIONING AND EQUIPMENT • For proximal pole fractures, the dorsal ap-
• A rolled towel can aid in flexion or extension of the wrist to achieve a central screw proach is preferred to facilitate capture of the
trajectory perpendicular to the fracture site. proximal fragment with the threads of the
headless compression screw.
• The wrist should be flexed as much as possible when performing fixation through a
dorsal approach and extended when using a volar approach.
EXPOSURES PITFALLS
DORSAL APPROACH • The dense fibers of the SLIL should be clearly
identified and dissected from the dorsal wrist
Exposure capsule to avoid inadvertent injury.
• A percutaneous approach can be used to stabilize nondisplaced scaphoid fractures. • Preservation of the soft tissue attachments
It carries an increased risk of tendon or nerve injury and should not be used unless along the dorsal ridge at the scaphoid waist
will ensure that the blood supply remains
the surgeon is particularly familiar with this approach. Percutaneous techniques are
intact.
not recommended for displaced fractures, which require an anatomic reduction.
FIGURE 25.11 Dorsal skin incision.

FIGURE 25.12 Identification of the fracture site.
• Under tourniquet control, a 6-cm dorsal incision is made ulnar to Lister tubercle
(Fig. 25.11). A no. 15 blade is used to incise skin and subcutaneous tissue, expos-
STEP 1 PEARLS ing the extensor retinaculum.
• Dissection is continued in the interval between the third and fourth extensor com-
• With scaphoid waist fractures, the distal frag-
ment often needs to be extended and supi- partments, and the dorsal wrist capsule is identified deep to the interval.
nated to obtain anatomic reduction. • The plane between the dorsal wrist capsule and the SLIL is developed.
• A temporary 0.045-in (1.14-mm) K-wire can • The dorsal surface of the scaphoid is sharply dissected, separating the bone from
be used for provisional fixation. It should be the loose capsular attachments.
placed dorsoradially to avoid interfering with
• The fracture can be identified by the presence of hematoma or early callus formation,
placement of the definitive fixation construct.
depending on its chronicity. A Freer elevator is passed into the fracture gap.
• Debridement of fracture site is performed as necessary using a dental pick, rongeur,
STEP 1 PITFALLS or small bone curette if callus is present (Fig. 25.12).
• Carefully examine all fluoroscopic views to en-
sure anatomic reduction. Step 1: Reduction and Provisional Stabilization of the Scaphoid
• If placing a joystick K-wire radially, be aware of • If the fracture is displaced, a 0.062-in (1.57-mm) joystick Kirschner wire (K-wire) can
the position of the radial artery as it courses
be inserted into each fragment to facilitate reduction (Fig. 25.13).
dorsally through the anatomic snuff box.
• Fracture reduction is confirmed visually and radiographically.
Step 2: Guidewire Placement

• After confirming anatomic reduction and trajectory of the guidewire, advance the
guidewire along the long axis of the scaphoid.
• The entry point of the guidewire should be confirmed by fluoroscopy. Once con-
firmed, the guidewire is advanced by a few millimeters and the trajectory is verified
by fluoroscopy again. This avoids multiple passes of the guidewire into the scaphoid.
• Ensure that the tip is in the distal subchondral bone. The manufacturer’s depth
gauge is placed over the wire to measure screw length (Fig. 25.14). To ensure that
the entire screw is buried within the bone, 4 mm should be subtracted from the
depth gauge measurement.
FIGURE 25.13 Intraoperative fluoroscopic image of

fracture reduction with Kirschner wires (K-wires).
Step 3: Drilling the Scaphoid STEP 2 PEARLS

• The provisional K-wire will help counteract rotational forces during drilling that could
• An imperfect guidewire can be left in place and
result in lost reduction. used as a reference for placement of a new wire.
• Drilling should be performed using a hand reamer. A power drill is not recommended • Multiple attempts at passing the wire will cre-
because it is difficult to control the trajectory of the drill over the guidewire and this ate several pathways through the bone, mak-
may lead to breaking the guidewire. ing it challenging to direct the wire correctly
along the long axis of the scaphoid.
• Assessment under fluoroscopy will ensure that drilling is carried down to the subchondral
bone of the distal fragment and that the path of the guidewire is maintained (Fig. 25.15).
Step 4: Compression Screw Placement

• The guidewire is advanced to capture the trapezium so that the wire does not come
loose after drilling. An appropriately sized headless compression screw is placed
under direct visual and fluoroscopic guidance (Fig. 25.16A–B).
• The provisional K-wire is removed or, rarely, cut at the cartilage surface to provide
additional stability during bony healing.
VOLAR APPROACH
Exposure
• The scaphoid is exposed via a curvilinear or chevron wrist incision. This incision
extends from the radial aspect of the thenar eminence, across the wrist, and parallel
and radial to the flexor carpi radialis (FCR) tendon (Fig. 25.17A–B).
FIGURE 25.14 Intraoperative depth gauge

measurement.
STEP 3 PEARLS
Holding the reduction during drilling is essential
and can be aided using the joystick K-wires. This is
particularly important in young patients with dense
bone.
STEP 3 PITFALLS
FIGURE 25.15 Intraoperative fluoroscopic image of drilling over a guidewire.
Headless screws with guidewires of less than
0.045-in (1.14-mm) are particularly susceptible to
shearing if drilling is not performed collinear with
the guidewire. Verify constantly with fluoroscopy.
STEP 4 PITFALLS
Advancing the screw can cause distraction at the
fracture site if the reduction is not stabilized or the
drill holes are not aligned as the screw is driven
across the fracture site.
EXPOSURE PEARLS
• Care is taken to identify and avoid the FCR
tendon.
• The LRL and a portion of the RSC ligament
should be preserved to stabilize the proximal
pole of the scaphoid and maintain reduction.
B
FIGURE 25.16 (A–B) Intraoperative fluoroscopic images of antegrade compression screw.

Flexor Flexor
carpi carpi
radialis radialis
A B
FIGURE 25.17 (A) Volar incision and (B) interval adjacent to flexor carpi radialis FIGURE 25.18 Identification of scaphoid fracture
for exposure of the scaphoid. through the volar approach.
• A no. 15 blade is used to dissect sharply to the level of the wrist capsule.
• The FCR sheath is opened longitudinally and the FCR is retracted ulnarly.
• The RSC ligament and LRL are incised, and the joint capsule is entered, exposing
the scaphoid.
• The fracture site can be identified by passing a periosteal elevator between the
proximal and distal fragments (Fig. 25.18).
• Fluoroscopy is used to confirm the fracture site.
• In the acute setting, minimal debridement is needed. A curette or rongeur can be
used to debride any callus or hematoma.
STEP 1 PEARLS Step 1: Reduction and Provisional Stabilization of the Scaphoid

A second 0.045-in (1.14-mm) K-wire can be • Once the fracture site is debrided and the distal scaphoid pole can be mobilized,
placed into the proximal fracture fragment and manual reduction is performed. The reduction is verified under fluoroscopy.
used as a joystick to aid in reduction (Fig. 25.20).
• While maintaining the reduction, a 0.045-in (1.14-mm) K-wire is inserted from distal
to proximal for provisional stabilization.
• It is important to start this wire slightly radial to the long axis of the scaphoid to avoid
interference with final screw placement (Fig. 25.19).
Joystick K-wire
Provisional
K-wire S
FIGURE 25.19 Stabilization of the scaphoid fracture FIGURE 25.20 Intraoperative photograph of Kirschner wire (K-wire)
with a provisional Kirschner wire (K-wire). assisted reduction.
STEP 2 PEARLS
• The trapezium often obscures the ideal entry
point into the scaphoid when using the volar
approach. Wrist extension and ulnar deviation
helps to move the trapezium out of the way
when inserting the guidewire.
• It may be necessary to trim a portion of the tra-
pezium to direct the K-wire along the desired
trajectory. This can be performed with a rongeur.
• An alternative technique is to direct the guide-
wire through the trapezium and into the
scaphoid along its desired trajectory. We typi-
cally do not disturb the trapezium in the volar
approach but attempt to place the screw as
central to the scaphoid as possible.
A B
STEP 3 PEARLS
FIGURE 25.21 (A–B) Intraoperative fluoroscopic image of retrograde guidewire.
• The K-wire must be in perfect position before
estimating the screw length. To ensure an ac-
curate estimate of length, there should not be
Step 2: Guidewire Placement any tissue between the guide and the distal
• With the provisional K-wire in place, the guidewire for the definitive screw is directed pole of the scaphoid.
from the distal scaphoid tubercle to the proximal ulnar corner of the scaphoid. • Fluoroscopy is used to confirm that the scaph-
• The desired trajectory for the definitive screw is typically central and in line with the oid has been drilled up to the proximal sub-
chondral bone.
long axis of the scaphoid to maximize length of the screw construct and to minimize
trauma to the scaphoid blood supply. Ideally, the screw trajectory should be as per-
pendicular as possible to the fracture line, which may not be possible in some frac- STEP 3 PITFALLS
ture patterns. Placement of the guidewire should be confirmed under fluoroscopy. • If the guidewire has been inserted through the
trapezium to obtain the desired trajectory within
Step 3: Drilling the Scaphoid the scaphoid, screw length must be estimated
• Before drilling, the manufacturer’s depth gauge is placed over the wire to measure using indirect means and may be inaccurate.
• If the guidewire has been inserted through the
screw length. To ensure that the entire screw is buried within the bone, 4 mm should
trapezium, it is crucial that the drill used is of
be subtracted from the depth gauge measurement. the same diameter as the screw head of the fi-
• After radiographic confirmation of trajectory, the guidewire is advanced into the nal implant. If the screw head is larger than the
distal radius to prevent the guidewire from pulling out and maintain the path of the drill, it will not advance through the trapezium.
drill when the scaphoid is drilled from distal to proximal (Fig. 25.21A–B).
STEP 4 PEARLS
Step 4: Compression Screw Placement
The patient’s wrist should be taken through a full range
• An appropriately sized screw is placed over the guidewire (Fig. 25.22A–B).
of motion to confirm that the screw is extraarticular.
• Screw placement, entirely within the bone, is confirmed radiographically and the
guidewire is removed. The provisional K-wire is removed (Fig. 25.23A–B).
POSTOPERATIVE CARE AND EXPECTED OUTCOMES Particularly for patients with risk factors for
• The patient is placed into a thumb spica splint. At 2 weeks postoperatively, the splint nonunion, it may be desirable to obtain a CT scan
to confirm fracture healing. Osseous bridging of at
is removed for wound check and suture removal. least 50% of the fracture site is typically considered
sufficient to wean immobilization.
A B
FIGURE 25.22 (A) Intraoperative and (B) fluoroscopic images of retrograde drilling of the scaphoid.
A B
FIGURE 25.23 (A–B) Postoperative radiographs of a retrograde compression screw.
A B
• A potential pitfall of the dorsal approach is
scarring on the dorsal wrist, and patients may
experience a decrease in wrist flexion com- C D
pared with the contralateral side.
• Proximal pole fractures may take up to 3 months FIGURE 25.24 (A–D) Postoperative photos of dorsal and lateral hand.
to heal. Patients should be instructed to protect
the wrist until that time.
• Scaphoid malunion is associated with increased • The patient is subsequently placed into a thumb spica cast and seen at 2- to 4-week
radioscaphoid contact area and early arthritis, intervals until healing is confirmed radiographically.
but the long-term clinical consequences are • At 24 months’ follow-up (Fig. 25.24A–D), the patient demonstrates range of motion
unknown.
and radiographic evidence of healing after dorsal screw placement.
See Video 25.1: Open Reduction and Internal Fixation of Acute Scaphoid Fracture Using
a Dorsal Approach, on Expertconsult.Com.
EVIDENCE
Chambers SB, Padmore CE, Grewak R, et al. The impact of scaphoid malunion on radioscaphoid joint
contact: A computational analysis. J Hand Surg Am. 2020;45(7):610–618.
This anatomic study investigated the biomechanical effects of scaphoid malunion with a computational
analysis of 6 cadaveric scaphoid specimens. Scaphoid waist fractures with 2 mm of bone loss and
various increments of angular deformity were simulated in the specimens. Angular deformities of
15 degrees or greater correlated significantly with increases in radioscaphoid joint contact area and
ulnar translation of the center of the contact area.
Daly CA, Boden AL, Hutton WC, et al. Biomechanical strength of retrograde fixation in proximal third
scaphoid fractures. Hand (N.Y.). 2019;14(6):760–764.
This biomechanical study compared fracture fixation strength between antegrade and retrograde
compression screw techniques in scaphoid proximal pole fractures. Twenty-two matched cadaveric
scaphoid specimens with proximal pole fractures were stabilized with variable pitch compression
screws. There were no significant differences in screw length needed, load to failure, cycles to
failure, or number of catastrophic failures between the antegrade and retrograde constructs.
Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical
fracture of the scaphoid waist (SWIFFT): A pragmatic, multicentre, open-label, randomised superior-
ity trial. Lancet. 2020;396(10248):390–401.
This randomized controlled trial involving 439 patients and 31 hospitals is the largest to date to com-
pare operative and nonoperative management of scaphoid waist fractures. Patients with fractures
displaced by equal to or greater than 2 mm were assigned to early operative management with a
compression screw or nonoperative management in a below-elbow cast. Patients managed nonoper-
atively who showed evidence of nonunion between 6 to 12 weeks of follow-up promptly underwent
surgical fixation. By 12 weeks after injury, there were no significant differences between the groups in
terms of patient-reported outcomes, pain, range of motion, or grip strength. By final follow-up at
1 year, the number of nonunions and days of lost productivity did not differ significantly between
groups. The number of potentially serious complications was significantly higher in the operative
group (14%) compared with the nonoperative group (1%). This practice-changing study provides
strong evidence for nonoperative management of scaphoid waist fractures displaced by less than or
equal to 2 mm.
Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: A cost-effectiveness analysis.
J Bone Joint Surg Am. 2015;97(22):1860–1868.
This cost-effectiveness study used decision analysis to compare three management strategies for sus-
pected scaphoid fractures in the setting of initially negative radiographs. The three strategies simu-
lated were (1) casting with repeat radiographs in 2 weeks, (2) immediate CT, and (3) immediate MRI.
The prevalence of occult scaphoid fractures and costs of investigations, lost productivity and surgery
were extrapolated from the literature. When factoring in the costs of lost productivity owing to immo-
bilization, and long-term costs of missed fractures, symptomatic nonunion and additional surgeries,
both advanced imaging strategies were found to be substantially less costly with better long-term
outcomes than empiric immobilization. MRI was slightly more cost-effective than CT because of its
superior diagnostic sensitivity and specificity.
Morsy M, Sabbagh MD, van Alphen NA, et al. The vascular anatomy of the scaphoid: New discoveries
using micro-computed tomography imaging. J Hand Surg Am. 2019;44(11):928–938.
This anatomic study investigated the vascular anatomy of the scaphoid in 13 cadaveric specimens
using micro-CT. Retrograde blood flow entering the scaphoid at the dorsal ridge was the dominant
vascular network, accounting for 83% of the blood supply, whereas a secondary network of vessels
entering the scaphoid volarly at the tubercle supplied the remainder of the bone in most specimens.
Using 3D-printed renderings of each bone, it was extrapolated that a screw placed along the central
axis of the scaphoid was least disruptive to the internal blood supply (14.5% disruption), followed by
a dorsal/antegrade axis screw (16.3%), long axis screw (17.0%), and volar/retrograde axis screw
(24.3%). Two distinct scaphoid phenotypes were found, with slender scaphoids being more
vulnerable to disruption of the vasculature by screw fixation.
CHAPTER 26
Treatment of Scaphoid Nonunion
Treatment of Scaphoid Nonunion

INDICATIONS
• Operative treatment of scaphoid nonunion varies based on the timing of the injury,
bone loss at the fracture site, location of the fracture, presence of humpback defor-
mity or an increased intrascaphoid angle, and the vascularity of the proximal pole.
• Humpback deformity results from collapse of the distal pole of the scaphoid. Normal
intrascaphoid angle is 30 degrees plus or minus 5 degrees. Humpback deformity is
present when the intrascaphoid angle measured on lateral x-ray or computed to-
mography (CT) scan is greater than 35 degrees (Fig. 26.1).
• Table 26.1 highlights our treatment algorithm for scaphoid nonunion based on spe-
cific fracture characteristics.
Contraindications
Signs of radiocarpal or intercarpal arthritis, especially patterns indicative of scaphoid
nonunion advanced collapse (SNAC; Fig. 26.2 and Table 26.2), often confirm that re-
pair/reconstruction are no longer options and salvage should be considered.
• The distal pole of the scaphoid may be tender to palpation, and axial compression
of the thumb may reproduce the pain.
• Nagging wrist pain or tenderness in the snuff box months after an injury may indicate
a scaphoid fracture that has progressed to a nonunion.
• Decreased wrist motion and grip strength are common findings in patients with a
scaphoid nonunion.
• If a patient continues to have radial-sided wrist pain with tenderness over the scaph-
oid in the anatomic snuff box despite prior treatment, this may reveal progression to
nonunion.
> 35°
30°
+/– 5
FIGURE 26.1 Intrascaphoid angle.
142
TABLE Treatment Algorithm for Scaphoid Nonunion Based on Specific

26.1 Fracture
Type of Fracture Treatment
Delayed union (, 6 months) Open reduction and internal fixation with
headless compression screw
Established nonunion without humpback Open reduction and internal fixation with head-
deformity less compression screw 1 bone graft (distal
radius, iliac crest cancellous bone graft)
Nonunion with humpback deformity but Open reduction via volar approach, corticocan-
no evidence of avascular necrosis cellous bone graft
Avascular nonunion without humpback Vascularized bone graft, dorsal or volar
deformity approach
Avascular nonunion with humpback Vascularized medial femoral condyle bone
deformity graft via volar approach
Stage I Stage II Stage III Stage IV
C
Nonunion
S
SNAC L
Radius
Radial styloid OA Stage I+Scaphocapitate OA Stage II+Lunocapitate OA Stage III+Radiolunate OA
Increased SL gap
SLAC
Radial styloid OA Stage I+Proximal Stage II+ Stage III+Radiolunate OA

radioscaphoid OA Scaphocapitate/Lunocapitate OA
FIGURE 26.2 Scaphoid nonunion advanced collapse (SNAC).
IMAGING
• A standard three-view wrist x-ray should be obtained. If present, the nonunion is TABLE Stages of Scaphoid Nonunion
often apparent (Fig. 26.3). 26.2 Advanced Collapse
• Bone loss, cyst formation, and degree of displacement should be noted. Stage Sites of Osteoarthritis
• Use the lateral view to approximate the lateral intrascaphoid angle to assess for col-
1 Radial styloid
lapse (Fig. 26.4; see also Fig. 26.1).
• Evaluate for signs of SNAC wrist (posteroanterior [PA] view) and abnormal scaph- 2 Stage 1 & Scaphocapitate
olunate angle (lateral view; see Table 26.2). 3 Stage 2 & Lunocapitate
• X-rays may show previously placed hardware.
4 Stage 3 & Radiolunate
• CT and magnetic resonance imaging (MRI) can be useful adjuncts to clinical exami-
nation and standard x-ray. Humpback deformity, joint incongruity, and structure of
the proximal pole are best appreciated on CT scan. MRI may be used to assess the
vascularity of the proximal pole, although there remains no diagnostic gold standard
for avascular necrosis (Fig. 26.5).
144 CHAPTER 26 Treatment of Scaphoid Nonunion
LISA
FIGURE 26.3 Three-view wrist x-ray. Arrow indicates site of scaphoid nonunion.
FIGURE 26.4 Lateral intrascaphoid angle (LISA).
FIGURE 26.5 Magnetic resonance imaging (MRI) assessment of proximal pole vascularity.
Ulna (Corticocancellous or Cancellous) Bone Graft

INDICATIONS
• Indications for ulna bone grafting:
• Established nonunion with or without humpback deformity
• No evidence of avascular necrosis of the proximal scaphoid pole
• Minimal cystic change, displacement, or carpal malalignment
Contraindications
Active smoking is a notable risk factor. We do not operate on patients who are current
smokers because of the high risk for nonunion. Urine cotinine testing is obtained to
clear a patient for surgery.
POSITIONING
Both the ulna donor site and scaphoid recipient site are prepped and draped into the
same operative field.
EXPOSURES
• The decision to use a volar or dorsal approach to the scaphoid is guided by the location
of the nonunion, the presence of humpback deformity, and the planned procedure.
• A proximal nonunion is treated via a dorsal approach for better exposure and for
the trailing screw head to purchase the proximal pole.
• The volar approach improves visualization of more distal fracture/nonunion locations.
• A notable humpback deformity is generally corrected via a volar approach.
FIGURE 26.6 Incision marking for volar approach.
A B
FIGURE 26.7 (A–B) Incision marking and exposure for dorsal approach.
• Recipient site:
• For the volar approach, the scaphoid is exposed via a curvilinear wrist incision.
This incision extends from the radial aspect of the thenar eminence, across the
wrist, parallel and radial to the flexor carpi radialis (FCR) tendon (Fig. 26.6).
• For a dorsal approach, a longitudinal or curved incision over the interval between
the third and fourth extensor compartments (use Lister tubercle as a landmark) is
used. Branches of the superficial radial nerve and the extensor pollicis longus
tendon must be protected during this approach.
• If using a corticocancellous graft, this incision can be somewhat limited
(Fig. 26.7A–B).
• If planning for vascularized bone options (see the section on “Pedicled Vascu-
larized Bone Graft From Dorsal Distal Radius [1,2 Intercompartmental Supra-
retinacular Artery]”), a wider approach is used.
• Donor site: A 5-cm longitudinal incision over the ulna, starting 1 cm distal to the
olecranon, is used to expose the flat portion of the proximal ulna in preparation for
bone graft harvest. The advantage of the proximal bone graft is that the exposure is
relatively avascular and the bone is easily accessible.
• Other graft sites (i.e., iliac crest) can also be used, but we prefer the ulna to keep
the procedure to one surgical limb.
SURGICAL ANATOMY
• The dominant blood supply to the scaphoid is via a branch from the radial artery that
enters through the dorsal ridge and supplies 70% to 80% of the intraosseous vas-
cularity to the proximal pole. This vessel and its branches enter distally and dorsally
and travel retrograde through the scaphoid (Fig. 26.8).
• The scaphoid proximal pole is uniquely susceptible to avascular necrosis after fracture
because of the high dependence on a dominant retrograde-traveling intraosseous vessel.
• A volar branch of the radial artery supplies 20% to 30% of the scaphoid in the region
of the distal tuberosity.
Dorsal carpal
branch
Superficial palmar
branch
Radial artery
Dorsal Volar
FIGURE 26.8 Blood supply to the scaphoid.
• Corticocancellous bone is harvested from the ulna, just proximal to the tip of the
olecranon. A 5-mm-wide by 10-mm-long by 5-mm-deep bone graft is usually all that
is needed for the scaphoid, but up to 20 mm by 30 mm by 10 mm can be harvested
as long as both cortices of the ulna are not violated.
PROCEDURE
STEP 1 PEARLS
The LRL and a portion of the RSC ligament should Step 1: Debridement of the Scaphoid
be preserved to stabilize the proximal pole of the
• The volar wrist incision is carried out through the skin and subcutaneous tissue. The
scaphoid and maintain reduction.
FCR is identified and protected.
• The radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments are incised,
and the joint capsule is entered, exposing the scaphoid.
• The nonunion site is identified by passing a periosteal elevator between the proximal
and distal fragments (Fig. 26.9). Fluoroscopy is used to confirm the nonunion site
(Fig. 26.10A–B).
• A curette or rongeur can be used to debride the scaphoid to healthy-appearing bone. Look
for punctate bleeding as one potential indicator of healthy bone. Necrotic bone is typically
whitish and hard, whereas the healthier bone has more of a porous, cancellous consistency.
Step 2: Ulna Bone Graft Harvest

• A 5-cm longitudinal incision, centered over the proximal ulna, is performed 1 cm
distal to the tip of the olecranon (Fig. 26.11).
FIGURE 26.9 Periosteal elevator identifies nonunion site.

Ulna periosteum
marked for bone
graft harvest
FIGURE 26.12 Marking the periosteum to plan harvest.
FIGURE 26.11 Incision marking

for ulnar graft harvest.
• The incision is continued to the level of the periosteum.

• The amount of bone necessary to bridge the gap in the scaphoid after debridement should
be estimated. This often is approximately 5 mm wide by 10 mm long by 5 mm deep.
• The flat portion of the ulna, near the tip of the olecranon, should be used for the bone
graft harvest.
• The template is measured and marked on the ulna (Fig. 26.12). The periosteum
overlying the graft is incised longitudinally and dissected carefully to facilitate reap-
B
proximation after graft removal.
• A 5-mm osteotome can be used to harvest the bone graft. FIGURE 26.10 (A–B) Fluoroscopy confirms non-
• To extricate the graft, a 45-degree osteotomy is performed, approximately 1 cm union site.
distal to the distal end of the graft. This will permit an osteotome to be introduced
at approximately 5 mm deep within the cancellous bone of the ulna. The graft can
STEP 2 PEARLS
be separated from the remaining cancellous bone by using a straight or curved os-
teotome (Fig. 26.13). Preserving periosteal flaps during the approach
to the bone graft harvest site will permit
reapproximation during closure.
Step 3: Fixation of the Graft
• If necessary, the graft is trimmed to fit within the gap in the scaphoid.
• The cortical portion of the graft is positioned along the volar cortex of the scaphoid
to resist compression.
FIGURE 26.13 Harvested bone graft.

A B C
FIGURE 26.14 (A) K-wire placed in scaphoid. (B–C) Fluoroscopy confirms Kirschner wire (K-wire) position.
STEP 3 PEARLS • With the graft in position, two 0.045-in (1.14-mm) Kirschner wires (K-wires) are used
• The wrist should be taken through range of to secure the graft.
motion (ROM) after placement of the K-wires/ • The K-wire enters the scaphoid along its distal tubercle and is directed through the
screw to ensure that the graft is secure. graft toward the proximal ulnar corner of the scaphoid (Fig. 26.14A).
• A second K-wire is directed collinearly to prevent rotation.
• The position of the K-wires should be confirmed fluoroscopically (see Fig. 26.14B–C).
• The K-wires are cut and buried under the skin for later removal.
STEP 4 PEARLS • If a cannulated screw is available, the screw can also be used for fixation. The
Because the skin overlying the olecranon is thin, initial K-wire should be the guidewire for the screw, and the screw, rather than
permanent suture material to close the periosteum K-wires, can then be used for internal fixation (Fig. 26.15).
should be avoided because the knots will be
palpable. Step 4: Closure
• The wrist capsule is closed using 3-0 Ethibond sutures.
• The periosteum of the elbow donor site is closed using 3-0 Vicryl suture.
• The skin is closed with either 4-0 Monocryl or 4-0 polydioxanone (PDS).
FIGURE 26.15 Kirschner wire (K-wire) serving as a guidewire for cannulated screw fixation.
Pedicled Vascularized Bone Graft From Dorsal Distal

Radius (1,2 Intercompartmental Supraretinacular Artery)
INDICATIONS
• Indications for pedicled vascularized bone graft:
• Established nonunion without humpback deformity
• If a humpback deformity is identified, a volar pedicled bone graft can be consid-
ered versus medial femoral condyle (MFC; see later section).
• Evidence of avascular necrosis of the proximal scaphoid pole
POSITIONING
• Both the distal radius donor site and scaphoid recipient site are prepped and draped
into the same operative field.
EXPOSURES EXPOSURES PEARLS
• A 6-cm curvilinear incision is designed over the dorsoradial wrist in preparation for Branches of the superficial radial nerve should be
identified and protected.
scaphoid debridement and bone graft harvest (Fig. 26.16).
SURGICAL ANATOMY
• Donor site: The vessels on the dorsal surface of the distal radius are described
based on their relationship to the dorsal extensor compartments. The 1,2 intercom-
partmental, supraretinacular artery (1,2 ICSRA) lies between the first and second
dorsal compartments, superficial to the extensor retinaculum, where it is closely
adherent to the radius (Fig. 26.17A–B).
• The 1,2 ICSRA branches from the radial artery approximately 5 mm proximal to the FIGURE 26.16 Curvilinear incision marking for
dorsal approach.
radiocarpal joint.
PROCEDURE
STEP 1 PEARLS
Step 1: Debridement of the Scaphoid Joystick 0.045-in (1.14-mm) K-wires can be
• The dorsal curvilinear incision is made. Dissect down to the extensor tendons/reti- placed within the proximal and distal scaphoid to
distract the nonunion site and aid in debridement
naculum. (Fig. 26.20).
• An incision between the second and fourth dorsal compartment tendons is used to
expose the wrist capsule directly overlying the scaphoid. Identify the extensor pollicis
longus tendon as it comes around the Lister tubercle and heads radially. Mobilize it
radially to keep it out of the surgical field.
• The tendons of the second and fourth compartments are identified and retracted,
radially and ulnarly.
• The dorsal wrist capsule is incised longitudinally, and the scaphoid nonunion site is
identified (Fig. 26.18). A periosteal elevator is passed into the nonunion site.
• Fluoroscopy can be used to confirm the position of the nonunion site (Fig. 26.19).
• A curette or rongeur is used to debride the scaphoid to healthy-appearing bone.
A B
1,2 ICSRA
FIGURE 26.17 (A–B) Exposure and identification of the 1,2 intercompartmental supraretinacular ar-
tery (1,2 ICSRA).
Nonunion site
FIGURE 26.18 Identification of the scaphoid nonunion site.

FIGURE 26.19 Fluoroscopy confirms position of
nonunion site.
Step 2: Bone Graft Harvest

• The 1,2 ICSRA is identified and protected. Its periosteal attachments are seen
approximately 10 to 15 mm proximal to the radiocarpal joint.
• A template from the scaphoid bone gap is transposed to the distal radius, centered
around the 1,2 ICSRA.
• A #15 blade is used to incise the periosteum in preparation for osteotomy.
• A 5-mm osteotome is used to harvest the bone from the distal radius. A curved
osteotome can be used to complete the harvest at a depth of approximately 5 mm.
• The pedicle and flap are dissected from proximal to distal, to the level of the radio-
carpal joint, where the pedicle bifurcates from the radial artery. This permits ade-
quate rotation into the scaphoid defect (Fig. 26.21).
FIGURE 26.20 Kirschner wires (K-wires) used to
distract the nonunion site. Step 3: Tunneling the Graft
• While avoiding tension on the pedicle or disruption of the periosteum, the bone flap
is tunneled under the extensor tendons and placed into the scaphoid bony defect.
• It is often necessary to trim the bone graft to permit correct placement (Fig. 26.22).
• The cortical portion of the graft is positioned dorsally or radially to resist compression.

• After confirming the position of the graft visually and fluoroscopically, the bone is
secured using two 0.045-in (1.14-mm) K-wires (Fig. 26.23A–B).
1,2 ICSRA Graft
• Before insetting the bone, cancellous bone is harvested from the radius to pack into
FIGURE 26.21 Dissection of the flap and pedicle. the void in the excavated distal and proximal poles of the scaphoid.
• The first K-wire can be driven from the proximal ulnar corner of the scaphoid and
directly along its long axis toward the distal pole.
STEP 2 PEARLS
• If a cannulated screw is available, this K-wire should be the guidewire for the screw.
• Care is taken to ensure that the periosteum
remains adherent to the underlying bone graft.
Disruption of the periosteum will limit or elimi-
nate blood flow.
• Flow to the bone graft can be confirmed by
deflating the tourniquet. Nevertheless, we
generally do not deflate the tourniquet to
visualize bleeding of the bone graft, given that
this procedure is not reversible after harvest.
Therefore great care must be taken to not
disrupt the pedicle and the periosteum on
the bone, particularly during inset.
STEP 4 PEARLS
The wrist should be taken through ROM after EPL
placement of the K-wires, with direct visualization
of the inset flap to ensure that it is secure. FIGURE 26.22 Graft is tunneled under extensor tendons and placed into bony defect. EPL, Extensor
pollicis longus.
A B
FIGURE 26.23 (A–B) Kirschner wire (K-wire) fixation of the graft under fluoroscopy.
• A second K-wire is used to prevent rotation of the graft. This can be placed collinear
to the first K-wire.
• If being used as the primary modality for fixation (no screw available), the K-wires
are cut and buried under the skin for later removal.
Step 5: Closure
• The wrist capsule is closed using 3-0 Ethibond sutures.
• The skin is closed with either 4-0 Monocryl or 4-0 PDS.
Pedicled Vascularized Bone Graft From Volar Distal Radius

INDICATIONS
• Indications for volar pedicled vascularized bone graft (flap):
• Established nonunion with humpback deformity benefiting from volar approach
to correct the deformity.
• The volar approach is used to add structural bone to the volar cortex that has
collapsed and foreshortened.
• The bone graft harvest from the volar cortex of the radius has its structure and
vascularity supported by the pronator quadratus muscle.
• Evidence of avascular necrosis of the proximal scaphoid pole.
POSITIONING EXPOSURES PEARLS

Both the distal radius donor site and scaphoid recipient site are in the same operative field. Step-cut of the RSC ligament (rather than
longitudinal split) may facilitate repair/closure after
EXPOSURES the flap is mobilized into the wrist.
A 6-cm L-shaped incision is designed over the volar wrist/FCR in preparation for
scaphoid debridement and bone graft harvest (Fig. 26.24).
SURGICAL ANATOMY
• Donor site: The volar carpal artery runs along the volar aspect of the carpus from
radial artery to ulnar artery.
• Around 98% of the time, the connection from the radial artery is dominant.
• Harvest site for flaps using the volar carpal artery are adjusted based on which
side is dominant (Fig. 26.25).
• Another option is to use a segment of the pronator quadratus as the vascular supply;
for this procedure, the bone is harvested from the radial styloid base (Fig. 26.26). FIGURE 26.24 Incision marking for volar
approach.
PROCEDURE
Step 1: Debridement of the Scaphoid
• The volar incision is carried out over the scaphoid distally and radius proximally.
• The FCR is identified and protected.
Ulnar artery
Radial artery
Volar carpal
artery
A B
FIGURE 26.25 (A-B) Volar carpal artery can receive dominant blood supply from radial or ulnar artery. From
Elzinga K, Chung KC. Volar radius vascularized bone flaps for the treatment of scaphoid nonunion. Hand Clin.
2019;35(3):353–363.
Distal pronator
quadratus contributes
vascular supply to flap
FIGURE 26.26 Pronator quadratus can provide vascular supply for volar approach. From Elzinga K,
Chung KC. Volar radius vascularized bone flaps for the treatment of scaphoid nonunion. Hand Clin.
2019;35(3):353–363.
STEP 1 PEARLS
Joystick 0.045-in (1.14-mm) K-wires can be
• The RSC and LRL ligaments are incised, and the joint capsule is entered, exposing
placed within the proximal and distal scaphoid to
distract the nonunion site and aid in debridement. the scaphoid.
• Consider step-cut for the RSC to facilitate closure.
• The nonunion site is identified by passing a periosteal elevator between the proximal
and distal fragments.
• If there is a notable humpback deformity, this must be corrected and confirmed with
fluoroscopy.
Step 2: Bone Harvest

• Decide on which volar flap to use; the leash on the pronator quadratus flap tends to
be more limited than the volar carpal artery flap, but both are usually viable options.
• If using a volar carpal artery flap, the artery is identified just distal to the margin
of the pronator quadratus.
• Mobilizing the most distal edge of the muscle proximally will help with exposure.
• Identify which side of the artery appears dominant to decide which segment
of bone to harvest.
FIGURE 26.27 Marking the bone harvest site and segment of the pronator quadratus.
• If using the pronator quadratus flap, identify alignment of the oblique fibers to
guide the muscle split.
• Mark the bone harvest site and associated muscle (Fig. 26.27).
• Bone harvest site is radial, proximal to the styloid tip, and volar to the abduc-
tor pollicis longus tendon.
• A template from the scaphoid bone gap is transposed to the distal radius at the
desired bone flap harvest site.
• A #15 blade is used to incise the periosteum in preparation for osteotomy.
• If using the volar carpal artery, a vascular clip may be needed for proper hemo-
stasis of the segment not being used for the flap.
• A 5-mm osteotome is used to harvest the bone flap/graft from the distal radius. A
curved osteotome can be used to complete the harvest at a depth of approximately
5 mm.
• The pedicle and flap are dissected as needed to allow for proper rotation. Cuts in
the periosteum, especially around the branching site of the volar carpal artery, may
be needed to optimize mobilization.
Step 3: Mobilize and Transpose the Bone

• While avoiding tension on the pedicle or disruption of the periosteum, the bone flap
is mobilized distally and placed into the scaphoid bony defect (Fig. 26.28).
• It is often necessary to trim the bone to permit correct placement.
• The cortical portion of the graft is positioned volarly to resist compression and add
structure to the scaphoid.

This step was explained previously.
FIGURE 26.28 Mobilizing the bone graft distally into the scaphoid nonunion site.
Free Vascularized Medial Femoral Condyle

INDICATIONS
• Indications for free MFC vascularized bone graft/flap:
• Established nonunion with humpback deformity
• Evidence of avascular necrosis of the proximal scaphoid pole
• Presence of scaphoid nonunion with a history of a failed nonvascularized bone graft
• If no intrascaphoid collapse is present (humpback deformity), vascularized bone grafting
can be attempted through a dorsal approach via a vascularized distal radius bone graft.
• A volar approach is necessary when humpback deformity is present. If the proximal
pole appears relatively well preserved and carpal alignment is not abnormal, a volar
pedicled vascularized graft from the distal radius (see previous section) is an alterna-
tive to the MFC.
SURGICAL ANATOMY
• Donor site:
• Proximal to the adductor hiatus, the superficial femoral artery gives off the de-
scending genicular artery. The descending genicular artery travels distally and
gives off saphenous and muscular branches. The superior medial genicular artery
arises from the superficial femoral artery more distally.
• The descending genicular artery and superior medial genicular artery continue
distally, penetrate the bone, and provide the blood supply to the medial femoral
condyle as intraosseous nutrient vessels.
• Blood supply to the medial femoral condyle skin flap is provided by the saphe-
nous branch of the descending genicular artery (Fig. 26.29).
POSITIONING
• The recipient site is prepared under tourniquet control of the upper extremity.
• The ipsilateral knee is maintained in slight flexion and abduction to access the me-
dial femoral condyle. A sterile tourniquet is placed on the thigh, near the groin
crease, in preparation for graft harvest.
EXPOSURES
• The scaphoid and radial arteries are exposed via a curvilinear volar wrist incision
extending from the radial aspect of the thenar eminence, across the wrist, parallel
and radial to the FCR tendon (Fig. 26.30).
Descending genicular
artery
Femur
Superficial femoral
artery
Saphenous branch
Tibia of descending
genicular artery
Medial collateral Superficial medial

ligament genicular artery
FIGURE 26.29 Vascular supply to the femoral condyle.
FIGURE 26.30 Volar wrist incision marking.
FIGURE 26.31 Incision marking for medial femoral condyle exposure.
• Exposure of the medial femoral condyle and its pedicle is achieved using an ap- EXPOSURES PEARLS
proximately 20-cm incision on the distal medial thigh, along the midaxis of the femur, This procedure can be performed with two teams
up to the joint line of the knee (Fig. 26.31). simultaneously.
TEAM 1: DONOR SITE (BONE GRAFT HARVEST)

STEP 3 PEARLS
Step 1: Identification of the Medial Thigh Structures
There is a bloodless, loose areolar plane between
The femur, patella, and femoral-tibial joint line of the ipsilateral lower medial thigh are
the VM and the descending genicular vascular
marked. The incision should be approximately 20 cm, centered on the midaxis of the pedicle.
femur starting from the femoral-tibial joint line. Wide exposure helps facilitate clean
dissection of the pedicle.
STEP 4 PEARLS
Step 2: Expose the Vastus Medialis The radial artery travels in close proximity to the
Skin, subcutaneous tissue, and the fascia of the vastus medialis (VM) are incised, volar scaphoid; therefore a long pedicle is often
exposing the underlying muscle (Fig. 26.32). unnecessary. Using a shorter pedicle can limit
dissection time.
Step 3: Anterior Elevation of the Vastus Medialis
The posterior border of the VM muscle is identified and elevation is carried out from
posterior to anterior, exposing the descending genicular vessels (Fig. 26.33).
Step 4: Mobilize the Pedicle

Identify the descending genicular artery and its periosteal extensions. After determining
the area on the medial femoral condyle that will be used for bone grafting, dissect the
pedicle proximally to obtain approximately 5 cm of length (Fig. 26.34).
Vastus medialis
Descending genicular artery
FIGURE 26.32 Exposure of vastus medialis. FIGURE 26.33 Exposure of descending genicular artery.
Descending genicular artery Harvest site
FIGURE 26.35 Harvested bone flap.
FIGURE 26.34 Descending genicular artery and harvest site.
STEP 5 PEARLS
Step 5: Design the Bone Flap Harvest
• The medial collateral ligament of the knee Based on the amount of scaphoid bone loss, a rectangular corticocancellous flap is
should be identified and protected.
• Because the avascular scaphoid often does not designed around the nutrient branches and periosteal extensions of the descending
have sufficient cortical bone strength to but- genicular artery. An approximately 5-mm-wide by 10-mm-long by 5-mm-deep cortico-
tress the bony defect, the bone graft must have cancellous segment is needed after debridement of the scaphoid (Fig. 26.35). Addi-
an adequate amount of cortical bone. The MFC tional cancellous bone graft can be harvested from the femur to pack around the
bone graft provides structure, not constrained vascularized graft.
by the pedicle length (unlike the radius pedicle
graft) and an abundance of vascularity, pro-
vided that the vascular anastomosis is patent, Step 6: Harvesting the Bone
which requires fine microsurgical expertise. • The markings on the periosteum are incised.
• A 5-mm osteotome is used to harvest the bone graft. To assist with final extrication
and to minimize the risk for fracture, a separate 45-degree osteotomy is performed
STEP 5 PITFALLS
just distal to the marked flap. This facilitates precise osteotomy of the deep margin
Excessive harvest of cancellous bone from the (Fig. 26.36).
femur risks weakening the bone to torsional forces;
avoid excess harvest of additional cancellous bone
after MFC flap harvest.
STEP 6 PEARLS
Meticulous dissection of the pedicle and of the
periosteum, proximal to the flap, will aid harvest.
FIGURE 26.36 Illustration of harvesting vascularized bone graft.

FIGURE 26.37 Closure of leg donor site.
Step 7: Ligation of the Vascular Pedicle STEP 1 PEARLS

• When adequate length has been confirmed, the proximal vascular pedicle is ligated, • Preserving much of the LRL and a portion of
and the graft is prepared for anastomosis at the wrist. the RSC ligament will help stabilize the proxi-
• Hemostasis is achieved, and the leg donor site is closed in layers over a closed suc- mal pole and maintain reduction.
tion drain (Fig. 26.37). • Volar capsulotomy of the scaphotrapezial joint
will improve visualization of the scaphoid
TEAM 2: PREPARATION OF THE RECIPIENT SITE (Fig. 26.38).
• Fluoroscopy is used to confirm the nonunion
Step 1: Exposure of the Scaphoid site.
• The incision is carried out along the radial border of the thenar eminence, across the
wrist and parallel to the FCR tendon.
• If the patient has had prior surgery, that scar may dictate the location of the
incision.
• The RSC and LRL are incised and the joint capsule is entered, exposing the scaphoid.
Step 2: Debridement of the Scaphoid Nonunion

• After careful exposure of the scaphoid, the nonunion is debrided back to healthy
bleeding bone of the distal pole. A small curette or rongeur is used for debridement
of fibrous tissue.
• The scaphoid articulations must be examined for the presence of arthritis. Careful
attention must be paid to the radioscaphoid and midcarpal joints. Care is taken
to not perforate the cortical shell of the proximal pole of the scaphoid during the FIGURE 26.38 Volar capsulotomy of the scapho-
debridement. trapezial joint to facilitate visualizing the scaphoid.
Step 3: Measurement of the Bony Defect STEP 2 PEARLS

After careful debridement, the size of the bony defect is measured and used as a tem- • Joystick 0.045-in (1.14-mm) K-wires can be
plate for bone flap harvest (Fig. 26.39). placed within the proximal and distal scaphoid
to distract the nonunion site and aid in de-
bridement.
• A slow-speed bur can be used to aid in de-
bridement; however, the scaphoid must be con-
tinuously irrigated to prevent further necrosis.
STEP 3 PEARLS
Bony defect
• Err on harvesting a slightly smaller bone flap
rather than one that is too large. This will per-
mit easier placement within the scaphoid recip-
ient site and reduce time spent on contouring
(and the risk for injury to the blood supply).
• Cancellous bone can be harvested from the
donor site to pack into the crevices of the
scaphoid defect. Time is often wasted on con-
touring a large bone graft when a slightly
smaller bone graft will fit more easily into the
scaphoid defect.
FIGURE 26.39 Size of bony defect determines size of bone flap harvest.
Step 4: Correction of the Dorsal Intercalated Segment Instability

Deformity
• Under fluoroscopic guidance, the dorsal intercalated segment instability (DISI) defor-
mity is corrected by flexing the wrist until the radiolunate angle is neutral (Fig. 26.40).
• A K-wire can be placed from the radius to the lunate to maintain the lunate in neutral
posture.
Step 5: Preparation of Recipient Vessels to Accept the Graft

• The radial artery is dissected radial to the FCR during initial exposure. Meticulous
Radiolunate dissection and identification of its venae comitantes should be performed.
angle (0–15°) • One end-to-end venous anastomosis will be performed to an associated vena
comitante. The most suitable recipient vessel is chosen based on size match.
• End-to-side anastomosis is performed to the radial artery.
Step 6: Fixation of the MFC

• The bone flap is contoured to fit into the scaphoid defect (Fig. 26.41A) and secured
using either buried K-wires (see Fig. 26.41B) or a headless compression screw.
• The benefit of K-wires is ease of placement. One K-wire should be directed along
the long axis of the scaphoid. The K-wire enters the scaphoid, centered on the dis-
tal pole, and is directed toward the proximal ulnar corner. An additional K-wire can
be placed collinearly to prevent rotation. Alternatively, K-wires can be directed
FIGURE 26.40 Dorsal intercalated segment in-
stability (DISI) deformity correction. obliquely to secure the graft.
• If available and the surgeon has familiarity with the hardware, a cannulated screw
STEP 6 PEARLS can provide excellent fixation. This has become the preferred option for many sur-
geons who perform this procedure.
The cortical surface of the graft is directed volarly
to resist compression and to correct the humpback • Reduction of the scaphoid and correction of the DISI deformity must be confirmed
deformity. during and after fixation.
Step 7: Microsurgical Anastomosis

STEP 7 PEARLS • The descending genicular artery is anastomosed to the radial artery in end-to-side
Although one venous anastomosis is sufficient, a fashion using 9-0 nylon sutures.
second anastomosis may be performed to improve • The venae comitantes of the donor and recipient pedicles can be anastomosed in
venous outflow. end-to-end fashion with 9-0 or 10-0 nylon.
Step 8: Closure
• Because of the microvascular anastomosis, the joint capsule cannot be closed.
• The skin is closed over the vessels using 4-0 nylon suture.
A B
FIGURE 26.41 (A) Bone flap placed into scaphoid bony defect. (B) Reduction of scaphoid confirmed with fluoroscopy.
• Because no postoperative monitoring is used with the anastomoses under the skin
closure, perfect anastomoses and robust flow in the pedicle must be assured before
skin closure.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE PEARLS

• The patient is placed in a thumb spica splint with the thumb palmarly abducted and Many surgeons use CT scans to confirm union
the wrist neutral to slightly flexed for 2 weeks until the wound is examined and su- before allowing the patient to begin active
tures are removed. A monitoring window can be fashioned to allow for nursing as- motion therapy. Generally, this scan is obtained
3 months after surgery as long as the x-ray shows
sessment of Doppler tones and early detection of vessel thrombosis. encouraging progress.
• After examining the wound, a short-arm thumb spica cast is placed and left on for
8 to 12 weeks until union is confirmed radiographically.
• If an ulna bone graft has been performed, a bulky, soft dressing is placed, and
the patient is encouraged to move the elbow to prevent stiffness. Weight restric-
tion, through the elbow, is limited to 1 to 2 pounds until union of the scaphoid is
confirmed.
• If an MFC flap has been performed, the knee and medial thigh are protected with a
soft, bulky dressing. The knee may be immobilized in the immediate postoperative
period for patient comfort, but we encourage gentle early use whenever possible.
• The patient is allowed to ambulate immediately after the procedure but should be
informed that pain may persist for several weeks.
• Fig. 26.42A–B shows 5-month postoperative x-rays after an MFC flap.
See Video 26.1, 26.2 and 26.3.
A B
FIGURE 26.42 (A–B) 5-month postoperative x-rays.

EVIDENCE
Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularized bone graft for nonunion of the
scaphoid: A systematic review. J Orthop Surg Res. 2014;1:9–21.
Twelve articles met inclusion criteria, which detailed 245 cases of scaphoid nonunion. Fifty-six patients
underwent vascularized bone grafts from the medial femoral condyle with reported union rate and
correction of humpback deformity in all patients. One hundred eighty-eight patients underwent
vascularized bone grafting from the iliac crest with a reported union rate of 87.7%. The authors
concluded that the rate of union was significantly different (P = 0.006) in favor of the medial femoral
condyle donor site.
Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2 intercompartmental
supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am.
2006;31:387–396.
In this retrospective review, the authors treated 50 scaphoid nonunions with 1,2 ICSRA vascularized
bone grafts. Thirty-four of 50 patients (68%) went on to radiographic union at an average of 15.6
weeks. Complications occurred in 8 patients (16%). Univariate analysis demonstrated that older age,
proximal pole avascular necrosis, humpback deformity, nonscrew fixation, tobacco use, and female
gender were all associated with a higher rate of complications.
Jones Jr. DB, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular
proximal pole and carpal collapse: A comparison of two vascularized bone grafts. J Bone Joint Surg
Am. 2008;90:2616–2625.
The authors retrospectively reviewed consecutive cases of scaphoid nonunion and carpal collapse in
which patients were treated with either vascularized bone from the distal radius or MFC flap. Twenty-
two patients were identified. Four of the twelve patients treated by distal radius pedicled flap went
on to union at a median of 19 weeks. All 12 nonunions treated with MFC flap went on to union at a
median of 13 weeks. They determined that rate of union was significantly higher (P = 0.005) and the
time to union was significantly shorter (P < 0.001) in favor of the MFC group.
CHAPTER 27
Salvage Procedures for Scaphoid Nonunion
Scaphoidectomy and Four-Corner Fusion

INDICATIONS
• Proximal row carpectomy (PRC) and scaphoidectomy with four-corner fusion (4CF)
are motion-preserving salvage operations for patients with proximal wrist degenera-
tion or advanced ligamentous injury.
• There are variations on the 4CF involving different intercarpal (two bone, three
bone) fusions; however, the only “partial wrist fusion” technique we will discuss
in this chapter is the traditional 4CF.
• Examples of pathology or surgical diagnoses include:
• Static scapholunate instability
• Scaphoid nonunion advanced collapse (SNAC), stage 1 or mild stage 2
• Scapholunate advanced collapse (SLAC), stage 1 or 2
• Kienbock, stage 3b or 4
• Indications for PRC and 4CF are similar, but the midcarpal joint must be preserved
(most notably the capitate articular surface) for PRC.
• Compared with 4CF, PRC does not require hardware or osseous union.
• The option for total wrist arthrodesis is preserved with either procedure.
• In elderly, low-demand patients, nonoperative management with splinting and non-
steroidal antiinflammatory drugs (NSAIDs) should be attempted even for advanced
degenerative changes. Surgery is reserved for failure of nonsurgical management
and intractable pain.
• For the younger, higher-demand patient, some believe that surgery may prevent
further progression of arthritis.
Contraindications
• Notable arthritic degeneration of the proximal capitate is a contraindication for PRC.
• Notable arthritic degeneration of the lunate facet of the radius is a contraindication
for PRC and 4CF.
• Ulnar translation of the carpus seen on posteroanterior (PA) x-ray may indicate liga-
mentous laxity and instability of PRC.
• Traditionally, surgeons have avoided PRC in younger patients or patients who per-
form heavy manual labor; however, a growing body of evidence supports use of PRC
in these patients as well.
• A thorough wrist examination is necessary, including range of motion, locations of
point tenderness, and any soft-tissue abnormalities.
• The wrist should be examined dorsally and volarly with direct palpation over bone
intervals to identify pain and inflammation.
• Check for tendon excursion because the overall kinematics at the wrist can change
with shortening.
• A predictable pattern of wrist arthritis develops with untreated scaphoid nonunion or
static scapholunate instability, termed scaphoid nonunion advanced collapse (SNAC)
and scapholunate advanced collapse (SLAC), respectively (Fig. 27.1).
• Degenerative changes of the radioscaphoid articulation are common because of
the incongruent shape of the scaphoid fossa on the scaphoid with positional
change and uneven loading. The lunate fossa is resistant to degenerative change
because of the spherical shape that remains congruent with loading in all posi-
tions of the wrist.
161
162 CHAPTER 27 Salvage Procedures for Scaphoid Nonunion
C
Nonunion
S
SNAC L
Radius
Radial styloid OA Stage I+Scaphocapitate OA Stage II+Lunocapitate OA Stage III+Radiolunate OA
Increased SL gap
SLAC
Radial styloid OA Stage I+Proximal Stage II+ Stage III+Radiolunate OA

radioscaphoid OA Scaphocapitate/Lunocapitate OA
FIGURE 27.1 Scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC).
• Patients are often seen for persistent wrist pain, and the diagnosis is confirmed
radiographically or arthroscopically.
• With stage III SNAC or SLAC arthritis, partial wrist fusion/4CF is preferred over a
proximal row carpectomy (PRC) because the capitolunate articulation has been af-
fected. Removal of the proximal row will result in contact of the arthritic capitate on
the lunate fossa of the radius and will lead to continued pain.
IMAGING
• Standard PA, oblique, and lateral x-rays of the wrist should be obtained (Fig. 27.2A–C).
These views are often sufficient for diagnosing wrist arthritis and confirming whether
or not the capitolunate or radiolunate articulations are affected.
• Ulnar translation of the carpus suggests that the palmar extrinsic wrist ligaments are
stretched and may not reliably support PRC.
A B C
FIGURE 27.2 (A–C) Posteroanterior, oblique, and lateral x-rays of the wrist.
• Advanced imaging such as computed tomography (CT) can be used to determine

the status of the midcarpal joint; however, most surgeons do not find this necessary.
• Arthroscopy is the reference standard for diagnosing and characterizing the degree
of wrist articular wear and can be used to guide the treatment algorithm if x-rays are
unclear; however, patients are made aware preoperatively that an intra-operative
decision to convert to a limited wrist fusion can be made if there is excessive, un-
recognized midcarpal joint degenerative change.
SURGICAL ANATOMY
• The volar extrinsic ligaments (radioscaphocapitate, short and long radiolunate)
originate from the volar radius and extend obliquely to the carpus. These should be
left intact. Attenuation, insufficiency, or iatrogenic injury may lead to ulnar translation
and instability, especially after PRC (Fig. 27.3).
• The dorsal ligaments of the wrist—dorsal radiocarpal (DRC) and dorsal intercarpal
(DIC) have a conjoined insertion on the triquetrum. They provide the capsulotomy
landmarks for ligament-sparing wrist exposure (Fig. 27.4).
• The posterior interosseous nerve can be found on the floor of the fourth dorsal com-
partment. Distal neurectomy at the wrist can be performed to aid in postoperative
pain control.
EXPOSURES
• A longitudinal, 6-cm incision is centered over the third metacarpal, just ulnar to the
Lister tubercle (Figs. 27.5 and 27.6). Flaps are elevated sharply at the level of the
extensor retinaculum, with care taken to not injure the dorsal sensory nerves.
• Dissection is carried out to the extensor retinaculum and the extensor pollicis longus
(EPL) is identified within its third dorsal compartment.
• An incision is made between the second and fourth dorsal compartments and the
EPL is transposed radially.
• If wider exposure is needed, especially for 4CF, elevate retinacular flaps radially and
ulnarly, through the intercompartmental septae for the second through fifth dorsal
compartments. This exposes the contents of these compartments but keeps the
dorsal retinaculum intact as a “roof” that can be repaired later.
Td
H CH C TC TT Tm
T TH SC
TC S
P RSC
L LRL
UT
UC UL SRL
PRU
DIC
U R
DRC
AIA RA
FIGURE 27.3 Volar extrinsic ligaments. AIA, Anterior interosseous artery;
C, capitate; CH, capitohamate; H, hamate; L, lunate; LRL, long radiolu-
nate; P, pisiform; PRU, palmar radioulnar; R, radius; RA, radial artery;
RSC, radioscaphocapitate; S, scaphoid; SC, scaphocapitate; SRL, short
radiolunate; T, triquetrum; TC, trapeziocapitate; Td, trapezoid;
TH, triquetrohamate; Tm, trapezium; TT, trapezium-trapezoid; U, ulna; FIGURE 27.4 Dorsal radiocarpal (DRC) and dorsal
UC, ulnocapitate; UL, ulnolunate; UT, ulnotriquetral. intercarpal (DIC) ligaments.
Lister tubercle
Dorsal ulnar sensory n.
FIGURE 27.5 Longitudinal incision marking. Dorsal radial sensory n.

FIGURE 27.6 Incision lies ulnar to the Lister tubercle.
EXPOSURES PEARLS
• Identify and avoid branches of the superficial
radial nerve.
• The dorsal capsular ligaments are more promi-
nent with the wrist in flexion. Placing a green
towel bump under the wrist can help with visu-
alization. Additionally, separation of fibrofatty
tissue off the surface with a sponge can be S
useful to better visualize the ligament fibers.
• For the ligament-sparing approach, leave a L
cuff of ligament along the radius rim for cap-
sular repair. This cuff should be small enough,
however, so that there is adequate exposure of
the proximal carpal row.
FIGURE 27.7 Exposure of the proximal carpal row. L, Lunate; S, scaphoid.
• The wrist can be entered in two different ways:

• Continuing the longitudinal incision through the dorsal wrist capsule exposes the
proximal carpal row (Fig. 27.7).
• For a “ligament-sparing approach,” a radially based dorsal capsular flap is de-
signed over the proximal carpal row. This is then incised along the DIC and DRC
ligaments (Fig. 27.8A–B).
STEP 1 PEARLS • Once the wrist is exposed, inspect the capitolunate and radiolunate articulations to
• A 0.062-inch (1.57-mm) joystick Kirschner confirm which procedure is appropriate.
wire (K-wire) can be used to aid in manipulat-
ing the scaphoid. FOUR-CORNER FUSION WITH CIRCULAR PLATE
• If the scaphoid is unhealthy (scaphoid non-
union), distal radius, iliac crest, or cancellous Step 1: Removal of the Scaphoid
bone allograft can be used to aid in fusion of
the remaining carpal bones. • The dorsal scapholunate ligament is sharply incised and the scaphoid is separated
from the lunate. A scalpel or a periosteal elevator can be used to free the scaphoid
from its attachments to the volar wrist capsule (Fig. 27.9).
STEP 1 PITFALLS
• Ideally, the scaphoid is removed in one piece (Fig. 27.10). Alternatively, a rongeur
• Careful dissection of the volar capsule should can be used to remove the scaphoid segmentally.
be performed to preserve the radioscaphocapi-
• The scaphoid can be morselized and used for bone graft if the bone quality is good.
tate and long radiolunate ligaments.
• The radiolunate articulation must not be in-
jured during removal of the scaphoid. Step 2: Reduction of the Lunate
• The radial artery is in relatively close proximity • A 0.062-inch (1.57-mm) joystick K-wire can be used to reduce the lunate into neutral
during this dissection, so caution must be position from its extended posture.
taken to not injure the artery, especially during
• Because the lunate is extended in a dorsal intercalated segment instability (DISI)
the volar dissection.
deformity, the K-wire should be placed from proximal to distal on the lunate.
FIGURE 27.8 (A–B) Dorsal capsular flap for a ligament-sparing approach.
Scaphoid excised
FIGURE 27.10 Removal of the scaphoid.

FIGURE 27.9 Freeing the scaphoid from attachments to the volar wrist
capsule.
STEP 2 PEARLS
• Reducing the lunate to neutral position is criti-
• The K-wire can then be flexed maximally toward the fingers, bringing the lunate to cal. If the lunate is fixed in dorsal posture,
neutral with respect to the long axis of the radius. wrist flexion will be reduced after the fusion.
• Wrist flexion can help present the lunate prop-
• After confirming the position of the lunate radiographically (Fig. 27.11A), another K-wire erly for guidewire placement.
can be passed from the radius into the lunate to maintain reduction (see Fig. 27.11B).
STEP 3 PEARLS
Step 3: Stabilize the Remaining Carpal Bones
After confirming neutral reduction of the lunate, the remaining carpal bones can be held The K-wires should be positioned volarly within the
carpal bones to avoid interfering with the reamer.
in alignment using additional 0.045-inch (1.45-mm) K-wires (Fig. 27.12).
Joystick
S
T
Radiolunate L
K-wire used to
stabilize the lunate
in neutral position
A B
FIGURE 27.11 (A) Fluoroscopy confirms reduction of lunate. (B) Second Kirschner wire passes from radius to lunate, stabilizing
the lunate.
H
T C
L
FIGURE 27.12 Stabilizing the remaining carpal bones.

FIGURE 27.13 Carpal bones to be reamed. C, Capi-
tate; H, hamate; L, lunate; T, triquetrum.
STEP 4 PITFALLS
Step 4: Ream the Carpal Bones in Preparation for Plate Placement
Reaming must be deep enough to permit placement
The reamer is centered over the four carpal bones, and the dorsal surface is reamed
of the entire circular plate beneath the dorsal cortices
of the carpal bones. Failure to do so may result in until the dorsal surfaces of the carpal bones lie within the two lines on the reamer
impingement of the plate on the distal radius. (Figs. 27.13 and 27.14).
Step 5: Remove the Cartilage Between the Four Carpal Bones

STEP 5 PEARLS Using a side-cutting bur, remove the cartilage from the four adjacent carpal bones
• Continuous irrigation of the bones while burring between which fusion is desired (Fig. 27.15).
will limit heat-induced necrosis at the fusion site.
• Meticulous removal of cartilage is necessary to Step 6: Packing of Bone Graft
optimize fusion rate.
Cancellous bone or bone allograft should be placed between the bones before applica-
tion of the plate.
Reamed bone
Placement of reamer
Two lines on the

reamer head
FIGURE 27.15 After dorsal central reaming, the cartilage between

FIGURE 27.14 Placement of reamer. reamed carpal bones has now also been removed.
Step 7: Placement of the Circular Plate STEP 7 PEARLS

• The correctly sized plate is placed within the reamed dorsal surface. According to Do not overtighten the hamate screw until the
the manufacturer’s guidelines, screws are placed into the four carpal bones. The lunate screw has been positioned. After these two
Acumed Hub Plate recommends fixation of the hamate first, followed by the lunate, screws have been placed, they should be tightened
capitate, and triquetrum. After placing one screw into each bone, additional screws sequentially to flatten the plate and ensure that it
does not remain prominent.
may be placed into the remaining holes.
• The Acumed system uses a 2.0-mm drill bit and 2.7-mm self-tapping screws. The
holes should be drilled to the subchondral bone of the far cortex but avoid bicortical
drilling.
Step 8: Placement of the Plate Cover

The central hole of the plate can be packed with additional bone graft, after which the
screw cover is placed (Fig. 27.16).
Step 9: Final Fluoroscopic Confirmation

Final fluoroscopic assessment should confirm proper placement of screws, and range
of motion should be free of impingement on the distal radius (Fig. 27.17A–B).
FIGURE 27.16 Placement of circular plate.
A B
FIGURE 27.17 (A–B) Fluoroscopy confirms placements of circular plate.

FIGURE 27.18 Dorsal wrist capsule is closed.
Step 10: Closure

• The dorsal wrist capsule is closed using 3-0 Ethibond suture (Fig. 27.18), after which
the tourniquet is deflated to ensure hemostasis.
• The extensor retinaculum is closed using 3-0 Ethibond. The skin can be closed with
4-0 Monocryl or 4-0 polydioxanone (PDS).
• A well-padded dressing and plaster splint are applied. A volar resting splint to the
level of the metacarpophalangeal (MCP) joints is adequate.
• The wrist should be splinted for at least 6 weeks to permit the carpal bones to fuse.
STEP 3 PEARLS
• Continuous irrigation while burring will limit FOUR-CORNER FUSION WITH KIRSCHNER WIRES
heat-induced necrosis of bone at the fusion
site.
Step 1
• Meticulous removal of the articular cartilage See previous section.
will increase predictability of union.
Step 2
See previous section.
Step 3
Using a rongeur or a small bur, the cartilage surfaces of the capitate, lunate, hamate,
and triquetrum are removed in preparation for fusion.
Step 4: K-Wire Fixation of Fusion Mass

• 0.062-inch (1.57-mm) K-wires are used to immobilize the carpal bone mass to pro-
mote fusion.
• K-wires should be driven across the lunotriquetral and capitolunate intervals
(Fig. 27.19A–B). A third K-wire can be passed from the triquetrum to the capitate.
• The starting point for the capitolunate wire can be directly visualized within the sur-
gical field. Start at the capitate waist and drive toward the proximal ulnar corner of
the lunate.
• The triquetrolunate wire is started percutaneously at the midportion of the trique-
trum. Direct this wire toward the proximal radial corner of the lunate.
• Choose a similar starting point for the triquetrocapitate wire. Drive this wire perpen-
dicular to the long axis of the forearm to capture the proximal capitate.
STEP 4 PEARLS
• Cancellous autograft or allograft is packed
between the bones, after pinning, to promote Step 5: Closure
union. See Step 10 in the previous section.
• Bury K-wires to reduce the risk for pin tract
infection. FOUR-CORNER FUSION WITH CANNULATED HEADLESS
COMPRESSION SCREWS
Step 1
See previous section.
A B
FIGURE 27.19 (A–B) Kirschner wire fixation of fusion mass.

See previous section. • Continuous irrigation of the bones while burr-
ing will limit heat-induced necrosis of bone at
Step 3 the fusion site.
• Meticulous removal of the articular cartilage
Using a rongeur or a small bur, the cartilage surfaces of the capitate, lunate, hamate, will increase predictability of union.
and triquetrum are removed in preparation for fusion.
Step 4: K-Wire Placement to Guide Screws for Fusion

• 0.062-inch (1.57-mm) K-wires are used to immobilize the carpal bone mass and
guide screw placement.
• At the end of wire placement, confirm that the lunate is properly positioned on the
radius and the capitate is well reduced/positioned on the lunate.
• We prefer to place all wires before any screws are drilled/placed.
• Many different screw combinations have been reported:
• All techniques use a capitolunate screw (Fig. 27.20).
• This screw can be placed distal to proximal, or proximal to distal.
• One or two screws can be used for this fusion site.
Scaphoid removed
FIGURE 27.20 Cannulated headless compression screws fuse the capitate and lunate. (Fig. 12.29
from Rizzo M. Wrist arthrodesis and arthroplasty. In: Wolfe S, Pederson W, Hotchkiss R, Kozin S,
Cohen, M, eds. Green’s Operative Hand Surgery. 7th ed. 2016; Elsevier: 373–417).
• Most advocate for a triquetrohamate screw.

• Some position this screw to also include the capitate.
• Some will also add a lunotriquetral screw, but others have reported that this
screw is not needed if there is good capitolunate and triquetrohamate compres-
sion screw placement.
• Capitolunate screw:
• If driving the capitolunate screw from distal to proximal, start at the distal dorsal
capitate and drive toward the proximal ulnar corner of the lunate.
• If going from proximal to distal, start relatively centrally on the lunate.
STEP 1 PEARLS • Some authors advocate placing a second smaller screw across this interval if
• If minor arthrosis is present on the proximal needed.
capitate or within the lunate fossa, a capsular • Triquetrohamate screw is generally placed proximal to distal.
interposition arthroplasty can be considered. • If a lunotriquetral screw is desired, consider volar/dorsal positioning when placing
This does require a different approach to the
carpus than previously described so that a the capitolunate and triquetrohamate screws (ideally aim both volar or both dorsal
dorsal capsular flap that is attached to the in the proximal row bones so there is adequate space for the third screw).
radius (proximally based) can be created.
• Osteochondral resurfacing has also been de- Step 5: Place the Screws
scribed as an adjunctive procedure with PRC • Before screw placement, pack the intercarpal intervals with autologous or allograft
for capitate chondrosis. An osteochondral graft
is obtained from the excised carpus, usually cancellous bone graft.
the lunate, and inserted into the defect created • Place the headless compression screws.
after excising the area of cartilage loss (limited • We prefer to start with the capitolunate screw.
to a single area ,10 mm in diameter). • Depending on the hardware system chosen, follow the appropriate instructions
for the screw of choice. We prefer using a fully threaded headless compression
screw system.
STEP 2 PEARLS
• Confirm visually and radiographically that the construct is secure, and screws are
• Preserve the volar ligaments and avoid injury not proud at any of the remaining articular surfaces.
during lunate excision.
• Pack additional bone graft as needed in the fusion sites.
• It is generally easier to completely remove the
lunate en bloc with careful circumferential dis-
section rather than using a piecemeal tech- Step 6: Closure
nique with a rongeur. See Step 10 under “Procedure: Four-Corner Fusion With Circular Plate.”
PROXIMAL ROW CARPECTOMY

STEP 2 PITFALLS
Step 1: Inspect the Joint Surface
Injuring the volar extrinsic ligaments can lead to
postoperative wrist instability and carpal ulnar The lunate fossa and the proximal capitate should be intact before proceeding with PRC.
translation.
Step 2: Excision of the Lunate
STEP 3 PITFALLS • The lunate and the scaphoid are identified (Fig. 27.21).
• Care should be taken in areas that are difficult to • K-wire joysticks can be placed into the scaphoid and the lunate to help maneuver
visualize. Avoiding injuries to the volar extrinsic the bones while performing soft tissue dissection.
ligaments, radial artery, and the proximal head of • Attention is first turned to the lunate. The lunotriquetral and scapholunate ligaments,
the capitate are the keys to the procedure. or scarring from a previous injury, are divided.
• During triquetrum excision, the ulnar nerve, • The K-wire in the lunate can then be turned to enable direct dissection of the volar
artery, and ulnar dorsal sensory branch lie in
close proximity. ligaments off of the lunate.
• En bloc resection assures no bone fragments • The lunate is then excised entirely (Fig. 27.22).
are left in the wrist. A sharp-edged freer is
helpful to detach the volar capsule from the Step 3: Excision of the Triquetrum and Scaphoid
carpal bones. • After removal of the lunate, the lunate articular surfaces of the triquetrum and scaph-
oid are identified.
STEP 4 PITFALLS • The triquetrum is excised en bloc with circumferential dissection. Avoid damaging
the proximal capitate.
• Radial stylocarpal impingement may persist if
the radiocarpal joint is not decompressed by • The scaphoid is controlled using the previously placed joystick wire. Avoid injuring
styloidectomy. the volar extrinsic ligaments or the radial artery during dissection of the scaphoid.
• When performing the styloidectomy, a short The scaphoid is removed en bloc rather than piecemeal when possible (Fig. 27.23).
oblique osteotomy of 3 to 4 mm or less is
ideal to avoid injury to the radioscaphocapitate Step 4: Seating the Capitate
ligament that inserts around 4 mm from the tip
of the styloid (Fig. 27.24). • The capitate is positioned within the lunate fossa to complete the PRC (see
Fig. 27.23).
Lunate
FIGURE 27.22 Lunate removed.

FIGURE 27.21 Preparing to excise the lunate.
C Radioscaphocapitate
ligament
S
T L Styloidectomy
Lunate fossa
FIGURE 27.23 Excision of the triquetrum, lunate, and scaphoid. C, Capitate;
L, lunate; S, scaphoid; T, triquetrum.
FIGURE 27.24 Avoid injury to the radioscaphocapitate ligament when

performing a radial styloidectomy (Fig. 31, from Weiss KE, Rodner CM.
Osteoarthritis of the wrist. J Hand Surg. 2007;32(5):724–746).
• Impingement from the radial styloid should be assessed with motion and, if present,
a radial styloidectomy performed.
Step 5: Closure and Repair of the Wrist Capsule

• The dorsal wrist capsule is repaired in interrupted fashion using nonabsorbable su-
ture (Fig. 27.25A).
• After capsular repair, the tourniquet is released, the wound is irrigated with normal
saline solution, and hemostasis is obtained with bipolar electrocautery.
• The extensor retinaculum is repaired, leaving the EPL transposed to prevent friction
at the Lister tubercle.
• Skin can be closed with either absorbable subcuticular or permanent running suture
(see Fig. 27.25B).
• A well-padded dressing and plaster splint are applied. A volar resting splint to the level
of the MCP joints is adequate as the patient can move their fingers postoperatively.
• Position of the capitate in the lunate fossa is confirmed with fluoroscopy and x-rays
at the first postoperative clinic appointment. (Fig. 27.26).
Dorsal wrist capsule
A B
FIGURE 27.25 (A–B) Closure of the dorsal wrist capsule and skin.
FIGURE 27.26 Postoperative wrist x-rays confirm that the capitate remains seated in the lunate fossa.

• Patients should be immobilized in a short-arm volar splint for 2 weeks, at which
point a custom thermoplastic splint should be worn for an additional 6 weeks.
• Gentle finger range of motion and strengthening are started at 2 weeks.
• Wrist range of motion exercises are formally started at 6 weeks.
• For PRC, some toggling motion before 6 weeks is permissible, as long as it does
not cause notable pain.
• For 4CF, initiation of wrist motion depends on fusion. The timeline may need to
be prolonged until radiographic evidence of healing is confirmed. Fusion can be
difficult because all of the carpal bones may not be compressed; therefore wrist
motion should not commence until radiographic union is seen.
• If used for 4CF, K-wires should be removed in the operating room when there is POSTOPERATIVE PEARLS
clinical and radiographic evidence of healing.
• Patients receiving wrist salvage operations
• Light strengthening can begin usually 10 to 12 weeks after surgery. Slowly progress should be counseled that pain often returns
as tolerated. over time, carpal degeneration is progressive,
• Long-term patients should expect a 50% loss in wrist range of motion compared with and future arthrodesis may be necessary for
the contralateral side. Grip strength can return to about 80% of the unaffected side. symptomatic relief.
See Video 27.1 and 27.2 • According to some reports, full recovery can
take as long as 12 to 18 months for this
operation.
EVIDENCE
Chung KC, Watt AJ, Kotsis SV. A prospective outcomes study of four-corner wrist arthrodesis using a
circular limited wrist fusion plate for stage II scapholunate advanced collapse wrist deformity. Plast
Reconstr Surg. 2006;118:433–442.
Eleven patients were prospectively enrolled in a study that detailed outcomes of scaphoidectomy and
four-corner arthrodesis using a circular plate for internal fixation. Ten of 11 patients completed their
1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were
not significantly different from preoperative values. Mean active range of motion was 87 degrees pre-
operatively and 74 degrees at 1-year follow-up (p  0.19). The Michigan Hand Outcomes Question-
naire showed no significant improvement in function, activities of daily living, work, pain, or patient
satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1-year postoperatively
(p  0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymp-
tomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptom-
atic nonunion. Authors concluded that using the first-generation circular plate as a means to achieve
four-corner arthrodesis resulted in continued pain, functional limitation, impairment at work, and poor
patient satisfaction. There was also a high rate of implant failure (3 of 11 patients).
Vance MC, Hernandez JD, Didonna ML, Stern PJ. Complications and outcome of four-corner arthrode-
sis: Circular plate fixation versus traditional techniques. J Hand Surg Am. 2005;30:1122–1127.
The authors retrospectively reviewed 58 patients who underwent four-corner arthrodesis. Twenty-seven
patients underwent fusion using a circular plate, and 31 patients underwent fusion using traditional
techniques (wires, staples, or screws). Major complication rate (nonunion or impingement) was signif-
icantly higher in the circular plate group (48% vs. 6%) compared with the group in which traditional
fixation was performed. Grip strength, range of motion, and patient satisfaction were also worse in
the circular plate group.
Erne HC, Broer PN, Weiss F, et al. Four-corner fusion: Comparing outcomes of conventional K-wire,
locking plate, and retrograde headless compression screw fixations. J Plast Reconstr Aesthet Surg.
2019;72(6):909–917.
Retrospective review of 4CF patients with 21 K-wire, 26 plate, and 17 screw techniques used. All
groups had pain reduction and reduced Disabilities of the Arms, Shoulders, and Hands (DASH)
scores compared with preoperative. The screw group, however, had significantly lower pain scores
and DASH scores. There were no significant differences in nonunion rates; however, this study was
likely underpowered for that outcome (Level IV evidence).
DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: Study with a minimum of ten years of
follow-up. J Bone Joint Surg Am. 2004;86:2359–2365.
Twenty-two PRCs in 21 patients were reviewed with an average follow-up time of 14 years. Eighteen of
the 22 patients demonstrated satisfactory pain relief, 72 degrees of flexion-extension arc, and recov-
ery of 91% of grip strength of the opposite side. Pain relief was graded as complete in 9, mild in 4,
and moderate residual in 5. There were 4 failures, all in patients younger than 35 years old (Level IV
evidence).
Lumsden BC, Stone A, Engber WD. Treatment of advanced-stage Kienböck’s disease with proximal
row carpectomy: An average 15-year follow-up. J Hand Surg Am. 2008;33:493–502.
Proximal row carpectomy was used to treat 17 patients with advanced-stage (Lichtman IIIA and IIIB)
Kienböck disease. Thirteen of the 17 patients with an average follow-up of 15 years were evaluated.
Twelve of 13 patients demonstrated excellent or good results. They achieved a total arc of motion of
73% of the uninvolved side and grip strength that averaged 92% of the uninvolved side. All patients
demonstrated some degree of degenerative changes. Despite radiographic evidence of radiocapitate
degenerative change in nearly all patients, clinical results did not correlate with radiographic degen-
eration (Level IV evidence).
Fowler JR, Tang PC, Imbriglia JE. Osteochondral resurfacing with proximal row carpectomy: 8-year
follow-up. Orthopedics. 2014;37(10):e856–e859.
This paper presents average 101-month follow-up in 5 patients that had osteochondral resurfacing of
the capitate in addition to PRC. Grip strength improved at every postoperative time point, but motion
did decrease over time. Mayo wrist score and DASH score both remained stable or improved from
18-month to final follow-up (Level IV evidence).
CHAPTER 28
Open Reduction and Fixation of Acute Lunate or
Perilunate Dislocation, With or Without Fracture
INDICATIONS
• Acute and subacute perilunate dislocation or fracture-dislocation (,6 weeks).
• Patients who present more than 6 weeks after the injury may be better served
by a salvage procedure, such as a proximal row carpectomy or partial wrist
fusion.
• Although urgent reduction of a perilunate dislocation can often be accomplished by
closed means, operative fixation and consideration of open ligamentous repair are
generally indicated.
• Perilunate injury can be purely ligamentous (lesser arc injury) or associated with
fracture of the scaphoid, capitate, or triquetrum (greater arc injury).
• A unique subset, termed scaphocapitate syndrome, is characterized by a trans-
scaphoid transcapitate fracture with the head of the capitate rotated 90 or
180 degrees out of position.
• Mayfield and colleagues described the progressive spectrum of pathology, moving from
radial to ulnar across the carpus, associated with perilunate/lunate injury (Table 28.1).
• In lunate dislocation, the lunate is displaced volarly and the remaining carpal bones
maintain alignment in relation to the distal radius.
• In perilunate dislocation, the lunate remains within its fossa on the distal radius, and
the remaining carpus dislocates dorsally (Fig. 28.1).
Contraindications
These injuries often occur in high-energy trauma. If surgery on the wrist is not safe for
the patient (or not the acute priority), reduction and splinting is acceptable even for a
few weeks until the patient is stabilized.
TABLE
28.1 Spectrum of Pathology Associated With Perilunate Injury
Radiographic Scaphoid Capitate Malrotation of Lunate dislocation
findings rotation dislocation scaphoid and
triquetrum
Triquetrolunate di-
astasis
Volar triquetral
fracture
Joint Scapholunate Scapholunate Scapholunate Scapholunate
disruption Capitolunate Capitolunate Capitolunate
Triquetrolunate Triquetrolunate
Radiolunate
Ligament Radioscaphoid Radioscaphoid Radioscaphoid Radioscaphoid
affected Scapholunate Scapholunate Scapholunate Scapholunate
Radiocapitate Radiocapitate Radiocapitate Radiocapitate
Radial collateral Radial collateral
Palmar Palmar radiotriquetral
radiotriquetral 1/2 Lunotriquetral
1/2 Ulnotriquetral 1/2 Dorsal radiocarpal
174
CHAPTER 28 Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture 175
Dorsally dislocated
carpus in relation
to lunate
Lunate
FIGURE 28.1 Lateral radiograph depicting a dorsally dislocated carpus in relation to lunate.
• Clinical examination may reveal extreme pain, wrist edema, tenderness, and ecchy-
mosis with diminished active and passive wrist motion.
• It may be accompanied by acute carpal tunnel syndrome (∼25% of patients), result-
ing in severe and progressive pain and paresthesia in the median nerve distribution.
• If severity of pain progresses despite radiographically confirmed closed reduction,
urgent carpal tunnel release and open reduction and fixation should be performed.
• If closed reduction results in a decrease in pain severity and improvement in numbness,
open reduction and fixation can be performed semielectively as soon as possible.
IMAGING
• The standard radiographic assessment of the wrist should be conducted, including
a careful evaluation of Gilula’s arcs (Fig. 28.2) to identify carpal dislocation.
• The radial shaft, lunate, capitate, and metacarpal shafts should be colinear on lateral
x-ray.
• Despite the severity of the injury, perilunate or lunate dislocation can be missed;
therefore it is important to carefully examine all radiographic views.
• Plain radiographs can also reveal associated fractures of the radial styloid, scaph-
oid, capitate, or triquetrum—demonstrating a greater arc pattern of injury (Fig. 28.3).
SURGICAL ANATOMY
• In severe injuries, the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments
are often injured (Fig. 28.4).
• In a volar dislocation, the lunate is forced through the space of Poirier, a weak
region in the volar capsule that is devoid of extrinsic ligaments. The arc of the
176 CHAPTER 28 Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture
FIGURE 28.2 Gilula’s arcs: First arc (red) is the proximal convexity of the scaphoid, lunate, and tri-
quetrum; the second arc (blue) represents the distal concavities of the scaphoid, lunate, and trique-
trum; the third arc (black) represents the proximal curvatures of capitate and hamate.
Scaphoid Carpus overlapping

waist lunate
fracture DIC
DRC
FIGURE 28.4 DIC, Dorsal intercarpal ligament;

FIGURE 28.3 Greater arc pattern of injury visible on plain radiograph. DRC, dorsal radiocarpal ligament.
radioscaphocapitate (RSC) and the ulnocapitate (UC) ligaments form the distal
anatomic border of the space of Poirier (Fig. 28.5).
• In a dorsal perilunate dislocation, the lunate remains in normal position on the distal
radius and the remaining carpus dislocates dorsally.
• Perilunate dislocation requires interosseous—scapholunate (SL) and lunotriquetral (LT)—
ligament injury. The dorsal SL ligament and volar LT ligament are repaired if possible.
• In a Mayfield IV lunate dislocation, the blood supply to the lunate is maintained by
the short radiolunate ligament volarly (Fig. 28.6).
• Reduction is performed through a series of specific steps:
• Encourage muscle relaxation via a limb block or sedation/anesthesia.
• Place around 10 lbs of longitudinal traction in finger traps for 10 to 15 minutes.
• Initiate with dorsally directed pressure on the volar aspect of the lunate and re-
move the traction weight once in this position.
Td
C TC TT
H CH Tm
T TH SC
S
TC
P RSC
Space of Poirier
L
UT LRL
UC UL SRL
PRU
U R
AIA RA
FIGURE 28.5 AIA, Anterior interosseous artery; C, capitate; CH, capitohamate ligament; H, hamate;
L, lunate; LRL, long radiolunate ligament; P, pisiform; PRU, palmar radioulnar ligament; R, radius;
RA, radial artery; RSC, radioscaphocapitate ligament; S, scaphoid; SC, scaphocapitate ligament;
SRL, short radiolunate ligament; T, triquetrum; TC, triquetrocapitate ligament; Td, trapezoid; TH, tri-
quetrohamate ligament; Tm, trapezium; TT, trapeziotrapezoid ligament; U, ulna; UC, ulnocapitate lig-
ament; UL, ulnolunate ligament; UT, ulnotriquetral ligament.
Long radiolunate
ligament
Scapholunar ligament
Palmar Dorsal
Neurovascular
bundle
Lunate
Short
radiolunate
ligament
FIGURE 28.6 Vascular supply to the lunate.
• With the weight off, maximally extend the wrist; then, with manual longitudinal
traction, flex the wrist. This should bring the capitate into flexion and onto the
lunate, reducing the injury.

• A standard radiolucent hand table and mini c-arm are used for intraoperative confir-
mation of reduction.
• Also, 5 to 10 pounds (2.3–4.5 kg) of a longitudinal traction applied via finger traps
may be used to facilitate reduction.
EXPOSURES PEARLS
EXPOSURES
Hematoma and edema may displace the median
• In volar exposure, an extended carpal tunnel incision is designed across the wrist
nerve or its palmar cutaneous branch. Identify and
avoid injury to these structures. crease (Fig. 28.7).
• After completely releasing the transverse carpal ligament, the carpal tunnel contents
are retracted to reveal the volar wrist capsule.
• In dorsal exposure, a 6- to 8-cm longitudinal incision is designed between the third
and fourth extensor compartments (Fig. 28.8).
• The dorsal wrist capsule is exposed by entering the interval between the second and
fourth compartments.
• A longitudinal incision can be made over the scapholunate interval to expose the
STEP 1 PEARLS proximal carpal row.
• The short radiolunate ligament should be • Alternatively, a radially based capsular flap can be designed in line with the fibers of
preserved to protect the blood supply to the the DRC and DIC ligaments (see “Ligament Sparing Approach” in Chapter 22).
lunate.
• The SL ligament is generally preserved in a
greater arc injury involving a scaphoid fracture OPEN REDUCTION, INTERNAL FIXATION TRANSSCAPHOID
(as opposed to the lesser arc injury where the
SL ligament is disrupted). Be sure not to injure
PERILUNATE FRACTURE/DISLOCATION
the ligament during exposure and fracture Step 1: Dorsal Exposure and Reduction of the Scaphoid Fracture
management. • An incision between the second and fourth dorsal compartments is used to expose
• It can be easier to place the reduction K-wires
into the triquetrum and scaphoid before per- the scaphoid. Tendons are retracted out of the operative field with a self-retaining
forming the reduction (inside-out pin place- retractor (Fig. 28.9).
ment) so they are properly positioned for even- • The scaphoid fracture is identified and any hematoma or early callous formation is
tual pinning into the lunate once the lunate is debrided.
reduced into its anatomic position. • Reduction of the scaphoid fracture is confirmed both visually and radiographically.
Step 2: Placement of Guidewire for Headless Compression Screw

Fixation
• A provisional 0.045-inch (1.14-mm) Kirschner wire (K-wire) is placed away from the
anticipated screw placement site to maintain scaphoid fracture reduction. This will
also prevent rotation of the fracture fragments upon screw advancement.
FIGURE 28.7 Volar exposure markings. FIGURE 28.8 Dorsal exposure markings.
FIGURE 28.9 Dorsal exposure approach.
Scaphoid
B S C S
FIGURE 28.10 (A–C) Placement of guidewire into scaphoid for headless compression screw fixation. (B) The wire is only in the
proximal segment of the scaphoid as it is being passed across the fracture line. White arrow in B and C points to scaphoid
wire.
• The cannulated screw guidewire should be started at the proximal ulnar corner of
the scaphoid (Fig. 28.10A). The wire is directed along the long axis of the scaphoid.
The K-wire should be driven into the subchondral bone of the distal scaphoid
tubercle (see Fig. 28.10B–C).
STEP 2 PEARLS • Confirm proper reduction of the scaphoid, including alignment of the scaphocapitate
• Use the long axis of the thumb as a visual aid articulation.
to help align the positioning and trajectory of • After confirming the appropriate trajectory and position of the guidewires, the manu-
the scaphoid guidewire. facturer’s guide is used to estimate screw length.
• To ensure that the screw is entirely within the
bone, 4 mm should be subtracted from the Step 3: Drilling the Scaphoid
length estimated by the manufacturer’s guide.
After confirming that the guidewire has been advanced to the subchondral bone of the
distal scaphoid, the bone is drilled in preparation for screw placement.
STEP 3 PEARLS
Guided by fluoroscopy, drilling is complete after Step 4: Screw Placement
reaching the subchondral bone of the distal pole After confirming a screw length that will be entirely within the bone, the screw is
of the scaphoid. advanced under fluoroscopy (Fig. 28.11A–B).
STEP 4 PEARLS Step 5: Pinning the Scapholunate, Lunotriquetral, and Midcarpal

Joints
• Fig. 28.11A–B demonstrates a correctly
placed screw positioned along the long axis of • Several K-wires should be used to immobilize the scapholunate, lunotriquetral, and
the scaphoid (the screw is deep within the car- midcarpal joints.
tilaginous component of the proximal scaphoid, • The lunate should be neutral, defined by a radiolunate angle of 0 to 15 degrees on
confirmed with direct visualization). lateral x-ray. If the lunate has assumed an extended or flexed posture because of
• Live fluoroscopy is used to confirm that the
screw is not prominent. remaining attachments, it must be properly reduced before fixation.
• Wrist circumduction should be performed • With extension or dorsal intercalated segment instability (DISI) deformity, the
intra-operatively. If concern exists that the wrist is flexed maximally, bringing the lunate into neutral position. A 0.062-inch
screw may be prominent within the joint, it K-wire can be driven from the dorsal, distal radius into the lunate to maintain
should be exchanged or repositioned. reduction.
• If the lunate is abnormally flexed (volar intercalated segment instability [VISI]),
the wrist should be maximally extended to bring the lunate into neutral position.
A K-wire is passed from the dorsal, distal radius into the lunate to maintain
reduction.
• After confirming that the radius and lunate are colinear, a 0.062-inch (1.57-mm) K-wire
can be placed from the triquetrum to the lunate (Fig. 28.12).
• The entry point on the midportion of the triquetrum can be confirmed radiographi-
cally. The K-wire should be driven into the subchondral bone of the lunate.
• Immobilization of the scapholunate interval can be achieved with one 0.062-inch
(1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial styloid. The
wire should be directed perpendicular to the long axis of the forearm to capture the
scaphoid and lunate. Confirm reduction of the scapholunate gap and restoration of
the normal scapholunate angle (30–60°) fluoroscopically.
• Place a 0.062-inch K-wire from the distal scaphoid to the capitate (see Fig. 28.12).
• A second 0.062-inch (1.57-mm) K-wire can be driven across the scaphocapitate
interval to aid in preventing midcarpal motion.
LT
SC
SL
A B
FIGURE 28.12 Pinning the scapholunate, lunotri-
FIGURE 28.11 (A–B) Screw has been placed. quetral, and scaphocapitate joints.
• Adjust the entry point as needed to avoid obstruction by the intrascaphoid screw. STEP 5 PEARLS
• As previously mentioned, pre-placement of the wires into the scaphoid and trique-
• K-wires are usually buried deep to the skin to
trum (inside-out placement) when treating a lesser arc injury can simplify this step. reduce the risk for pin tract infection.
• Multiple fluoroscopic views are necessary to
Step 6: Repairing the Scapholunate and Lunotriquetral Ligaments confirm that the K-wires have been positioned
• When present, a midsubstance tear of the dorsal SL and/or LT ligaments should be correctly.
repaired using 3-0 Ethibond sutures.
• If the ligament has been avulsed from its bony attachment, a suture anchor can be
used to facilitate reattachment.
Step 7: Carpal Tunnel Release and Repair of the Volar Capsule

• An extended carpal tunnel release is performed, in which the structures of the carpal
tunnel are identified and protected.
• If the lunate is volarly dislocated and cannot be properly reduced with a closed
technique, this volar approach is performed first.
• Once open, use the same reduction maneuver as previously described but now
with pressure directly on the exposed lunate bone.
• The capsule can obstruct reduction, so it may need to be mobilized off the lunate.
• Even with appropriate closed lunate reduction, beginning with the volar approach
is acceptable based on surgeon preference.
• Many surgeons advocate for always including the volar approach for Stage III and
IV injuries to facilitate repair of the capsule and deeper volar structures.
• Inspection of the floor of the carpal tunnel may reveal a rent or tear in the volar
capsule. The synovial lining is the most easily visualized component of the cap-
sule, whereas the more important deeper structures are harder to visualize.
• Capsular tears are repaired using 3-0 Ethibond suture (Fig. 28.13A–B).
Tear in volar
wrist capsule
FIGURE 28.13 (A–B) Carpal tunnel release and repair of the volar capsule.
• Inspect deep to the tear and visualize injuries to deeper (more important) struc-
tures.
• Closely evaluate the radial and ulnar corners of the tear where the radial
radioscaphocapitate ligament and ulnar LT ligament are often found.
• Include these deeper structures in the repair if possible.
Step 8: Closure
• The dorsal wrist capsule is closed with 3-0 Ethibond suture, after which the tourni-
quet is deflated and hemostasis is ensured.
• The dorsal skin is closed with 4-0 Monocryl or 4-0 PDS.

• A forearm-based splint is applied at the conclusion of the procedure; if a scaphoid
fracture was also repaired as part of the injury, we prefer using a thumb spica
splint. The patient is instructed to keep the splint clean and dry for 10 to 14 days,
at which point the splint is removed, the wound is inspected, and sutures are
removed.
POSTOPERATIVE PEARLS • The patient is placed in a cast for 8 to 12 weeks.
• It is important to manage expectations preop- • Follow-up should be scheduled every 3 to 4 weeks to ensure that the reduction is
eratively by educating the patient about sub- maintained and to monitor fracture healing radiographically.
stantial postoperative wrist stiffness, even with • The cast and K-wires are removed at 8 to 12 weeks under local anesthesia or sedation.
a perfect repair/reconstruction. • Occupational therapy is initiated once wires have been removed, beginning with
• Despite anatomic reduction, the majority of gentle range of motion and progressing to strengthening.
patients will develop wrist arthritis.
• Fig. 28.14A–B shows 1-year postoperative x-rays that demonstrate fracture union
and maintenance of the scapholunate and lunotriquetral intervals.
See Video 28.1
FIGURE 28.14 (A–B) One-year postoperative x-rays.

EVIDENCE
Israel D, Delclaux S, André A, et al. Peri-lunate dislocation and fracture-dislocation of the wrist: Retro-
spective evaluation of 65 cases. Orthop Traumatol Surg Res. 2016;102(3):351–355.
The authors retrospectively reviewed 18 dislocations and 47 fracture-dislocations, all treated surgically.
The average follow-up was 8 years (ranged 2–16). Average quick Disabilities of the Arm, Shoulder,
and Hand score was 21 and average Patient-Rated Wrist Evaluation score was 28. Pain averaged 1.3
out of 10 at rest but up to 4.3 out of 10 with effort/use. Average flexion/extension arc was 96 de-
grees and strength averaged 70% of contralateral. Radiographic evaluation showed arthritic changes
in nearly 60% of cases, and 26% needed secondary surgery at the time of the most recent evalua-
tion. Findings and outcomes between the dislocation and fracture-dislocation were not significantly
different in this small study. Notably, an observed osteochondral defect at the time of initial surgery,
and altered scapholunate angle, were both correlated with subsequent osteoarthritis during follow-up
evaluations (Level IV evidence).
Krief E, Appy-Fedida B, Rotari V, et al. Results of perilunate dislocations and perilunate fracture dislo-
cations with a minimum 15-year follow-up. J Hand Surg Am. 2015;40:2191–2197.
The authors retrospectively reviewed 30 patients at a mean follow-up of 18 years who were treated for
perilunate dislocation or perilunate fracture-dislocation. The mean flexion-extension arc, radial-ulnar
abduction arc, and pronation-supination arc were, respectively, 68%, 67%, and 80%, compared with
the contralateral side. The mean grip strength was 70%, relative to the contralateral side. The mean
Mayo wrist score was 70, and the mean Quick Disabilities of the Arm Shoulder and Hand and
Patient-Rated Wrist Evaluation scores were 20 and 21, respectively. Five patients underwent a
secondary procedure. Six patients were diagnosed with complex regional pain syndrome.
Arthritis was evident in 70% of wrists.
CHAPTER 29
Ulnar Shortening Osteotomy for Ulnar Impaction
Syndrome

This chapter includes the following video: Video 29.1 – Transmetaphyseal Ulnar
Shortening Osteotomy.
KEY CONCEPTS
• Ulnar shortening osteotomy is indicated for ulnocarpal abutment (ulnar impaction
syndrome), posttraumatic incongruency of the distal radioulnar joint (DRUJ), loss of
radial height associated with distal radius fracture malunion, and Madelung deformity.
• Ulnar variance is measured on a neutral rotation posteroanterior (PA) view with
shoulder and elbow at 90 degrees. Ulnar positive variance may be associated with
ulnocarpal abutment. Other radiographic features of this disorder include sclerosis
of the ulnar corner of the lunate, the triquetrum, or the radial portion of the ulnar
head. Wrist arthroscopy can facilitate the diagnosis of ulnocarpal abutment and rule
out other wrist pathologies.
• The ulnocarpal joint transmits around 20% of the load across the neutral ulnar wrist,
whereas the radiocarpal joint transmits around 80% of the load. Load transmission
across the ulna in patients with 2.5-mm positive ulnar variance increases to 42%.
This considerable increase in load with ulnar-positive variance puts the wrist at a
high risk for articular degeneration and ligamentous injury. Increased dorsal tilt of the
radius can further exacerbate loading onto the ulnar side of the wrist. With 2.5-mm
negative ulnar variance, the load transmission decreases to 4.3%. This is the basis
for the ulnar shortening osteotomy.
• Ulnar shortening with the metaphyseal technique achieves similar results compared
with the diaphyseal shortening approach and may have a lower risk of malunion. The
more distal and dorsal approach, however, may carry a greater risk for injury to the
dorsal sensory branches of the ulnar nerve.
FIGURE 29.13 Limited subperiosteal dissection provides adequate exposure of the ulna and avoids
unnecessary injury to the surrounding structures and blood supply.
184
CHAPTER 29
Ulnar Shortening Osteotomy for Ulnar
Impaction Syndrome
INDICATIONS
Indications for the procedure include:
• Inherited or acquired ulnocarpal abutment (ulnar impaction syndrome)
• Posttraumatic incongruency of the distal radioulnar joint (DRUJ)
• Loss of radial height associated with distal radius fracture malunion
• Madelung deformity or premature physeal closure of the distal radius
Contraindications
There are also several contraindications:
• DRUJ arthritis
• Dorsal DRUJ dislocation or other notable DRUJ instability
• Caution use (relative contraindication) in patients with DRUJ malalignment.
• Specifically, reverse oblique DRUJ configuration is considered by some to be a
notable relative contraindication (Fig. 29.1) because the ulnar shortening may
adversely affect DRUJ loading and accelerate arthritic wear of the DRUJ.
• If DRUJ alignment is a concern, consider a distal wafer procedure—either open
or arthroscopic—to reduce the height of the ulnar head without altering DRUJ or
ulnar styloid position.
• Patients present with ulnar-sided wrist pain with swelling and decreased range of
motion of the wrist. Ulnar-sided wrist pain is a symptom of various conditions, and
these must be investigated with physical examination and radiographic or ar-
throscopic techniques.
• Other common causes of ulnar-sided wrist pain include triangular fibrocartilage
complex (TFCC) injuries, DRUJ instability or arthritis, extensor carpi ulnaris (ECU)/
flexor carpi ulnaris (FCU) tendinopathy, carpal fracture or instability, vascular (hypo-
thenar hammer syndrome), or neurogenic pathology (ulnar dorsal sensory neuritis,
compression in the Guyon canal).
• The ulnocarpal stress test and ulnar foveal signs may be positive with ulnocarpal
abutment, but neither is specific.
I II III
Parallel Oblique Reverse oblique
FIGURE 29.1 Tolat classification of DRUJ. (Fig. 1, reprinted with permission from Heiss-Dunlop W,
Couzens GB, Peters SE, Gadd K, Di Mascio L, Ross M. Comparison of plain x-rays and computed
tomography for assessing distal radioulnar joint inclination. J Hand Am Surg. 2014;39(12):2417–2423).
184.e1
184e2 CHAPTER 29 Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome
FIGURE 29.2 Ulnocarpal stress test (TFCC FIGURE 29.3 Eliciting the ulnar foveal sign.
grind test). The lightning bolt indicates pain.
• The ulnocarpal stress test (TFCC grind test) attempts to recreate ulnar-sided wrist
pain when the wrist is maximally ulnarly deviated and axial-loaded. The maneuver is
tested while the wrist is passively put through the arc of pronation and supination. A
positive ulnocarpal stress test may be caused by ulnocarpal abutment or isolated
TFCC injury. Extreme pronation brings the carpus in line with the ulnar head and will
likely exacerbate pain with ulnar loading if ulnar abutment is present (Fig. 29.2).
• The ulnar foveal sign is a provocative maneuver that is useful in diagnosing foveal
detachment of the TFCC or ulnotriquetral ligamentous injury. The examiner identifies
the interval along the ulnar side of the wrist between the pisiform and the ulnar styloid
and applies direct pressure with the wrist and forearm in neutral position (Fig. 29.3).
• To perform a pisiform boost, while simultaneously depressing the ulnar head with
volar-directed force and applying dorsally directed pressure on the volar aspect of
the pisiform, the patient is asked to both actively and passively ulnarly deviate the
wrist. This provocative maneuver loads the central portions of the ulnar dome, TFCC
disk, lunate, and triquetrum. A painful positive test suggests TFCC pathology, ulnar
abutment, or DRUJ arthritis.
IMAGING
• Standard posteroanterior (PA), oblique, and lateral x-rays of the wrist are obtained
with a particular interest in the relationship between the articular surfaces of the
distal ulna and the radius. Ulnar variance is measured on a neutral rotation PA view
with the shoulder and elbow at 90 degrees. When the lunate facet of the distal radius
and dome of the ulna are measured at the same level, this is termed neutral variance
and is seen in 12% of the general population (Fig. 29.4). If the ulnar articular surface
is distal to the lunate facet of the radius, this is called positive variance (55%).
Negative ulnar variance exists when the ulna is proximal to the radius (33%). Normal
variance is considered to be 22 mm to 12 mm. Pronation (up to 11 mm) and power
grip (up to 12.5 mm) may change the articular relationship (Fig. 29.5). Considering
the wide range of so-called “normal” variance, always check a contralateral x-ray
before deciding on the diagnosis/treatment for ulnar abutment.
• Ulnar-positive variance may be associated with ulnocarpal abutment. Other radio-
graphically apparent features of this disorder include cystic changes or sclerosis of
the ulnar corner of the lunate, the triquetrum, or the radial portion of the ulnar head
(Fig. 29.6).
CHAPTER 29 Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome 184.e3
R U R U
U R
A B C
FIGURE 29.4 Ulnar variance. (A) Neutral. (B) Negative. (C) Positive. (Fig. 3A–C, reprinted with per-
mission from Mag Res Imag Clin of Nor Am. 2010;18(4):643–662.)
Ulnar
variance
Ulnar
variance
FIGURE 29.5 Ulnar positive variance may be associated with ulnocarpal abutment.
FIGURE 29.6 Sclerosis of the ulnar corner of the
lunate (right arrow) and radial corner of the
triquetrum (left arrow).
• Magnetic resonance imaging (MRI) may be useful in identifying changes associated
with ulnocarpal abutment. Short T1-weighted inversion recovery images and fat-
suppressed T2-weighted images may reveal subchondral bone marrow edema and
early chondromalacia (Fig. 29.7). Focal proximoulnar cystic changes in the lunate
(see Fig. 29.7) are a pathognomonic radiographic finding of ulnar abutment.
• Wrist arthroscopy can be used to accurately diagnose ulnocarpal abutment and to
rule out other associated pathology of the wrist. A large central TFCC perforation
with associated articular wear of the ulnar head or proximal articular cartilage of the
lunate or triquetrum suggests that the bones are contacting.
• The distal radioulnar joint must be examined radiographically for signs of arthritis be-
cause this could contribute to wrist pain and may be exacerbated by shortening the ulna.
SURGICAL ANATOMY
The ulnocarpal joint transmits around 20% of the load across the neutral ulnar wrist,
whereas the radiocarpal joint transmits around 80% of the load. Load transmission
across the ulna in patients with 2.5-mm positive ulnar variance increases to 42%. This
C C
B B
A A
EXPOSURES PEARLS
• Dissect over the ulnar diaphysis in the supra-
FIGURE 29.7 Subchondral bone marrow edema and early chondromalacia seen on mag-
periosteal plane. This preserves blood supply
netic resonance imaging. (A) Early chondromalacia. (B) Focal proximoulnar cystic changes in the
at the osteotomy site and may promote union.
lunate. (C) Subchondral bone marrow edema.
• Only perform subperiosteal circumferential dis-
section around the osteotomy site to preserve
the blood supply. One of the major causes of
nonunion may be injudicious stripping of peri-
osteum circumferentially for the full extent of considerable increase in load with ulnar-positive variance puts the wrist at a high risk
the ulna along the incision, which devascular- for articular degeneration and ligamentous injury. Increased dorsal tilt of the radius can
izes the osteotomy site. further exacerbate loading onto the ulnar side of the wrist. With 2.5-mm negative ulnar
variance, the load transmission decreases to 4.3%. This is the basis for the ulnar short-
EXPOSURES PITFALLS ening osteotomy.
• Take care in identifying and protecting the dor-
sal sensory branch of the ulnar nerve. It arises EXPOSURES
8 cm proximal to the ulnar styloid, passes • For shortening the diaphysis, an approximately 10-cm longitudinal incision is de-
deep to the FCU, and courses obliquely toward signed over the ulna along its subcutaneous border. The incision stops 2 to 3 cm
the ulnar styloid, crossing from volar to dorsal
proximal to the ulnar styloid to avoid injuring the dorsal sensory nerve that crosses
around 1.5 cm proximal to the ulnar styloid
(Fig. 29.12). the incision distally. After incising the skin and subcutaneous tissue, the ECU and
• The metaphyseal technique may have a lower FCU are identified and the interval between them is developed to expose the ulna
risk for malunion. Nevertheless, the more distal (Figs. 29.8 and 29.9).
and dorsal approach may carry a greater risk • Alternatively, a metaphyseal shortening technique has been described. This tech-
for injury to the dorsal sensory branches of the
nique uses a more dorsal approach (Fig. 29.10) to expose the ulnar head. The ap-
ulnar nerve.
proach is between the fifth and sixth extensor compartments (Fig. 29.11).
FIGURE 29.8 Design for longitudinal incision over the ulna along FIGURE 29.9 ECU and FCU are identified and the interval be-
its subcutaneous border. The incision stops 2 to 3 cm proximal tween them is developed to expose the ulna. ECU, Extensor
to the ulnar styloid. carpi ulnaris; FCU, flexor carpi ulnaris.
FIGURE 29.10 Dorsal incision used to approach the ulnar head for the
metaphyseal shortening technique. FIGURE 29.11 Exposing the interval between the fifth and sixth extensor
compartments to approach the ulnar head/metaphysis. Black arrow
points to the planned longitudinal incision over the neck/metaphyseal
region of the ulna.
DBUN
STEP 1 PEARLS
• Various cutting guide systems are available, or
the osteotomy can be done freehand if needed.
We most frequently use a Rayhack device (Gen-
US eration I or II) to create the oblique osteotomy
(Fig. 29.14), and demonstrate that device in this
section. A six-hole, low-profile locking plate or a
ECU
six-hole limited contact dynamic compression
plate can be used. The use of newer, lower-pro-
file locking plates may reduce plate-related
complications and need for removal.
• When a compression device is not available and
the plan is for freehand osteotomy, the surgeon
can apply a compression plate over the ulna by
drilling and placing screws proximal to the oste-
otomy site. Then, the bone wafer is cut out of
Proximal the ulna, and shortening is achieved by using
the compression mode of the plate to bring the
two cut ends of the ulna together. Alternatively,
if no cutting/compression system is available, a
FIGURE 29.12 Identify and protect the dorsal sensory branch of the ulnar nerve. DBUN, Dorsal step-cut shortening can be performed and is
branch of ulnar nerve; ECU, extensor carpi ulnaris; US, ulnar styloid. easier to do freehand (Figs. 29.15 and 29.16).
• The freehand technique is especially useful
when a large amount of shortening (5 mm
PROCEDURE or greater) is required.
• The limbs of the step cuts (see Fig. 29.15B)
Step 1: Exposure of the Ulna in Preparation for the Osteotomy can be made long and then sequentially
After incising the skin and subcutaneous tissue, the interval between the FCU and ECU shortened as needed to provide an ade-
quate amount of ulnar excision.
is developed, and tendons are retracted volarly and dorsally. The osteotomy site should
• The metaphyseal shortening technique uses
be marked on the ulna, followed by limited subperiosteal dissection, approximately one K-wire to confirm that the osteotomy is
2 cm (Fig. 29.13). The ideal osteotomy location is approximately 5 to 7 cm proximal to proximal to the DRUJ, and a second K-wire to
the ulnar styloid and 2 to 3 cm proximal to the sigmoid notch. mark the proximal margin of the wedge exci-
sion (Fig. 29.17).
Step 2: Placement of the Guide • Before any screw placement, evaluate the pro-
posed osteotomy site radiographically to en-
• The plate is selected and placed within the wound at the level of the desired oste- sure that the distal-most screw will not be
otomy. The distal end of the plate should be approximately 3 to 4 cm from the ulnar placed near the DRUJ.
styloid, ensuring that all screws will avoid the DRUJ. • It is essential to avoid subperiosteal dissection
• The second hole (from proximal) is marked on the bone and then the plate is moved beyond the proposed osteotomy site. Preserv-
away and replaced by the Rayhack cutting guide where the second hole (from ing periosteum will improve vascularity and
promote union.
proximal) is lined up with the marking.
Distal Proximal
3 21 Blade slots
Hypotenuse 7.4 mm 4.9 mm 3.5 mm

2.5 mm
90 o 3.5 mm
5.2 mm
FIGURE 29.13 Limited subperiosteal dissection
provides adequate exposure of the ulna and
avoids unnecessary injury to surrounding struc-
3 2 1
tures or blood supply.
FIGURE 29.14 Cutting guide systems can facilitate various sizes of oblique osteotomy.
1 2 3 4 5 6 7 Dorsal
A Volar
B X
C X
FIGURE 29.15 Freehand step-cut osteotomy is an acceptable alterna-

tive to using a cutting guide system. (A) An AO plate is used as a
template to facilitate design of the step cut between the third and fifth
holes. (B) The desired distanced for shortening is marked and cut.
(C) After reduction, a lag screw is placed at the dorsal surface to com-
press the arms of the osteotomy. A 3.5-mm AO neutralization plate is
then applied to the volar surface. (Fig. 1, reprinted with permission from FIGURE 29.16 Final fixation for diaphyseal step-cut shorten-
Darlis NA, Ferraz IC, Kaufmann RW, Sotereanos DG. Step-cut distal ing osteotomy.
ulnar-shortening osteotomy. J Hand Am Surg . 2005;30(5):943–948).
• The cutting guide is held manually. Using a straight drill guide, a 2.5-mm drill is
used to make a hole through the second hole on the guide. The depth of the hole
is measured, the hole is tapped with a 3.5-mm tap, and a 3.5-mm cortical screw
is placed. This procedure is repeated for the fourth and then the third holes on the
saw guide.
STEP 1 PITFALLS
• The plate may be positioned on the volar or
dorsal/subcutaneous border of the ulna. The
volar approach requires more soft tissue dis-
section and periosteal stripping and may result
in a higher incidence of delayed or nonunion.
Although the dorsal approach may result in
palpable hardware because of the paucity of
soft tissue, we prefer this method because of
the ease of placement, reduction in soft tissue
stripping, and possible increase in overall
union rate. A devastating complication is injur-
ing the ulnar neurovascular bundle, which lies
adjacent to the FCU tendon. Use retractors to
protect these structures during dissection and
osteotomy.
• Place the plate in the wound as a guide to deter-
mine the amount of soft tissue dissection
needed to accommodate and to help localize the
osteotomy site before any periosteal stripping.
FIGURE 29.17 K-wires guide the osteotomy for the metaphyseal shortening technique. The distal
wire (left arrow) marks proximal to the distal radioulnar joint, and the proximal wire (right arrow) mea- STEP 2 PEARLS
sures the osteotomy width.
Although not always necessary, prebending the
ulnar plate before screw placement ensures that
the volar cortex will not open with tightening of the
compression screws.
Step 3: Performing the Oblique Osteotomy
• The amount of bone to be removed can be measured on the 90 to 90 neutral PA view
and should equal the amount of positive ulnar variance plus the amount of negative STEP 3 PEARLS
ulnar variance desired. • Careful retraction of tendons and dorsal sen-
• Generally, 2 to 2.5 mm of negative ulnar variance is desired. The slots (numbered sory branches of the ulnar nerve must be per-
from proximal to distal) that are used to make the parallel oblique osteotomy cuts formed to avoid inadvertent injury from the
will determine the amount of resultant ulnar shortening (slots 1 and 2 5 3.5 mm; saw blade.
• A smaller saw blade (~5 mm) may be used in-
slots 2 and 3 5 4.9 mm; and slots 1 and 3 5 7.4 mm; Fig. 29.18; see also Fig. 29.14). stead of the proposed 10-mm blade to more
• The distal and proximal osteotomies can be performed in sequence. Limited circum- precisely control the osteotomy.
ferential subperiosteal dissection is used to expose the osteotomy site. • It may be necessary to remove the guide to
• Homan retractors are placed behind the ulna to prevent injury to deeper structures, complete the osteotomy.
including the ulnar nerve. Contact with the retractor by the saw blade will cue the • If correctly performed, removal of the wafer
should reveal smooth, parallel surfaces. If
surgeon that the osteotomy is complete. The blade’s trajectory must be seen as it there is a step off, or change in contour, the
traverses the bone to ensure the blade does not plunge deeply past the bone. remaining ulna should be inspected for an
incomplete osteotomy.
• If necessary, a rongeur can be used to smooth
the osteotomy cuts and ensure direct apposi-
tion of the proximal and distal segments.
• Saline irrigation during osteotomy can prevent
heat-induced thermal necrosis of the bone.
• The screws used to hold the guide in place will
be reused to apply the plate. Be sure to keep
track of which holes the screws came from if
the lengths are variable.
FIGURE 29.18 Rayhack device in place, guiding the osteotomy cuts.

• After completion of the osteotomy, the guide can be removed, revealing the wafer of
bone to be discarded.
• For the metaphyseal technique, the K-wires frame the osteotomy site and provide
the wafer width for amount of shortening.
STEP 4 PEARLS
Step 4: Application of the Plate and Compression of the Osteotomy
• The pre-bent six-hole plate is positioned according to the previously identified screw
• The osteotomy must be aligned perfectly
before tightening the compression device. It holes and a 3.5-mm screw is passed into the second hole of the plate (from proxi-
may be necessary to pre-align the proximal mal). The Rayhack compression device is secured using the third hole (through the
and distal ulna before tightening the device. plate and into the ulna) with a screw that is 4 mm longer than the previously selected
• Balanced compression can be confirmed screw (Fig. 29.19).
radiographically.
• Another screw is passed between the compression arms of the device and into the el-
• Avoid overcompression with the external
device because further compression will be liptical hole on the plate and third hole in the bone. Do not fully tighten the screw. Instead,
achieved by the interfragmentary lag screw. leave some laxity to permit movement within the elliptical hole during compression.
• Alternate between tightening each of the longitudinally directed screws on the com-
pression device until the osteotomy surfaces appear to be compressed.
STEP 4 PITFALLS • For the metaphyseal technique, a cannulated screw is used to provide fixation and
• Alternate tightening turns of both compression compression of the osteotomy (Figs. 29.20 and 29.21).
arms. Using only one side for tightening can
create poorly balanced forces that damage the
device.
• For the metaphyseal technique, a point-to-
point clamp can be used to hold the reduction
and prevent distraction while using the screw
across the osteotomy site.
FIGURE 29.19 Application of the plate and compression of the osteotomy.
B
A
FIGURE 29.20 Guidewire for the cannulated screw (A) and derotational wire (B) in place for the me-
taphyseal shortening osteotomy.
FIGURE 29.21 With the derotational wire removed and cannulated screw in place (B), the metaphy-
seal osteotomy site is now compressed (A).
STEP 5 PITFALLS
Step 5: Placement of the Interfragmentary Lag Screw
• The 22-degree angled drill guide is placed into the round hole of the compression Do not drill the far cortex with the 2.7-mm drill bit
because this will prevent proper lag compression.
block.
• A 2.7-mm drill bit is used to drill the near cortex. The far cortex is drilled with a
2.0-mm drill bit.
• After measuring the depth, the drill guide is reapplied, and the far cortex is tapped
with a 2.7-mm tap. Remove the drill guide and then insert a 2.7-mm cortical lag
screw to aid in compression.
Step 6: Final Plate Fixation

• A 2.5-mm drill bit and handheld drill guide are used to drill through the fifth hole of the
plate. The depth is measured, and the hole is tapped. A 3.5-mm cortical screw is placed.
• A locking screw drill guide is inserted into the sixth hole, and a 2.3-mm drill bit is
used to make a hole. This depth is measured, and a 2.7-mm locking screw is placed.
• The longitudinally oriented compression screws of the compression block should be
loosened before removing the screws that are holding it onto the plate.
• After removing the compression device, the original screws for holes 3 and 4 are
re-inserted (Fig. 29.22).
FIGURE 29.22 Final plate fixation for diaphyseal wedge osteotomy shortening.
FIGURE 29.23 Fluoroscopy can facilitate detection of screws that are incorrectly sized.
• The position of the plate and screws is confirmed fluoroscopically (Fig. 29.23).
Replace any incorrectly sized screws.
Step 7: Closure
After release of the tourniquet, ensure hemostasis. The wound should be closed in lay-
ers using interrupted 4-0 Monocryl or 4-0 PDS. An ulnar gutter splint is placed over the
forearm and wrist.
POSTOPERATIVE PITFALLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Complications after ulnar shortening osteotomy • The wrist is maintained in an ulnar-sided splint for 4 weeks. At that time, early range-
include delayed union or nonunion (5%), chronic of-motion exercises can be initiated. Once bony union is evident radiographically
pain, DRUJ stiffness, prominence of hardware (Figs. 29.24 and 29.25), splinting can be discontinued and progressive strengthening
requiring removal (up to 20%), and injury to the
dorsal sensory branch of the ulnar nerve. exercises initiated. In the absence of complications, the patient will have no restric-
tions by 3 months postoperatively.
• The majority of patients will achieve good-to-excellent results in terms of pain con-
trol and recovery of function.
• Ulnar shortening with the metaphyseal technique achieves similar results compared
with the diaphyseal shortening approach (Fig. 29.26).
See Video 29.1
Preoperative Postoperative Preoperative Postoperative

FIGURE 29.24 Three-month postoperative imaging. FIGURE 29.25 Three-month postoperative imaging.
B
A
FIGURE 29.26 Two weeks after metaphyseal shortening for a patient with mild Madelung deformity
and prominent ulna. Note the correction from ulnar positive (A) before surgery to near neutral (B) after.
EVIDENCE
Baek GH, Chung MS, Lee YH, Gong HS, Lee S, Kim HH. Ulnar shortening osteotomy in idiopathic
ulnar impaction syndrome. J Bone Joint Surg Am. 2005;87:2649–2654.
The authors retrospectively reviewed 31 patients who underwent ulnar shortening osteotomy for ulnar
impaction syndrome. An average preoperative ulnar variance of +4.6 mm (range, 2–7.5 mm) was re-
duced to an average of −0.7 mm (range, −4 to +1 mm) postoperatively. Preoperatively, the modified
Gartland and Werley score was an average (and standard deviation) of 69.5 ± 7.6, with 24 wrists
rated poor and 7 rated fair. Postoperatively, the score improved to an average of 92.5 ± 8.0, with
24 wrists rated excellent; 5, good; 1, fair; and 1, poor. Dorsal subluxation of the distal aspect of the
ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening oste-
otomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not
evident 1 to 2 years after the operation.
Baek GH, Lee HJ, Gong HS, et al. Long-term outcomes of ulnar shortening osteotomy for idiopathic
ulnar impaction syndrome: At least 5-years follow-up. Clin Orthop Surg. 2011;3:295–301.
The authors retrospectively reviewed 36 patients who underwent ulnar shortening osteotomy for ulnar
impaction syndrome. At a mean follow-up of 79.1 months, the average modified Gartland and Werley
wrist score improved from 65.5 ± 8.1 preoperatively to 93.4 ± 5.8 at the last follow-up visit. The aver-
age preoperative ulnar variance of 4.7 ± 2.0 mm was reduced to an average of −0.6 ± 1.4 mm post-
operatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 ± 11.1 months follow-up in
6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider
preoperative ulnar variance, a longer distal radioulnar distance, and a greater length of ulnar shorten-
ing, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were compara-
ble to those who did not have osteoarthritic changes in the DRUJ.
Fufa DT, Carlson MG, Calfee RP, Sriram N, Gelberman RH, Weiland AJ. Mid-term results following ulna
shortening osteotomy. HSS J. 2014;10:13-17.
At a minimum of 5-year follow-up, the authors reviewed the results of ulnar shortening osteotomy in a
cohort of 33 patients. Mean follow-up was 10 years. Eighty-eight percent of patients reported they
were either satisfied or very satisfied with the procedure and 91% reported they would have the
same procedure again. At final follow-up, average pain rating was 2 out of 10. The mean Disabilities
of the Arm, Shoulder, and Hand (DASH) score was 11 (range, 0–39). Removal of hardware was per-
formed in 10 patients (30%). The overall rate of reoperation was 45%.
Papatheodorou LK, Sotereanos DG. Step-cut ulnar shortening osteotomy for ulnar impaction syn-
drome. JBJS Essent Surg Tech. 2017;7(1):e3. doi:10.2106/jbjs.st.16.00062.
Article available free on PMC, presenting the technique for step-cut ulnar shortening osteotomy. This is an
excellent technique, especially for situations where added hardware and cutting guides are not available.
Hammer WC, Williams RB, Greenberg JA. Distal metaphyseal ulnar-shortening osteotomy: Surgical
technique. JHS. 2012;37A:1071–1077.
Article describing the metaphyseal shortening technique, another excellent alternative to diaphyseal
shortening when additional hardware and cutting guides may not be readily available.
CHAPTER 30
Distal Radioulnar Joint Reconstruction Using
Palmaris Longus Graft
INDICATIONS
• Chronic, symptomatic distal radioulnar joint (DRUJ) instability that is generally associ-
ated with irreparable triangular fibrocartilage complex (TFCC) injury/degeneration.
• No evidence of distal radioulnar joint arthritis.
• No evidence of a malunited distal radius fracture with resulting DRUJ dysfunction.
Contraindications
Although not a true contraindication, a relatively flat DRUJ may risk failure of the recon-
struction because of inadequate added support and stability from DRUJ anatomy.
• It is important to consider and properly diagnose other conditions that may result in
ulnar-sided wrist pain before performing a DRUJ reconstruction. Ulnar-sided pain
may be caused by extensor carpi ulnaris (ECU) or flexor carpi ulnaris (FCU) tendini-
tis, ECU subluxation, lunotriquetral instability, TFCC injury that does not create
DRUJ instability (e.g., a central TFCC tear), or ulnar impaction syndrome.
• Several clinical examination maneuvers can be useful in confirming instability of the
DRUJ: the piano key sign, the radioulnar ballottement test, the press test, the ulnar
compression test, and the Schaeffer test.
The Piano Key Sign

With the forearm pronated and resting on the table, the ulnar head tends to be promi-
nent when the DRUJ is unstable. If the ulnar head can be depressed easily and springs
back dorsally into the proud position, that is a positive piano key sign.
The Radioulnar Ballottement Test

The examiner stabilizes the distal radius as the distal ulna is moved volar to dorsal with
the other hand (Fig. 30.1). Comparison to the contralateral, unaffected side may reveal
excessive motion or pain. The wrist should be stressed in pronation, neutral, and supi-
nation. More laxity typically occurs in neutral because the radioulnar ligaments of the
DRUJ are tightened in extremes of pronation and supination.
The Press Test

The patient is asked to rise from a chair by pushing off with his or her hands. If instabil-
ity of the DRUJ is present, the affected ulna head will depress in relation to the radius
and compared with the contralateral side. This will result in pain.
Ulnar Compression Test

With the elbow in 90 degrees of flexion and the forearm neutral, manually compress the radius
and ulna at the DRUJ (Fig. 30.2). Pain indicates likelihood of DRUJ arthritis or synovitis.
Schaeffer Test
Use the Schaeffer test to evaluate for the presence or absence of a palmaris longus (PL)
tendon: The patient is asked to oppose the thumb to the small finger and flex the wrist.
If present, the PL tendon will be identifiable and prominent immediately ulnar to the
flexor carpi radialis tendon.
185
186 CHAPTER 30 Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft
FIGURE 30.1 Radioulnar ballottement test. (From

Atzei A, Luchetti R. Foveal. TFCC tear classification FIGURE 30.2 Ulnar/distal radioulnar joint (DRUJ) com-
and treatment. Hand Clin. 2011;27(3):263–272.) pression test.
IMAGING PEARLS IMAGING

Ensure that the lateral radiograph is positioned • Standard posteroanterior (PA), oblique, and lateral x-rays should be obtained with a
correctly: The index, long, and ring metacarpals, the PA and lateral in 90-90 positioning: shoulder abducted to 90 degrees and elbow
proximal pole of the scaphoid on the lunate, and flexed to 90 degrees with wrist neutral. The PA view may reveal widening of the
the radial styloid in the center of the lunate should DRUJ (Fig. 30.3). The lateral view may demonstrate dorsal or volar translation of the
all be aligned. Additionally, the palmar surface of
the pisiform should be visible midway between the ulnar head.
palmar convexities of the distal pole of the scaphoid • The PA view may also demonstrate a fracture through the base of the ulnar styloid
and the capitate (Fig. 30.6). (Fig. 30.4) or a bony avulsion within the ulnar fovea.
• Confirm no notable positive ulnar variance or DRUJ arthritis on PA view.
• A stress view, with wrist loading of 5 to 8 pounds (2.3–3.6 kg), may demonstrate
instability by accentuating a subtle deformity (Fig. 30.5).
DRUJ widening
FIGURE 30.3 Distal radioulnar joint (DRUJ) widening visible on x-ray.
CHAPTER 30 Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft 187
Ulnar styloid
fracture
Stress view
FIGURE 30.4 Ulnar styloid fracture.
FIGURE 30.5 Dorsal displacement of ulnar head
after loading an unstable distal radioulnar joint
(DRUJ).
Palmar surface of pisiform
Proximal pole of scaphoid
FIGURE 30.6 Properly aligned lateral x-ray.
• A computed tomography (CT) scan can confirm subtle degrees of joint instability,
better characterize sigmoid notch alignment, and identify arthritic changes.
• Magnetic resonance imaging (MRI) or arthroscopy can evaluate the TFCC and DRUJ
and rule out or treat other causes of ulnar-sided pain.
SURGICAL ANATOMY
• The DRUJ is an articulation between the sigmoid notch of the radius and the ulnar
head. The DRUJ is stabilized predominantly by ligaments, fibrocartilage of the volar
and dorsal rims of the sigmoid notch, and the shape of the sigmoid notch in the
coronal plane that can be quite variable.
• The extrinsic stabilizers of the DRUJ include the TFCC, pronator quadratus (PQ),
ECU, and interosseous membrane (Fig. 30.7).
• The TFCC refers to all of the soft tissues and support structures that span the DRUJ
and ulnocarpal joints. The TFCC includes the triangular fibrocartilage (TFC, also
known as the articular disk), meniscus homologue, palmar and dorsal radioulnar
ECU tendon
ECU subsheath
PQ
Interosseous
membrane
FIGURE 30.7 Extrinsic stabilizers of the distal radioulnar joint (DRUJ). ECU, Extensor carpi ulnaris;
PQ, pronator quadratus.
ligaments, ulnar collateral ligament, ulnotriquetral ligament, ulnolunate ligament,

ECU subsheath, and prestyloid recess.
• The main stabilizers of the DRUJ are the palmar and dorsal radioulnar ligaments.
These ligaments extend from the palmar and dorsal distal margins of the sigmoid
notch and converge in a triangular configuration to attach to the ulna. Each radioul-
nar ligament divides in the coronal plane into a deep limb that inserts into the ulnar
fovea and a superficial limb that inserts into the midportion of the ulnar styloid
(Fig. 30.8A–B).

EXPOSURES PEARLS
Axial traction is applied to the wrist similar to what is used in preparation for arthros-
Avoid incising the uninjured portions of the TFCC,
including any intact radioulnar ligament. If present, copy. Finger traps should be placed on the index and long fingers, and up to 10 pounds
a tear in the articular disk can be debrided. (4.5 kg) of traction is used to distract the wrist (Fig. 30.9).
EXPOSURES
EXPOSURES PITFALLS
• A Y-shaped dorsal, longitudinal incision is designed over the interval between the
Identify and protect the dorsal sensory branches of fifth and sixth extensor compartments. The longitudinal limb is positioned over the
the ulnar nerve. ulnar styloid. The volar limb extends toward the pisiform and the dorsal limb is
directed toward the Lister tubercle (Fig. 30.10).
STEP 1 PEARLS • The fifth extensor compartment is opened over the DRUJ and the extensor digiti
Avoid injury to normal TFCC structures, including minimi tendon is retracted radially.
the ECU subsheath that reflects over the ulnar • An L-shaped capsular flap is created to expose the DRUJ and TFCC. The longitudi-
styloid. nal limb is designed through the ulnar aspect of the floor of the fifth extensor
compartment and the transverse limb is positioned over the articular cap of the ulna
(Fig. 30.11).
PROCEDURE
Step 1: Inspection of the TFCC and Debridement of Existing Injury
After exposing the TFCC by the aforementioned approach, integrity should be as-
sessed and potential for repair should be determined. If it is not amenable to repair,
debridement of any granulation tissue or scar should be performed (Fig. 30.12).
Scaphoid fossa Lunate fossa PRUL
DRUL TFCC
Ulna styloid
Volar
Dorsal FIGURE 30.9 Finger traps provide axial traction.

TFC superficial limb
TFC deep limit
(ligamentum subcruetum)
Fovea
R U
B
FIGURE 30.8 (A) Cadaver dissection depicting key anatomic structures of the triangular fibrocartilage
complex (TFCC). (B) Illustration of key anatomic structures of TFCC. (From Carr LW, Adams B.
Chronic distal radioulnar joint instability. Hand Clin. 2020;36(4):443–453.)
Dorsal branch
of ulnar nerve DRUJ Ulnar head
FIGURE 30.10 Y-shaped dorsal, longitudinal incision. FIGURE 30.11 Creation of L-shaped capsular flap.
Step 2: Exposuring the Radius

A subperiosteal dissection is performed beneath the fourth dorsal compartment, radial
to the sigmoid notch.
Step 3: Creating a Bone Tunnel Within the Radius

• Use live fluoroscopy to confirm that the entry point on the radius is far enough away
from the sigmoid notch and lunate fossa to avoid inadvertently entering the joint
3
(Fig. 30.13A–B).
• A guidewire for a 3.5-mm cannulated drill is driven through the radius parallel to the
4
articular surface of the sigmoid notch. After confirming proper guidewire placement,
1
the tunnel is formed using a 3.5-mm cannulated drill.
2
Step 4: Creating a Bone Tunnel Within the Ulna
• Subperiosteal dissection is performed around the ulnar neck.
• A guidewire is passed from the ulnar fovea to the subcutaneous border of the ulna,
FIGURE 30.12 Inspection of the triangular fibro- at the level of the ulnar neck.
cartilage complex (TFCC). 1, Ulna head. 2, Ex- • Using a 3.5-mm cannulated drill, create an anterograde tunnel from the ulnar neck
tensor carpi ulnaris tendon. 3, Ulnar corner of to the fovea (Fig. 30.14A–C).
distal radius. 4, Dorsal radioulnar ligament of
TFCC. Step 5: Harvesting the Palmaris Longus Tendon
After identifying the PL tendon, several discontinuous incisions can be made to harvest
STEP 2 PEARLS the full length of the tendon from the wrist to its musculotendinous junction.
Dissection should be carried out approximately
5 mm radial to the sigmoid notch and 5 mm Step 6: Passing the Tendon Graft Through the Radius
proximal to the lunate fossa articular surface in • The volar limb of the Y-shaped incision is used to expose the volar wrist.
preparation for drill hole placement. If the drill hole
• The finger flexor tendons and ulnar neurovascular bundle are retracted to reveal the
is created too close to these articular surfaces,
inadvertent entry into the joint and fracture of the volar wrist capsule.
cortex could occur. • Fluoroscopy is used to confirm the position of the bone tunnel within the radius.
• A suture retriever or fine wire is passed through the bone tunnel from dorsal to volar
to pull the tendon through the radius bone tunnel from volar to dorsal (Fig. 30.15A–B).
STEP 3 PEARLS
The sigmoid notch is a curved structure; be Step 7: Passing the Tendon Through the Ulna
sure that the drill hole is 5 mm or more from the • A straight hemostat is used to create a tunnel through the volar wrist capsule and to
deepest part of the notch, not the rim of the notch
that is often easier to see on fluoroscopy. The same pass the tendon graft from volar (extracapsular) to dorsal back within the capsule.
consideration must also be made for the lunate • This grasps some of the volar capsule with the tendon graft, theoretically provid-
fossa. ing added volar stability to the reconstruction
STEP 5 PEARLS
• Alternatively, a single, transverse incision can
be made over the distal wrist crease where the
palmaris longus (PL) tendon is transected. A
tendon stripper can be passed over the PL
up to the musculotendinous junction while
applying gentle, longitudinal countertraction on
the PL tendon. This returns the full length of
the tendon without the morbidity of several
incisions.
• A strip of flexor carpi radialis tendon can be
used if the PL tendon is absent.
STEP 6 PEARLS
Many surgeons prefer to pass the tendon from
dorsal to volar through the radius to improve
visualization; either approach is acceptable.
A B
FIGURE 30.13 (A–B) Creation of bone tunnels in radius.

Ulna
A B C
FIGURE 30.14 (A–B) Creation of bone tunnels in ulna. (C) Illustration of bone tunnels. (From Carr LW, Adams B. Chronic distal radioulnar joint instability.
Hand Clin. 2020;36(4):443–453.)
Suture
passer
Radius Ulna
PL tendon graft
A B
FIGURE 30.15 (A–B) Tendon graft is passed through the radius.
• Through the dorsal exposure, a hemostat is used to grasp the tendon and bring it STEP 7 PEARLS
through the capsule. Both ends of the tendon graft are then passed through the ulna The ulna bone tunnel may need to be enlarged to
bone tunnel, directed from the fovea to exit the ulna neck, using a suture retriever or accommodate both ends of the tendon graft.
fine wire (Fig. 30.16A–B).
Step 8: Securing the Tendon Graft

• Both limbs of the tendon are wrapped around the neck of the ulna and tension on
the repair is confirmed with the wrist in neutral position.
7
6
ECU 4
3
Wire loop 2
1
Ulna
Wire loop
Tendon graft pulled through
bone tunnel
A B
FIGURE 30.16 (A) Tendon graft is passed through the ulna. (B) Illustration of tendon graft through ulna bone tunnel.
A B
FIGURE 30.17 Fluoroscopy confirms appropriate

FIGURE 30.18 (A–B) Closure of distal radioulnar joint (DRUJ) capsule and extensor retinaculum.
distal radioulnar joint (DRUJ) alignment.
STEP 8 PEARLS
If the tendon graft length is not sufficient to wrap around • The limbs of the tendon are sutured together using 2-0 Ethibond.
the ulna, the graft may be secured in other ways: • Confirm appropriate DRUJ alignment and positioning (Fig. 30.17).
• Bone anchors can be used to secure the ends
of the tendon graft either within the ulnar
fovea or proximal to the exit hole on the Step 9: Closure
subcutaneous border of the ulna. • The DRUJ capsule and extensor retinaculum are closed in a single combined layer
• An interference screw can be placed within the using 3-0 Ethibond suture (Fig. 30.18A–B). The extensor digiti minimi can be left out
bone tunnel, started at the ulna neck and
of the sheath in the subcutaneous plane.
driven toward the fovea.
• Place a second bone tunnel from the fovea to the • The skin of the dorsal and volar wrist is closed in layers with 4-0 Monocryl.
ulnar neck parallel to the initial tunnel and pass • The DRUJ is pinned using a stout pin to stabilize the DRUJ in the neutral posture.
each limb of the graft through a separate tunnel, The pin is removed at 4 weeks before initiating wrist motion.
then secure the graft over the ulnar neck. This ap-
proach may risk fracturing the ulna so a smaller Step 10: Immobilization
drill hole such as 2.0 mm may be considered.
A long-arm splint is applied with the forearm in neutral posture.

• The long-arm splint is removed after 10 to 14 days and the wounds are examined.
The splint is replaced with another long-arm splint for a total duration of 4 weeks of
above the elbow splinting after surgery. The DRUJ pin is removed 4 weeks after
surgery.
• The long-arm splint is replaced with a short-arm splint for an additional 4 weeks, at
which point no further splinting is needed.
• Physical therapy is initiated at 8 to 10 weeks postoperatively, beginning with gentle
range of motion and transitioning to strengthening at 12 weeks.
• The goal should be to recover approximately 85% of forearm motion by 6 months,
compared with the contralateral side.
See Video 30.1
EVIDENCE
Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic
distal radioulnar joint instability. J Hand Surg Am. 2002;27:243–251.
This article describes a commonly used technique of distal radioulnar ligament reconstruction for post-
traumatic DRUJ instability in 14 patients with 4 years’ follow-up. This technique restored stability and
range of motion with pronation and supination for all patients except for those with associated ulno-
carpal ligament injury and sigmoid notch deficiency (Level V evidence).
Lawler E, Adams BD. Reconstruction for DRUJ instability. Hand (NY). 2007;2:123–126.
This article introduces an update of the procedure developed by the senior author that anatomically recon-
structs the palmar and dorsal radioulnar ligaments at their anatomic origins and insertions. It includes an
update on indications/contraindications, surgical technique, rehabilitation, and complications.
Gillis JA, Soreide E, Khouri JS, Kadar A, Berger RA, Moran SL. Outcomes of the Adams-Berger liga-
ment reconstruction for the distal radioulnar joint instability in 95 consecutive cases. J Wrist Surg.
2019;8(4):268–275.
Retrospective review of 95 consecutive wrists in 93 patients treated with a tendon weave DRUJ recon-
struction procedure. The average follow-up time was 65 months. A stable DRUJ was achieved in
over 90% of patients, and 76% reported mild or no pain. Twelve patients (14%) underwent revision at
an average of 13 months after the initial reconstruction, with 86% being considered successful re-
constructions. In this series, using an interference screw to secure the tendon was the most notable
factor associated with failure. Type of graft and notch anatomy were not significant contributors to
failure in this cohort (Level IV evidence).
Teoh LC, Yam AKT. Anatomic reconstruction of the distal radioulnar ligaments: Long-term results.
J Hand Surg Br. 2005;30:185–193.
The authors describe outcomes after open ligamentous repair for chronic DRUJ instability in nine pa-
tients with an average of 9 years of follow-up. Patient outcomes were assessed using the Mayo Wrist
Score. The authors reported significant improvement in wrist scores after the repair that extended
throughout the postoperative period. At follow-up, arthritis did not develop in any patients, but two
patients developed recurrent instability (Level IV evidence).
CHAPTER 31
Procedures for Avascular Necrosis of the Lunate
(Kienböck Disease)
INTRODUCTION
• Kienböck disease describes the avascular necrosis of the lunate. Although its cause
and natural history are uncertain, it is thought to progress through four stages: ne-
crosis and subsequent collapse of the lunate, leading to changes in biomechanics
of the other carpal bones and finally to the development of arthritis.
• Nonoperative management of Kienböck disease is controversial and is usually indi-
cated only in stage I disease.
• Operative treatments fall into 3 categories: (1) strategies to off-load the lunate
(see “Capitate Shortening” or “Radius Shortening”), (2) strategies to revascularize
the lunate (see “Pedicled Vascularized Bone Grafts From the Middle Finger Meta-
carpal or Distal Radius” and “Free Osteochondral Flaps”), and (3) salvage arthrod-
esis procedures (see Chapter 53 Total Wrist Fusion and proximal row carpectomy
[PRC] in Chapter 27 Salvage Procedures for Scaphoid Nonunion).
INDICATIONS
• The treatment of Kienböck disease is guided by its stage. The most common staging
system is the Lichtman classification (Fig. 31.1).
• Stage I: Plain x-ray negative or single linear fracture; decreased signal in lunate
on T1-weighted magnetic resonance imaging (MRI).
• Stage II: Multiple fractures and/or sclerosis seen within the lunate but no evi-
dence of lunate collapse.
• Stage IIIA: Lunate collapse but the carpal alignment has been maintained.
• Stage IIIB: Lunate collapse with fixed scaphoid flexion.
• Stage IV: Arthritis around the lunate.
• If the patient has stage IV disease, salvage procedures are performed (wrist dener-
vation, PRC, or limited arthrodesis, depending on the arthritic surfaces).
• If a patient has stage I, II, or IIIA disease, a combination of lunate off-loading and
revascularization is performed during a single surgical session. We prefer to perform
a capitate shortening osteotomy and pedicled bone flap from the middle finger
metacarpal in most situations because it is relatively simple, requires a limited expo-
sure, and avoids donor site morbidity. Osteochondral flaps may also be considered.
• If a patient has stage IIIB disease, then the biomechanical changes may progress to
arthritis even with off-loading or revascularization procedures. Treatment at this
stage is controversial. Though some surgeons perform off-loading and revascular-
ization procedures, others recommend salvage procedures when symptoms are
intolerable.
Contraindications
• Performing a radial shortening osteotomy in patients with ulnar negative variance
can lead to ulnocarpal abutment syndrome. Capitate shortening osteotomy should
be performed in these patients instead.
• One contraindication is evidence of wrist arthritis.
• Another is flexion of the scaphoid with radioscaphoid angle greater than 60 degrees
because this indicates stage IIIB disease. This is controversial, however, because
some surgeons achieve good results with off-loading and revascularizing proce-
dures in patients with stage IIIB disease.
194
CHAPTER 31 Procedures for Avascular Necrosis of the Lunate (Kienböck Disease) 195
I II
A B
Lunate collapse, Flexion

normal carpal of the
alignment scaphoid
IIIA IIIB
C D
FIGURE 31.1 (A–D) The Lichtman classification for Kienböck disease.
CLINICAL EXAMINATION CLINICAL EXAMINATION PEARLS

• Kienböck disease is difficult to diagnosis early because patients typically present Kienböck disease should be suspected in any
with vague dorsal wrist pain and limited range of motion (ROM), with or without young person with vague wrist pain.
antecedent trauma.
• A thorough wrist examination is necessary to assess ROM, locations of point tender-
ness, and any soft tissue defects.
• The wrist should be examined dorsally and volarly with direct palpation over bone
intervals and the carpus to identify pain and inflammation. The pain may be localized
to the radiolunate joint. It often increases with activity and is relieved with rest and
immobilization.
• Test for pain with axial loading or inherent joint instability because these are relative
contraindications to PRC.
• Check for tendon excursion because the overall kinematics at the wrist will change
with shortening.
• Tenderness is common over the dorsal lunate, which can be palpated just distal and
ulnar to the Lister tubercle.
196 CHAPTER 31 Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)
IMAGING
Radiographs
• Standard radiographs are always obtained to (1) rule out other pathology, (2) diag-
nose stage II or later Kienböck disease, and (3) determine ulnar variance. The lunate
may appear normal on x-rays despite the presence of stage I disease.
• Radiographs can show lunate sclerosis in stage II or lunate collapse in stage III and
beyond (Fig. 31.2). Stage IIIA has normal overall carpal alignment, whereas stage IIIB
has carpal collapse with scaphoid flexion.
• Two measurements are used to distinguish stage IIIA from stage IIIB (Fig. 31.3):
(1) The radioscaphoid angle reflects scaphoid flexion. It is measured between the long
axis of the radius and the axis of the scaphoid and should be between 30 and 60 de-
grees. (2) Carpal height ratio reflects collapse of the carpus onto a collapsed lunate and
flexed scaphoid; it is the ratio of carpal height to middle finger metacarpal height. The
range is 0.52 plus or minus 0.02; less than 0.45 generally indicates carpal collapse.
• Stage IV disease demonstrates arthritis and is treated with observation, rest, and
splinting, or salvage operations such as wrist denervation, PRC, or limited wrist fusion.
Sclerotic
lunate
Coronal
fracture
through
A B lunate
FIGURE 31.2 Radiographs of a patient with stage IIIA disease, PA (A) and lateral (B). Note lunate
sclerosis and collapse on the PA and coronal split on lateral. PA, Posteroanterior.
Axis of
radius
3rd metacarpal
height: 64 mm
Axis of
scaphoid
Carpal height,
measured at
capitate-lunate:
33 mm
Radioscaphoid
angle: 58°
A B
FIGURE 31.3 Same patient from Fig. 31.2. (A) Carpal height ratio is 33/64, or 0.52 (normal).
(B) Radioscaphoid angle is 58 degrees (normal).
• Ulnar variance is measured on a neutral rotation posteroanterior (PA) view. When the
distal radius and ulna are measured at the same level, this is termed neutral variance.
If the ulnar articular surface is distal to the articular surface of the radius, this is
called positive variance. Negative ulnar variance exists when the ulna is proximal to
the radius. Normal variance is considered 22 mm to 12 mm. Pronation (up to 11
mm) and power grip (up to 12.5 mm) may change the articular relationship.
• Shortening the radius can decrease the lunate strain by up to 70%, and 90% of this
can be accomplished with 2 mm of radial shortening.
• If x-rays demonstrate ulnar neutral or ulnar positive variance, shortening of the ra-
dius could lead to ulnocarpal abutment and subsequent wrist pain. In these patients,
a capitate shortening should be considered.
Magnetic Resonance Imaging

Stage I disease is only reliably detected with MRI imaging that demonstrates decreased
T1 signal diffusely throughout the lunate (Fig. 31.4). The decrease in signal intensity
must be seen uniformly throughout the lunate to diagnose avascular necrosis of the
lunate. Ulnar impaction syndrome, fractures, interosseous ganglions, or enchondromas
may cause focal decrease in signal on T1 or hyperintense signal on T2.
SURGICAL ANATOMY
• There is a rich anastomotic network of arteries at the dorsal wrist that provides sev-
eral pedicled bone flap options (Fig. 31.5).
• Pedicled bone flaps either travel above or below the extensor retinaculum. We use
the fourth extensor compartment artery (ECA) bone flap, which travels below the
extensor retinaculum. Other surgeons use bone flaps that travel above the extensor
retinaculum, or “supraretinacular” SRA flaps: the 1,2- and 2,3-intercompartmental
supraretinacular artery (ICSRA).
• For the revascularization procedures presented in this chapter, it is necessary to bur
out the necrotic lunate to receive the pedicled bone flap. It is challenging to fit the flap
within the lunate because the lunate is curved and the bone flap is a cube (Fig. 31.6).
RA dICa
Collapsed
dRCa UA
lunate with T1
hypointensity
on MRI
dSRa
1, 2 ICSRA
2, 3 ICSRA
4th ECA
5th ECA
FIGURE 31.4 T1-weighted MRI showing avascular necrosis of PIA

the lunate with collapse, indicating stage IIIA disease. Stage I aAIA
disease is indicated by a normal x-ray and the same MRI ap- pAIA
pearance of the lunate but no collapse. MRI, Magnetic reso-
nance imaging.
AIA
FIGURE 31.5 There is a rich anastomotic network of vessels around the dorsal wrist
that can supply multiple pedicled bone flaps for lunate revascularization.
FIGURE 31.6 The lunate’s curved three-dimensional shape makes it difficult to remove the central
necrotic bone. Care must be taken to avoid damaging the cortical articular bone.
Capitate Shortening Osteotomy

POSITIONING
• All procedures in this chapter require the same positioning: general anesthetic or a
block and monitored anesthesia care, supine on the operating room table with a
tourniquet.
• Prophylactic antibiotics are administered.
Step 1: Markings
STEP 1 PEARLS
The incision is designed over the fourth extensor compartment, from the distal radius
• Use long incisions to achieve better visualization. to the mid-third metacarpal (Fig. 31.7).
• Confirm markings are over the capitate with
fluoroscopy before incision.
Step 2: Expose the Dorsal Wrist Capsule
• The tourniquet is inflated with minimal exsanguination to help identify vessels.
STEP 2 PEARLS • A standard dorsal approach to the wrist is used to expose the dorsal wrist capsule.
• Elevate thick subcutaneous flaps that contain all Incise through the skin and take care to protect the subcutaneous nerves and veins.
structures superficial to the extensor retinacu- • Identify and transpose the extensor pollicis longus (EPL) to protect it, then enter the
lum. This will ensure that the radial sensory and fourth extensor compartment. Use self-retaining retractors to retract the fourth ex-
dorsal cutaneous ulnar nerves are raised in the
tensor tendons and expose the dorsal wrist capsule.
skin flaps.
• Cauterize any crossing veins. There is no benefit
to preserving them, and they can often bleed
when the tourniquet is taken down.
STEP 2 PITFALLS Capitate, with Sclerotic and

3rd metacarpal two parallel collapsed
The EPL tendon is more easily transected than the lines indicating lunate
fourth extensor tendons because it crosses the resection
dorsal wrist at an angle and is more superficial,
whereas the other extensor tendons are longitudinal
and deeper.
Incision
FIGURE 31.7 Dorsal wrist markings, showing the metacarpal, capitate, and collapsed lunate, with a
dorsal wrist incision placed in line with these structures.
Step 3: Confirm Anatomy With Fluoroscopy STEP 3 PEARLS

Use fluoroscopy to identify the third carpometacarpal (CMC) joint, between the distal
• The pedicles for local bone flaps are close
capitate and third metacarpal; this will form the distal position of wrist capsulotomy. to the capsulotomy incisions required to
Mark with a marking pen. access the wrist; precise cuts in the wrist
capsule can be made at the distal capitate
Step 4: Expose Capitate using fluoroscopic guidance.
• The dorsal interosseous muscles appear distal
A ligament-sparing ulnar-based capsular flap is created to open the wrist.
to the metacarpal bases. The bases articulate
with each other, and then narrow to form the
Step 5: Perform Capitate Osteotomy shafts, between which are the interossei.
A 1-mm wafer of capitate is removed from the proximal third of the bone using a small Therefore the CMC joint is proximal to the
sagittal saw (Fig. 31.9). This wafer of bone can be used as a bone graft to fill the void interossei.
in the long finger metacarpal after harvest.
STEP 3 PITFALLS
Step 6: Perform Hamate Osteotomy if Necessary
The third metacarpal bone flap is taken from the
If the capitate has a pseudoarthrosis with the hamate, then osteotomy is also indicated white-appearing metacarpal base (Fig. 31.8).
for the hamate. Remove a 1-mm wafer of bone from the hamate, proximal to the hook. Recognize that this is not the capitate, and design
a capsule incision proximal to it.
Step 7: Fixation
A 2.5-mm cannulated screw is used to fixate the capitate (and hamate) using Kirschner
STEP 4 PEARLS
wires (K-wires) as guides (Fig. 31.11).
• It is better to protect the bone flap pedicle than
perform a complete ligament-sparing
approach.
• Care is taken to avoid injury to the scapholu-
Location of
nate and lunotriquetral interosseous ligaments.
capitate
Location of 3rd STEP 5 PEARLS
metacarpal base
• The bone will be shortened by approximately
pedicled bone flap
3 mm, given that the sagittal saw is roughly
1 mm thick.
• Use irrigation to cool the bone and facilitate
union.
• Note that the carpal tunnel contents are deep
to the osteotomy.
• If a hamate osteotomy is required as well (see
the following section), this is performed at the
same level as capitate osteotomy. When the
capitate and hamate have tight articulation,
both the hamate and capitate osteotomies are
done proximal to the hamate hook and can be
FIGURE 31.8 Plan a dorsal wrist capsule incision to protect the pedicled bone flap from the third confirmed with fluoroscopy.
metacarpal base. The white structure indicated at left is the third metacarpal base, and the capsule
incision is placed proximal to this.
STEP 5 PITFALLS
Performing capitate osteotomy requires a high level
Capitate osteotomy of skill. Inexperience can lead to median nerve injury.
Bone wafer
removed
STEP 6 PEARLS
Perform hamate osteotomy proximal to the hook to
avoid injuring the ulnar nerve (Fig. 31.10).
STEP 6 PITFALLS
Hamate osteotomy also requires a high level of skill.
An inexperienced surgeon is more likely to injure
the deep branch of the ulnar nerve (see Fig. 31.10).
Location of 3rd STEP 5 PEARLS

metacarpal base
pedicled bone flap • Flex the wrist to ensure that the K-wires have
a straight trajectory.
• Ensure that the screw is not proud (Fig. 31.12).
FIGURE 31.9 Capitate wafer removed.
Abductor digiti minimi

Flexor digiti minimi
Opponens digiti minimi
Ulnar nerve (deep branch)
Hook of hamate
Trans carpal
ligament
Volar carpal Ulnar nerve

ligament (cut) (superficial branch)
Piso-hamate
ligament (cut)
Pisiform
Ulnar artery
PB
TCL
UA FDS
UN MN FPL FCR APB
ADM
OP
FDP APL
Tm EPB
Td RA
H C
ECU
EPL
EDM ECRL
ECRB
EDC
B
FIGURE 31.10 (A–B) Hamate osteotomy must be proximal to the hook of hamate to avoid damage
to ulnar nerve. ([A] from Hagert, E. Nerve entrapment syndromes. In Chang J, Neligan PC, Liu DZ,
eds. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018: 525–548.e5. [B] From
Chhabra, AB. Wrist and hand. In Miller M, Chhabra AB, Park J, Shen F, Weiss D, Browne J.
Orthopaedic Surgical Approaches. 2nd ed. Elsevier: 2014; 105–159.
Cannulated screw over

the K-wire in capitate
FIGURE 31.11 A 2.5-mm cannulated screw is used to fixate the capitate (and hamate) using Kirschner-
wires (K-wires) as guides.
Cannulated screw beneath the

capitate’s articular surface
FIGURE 31.12 Screw beneath the articular surface.

STEP 1 PEARLS
Given the rich anastomotic plexus in the dorsal
Step 8: Closure wrist, multiple pedicles exist and their structures
Perform a pedicled bone flap before closure (see next procedure). vary between patients (see Fig. 31.5). Choose the
largest pedicle that will provide adequate rotation.
PEDICLED VASCULARIZED BONE FLAP FROM MIDDLE
FINGER METACARPAL STEP 1 PITFALLS
Capitate shortening and fixation is performed before the more delicate pedicled bone Avoid a larger pedicle without appropriate reach.
flap procedure.
Step 1: Identify Bone Flap STEP 2 PEARLS

As previously mentioned, use fluoroscopy to identify the metacarpal base that will be • It is safer to use an osteotome rather than a
harvested (see Fig. 31.8). sagittal saw to perform the final osteotomy on
the fourth border, underneath the pedicle.
Step 2: Raise Third Metacarpal Bone Flap • A curved osteotome and a Freer are used to
obtain the corticocancellous bone flap from the
• Use a knife to outline three sides of the bone flap, distal to the pedicle insertion metacarpal base (Fig. 31.13).
(Fig. 31.13). Subsequently, use a sagittal saw to create three osteotomies, ensuring • To help elevate the pedicle, cauterize the adja-
that they do not go through the deep cortex. cent periosteum far from the pedicle, then use
• Use a Freer elevator to lift the pedicle off of the bone before it enters the flap. This a Freer to “roll up” this periosteum toward the
pedicle and ultimately lift the pedicle off of the
creates space to perform the final fourth osteotomy with an osteotome. underlying bone.
Step 3: Prepare the Lunate

STEP 2 PITFALLS
The medullary cavity of the lunate is removed before placement of the bone flap.
• Penetrating the deep cortex during osteoto-
Step 4: Rotate Bone Flap Into Lunate and Fixate as Necessary mies can destabilize the metacarpal.
• Avoid raising the periosteum too close to the
Scissors and bipolar cautery are used to develop the bone flap sufficiently, so that it pedicle to prevent pedicle injury.
can rotate into the prepared lunate (Fig. 31.14).

• Standard wrist closure is performed using 4-0 Vicryl to close the capsule and exten- It can be challenging to fit the cube-shaped bone
sor retinaculum and 3-0/4-0 Monocryl for skin closure. flap into the curved portion of the lunate (see
• The patient is placed in a volar wrist splint and is instructed to return to the clinic in Fig. 31.6). Nevertheless, it is necessary to ensure
7 to 10 days, at which point the wound is inspected and the patient transitions to that as much necrotic lunate is removed as possible
without disrupting the articular surfaces and
cast immobilization. that the bone flap is large enough to encourage
revascularization. This cortical bone graft serves to
PEDICLED VASCULARIZED BONE GRAFT FROM THE DISTAL provide a strut to the lunate to prevent its collapse.
RADIUS
STEP 3 PITFALLS
Step 1: Markings
The same principles apply to the dorsal approach to the wrist, but the exposure is more Avoid fracturing the lunate cortex with bur or
rongeur.
proximal (Fig. 31.16).
Sagittal
saw cuts
STEP 4 PEARLS
• Make the pedicle as short as possible to pro-
tect the collaterals that feed it, also ensuring
that it can be rotated without tension.
• If the bone flap does not fit the lunate well, it is
better to carve the lunate, which is avascular,
rather than the bone flap, which is vascular.
• If the bone flap dislocates from the lunate with
minor movement, fixate with a K-wire (Fig. 31.15).
STEP 4 PITFALLS
Osteotome
Avoid thinning the bone flap at all costs because cut
it has the osteogenic potential to heal the lunate. A
STEP 5 PEARLS
Dexmedetomidine can help this young patient Delicate pedicle
population to emerge from anesthesia calmly,
protecting the delicate reconstruction.
STEP 5 PITFALLS
Lunate preparation, bone flap transposition, and
fixation are delicate; do not be too aggressive with
closure, splinting, or anesthesia emergence.
FIGURE 31.13 (A–B) Two views of the corticocancellous bone flap taken from the third metacarpal
base and its delicate pedicle.
Delicate pedicle
Bone flap beneath this
pedicle, in the lunate
FIGURE 31.14 Scissors and bipolar cautery are used to develop the bone flap sufficiently, so that it
can rotate into the prepared lunate.
STEP 2 PEARLS
• Take care not to damage the fourth ECA
pedicle, found on the floor of the fourth Step 2: Exposure of the Bone Graft Donor Site
extensor compartment just ulnar to the Similar to the first procedure, the skin is incised, subcutaneous flaps are raised by
Lister tubercle (Fig. 31.18). protecting radial sensory and dorsal cutaneous ulnar nerves and dividing superficial
• A posterior interosseous nerve (PIN) neurectomy
veins, the extensor retinaculum is divided and EPL is transposed, and the fourth exten-
can be performed at this time.
sor compartment is entered (Fig. 31.17).
FIGURE 31.15 PA and lateral views showing cannulated screws in the capitate and hamate, and a
Kirschner wire (K-wire) fixating bone flap into lunate. PA, Posteroanterior.
Lister tubercle
FIGURE 31.16 Dorsal approach to the wrist, incising ulnar to the Lister tubercle into the fourth compartment.
FIGURE 31.17 Incising extensor retinaculum and retracting extensor tendons reveals the bone flaps pedicle on the base of the
fourth compartment. ECA, Extensor compartment artery.
Lister tubercle 4th ECA

FIGURE 31.18 Incising extensor retinaculum and retracting extensor tendons reveals the bone flaps
pedicle on the base of the fourth compartment. ECA, Extensor compartment artery.
Dorsal lunate
removed
Lunate
prepared
FIGURE 31.19 The lunate is found just distal and ulnar to the Lister tubercle. Confirm its position
clinically and radiographically.
STEP 3 PITFALLS Step 3: Exposure of the Lunate

Care is taken to avoid injury to the scapholunate • The lunate is found just distal and ulnar to the Lister tubercle. Confirm its position
and lunotriquetral interosseous ligaments. clinically and radiographically (Fig. 31.19).
• An ulnarly based flap of dorsal wrist capsule is raised to expose the lunate.
Step 4: Prepare the Lunate

See the pedicled vascularized bone flap from the middle finger metacarpal procedure
(Step 3 and Fig. 31.8).
STEP 5 PEARLS Step 5: Elevation of the Pedicled Fourth Extensor Compartment

• It is important to maintain maxi harvested and Artery Bone Flap
raised in a similar fashion to the third metacar-
• The fourth ECA is carefully dissected proximal to its bifurcation with the fifth ECA
pal base mal proximal-to-distal length when fit-
ting the flap into position to prevent collapse of (see Fig. 31.5).
the lunate. • The fourth ECA pedicle is divided just proximal to this bifurcation, producing a dis-
• The thicker cortical side of the bone flap tally based flap based on the fifth ECA (Fig. 31.20).
should be placed within the lunate to maximize • The corticocancellous flap is harvested and raised in a similar fashion to the third
the strut support. Care must be taken to avoid
metacarpal base flap, as described in the pedicled vascularized bone flap from the
disruption of the periosteal blood supply to the
flap. middle finger metacarpal procedure (Step 2; Fig. 31.21).
• The flap is placed into the prepared lunate (Fig. 31.22).
FIGURE 31.20 The fourth ECA pedicle is divided just proximal to this bifurcation, producing a distally based flap based on the fifth
ECA. ECA, Extensor compartment artery.
Sagittal saw Osteotome osteotomy

osteotomies
A B
Bone flap pedicle
Bone flap
pedicle
Bone flap
C D
FIGURE 31.21 (A–D) The corticocancellous flap is harvested and raised in a similar fashion to the third metacarpal base flap, as
described in step 2 of the pedicled vascularized bone flap from middle finger metacarpal procedure.
Step 6: Unload the Lunate by Pinning the Scaphoid to the Capitate

• This step is not always performed.
• While distracting the wrist, a 0.062-in (1.57-mm) K-wire is passed from the scaphoid to
the capitate to unload the lunate.
• The K-wire position is confirmed radiographically (Fig. 31.23).
Bone flap
pedicle
Bone flap
placed into
prepared
lunate
FIGURE 31.22 The flap is placed into the prepared lunate.
A B
FIGURE 31.23 The Kirschner wire (K-wire) position is confirmed radiographically.
Step 7: Closure
• Standard wrist closure is done using 4-0 Vicryl to close the capsule and extensor
retinaculum and 3-0/4-0 Monocryl skin closure.
• The patient is placed into a volar wrist splint and is instructed to return to the clinic
STEP 1 PEARLS in 10 to 14 days, at which point the wound is inspected and the sutures removed.
• The radial shaft osteotomy is designed proximal

to the distal radius metaphyseal flare, which is RADIAL SHORTENING OSTEOTOMY FOR LUNATE
more proximal than most distal radius expo- UNLOADING
sures. Fluoroscopy is useful to confirm that the
incision design is proximal enough (Fig. 31.25). Step 1: Markings
• The FCR tendon can be readily palpated and A standard volar Henry approach is taken, using an 8- to 10-cm longitudinal incision
marked when the patient is awake and flexes
their wrist. over the FCR (Fig. 31.24).
Step 2: Exposure of the Radius in Preparation for the Osteotomy

STEP 2 PEARLS • Under tourniquet control, the skin is incised, exposing the FCR tendon. A longitudi-
It is possible to approach the FCR radially instead nal incision is performed along the radial border of the FCR and the tendon is re-
of ulnarly. Nevertheless, this approach puts the tracted ulnarly.
palmar cutaneous median nerve at greater risk for • The interval between the FCR and radial artery is entered and the flexor pollicis
injury.
longus (FPL) is identified and protected.
FIGURE 31.24 A standard volar Henry approach is taken, using an 8-to 10-cm longitudinal incision
over the FCR. FCR, Flexor carpi radialis.
A B
FIGURE 31.25 The radial shaft osteotomy is designed proximal to the distal radius metaphyseal
flare, which is more proximal than most distal radius exposures. Fluoroscopy is useful to confirm that
the incision design is proximal enough.
• The radial pronator quadratus attachments are released from the radius using a
scalpel or bipolar cautery, and the radius is dissected subperiosteally to place the
cutting jig (Fig. 31.26).
• The radial shaft osteotomy is designed proximal to the distal radius metaphyseal
flare (see Fig. 31.25).
• If the cutting jig is unavailable, a compression plate can be used with screws placed
eccentrically.
Step 3: Radius Osteotomy STEP 3 PEARLS

• A Rayhack device is used to create a precision oblique osteotomy. A six-hole, low- • Saline irrigation during osteotomy can prevent
profile locking plate, or a six-hole, limited-contact dynamic compression plate can heat-induced thermal necrosis of the bone.
be used. Alternatively, the newer low-profile locking plates can be used to reduce • The screws used to hold the guide in place will
be reused to apply the plate. Be sure to keep
the incidence of soft tissue irritation that can require plate removal. track of which holes the screws came from
• If the cutting guide is not available, two parallel transverse osteotomies can be cre- and the screw lengths, if they are different.
ated proximal to the metaphyseal flare of the radius. The cuts must be parallel to
avoid alteration of the tilt or inclination of the distal radius articular surface.
• The amount of bone to be removed can be measured on the neutral PA view and
should not result in significant ulnar positivity after compression.
• In general, about 2 to 3 mm of radial shortening is desired (Fig. 31.27).
• Using the Rayhack system, an oblique 2-mm shortening osteotomy is performed
by sagittal saw. The distal osteotomy is performed first, followed by the proximal
osteotomy.
A B
FIGURE 31.26 (A–B) The radial pronator quadratus attachments are released from the radius using a scalpel or bipolar cautery,
and the radius is dissected subperiosteally to place the cutting jig.
A B
FIGURE 31.27 (A–B) In general, about 2 to 3 mm of radial shortening is desired.
• The anticipated shortening using the Rayhack system depends on the slots that are
used to make the parallel oblique osteotomy cuts.
• Using slots 1 and 2 (from proximal) will result in approximately 3.5 mm of shortening.
• Slots 2 and 3 result in 4.9 mm of shortening, and slots 1 and 3 result in 7.4 mm of shortening.
Step 4: Fixation
• The plate is selected from the set and placed within the wound at the level of the
desired osteotomy. The distal end of the plate should be approximately 2 to 3 cm
from the distal radius watershed line. The second hole (from proximal) is marked on
the bone, and then the plate is replaced with the cutting guide; its second hole (from
proximal) is lined up with the marking.
• The cutting guide is held manually and, using a straight drill guide, a 2.5-mm drill is used
to make a hole through the second hole on the cutting guide. The depth of the hole is
measured, the hole is tapped with a 3.5-mm tap, and a 3.5-mm cortical screw is inserted.
This procedure is repeated for the fourth and then the third holes on the cutting guide.
STEP 5 PITFALLS
Care should be taken to avoid drilling the far cortex Step 5: Placement of the Interfragmentary Lag Screw
with the 2.7-mm drill bit because this will limit • The 22-degree angled drill guide is placed into the round hole of the compression
compression.
block.
• A 2.7-mm drill bit is used to drill the near cortex, and the far cortex is drilled with a
2.0-mm drill bit.
• After measuring the depth, the drill guide is reapplied, and the far cortex is tapped
with a 2.7-mm tap. The drill guide is removed, and the 2.7-mm cortical lag screw is
inserted to provide additional compression.
Step 6: Final Plate Fixation STEP 6 PITFALLS

• A handheld drill guide and a 2.5-mm drill bit are used to make a hole through the fifth hole Loosening the longitudinally oriented screws of the
of the plate. This hole is measured and tapped, and a 3.5-mm cortical screw is placed. compression block will make it easier to remove
• A locking screw drill guide is inserted into the sixth hole, and a 2.3-mm drill bit is the screws that are holding it onto the plate.
used to make a hole. This hole is measured, and a 2.7-mm locking screw is placed.
• The compression device is removed, and the original screws for holes 3 and 4 are
reinserted. The position of the plate and screws is confirmed fluoroscopically
Step 7: Closure
After releasing the tourniquet, ensure hemostasis. The wound should be closed in layers
using interrupted 4-0 Monocryl or 4-0 PDS.

• A volar wrist splint is placed and the patient is instructed to return to the clinic in
10 to 14 days for wound check and suture removal. Complications after radial shortening osteotomy
include delayed union or nonunion, chronic pain,
• The wrist is maintained in a short-arm cast for 6 to 12 weeks or until clinical and distal radioulnar joint stiffness, prominence of
radiographic confirmation of union. At that time, early ROM exercises can be initi- hardware requiring removal, and injury to the
ated. Once bony union is evident radiographically, splinting can be discontinued and palmar cutaneous branch of the median nerve.
progressive strengthening exercises can be initiated.
• Fig. 31.28 demonstrates maintenance of hardware without complication and slight
ulnar positive variance at 8 months’ follow-up, after radial shortening osteotomy.
• Fig. 31.29 is at 6 weeks postoperative from procedures 1 and 2 and shows radio-
graphic healing of capitate and hamate shortening osteotomy, new radiopacity in the
lunate, and clinical ROM.
• The majority of the patients achieve good to excellent results in terms of pain control
and recovery of function.
• Computed tomography or MRI can be performed at approximately 3 months to as-
sess for union and/or vascularity of the lunate, but neither are necessary.
• Some patients will go on to require a salvage operation, such as a wrist fusion or
total arthroplasty.
See Video 31.1
A B C
FIGURE 31.28 (A-C) Postoperative radiographs.

A B
FIGURE 31.29 (A–B) Postoperative radiographs.
EVIDENCE
Almquist EE, Burns Jr JF. Radial shortening for the treatment of Kienböck’s disease—a 5 to 10 year
follow-up. J Hand Surg Am. 1982;7:348–352.
The authors reviewed a series of patients who underwent radial shortening osteotomy for Kienböck
disease and had intermediate to long-term follow-up. Eleven of the 12 patients were satisfied with
their treatment and showed functional improvement. These patients returned to their normal
activities. Grip strength was satisfactory, and ROM improved after surgery.
Elhassan BT, Shin AY. Vascularized bone grafting for treatment of Kienböck’s disease. J Hand Surg.
2009;34A:146–154.
In this review article, the authors discuss indications and vascularized bone grafting techniques for the
treatment of Kienböck disease.
Moran SL, Cooney WP, Berger RA, Bishop AT, Shin AY. The use of the 4/5 extensor compartmental
vascularized bone graft for the treatment of Kienböck’s disease. J Hand Surg Am. 2005;30:50–58.
The authors from the Mayo Clinic published their results using this technique. Twenty-six patients were
followed for an average of 31 months. Ninety-two percent of the wrists were pain-free. Grip strength
increased from 50% of the contralateral extremity to 89% postoperatively. During follow-up, 23% of
patients developed radiographic evidence of continued collapse of the lunate. MRI was performed at
an average 20 months after surgery on 17 wrists, and 71% had evidence of revascularization. There
were two failures in the study cohort who underwent total wrist arthroplasty.
Rock MG, Roth JH, Martin L. Radial shortening osteotomy for treatment of Kienböck’s disease. J Hand
Surg Am. 1991;16:454-460.
The authors reviewed 16 patients who underwent shortening of the radius for Kienböck disease stages
II, III, and IV. Average follow-up was 4.5 years. Thirteen of 16 patients were pain-free and 3 had mild
pain at follow-up. ROM and grip strength increased in all patients. Radiographic alignment was
preserved in all but one patient in whom carpal collapse was observed.
Weiss AP, Weiland AJ, Moore JR, Wilgis EF. Radial shortening for Kienböck disease. J Bone Joint Surg
Am. 1991;73:384-391.
Twenty-nine consecutive patients who underwent radial shortening osteotomy for Kienböck disease
stages I, II, IIIa, and IIIb were reviewed. Average follow-up was 3.8 years. Pain had decreased in 87%
of the wrists. Extension of the wrist had improved an average of 32%; flexion, 27%; radial deviation,
30%; ulnar deviation, 41%; and grip strength on the affected side, 49%. Analysis of the radiographs
showed no significant changexs in the amount of collapse of the lunate at the latest follow-up. There
were two complications at follow-up, excessive shortening of the radius and nonunion of the radial
osteotomy.
ddsf
SECTION IV
Forearm Fractures
CHAPTER 32 Operative Treatment of Distal Radius
Fractures 212
CHAPTER 33 Corrective Osteotomy of Radius Malunion 243
CHAPTER 34 Associated Ulnar Fixation (Ulnar Styloid and
Metadiaphyseal Fractures) 258
CHAPTER 35 Radius and Ulna Fracture Dislocations
(Galeazzi and Monteggia) 266
211
CHAPTER 32
Operative Treatment of Distal Radius Fractures
INDICATIONS
Operative management is indicated for distal radius fractures that have a dorsal tilt
greater than 10 degrees, radial inclination angle of less than 15 degrees, radial shortening
greater than 5 mm, positive ulnar variance greater than 3 mm, and/or an intraarticular
step-off greater than or equal to 2 mm.
• The wrist should be assessed for deformity and any open wounds. Open fractures
require urgent washout, fracture treatment, and antibiotics.
• Significant displacement of the ulna may indicate ligamentous injury. The distal ra-
dioulnar joint (DRUJ) should be assessed for instability.
• A complete neurovascular examination should be performed, with specific attention
paid to median nerve function. Findings that indicate compromised median nerve
function include numbness over the volar thumb, index, and middle finger, and
numbness along the radial aspect of the ring finger and the corresponding part of
the palm.
• The elbow should be assessed for tenderness and deformity. These findings could
indicate an associated radial head fracture or dislocation. Fracture patterns com-
monly associated with radial head trauma include:
• Essex-Lopresti injury: A fracture of the radial head with disruption of the forearm
interosseous membrane and DRUJ dislocation.
• Monteggia fracture: Ulnar shaft fracture with associated radial head dis-
location.
IMAGING
• Anteroposterior (AP), lateral, and oblique images of the wrist should be obtained.
Proper reduction should restore radial inclination to 22 to 25 degrees, radial height
to 10 to 15 mm, and volar tilt to 11 to 15 degrees (Fig. 32.1A–C).
• The fracture pattern of the distal radius is assessed, such as whether the fracture
pattern is intraarticular or extraarticular.
• The ulna should be assessed for injury and the carpal bones assessed for displace-
ment, abnormal spacing, or concomitant fracture.
• Pay attention to the integrity of the radial shaft and metacarpals to ensure that these
are available to provide sites for external fixation if necessary.
• Computed tomography (CT) and magnetic resonance imaging (MRI) are usually un-
necessary. Nevertheless, these imaging modalities can provide more detailed infor-
mation for cases with comminuted articular fracture or suspicion of an associated
lesion, such as ligament and carpal bone injuries.
Percutaneous Pinning of Distal Radius Fractures:

Kapandji Pinning Technique
INDICATIONS
• Displaced and unstable extraarticular distal radius fractures, with minimal comminution
(Fig. 32.2A–C).
• Simple two-part or three-part intraarticular distal radius fractures.
• Displaced distal radius fractures in children or adolescents.
212
CHAPTER 32 Operative Treatment of Distal Radius Fractures 213
Volar
tilt
Radial Radial
inclination height
A B C
FIGURE 32.1 (A) Radial inclination is measured on the anteroposterior (AP) view as the angle of the articular surface of
the radius relative to a line perpendicular to the shaft. (B) Radial height is measured on the AP view as a distance
between two parallel lines perpendicular to the radius. One line is drawn at the top of the radial styloid, and another is
drawn at the base of the articular surface. (C) Volar tilt is assessed on the lateral view. It is the angle between the radial
articular surface and a line perpendicular to the long axis of radius.
A B C
FIGURE 32.2 (A–C) A distal radius fracture that is indicated for operative management because of exces-
sive radial shortening, decreased radial height, and dorsal tilt.
SURGICAL ANATOMY
• Extensor tendons, the cephalic vein, and the superficial radial nerve are at potential
risk for injury when inserting the pins.
• Radial-sided pins are placed between the first and second dorsal compartments.
• Dorsal-ulnar pins are placed in the intermediate column of the radius between the
fourth and fifth extensor compartments.
POSITIONING
A radiolucent hand table is used with the forearm placed in a pronated position.
EXPOSURES
• Percutaneous Kirschner wire (K-wire) pinning can be performed in most cases. The
K-wires are relatively blunt and will not skewer the tendons and nerves during the
drilling process. Therefore most cases will not need open exposures.
214 CHAPTER 32 Operative Treatment of Distal Radius Fractures
• For some patients who present with previous trauma or scar tissue over the insertion
site, a so-called “mini-open” technique using 1 to 2 cm incisions can be performed
to prevent injury to the underlying tendons and nerves during pinning. With the open
approach, the soft tissue flaps are elevated, and the skin is retracted. Branches of
the superficial radial nerve are identified and carefully protected.

• If there is difficulty in reducing the fracture, a
blunt Freer elevator can be placed percutane- Step 1
ously. This can be inserted into the fracture • The first 0.062-in (1.57-mm) K-wire is inserted into the radial aspect of the dorsal
site dorsally and used to lever the fracture into fracture line until the volar cortex is felt (Fig. 32.3A–B). This step is necessary to
a reduced position.
achieve suitable dorsal volar inclination of 11 degrees.
• To maintain stability in the volar cortex, the
K-wire should be drilled only once. Drilling, • Using the dorsal cortex as a lever’s fulcrum, the wire driver and wire are then moved
reversing, and then redrilling can lead to distally to lever and buttress the distal radial fragment into reduction (see Fig. 32.3C).
loosening of the wire and fixation. • With the fracture reduced, this pin is advanced into the volar cortex to secure the
reduction. Be sure not to pass the K-wire back and forth over the volar cortex, which
will enlarge the drill hole and loosen the K-wire.
STEP 1 PITFALLS
• A second pin should always be placed in the dorsoulnar aspect of the fracture to
Care should be taken not to over-reduce the further support the reduction (Fig. 32.4A–C).
fragment. Excessive flexion can displace the
fragment volarly.
Step 2
• A third pin is inserted in the radial aspect of the fracture line, perpendicular to the
STEP 2 PITFALLS dorsal-volar pins (Fig. 32.5A–B). The aim of this pin is to restore radial inclination and
prevent radial translation of the distal segment.
Applying a lever force at the tip of the wire will
lead to bending of the wire without reducing the • The entire pin is then translated distally, with the surgeon’s fingers levering and
fracture. Force is applied as close to the bone pushing the distal fragment to restore radial inclination (see Fig. 32.5C–D). Do not
as possible while pushing with fingers to guide bend the K-wire during this reduction maneuver. Gently lever the distal fragment
the distal fragment into reduction. An acceptable using pin and finger pressure.
reduction is achieved when the thick volar cortices • The pin is then driven through the ulnar cortex of the radius to secure its position
are aligned, rather than overlapping.
(Fig. 32.6).
A B C
FIGURE 32.3 (A–C) A Kirschner wire (K-wire) is inserted into the ulnar aspect of the dorsal fracture line.
The wire driver and wire are then moved distally to reduce the distal radius fragment.
A B C
FIGURE 32.4 (A–C) A second pin is placed in the dorsoradial aspect of the fracture to further support
the reduction.
A B
C D
FIGURE 32.5 (A–B) A third pin is inserted in the radial aspect of the fracture line perpendicular to the
dorsal-volar pins. (C–D) The entire pin is translated distally to restore radial inclination.
FIGURE 32.6 The pin is then driven through the ulnar cortex of the radius to secure its position.

A fourth pin is placed through the cortex of the radial styloid and advanced into the Percutaneous pinning can lead to tethering of the
ulnar cortex to secure the reduction achieved by the intrafocal wires (Fig. 32.7). surrounding skin. Skin incisions may be necessary
to release tethering around any pins.
Step 4
• Several different percutaneous techniques have been described and can be tailored STEP 3 PITFALLS
to the fracture pattern (Fig. 32.8A–D): Because the radial styloid can be easily fragmented,
(A) Multiple radial styloid pins avoid multiple passes of the K-wire.
(B) Cross radial pins
(C) Radial styloid and radial-ulnar pins, which can stabilize the DRUJ
(D) The De Palma technique, which uses the ulna to support the radius. Pins are
placed from the ulna toward the radial styloid, targeting both the volar or dorsal
cortex of the radius with separate pins.
• Pediatric fractures of the epiphysis in some cases can be treated adequately with a
single radial pin (Fig. 32.9A–D).
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE CARE PEARLS

• Patients are seen after 2 weeks for a dressing change and are converted to a remov- Prolonged immobilization delays restoration of
able thermoplastic splint. motion. Pins should be removed, and motion
initiated as soon as there is evident callus formation
• The removable splint provides stability and enables cleaning of the pins. Active
to provide stability from displacement.
range of motion (ROM) of the fingers and elbow are initiated.
FIGURE 32.7 A fourth pin is placed through the cortex of the radial styloid and advanced into the
ulnar cortex.
A B
C D
FIGURE 32.8 (A) Multiple radial styloid pins. (B) Cross radial pins. (C) Radial styloid and radial-ulnar
pins, which can stabilize the distal radioulnar joint (DRUJ). (D) De Palma technique.
POSTOPERATIVE CARE PITFALLS
For older patients who do not have attendant care,
or if a patient is at risk for poor hygiene habits, • Pin tract infection (Fig. 32.10) is a potential complication of percutaneous pinning,
pins should be buried beneath the skin at the time which presents with redness, warmth, swelling, and continuous discharge at the pin
of the initial operation to reduce infection risk. The sites. If pin tracts become infected, pins are removed immediately, although this
pins can be retrieved later with a short second
premature removal may lead to fracture collapse if the fracture has not reached full
procedure under local anesthesia.
stability. Failure to promptly recognize and treat pin tract infections can cause the
A B
C D
FIGURE 32.9 (A–D) Pediatric fractures of the epiphysis in some cases FIGURE 32.10 Redness, swelling, and discharge at the pin sites indi-
can be treated adequately with a single radial pin. cate pin tract infection.
infection to progress to osteomyelitis, a disastrous complication that must be

avoided at all costs.
• To prevent pin tract infections, K-wires should be inspected and cleaned several
times daily with 50% peroxide solution.
• The K-wires are removed 6 weeks after surgery.
External Fixation of Distal Radius Fractures

INDICATIONS
• Distal radius fractures with severe comminution.
• Fractures with significant impaction (Fig. 32.11).
• Open injuries with significant soft tissue loss that may preclude the use of internal
fixation.
SURGICAL ANATOMY
• The distal pins are placed along the dorso radial aspect of the second metacarpal.
The superficial radial sensory branch runs near the incision site and must be ele-
vated away and protected.
• The proximal pins are placed along the dorsal radial shaft of the radius. The position
is proximal to the crossing of the tendons of the first compartment and distal to the
insertion of the pronator teres (PT). The radial sensory nerve is also located in this
area and should be protected. EXPOSURES PITFALLS
Pure percutaneous placement or open incisions
EXPOSURES without adequate visualization increase the risk for
• A 3-cm longitudinal incision is made along the dorsal radial side of the second meta- iatrogenic nerve injury.
carpal (Fig. 32.12).
FIGURE 32.12 Two 3-cm longitudinal incisions (black dotted lines) are
FIGURE 32.11 Preoperative films of a patient with an impacted, dorsally made along the dorso radial aspect of the second metacarpal and the
angulated, and comminuted fracture. dorso radial aspect of the radius.
• Another 3-cm longitudinal incision is made on the dorso radial aspect of the radius,
8 to 12 cm proximal to the wrist (see Fig. 32.12). Blunt dissection is used to expose
the radius and proceeds between the tendons of the brachioradialis (BR) and exten-
sor carpi radialis longus (ECRL).
STEP 1 PITFALLS
PROCEDURE
• Avoid oversinking the pins. This may inadver-
tently injure the interossei muscles. Step 1
• A pin placed too dorsal or volar can risk frac-
• A 3-mm partially threaded pin (Fig. 32.13) is inserted in a plane parallel to the meta-
turing the cortical bone of the metacarpal.
carpals near the base of the index finger metacarpal using a double pin guide. The
pin is driven perpendicular to the index finger metacarpal shaft (Fig. 32.14). Be sure
that the pin is centered over the bone to avoid iatrogenic fracture.
• The pin is centered between the dorsal and volar cortex and then driven from the
radial cortex of the metacarpal to the ulnar cortex.
• The parallel pin guide is used to place a second pin distal to the first. The guide
facilitates insertion of the second pin at the same angle and plane as the first pin.
FIGURE 32.13 The 3-mm partially threaded pins are used for FIGURE 32.14 The pins are inserted in a parallel plane using the double
external fixation. pin guide.
FIGURE 32.15 All pins should be in a similar plane and at the same angle.

• After exposure of the radius, a 3-mm partially threaded pin is inserted perpendicular The partially threaded pins used for this procedure
to the radial shaft between the BR and ECRL tendons in the same plane as the are self-tapping. Therefore these pins should be
metacarpal pins. inserted with enough force to avoid getting stuck
at the far cortex, which can lead to widening of
• A second pin is inserted distal to the first pin using the parallel pin guide.
the hole in the near cortex and pin loosening.
• All pins should be in a similar plane and angle (Fig. 32.15). An alternate pin site needs to be chosen if this
happens.
Step 3
• The proximal and distal incisions are closed with 4-0 nylon sutures around the pins.
• A single distraction rod is applied, and the fracture is reduced into anatomic align- STEP 3 PEARLS
ment using ligamentotaxis by distracting the wrist joint and using the ligaments
Ensure adequate skin-to-fixator distance so that
around the wrist to reduce the fractures (Fig. 32.16). the device will not impinge on the soft tissues as
• More complex fractures may require a multibar system. they swell postoperatively.
• Percutaneous pins or open reduction and internal fixation can be used to supple-
ment external fixation for adequate restoration of the articular surface.
STEP 3 PITFALLS
• The pins are wrapped with petroleum gauze to protect the incisions until they heal.
Take care not to injure the radial nerve and
POSTOPERATIVE CARE AND EXPECTED OUTCOMES branches during closure because these structures
lie directly beneath both incisions.
• Dressings and sutures are removed at 10 to 14 days.
• Patients can use soap and water to clean around the pins but should not wet the
entire fixator in the shower or bath.
• Finger ROM is encouraged after suture removal (Fig. 32.17).
• The fixator is removed in the office at 5 to 6 weeks.
• Patients can achieve excellent ROM at follow-up, but it may take several months
because of prolonged wrist immobilization.
FIGURE 32.16 A single distraction rod is applied and the fracture is reduced. Anatomic alignment is
verified radiographically.
FIGURE 32.17 Finger motion is encouraged after suture removal. This patient achieved excellent recovery of
range of motion at 1 month.
Volar Plate Fixation

INDICATIONS
• Comminuted or unstable intraarticular fractures (Fig. 32.18)
• Unstable extraarticular fractures
• Volar shearing fractures
SURGICAL ANATOMY
• The palmar cutaneous branch of the median nerve is ulnar to the flexor carpi radialis
(FCR). For incisions radial to the FCR, there is no need to visualize this nerve during
exposure (Fig. 32.19).
Palmar cutaneous
branch of median
nerve
Flexor digitorum
Radial artery
superficialis
Median nerve
Palmaris longus
Flexor pollicis
(retracted)
longus
Flexor carpi
radialis
Brachioradialis
FIGURE 32.18 Preoperative films of a patient with an intraarticular frac-

ture of the distal radius with dorsal displacement and angulation. FIGURE 32.19 Surgical anatomy of volar plating.
• The dissection takes place along the border of the FCR through the subcutaneous
tissue to find the flexor pollicis longus (FPL).
• Retracting the FPL ulnarly protects the median nerve.
• A superficial branch of the radial artery courses slightly ulnar near the distal aspect
of the dissection and should be protected.
POSITIONING
• The upper extremity is extended on a hand table with the forearm supinated.
EXPOSURES
• A 7- to 10-cm longitudinal incision is made along the radial border of the FCR, start-
ing at the wrist crease and proceeding proximally. If more distal exposure is needed,
the incision is extended as a zigzag over the joint (Fig. 32.20). EXPOSURES PEARLS
• Use a sharp blade to perform the dissection. Identify and protect the radial artery
A blunt, rather than sharp, self-retaining retractor
and associated veins by retracting them radially. Crossing arterial branches are should be used to hold the exposure and avoid
cauterized. puncturing critical structures.
• The FPL tendon and its muscle belly are manually swept away using a finger
(Fig. 32.21) and then retracted ulnarly to expose the pronator quadratus (PQ;
EXPOSURES PITFALLS
Fig. 32.22A).
• The PQ is divided with an L-shaped incision along its radial and distal border, then Take care not to disrupt the volar carpal ligaments
elevated (see Fig. 32.22B). from the radius, which can occur if the surgeon
dissects too far distally.
• An elevator is used to strip the periosteum and expose the fracture (Fig. 32.23).
FIGURE 32.20 Longitudinal incision along the radial border of the flexor
carpi radialis (FCR), extended as a zigzag over the joint if more distal FIGURE 32.21 The flexor pollicis longus (FPL) tendon and its muscle
exposure is necessary. belly are manually swept away.
A B
FIGURE 32.22 (A) The flexor pollicis longus (FPL) is retracted ulnarly to expose the pronator quadratus (PQ). (B) The PQ is divided along its
radial and distal border.
FIGURE 32.23 An elevator strips the pronator quadratus and exposes the fracture. The white arrow indi-
cates the comminuted metaphyseal region.

• Releasing the insertion of the BR may facilitate
reduction because this minimizes the deform- Step 1: Fracture Reduction
ing forces on the distal segment, particularly • The fracture anatomy is identified. The volar fragments are disimpacted by hyperex-
when the distal fragment is translated radially tension of the wrist.
(Fig. 32.25). • An osteotome is placed into the volar fracture line to lever the segments into reduc-
• Ensure that all fracture fragments are mobile
enough for reduction. tion (Fig. 32.24A–C). The repositioning is aided by simultaneous traction.
• The reduction can be temporarily secured with • The reduction is checked both visually and with fluoroscopy.
a radial styloid 0.045-in percutaneous K-wire.
A B
FIGURE 32.24 (A) An osteotome is placed into the volar fracture line. (B) Lever the volar displaced
and tilted segment into reduction. (C) Lever the dorsal displaced and tilted segment into reduction
with the opposite direction.
A non-locking screw in the elliptical hole
FIGURE 32.26 A nonlocking bicortical screw is drilled and placed into

FIGURE 32.25 Releasing the insertion of the brachioradialis can mobilize
the elongated central elliptical hole over the radial diaphysis, which
the distal segment and facilitate reduction. The white arrow points to the
permits proximal and distal translation guided by fluoroscopy.
brachioradialis tendon.
Step 2: Plate Placement and Shaft Fixation STEP 2 PEARLS

• After assessment of the reduction, a volar plate is selected. • Most plating systems offer a variable length of
• The plate is centered on the radial shaft and placed distal enough to capture the the diaphyseal component and wider or slim-
distal fragment(s). The plate can be checked under fluoroscopy and adjusted as mer options for the metaphyseal component,
depending on the size of the radius and frac-
necessary. ture anatomy.
• A nonlocking bicortical screw is drilled and placed into the elongated central elliptical • All volar plates have a similar concept for the
hole over the radial diaphysis. Use of this hole permits proximal and distal translation plate to buttress the volar cortex and the distal
guided by fluoroscopy (Fig. 32.26). locking screws to support the articular surface
• Positioning is checked both visually and under fluoroscopy, and the plate is adjusted (Fig. 32.27).
• Ensure that the plate is centered on the radial
as needed. If the position is satisfactory, the first screw is tightened down. shaft before the first screw is placed. The
elliptical hole enables rotation and distal-
Step 3: Distal Fixation to-proximal translation but does not permit
• Distal locking screws are placed to secure the distal fragment. radial and ulnar translation.
• Fixed or variable angle guides can be used, but attention must be paid to the angle
for each individual screw (Fig. 32.28). In general, there is a slight increase in distal
angulation as you move from the most ulnar screw hole to the radial screw holes.
FIGURE 32.27 A bicortical screw is tightened to compress

the plate over the radial diaphysis, whereas the distal lock-
ing screws support the articular surface. FIGURE 32.28 The angulation of the distal locking screw is greater at the radial aspect.
STEP 3 PITFALLS
• Overly penetrated screws can lead to extensor
tendon irritation and injury, especially of the
extensor pollicis longus (EPL) tendon
(Fig. 32.30). The distal screws or pegs FIGURE 32.29 A 22-degree oblique lateral view for inspection of the entire articular surface.
should be 2 mm under the dorsal cortex.
• Plates positioned too distally or with significant
volar prominence increase the risk for tendon
irritation or rupture.
• A 22-degree oblique lateral view is necessary to check screw placement to ensure
that there is no articular penetration. Angle the patient’s hand, or the C-arm machine,
STEP 4 PEARLS to correct the overlap of the articular surface caused by the radial inclination on a
PQ repair provides a soft tissue layer between the standard lateral view. The 22-degree oblique lateral view promotes visibility of the
plate and overlying tendons (see Fig. 32.31). The entire articular surface (Fig. 32.29).
PQ should be repaired unless it is shredded and
incapable of holding sutures.
Step 4: Closure
• The PQ is sutured to the BR fascia with 3–0 Vicryl sutures (Fig. 32.31). The PQ
STEP 4 PITFALLS should be detached from the radius without leaving any residual muscle fibers to
• When closing the PQ to the BR fascia, avoid facilitate its attachment to the BR fascia, which is more stout.
suturing the radial artery or first compartment • The incision is closed with a running subcuticular suture.
tendons. • A short-arm volar splint is placed.
• One must distinguish between the PQ and the
FPL muscle. The FPL muscle lies slightly su-
perficial and has longitudinal muscle fibers, in
contrast to the transverse-oriented fibers of
the PQ. • The splint is removed at 10 to 14 days postoperatively.
• Patients are changed to a removable thermoplastic splint and start ROM exercises
with self-directed hand therapy. Patients who develop wrist stiffness during the heal-
POSTOPERATIVE CARE PEARLS ing period will require treatment from a hand therapist.
Patients who are noted to have signs of continued • Patients with volar plating have been shown to regain function faster than other
tendon irritation should be considered for elective methods because of early postoperative mobilization.
hardware removal at 6 months when the fracture
• Repeat x-rays are performed at 5 to 6 weeks. If there is adequate healing, patients
has healed.
start or increase strengthening activities.
Brachioradialis fascia
FIGURE 32.30 The overly penetrated screws (black arrow) can lead to ex- FIGURE 32.31 Pronator quadratus is sutured to the brachioradialis fascia
tensor tendon irritation and injury. and provides a soft tissue layer between the plate and overlying tendons.
Fixation of Volar Ulnar Rim Fracture

INDICATIONS
• Displaced intraarticular fractures
• Unstable DRUJ because of volar facet fragment
• Volar instability of the wrist joint (Fig. 32.32A–C)
SURGICAL ANATOMY
• The volar lunate facet of the radius is a primary load-bearing articular surface and is
essential for the stability of both distal radioulnar and radiocarpal joints.
• The origins of volar wrist ligaments over the radius include the radioscaphocapitate
(RSC) ligament, long radiolunate (LRL) ligament, and short radiolunate (SRL) liga-
ment. The volar radioulnar ligament originates from the volar edge of the sigmoid
notch (Fig. 32.33A).
• Volar ulnar rim fracture is primarily a ligamentous injury, with associated osseous avul-
sion of volar lunate facet (see Fig. 32.33B). The fragment is typically small and distal
to the watershed line, which limits the stability afforded by standard volar plates.
L L
A B C
FIGURE 32.32 (A) Volar subluxation of the wrist joint is noted in lateral wrist view. (B–C) The
displaced fragment is recognized in the sagittal plane of computed tomography images. The white
arrows represent volar ulnar rim fragments. L, Lunate.
Short radiolunate
ligament
Volar radioulnar
ligament
B
A
FIGURE 32.33 (A) Relationship between volar wrist ligaments and the volar ulnar rim fracture. (B) The
black dotted line indicates a volar ulnar rim fragment.
• This fracture pattern can be easily missed. The surgeon should be suspicious of a
volar ulnar rim fracture when the fracture extends to the sigmoid notch. CT imaging
can help define this distinctive fracture pattern in comminuted fractures.
EXPOSURES PEARLS • See “Volar Plate Fixation.”
For an isolated ulnar rim fracture, the incision can POSITIONING
be made over the palmaris longus tendon for better
access to the ulnar corner of the distal radius. • See “Volar Plate Fixation.”
EXPOSURES
EXPOSURES PITFALLS
• See “Volar Plate Fixation.”
When dividing and reflecting the PQ, avoid detaching • In addition to the standard volar approach, a zigzag incision across the wrist joint
any ligaments from the volar rim fragment.
crease can offer more distal exposure.

The wrist can be classified into three supportive Step 1: Radial Column Reduction (if indicated)
columns:
• Radial column, which contains the radial • If both a volar ulnar rim fracture and radial column fracture are present, restoration
styloid and scaphoid facet of the radial column is initially performed to maintain length and decrease loading at
• Middle column, which contains the ulnar the lunate facet.
radius and lunate facet • The impacted radial fragment can be disimpacted by maneuver or elevator.
• Ulnar column, which is the distal ulna
• After a satisfactory anatomic reduction, a K-wire can offer temporary stabilization.
Step 2: Reduction of Volar Ulnar Rim

STEP 2 PITFALLS
• After reducing the radial column, the shaft can be supinated using forceps to help
The volar ulnar rim fragment is partially covered visualize the lunate facet fragments.
by the volar wrist capsule. Be careful not to detach
• To restore normal carpal alignment, apply dorsally directed traction to the hand.
any ligaments when exposing this small fragment.
• Carefully reduce the rotated volar ulnar rim fragment to the anatomic position. To
confirm anatomic reduction, check the metaphysis for continuity of the volar cortex.
• The fracture reduction and carpal alignment are verified using x-ray imaging after
temporary K-wire fixation.
Step 3: Plate Placement

• Select a volar plate that offers ulnar rim extension using hooks or an extended plate
with miniscrews. These plates are useful not only for volar ulnar rim fractures, but
also for combined fractures with radial column or diaphyseal fracture.
• The plate is centered on the radial shaft and placed in a position capable of captur-
ing the ulnar rim fragment (Fig. 32.34).
• The plate can be checked both visually and under fluoroscopy and adjusted as
necessary (Fig. 32.35).
FIGURE 32.34 The extended hooks (within the white dotted line) FIGURE 32.35 Black arrows indicate the volar ulnar rim fragment
secure the volar ulnar rim fragment. captured via extended hooks.
• A nonlocking bicortical screw is drilled and placed into the elongated central ellipti- STEP 3 PEARLS
cal hole over the radial diaphysis.
• Fragments can be fixed individually by using
• The remaining screwing process is the same as in volar plate fixation. small and low-profile implants (Fig. 32.36A).
• Confirm the stability of wrist and distal radioulnar joints at the end of procedure. Fragment-specific fixation works best for frag-
ments that are greater than 1 cm in width and
Step 4: Closure at least 5 mm long and 4 mm thick. A custom-
ized or tailored plate can be used for fixation
See “Volar Plate Fixation.”
of the volar-ulnar fragment alone.
• Some fragments may be too small to fix with
POSTOPERATIVE CARE AND EXPECTED OUTCOMES any implant, such as avulsed fragments pro-
• Patients wear the splint for 2 weeks postoperatively. duced from a volar ulnar rim fracture. In this
• The splint is changed to a removable thermoplastic splint for an additional 4 to case, it is more advantageous to repair the
soft tissue instead of the bone. One option for
6 weeks. At this time, patients should start gentle ROM exercises of the fingers and
repair is the suture anchor technique. After the
wrist as tolerated. suture anchor is inserted into the fracture site,
• After 6 to 8 weeks postoperatively, patients can begin gradual strengthening activities. nonabsorbable sutures that are part of the
• Patients may have tendon irritation or impingement because of distal plate place- anchor’s eyelet can be used to restore the
ment. Hardware removal should be considered after the fracture has healed. volar capsule and volar ligaments to their
proper position. This repair can prevent subse-
quent radiocarpal subluxation and will encour-
Dorsal Plate Fixation age contact and healing between the fragment
and the fracture site (see Fig. 32.36B).
INDICATIONS
STEP 3 PITFALLS
• Substantial initial dorsal displacement, for which reduction through a volar approach
is not feasible. If the volar ulnar rim fragment is not properly
stabilized, the fragment can dislodge and easily
subluxate the carpus (Fig. 32.37).
Lunate
Volar capsule
and ligaments Suture
with fragments anchor
Dorsal Volar
Lat
Latera
erall vview
Lateral iew
w
B
FIGURE 32.37 Failure to stabilize volar
FIGURE 32.36 (A) Fragment-specific fixation works by using small and low-profile implants. (B) Suture ulnar rim fragment can cause carpal
anchor repair for fragments that are too small to fix. (Fig. 15.51B–C from Wolfe S, Pederson W, Kozin subluxation. The white arrow indicates
SH, Cohen M, eds. Green’s Operative Hand Surgery. 7th ed. Elsevier; 2017). the fragment.
• Severe dorsal comminution in need of support from a dorsal plate.

• Dorsal-shearing type intraarticular fracture (dorsal Barton fracture).
• Severely comminuted C3 type fractures that need both volar and dorsal plates fixa-
tion for stability.
• Extraarticular fracture with disruption of the volar cortex distal to the watershed line.
The screws of a volar plate will be unable to secure the distal fragment.
SURGICAL ANATOMY
• The extensor retinaculum is superficial to the extensor tendons and separates all
extensor tendons into six compartments (Fig. 32.38).
• The first compartment includes the abductor pollicis longus (APL) and the extensor
pollicis brevis tendons (EPB). The sensory branch of radial nerve lies superficial to
this compartment.
• The second compartment includes the ECRL and extensor carpi radialis brevis
(ECRB), which are straight and radial to the Lister tubercle.
• The third compartment includes the EPL, which is ulnar to the Lister tubercle. It turns
an angle to control the thumb after going through the compartment.
• The fourth compartment includes the extensor indicis proprius (EIP) and extensor
digitorum communis (EDC), which lie over the dorsoulnar radius.
• The fifth compartment includes the extensor digiti minimi (EDM) that lies over the
DRUJ.
• The sixth compartment includes the extensor carpi ulnaris (ECU); only one compart-
ment lies over the distal ulna and contributes to triangular fibrocartilage complex
(TFCC) stability.
POSITIONING
A tourniquet is placed on the upper arm, and the upper extremity is extended on a hand
table with the forearm pronated.
EXPOSURES
• Make a 6- to 10-cm longitudinal skin incision dorsal and ulnar to the Lister tubercle,
centered over the radial metaphysis.
EXPOSURES PEARLS
• The subcutaneous layer is dissected down to extensor retinaculum, taking care to
• A dorsal approach can improve visualization avoid injury to the dorsal sensory branches of the radial and ulnar nerves.
and reduction of the impacted articular frag- • Incise the extensor retinaculum just ulnar to the Lister tubercle to expose the EPL
ment. In addition, the approach offers access
for bone graft placement to support the tendon. The tendon can be retained in the remaining third compartment, which will
reduced articular surface if needed. later be elevated subperiosteally.
• After the procedure, the periosteum of the • Use a scalpel to elevate the second and fourth dorsal compartment subperiosteally in
extensor compartments can be repaired and the radial and ulnar direction for exposure of the entire dorsal radius (see Fig. 32.38).
used as a barrier between the plate and exten- • The terminal branch of the posterior interosseous nerve can be resected during
sor tendons if appropriately elevated.
exposure.
3 4
5
2 6
1 Ulna
Radius
FIGURE 32.38 The black dotted line highlights the subperiosteal elevation of the second to fourth
dorsal compartments. 1, Abductor pollicis longus and extensor pollicis brevis; 2, extensor carpi
radialis longus and extensor carpi radialis brevis; 3, extensor pollicis longus; 4, extensor indicis and
extensor digitorum communis; 5, extensor digiti minimi; 6, extensor carpi ulnaris.
PROCEDURE
STEP 1 PEARLS
Step 1: Fracture Reduction
A dorsal capsulotomy can help visualize the
• The fracture fragments are identified after exposure (Fig. 32.39). articular surface, but this is often unnecessary.
• The articular fragments can be reduced by slight wrist flexion combined with trac- The articular reduction by itself should sufficiently
tion. Use an osteotome or elevator to disimpact the depressed articular fragment elevate the depressed fragments, with the convex
(Fig. 32.40A–B). articular surface of the carpus guiding the fragment
into anatomic position.
• If there is a severe metaphyseal defect, a bone graft can be placed to support re-
duced articular fragments.
• The reduction is confirmed both visually and with fluoroscopy.

• The selected plate is bent to fit the dorsal surface. STEP 2 PEARLS
• The plate is applied directly and first secured with a cortical screw inserted into the • A low-profile and fitted plate is essential to
oval hole over the radial diaphysis. minimize the incidence of tendon-related com-
• The position of the plate and fracture reduction are confirmed using fluoroscopy and plications, including synovitis, irritation, and
adjusted as appropriate (Fig. 32.41). rupture.
• The distal locking screws can be inserted to
• The remaining cortical screws are inserted in the radial shaft. Reduction and stability
support the subchondral bone.
will need to be confirmed again.
Comminuted dorsal fragments
EPL Partial third compartment
FIGURE 32.39 Fracture fragments are identified after exposure. The white dotted line indicates com-
minuted dorsal fragments. EPL, Extensor pollicis longus.
Dorsal Volar Dorsal Volar
A B
FIGURE 32.40 (A) A distal radius fracture with a depressed articular fragment, loss of dorsal
buttress, and dorsal carpal subluxation. (B) Reduction by slight wrist flexion combined with traction.
Furthermore, use an elevator to push the depressed articular fragment upwards.
FIGURE 32.41 The position of the plate and fracture reduction are confirmed using fluoroscopy.
FIGURE 32.42 The second and fourth compartments are closed back over the plate, and the
retinaculum is sutured.
Step 3: Closure
• The second and fourth compartments are closed back over the plate, and the reti-
naculum is sutured with 3-0 Vicryl (Fig. 32.42).
• The incision is closed with a running subcuticular suture.
• A short-arm volar splint is applied.

• With volar splint protection, the patient can start finger ROM exercises immediately
after surgery to avoid adhesion of extensor tendons.
• The volar splint is used for 2 weeks postoperatively, and then the sutures are removed.
• The splint is changed to a removable thermoplastic splint for an additional 4 to 6 weeks,
and the patient is encouraged to begin gentle ROM exercises of the wrist as tolerated.
• After 6 to 8 weeks postoperatively, the patient can start gradual strengthening exercises.
Dorsal Bridge Plate

INDICATIONS
INDICATION PEARLS • Severely comminuted intraarticular distal radius fractures that cannot be fixed with
conventional approaches.
The dorsal bridge plate can serve as a reduction
tool by buttressing the dorsal fragments and • Distal radius fractures with associated metaphyseal or diaphyseal comminution.
reducing the fracture via ligamentotaxis during • Osteoporotic bone, in which direct fracture fixation is likely to fail.
traction. Compared with external fixation, a dorsal Patients who refuse external fixation or are poor candidates because of bone quality,
bridge plate offers earlier return of hand mobility, hygiene issues, or psychological illness.
simpler wound care, and greater comfort for the
• Preoperative x-rays that show a severely displaced fracture with distal diaphyseal
patient.
comminution and osteoporotic bone (Fig. 32.43).
FIGURE 32.43 Severely displaced fracture with distal diaphyseal comminution and osteoporotic
bone.
SURGICAL ANATOMY
• See “Dorsal Plate Fixation.”
• The extensor tendons of the middle finger and branches of the radial nerve are found
distally and should be identified and retracted away for protection.
• The plate will pass from the second or third metacarpal through the fourth dorsal
compartment, which contains the EDC and extensor indicis proprius (EIP). The EPL
tendon of the third compartment crosses the path of the plate and should be re-
leased for its own protection.
• The muscle bellies of the APL and EPB are also encountered in the proximal dissection.
• The superficial radial nerve is at risk for injury during the proximal dissection in the
forearm.
POSITIONING
See “Dorsal Plate Fixation.”

• Before operating, longitudinal traction is applied on the second and third metacarpal • A bridge plate may also be attached to the
individually to promote reduction via ligamentotaxis. The reduction is then assessed second metacarpal. In these circumstances,
radiographically. The surgeon should compare the reduction that is achieved with the plate passes through the second dorsal
compartment, which contains the ECRB and
traction on the second metacarpal versus the third metacarpal. The plate should be ECRL. The plate is placed proximally in the in-
passed over the metacarpal that produced a better reduction under traction. terval between the muscle bellies of the ECRB
• Passing the plate over the second metacarpal will result in slight ulnar deviation and ECRL.
of the hand after fixation of the plate. This would benefit patients with a distal • Fixation to the index finger metacarpal will
radius fracture that is radially displaced because ulnar deviation would counter- cause slight ulnar deviation of the wrist and
may make it easier to reestablish radial incli-
act this displacement. nation when the fracture is reduced.
• Passing the plate from the third metacarpal, however, will produce a more neutral
hand position after plate fixation and will directly buttress the intermediate col-
umn of the radius.
• The dissection takes place proximally over the dorsal radius and distally over the
third metacarpal.
• The exposure involves two or three longitudinal incisions.
• A 4-cm incision is made distally over the shaft of the third metacarpal (Fig. 32.44).
• The subcutaneous tissue is incised, and the extensor tendons and nerve branches
are retracted radially.
• A 6-cm incision is made along the dorsal radial shaft. Dissection proceeds through
the subcutaneous tissue down to the radial shaft. The interval adjacent to the BR
FIGURE 32.44 A 4-cm incision is made distally over the third metacarpal shaft and a 6-cm incision
along the dorsal radial shaft.
ECRL
ECRB
APL
EPL
EDC
FIGURE 32.45 Dissection proceeds at the radial shaft via the interval between BR/ECRL (black dotted
line) or between the ECRB/EDC (red dotted line). APL, Abductor pollicis longus; BR, brachioradialis;
ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; EPL, extensor pollicis
longus.
and ECRL or between the ECRB and EDC is used. Care must be taken not to injure
the superficial branch of the radial nerve (Fig. 32.45).
• An optional 2- to 3-cm incision over the Lister tubercle can be used to release the
EPL or applied to aid with fracture reduction. Alternatively, the proximal incision can
be extended distally to facilitate exposure.
PROCEDURE
Step 1: Plate Insertion
STEP 1 PEARLS • The 2.4-mm distal radius bridge (DRB; Synthes) plate with tapered ends is used. The
Other plates, including a mandibular reconstruction plate should span from the distal third metacarpal to the radial shaft to fix at least
plate or the variable length 3.5-mm dynamic three screws 4 cm proximal to the fracture.
compression plate (Synthes), have also been • Starting distally along the metacarpal bone, a Freer or Cobb elevator is used to
described for use in this technique.
develop a plane between the extensor tendon and the joint capsule over the fourth
compartment. The plate will lie superficial to the joint capsule.
STEP 1 PITFALLS • After a path is made, the plate is inserted in a retrograde fashion from the area of the
Ensure that all tendons are retracted away and that metacarpal. The EPL, which has already been mobilized, is retracted radially to pre-
the plate is directly against the bone. The EPL and vent capture under the plate (Fig. 32.46).
digital extensors will be at risk for immobility or • As the plate is advanced, it is visualized in the proximal incision and care is taken to
rupture if compressed under the plate.
make sure the plate travels under tendons and muscle.
FIGURE 32.46 The extensor pollicis longus is retracted radially to prevent capture under the plate.
Step 2: Distal Fixation STEP 2 PITFALLS

• The fracture is provisionally reduced with traction. Ensure that the screw is centralized in the
• The plate is centralized over the third metacarpal and aligned on the radial shaft. metacarpal. Violation of the ulnar or radial cortex
• The second-to-last hole at the distal end of the plate is drilled, and a bicortical screw could lead to iatrogenic fracture.
is placed in the metacarpal. Placement of a single screw facilitates some slight plate
adjustment if necessary.
Step 3: Proximal Fixation

• Traction is applied again, and the fracture is reduced.
• The plate is centralized to the radial shaft, whereas the forearm is kept in neutral
rotation.
• The plate is clamped to the radial shaft with a bone reduction clamp. STEP 3 PITFALLS
• Fluoroscopy is used to assess fracture reduction (Fig. 32.47). Overdistraction can restrict finger ROM and may
• If reduction is adequate, the proximal portion of the plate is secured to the radius lead to complex regional pain syndrome (CRPS).
with a bicortical screw (Fig. 32.48). Passive ROM should be checked in the digits after
• The remaining screws are placed so that there are at least three screws distally and plate fixation; the radiocarpal space should not
exceed 5 mm.
three screws proximally.
FIGURE 32.47 Fluoroscopy is used to assess fracture FIGURE 32.48 A proximal plate is secured to the radius with a
reduction. bicortical screw.
FIGURE 32.49 Approximation of multiple fracture pieces can be achieved with cerclage wires.
STEP 4 PEARLS Step 4: Adjunct Fracture Treatments

Bone grafting can fill in large gaps for severely • Distraction may not fully reduce severely comminuted fractures.
impacted fractures. • Approximation of multiple fracture pieces can be achieved with cerclage wires
(Fig. 32.49).
STEP 4 PITFALLS • K-wires or lag screws can be used to stabilize individual segments.
Aggressive fixation may lead to more comminution Step 5: Closure
or compromise fragile vascular supply to small
bone fragments. • The surgical wounds are irrigated, and the deep subcutaneous tissues are approxi-
mated with interrupted sutures.
• The skin is closed with running absorbable sutures.
• A short-arm volar splint is placed.

• The splint is removed at 10 days.
• Active ROM of the digits and forearm rotation is performed immediately and main-
tained throughout the fixation period.
• Patients can use the extremity with a weight restriction of less than 5 pounds of lifting.
• Fracture healing is monitored radiographically and clinically every 4 to 6 weeks.
• The plate is removed typically at 3 months postoperatively but can be earlier or later
depending on fracture healing.
• Aggressive ROM of the wrist begins immediately after hardware removal.
• Outcomes in regard to ROM and function are reported to be similar at 1 year post-
operatively in comparison to other techniques.
INDICATIONS PEARLS Arthroscopic Reduction and Fixation Technique

Distal radius fractures often occur with associated
injuries to the scapholunate interosseous ligament INDICATIONS
(SLIL), lunotriquetral interosseous ligament (LTIL), • Wrist arthroscopy can assist anatomic restoration of articular fragments and also
and TFCC. Without arthroscopic assistance, these
evaluate the associated intraarticular soft tissue injuries.
injuries may go undetected.
• Arthroscopy can be used when any associated injury is suspected, including carpal
ligament tear, scaphoid fracture, and TFCC injury. The surgeon can further confirm
and repair these injuries simultaneously if they are detected.
• One indication is distal radius fractures with articular involvement, especially those
with more than three fragments.
• Wrist arthroscopy is used as an adjunct visualization for impacted fracture patterns,
such as die-punch fracture (Fig. 32.50), which are challenging to restore a smooth
articular surface.
Contraindications
Contraindications for the procedure include:
• Visible swelling or compartment syndrome
• Neurovascular compromise
FIGURE 32.50 The die-punch fracture pattern is characterized by a depressed central portion of the
articular surface.
• Open fracture without adequate soft tissue coverage

• Elderly patients with delicate finger skin, which is not conducive for finger trap
SURGICAL ANATOMY
• See Chapter 19.
POSITIONING STEP 1 PEARLS

• See Chapter 19 about position and equipment for wrist arthroscopy. • Arthroscopic assistance is necessary for com-
• The upper extremity is extended on a hand table with the forearm supinated. minuted intraarticular fractures. These cases
are typically caused by the violent crush of the
• A tourniquet is wrapped on the upper arm.
lunate bone, resulting in severe depression
and fragmentation of the joint surface. Be-
EXPOSURES cause the first contact force is primarily loaded
• See Chapter 19, the setting of arthroscopic portals and systemic evaluation. over the lunate facet, the trauma to this region
• See “Volar Plate Fixation.” is usually more severe. Therefore we recom-
mend restoring the radial column first because
this is more feasible.
PROCEDURE • We recommend performing the volar approach
before arthroscopic evaluation for the following
Step 1: Volar Approach and Restoration of Radial Column reasons (Fig. 32.52):
• Access to the radius is performed similarly to access required for volar plating. • After articular reduction, the fracture can be
fixed immediately with distal screws. There
• The dissection should extend distally to reach the watershed line, taking care not to
is no need to waste time approaching and
detach the volar ligaments. reducing the fractured metaphyseal region,
• The radial column is initially reduced to restore the radial height and unload the lu- which risks loss of articular reduction.
nate facet. Release the insertion of BR, if needed, because this may aid reduction • The volar approach, performed before an
by reducing the deforming force. arthroscopic evaluation, permits the surgeon
to use instruments to elevate the articular
• The radial column is reduced by wrist hyperextension with traction, then flexed to
surface during arthroscopic evaluation.
minimize the gap over the volar cortex. Also, Kapandji intrafocal pinning can be in- • Swelling and deformity can make it difficult
serted to level and fix the radial column (Fig. 32.51A–B). The integrity of the radial to recognize the landmarks of portals and
cortex can be used to determine whether anatomic reduction was successful (see the joint line. The volar approach and resto-
Fig. 32.51A). ration of the radial column can facilitate
identification of these landmarks.
• Temporarily stabilize the radial column with K-wires after anatomic reduction under
fluoroscopic guidance (see Fig. 32.51B).
STEP 2 PEARLS
Step 2: Reduction of Intermediate Column and Plate Placement
• It is essential to restore the articular surface as
• After the restoration of the radial column, the radial styloid and scaphoid facet can completely as possible. This will ensure opti-
serve as a landmark to determine whether the depressed lunate facet fragments are mal radial length, volar tilt, and inclination.
reduced adequately. • If there is a significant defect over the metaphysis
• Identify the comminuted-metaphyseal cortex of the intermediate column and use after elevating the articular surface, a bone graft
can be used for subchondral support.
blunt instruments to elevate the lunate facet fragments from the cortical defect.
A B
FIGURE 32.51 (A) The integrity of the radial cortex can be used to determine whether anatomic reduction was successful.
(B) Temporary Kirschner wire (K-wire) fixation of the radial column after anatomic reduction under fluoroscopic guidance.
FIGURE 32.52 The volar approach has been performed before wrist arthroscopy.
• Alternatively, a cortical bone window (1 x 1 cm) 2 cm proximal to the watershed line

should be created if there is no defect over volar metaphysis (Fig. 32.53A–B).
• Reduction of the articular surface is achieved by gradual and gentle elevation with
freer elevator or bone graft impactor (Fig. 32.54A–F).
• Under fluoroscopic guidance, the surgeon should proceed with the plate placement
if the reduction appears satisfactory or if no further improvement is possible.
• After temporary fixation by K-wires (Fig. 32.55A), a volar plate is applied to the radius
(see Fig. 32.55B). A cortical screw is inserted into the elliptical hole on the shaft of
the plate, which permits slight adjustment of plate position.
• Once the plate’s position is confirmed, the second screw at the shaft and the distal
locking screw toward the radial styloid can be inserted (Fig. 32.56A–B).
• Several K-wires are inserted into the distal fragments through the distal holes of the
plate for subchondral support (see Fig. 32.56C).
2 cm
A B
FIGURE 32.53 (A) The white dotted line represents a cortical bone window (1 x 1 cm) that is
created for reduction. (B) The window is 2 cm proximal to the watershed line, making the entire
articular surface accessible.
A B C
D E F
FIGURE 32.54 (A–F) The process of reduction by gradual and gentle elevation.
A B
FIGURE 32.55 (A) Temporary fixation by Kirschner wires (K-wires). (B) Volar plate is applied to the radius.
A B
FIGURE 32.56 (A–C) Once the plate’s position is confirmed, insert the second screw at the shaft and the distal lock-
ing screw toward the radial styloid. Kirschner wires (K-wires) are inserted into the distal fragments through the distal
holes of the plate.
A B
FIGURE 32.57 (A) The intraarticular hematoma blurs the arthroscopic visualization. (B) Improved visualization after evacu-
ating the fracture hematoma.
Step 3: Arthroscopic Assisted Reduction STEP 3 PEARLS

• Suspend the wrist in a vertical traction tower. Establish 3 to 4 (between EPL and • Loss of the Lister tubercle and associated
EDC), 4 to 5 (between EDC and EDM), and 6R (radial to ECU) portals. The 6U portal swelling can make it challenging to establish
is percutaneously placed with an 18-gauge needle for outflow. sites for portals, because palpating for land-
• A 2.3-to 2.7-mm 30-degree angle scope is introduced through the 3 to 4 portal, and marks becomes unreliable. The surgeon can
still determine the radiocarpal joint line through
a shaver is inserted through 4 to 5 or 6R portals to evacuate the fracture hematoma the volar approach wound or locate the portals
for better visualization (Fig. 32.57A–B). under fluoroscopy.
• The intraarticular structures, including fracture fragments and soft tissue, are sys- • K-wires that are inserted to prevent reduction
tematically inspected. See Chapter 19. should be removed to release the articular
• The viewing portal and working portal can be swapped among 3 to 4, 4 to 5, and 6R fragment. After reduction is obtained, drive the
K-wire again through the fragment to maintain
portals. reduction. Use K-wires that are less than
• Displaced articular fragments with gaps or step-offs are subsequently reduced un- 1.6 mm in diameter and insert from the
der arthroscopic visualization. Common techniques include clamping, joystick, hook radial and dorsal aspects.
the fragment, and push-ups.
Clamping STEP 3 PITFALLS
Fragments with gaps but without step-offs can be reduced by percutaneous clamping. When setting up the wrist arthroscopy, the surgeon
should gently suspend the wrist to avoid losing the
Joystick reduction of the articular surface and metaphysis.
After using a percutaneous K-wire to fix the rotated fragment (Fig. 32.58A), push up-
wards on the end of K-wire, similar to a joystick, to correct the step-off and reach the
smooth articular surface (see Fig. 32.58B).
Hook the Fragment

A probe is inserted to hook the fragment (Fig. 32.59A), which is rotated and depressed.
The fragment is pulled distally to obtain an even articular surface (see Fig. 32.59B).
Push-Up
For depressed fragments, insert an elevator or K-wire through the volar cortical defect
of the metaphysis (Fig. 32.60A), pushing distally from the base of the articular frag-
ments (see Fig. 32.60B).
Press
For elevated fragments, use the Freer elevator to depress the articular fragment
(Fig. 32.61A) and eliminate the step-off (see Fig. 32.61B). If the fragment is difficult
to depress, releasing some of the traction may help.
A B
FIGURE 32.58 (A–B) After using a percutaneous Kirschner wire (K-wire) to fix the rotated fragment, push up-
wards on the end of K-wire, similar to a joystick.
A B
FIGURE 32.59 (A–B) A probe is inserted to hook the fragment, which is rotated and depressed.
A B
FIGURE 32.60 (A–B) For depressed fragments, insert an elevator or Kirschner wire (K-wire) through the volar corti-
cal defect of the metaphysis and push distally from the fragment base.
Elevated fragment
A
Fragment following reduction
FIGURE 32.61 (A–B) For elevated fragments, use the Freer elevator to depress the articular fragment and eliminate the step-off.
Temporary K-wire fixation is performed after the fragment is reduced. Finally, insert
all distal locking screws through the holes of the distal plate.
Step 4: Screws Fixation and Closure

• Once the articular surface is reduced and provisionally fixed with K-wires, all the
locking screws are inserted under traction.
• Arthroscopic visualization can confirm whether the screws have articular penetration
and identify whether loss of reduction has occurred.
• After plating, the associated soft tissue injuries should be arthroscopically repaired
before closure.
• The PQ can be repaired via suturing to the BR fascia with 3–0 Vicryl suture.
• The volar skin incision and portal wounds are closed with a running subcuticular suture.
• A short-arm volar splint is placed.

• For patients who have associated TFCC injuries or carpal instability, postoperative
care should follow each procedure’s protocol.
See Videos 32.1, 32.2, 32.3, and 32.4
EVIDENCE
Chung KC, Kim MH, Malay S, Shauver MJ, Wrist and Radius Injury Surgical Trial Group. The Wrist and
Radius Injury Surgical Trial: 12-Month outcomes from a multicenter international randomized clinical
trial. Plast Reconstr Surg. 2020;145(6):1054e–1066e.
Because the optimal treatment for distal radius fractures in older adults remains uncertain, the authors
conducted a randomized multicenter clinical trial that enrolled 304 adults aged 60 years and older
with isolated, unstable distal radius fractures at 24 institutions. The surgery group (n = 187) were
randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred
conservative management (n = 117) received casting. The loss of radiographic alignment was
common in casting participants. Nevertheless, there were no meaningful differences in primary
outcomes (Michigan Hand Outcomes Questionnaire) at 12 months. Recovery was fastest for internal
fixation, whereas the external fixation was slower than the other two methods (Level I Evidence).
Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius: A prospective comparison
between transstyloid and Kapandji fixations. J Bone Joint Surg Br. 1995;77:562–567.
This is a prospective study of 96 patients with extra- or intraarticular distal radius fractures with a
dorsally displaced posteromedial fragment, treated with either transstyloid or Kapandji (intrafocal)
fixation. Patients were followed at 6 weeks and 3, 6, 12, and 24 months. Although there was some
improvement in ROM in early follow-up with Kapandji fixation, the results were similar in both groups
at 24 months (Level III evidence).
Harley BJ, Schargenberger A, Beaupre L, Jomha N, Weber D. Augmented external fixation versus per-
cutaneous pinning and casting for unstable fractures of the distal radius—A prospective randomized
trial. J Hand Surg Am. 2004;29:815–824.
This prospective, randomized study showed that in patients younger than 65 years, percutaneous pin-
ning and casting were equivalent to augmented external fixation. Fifty-five patients were enrolled and
followed for 1 year both clinically and radiographically. Both groups were similar in terms of fracture
type and the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixa-
tion's (AO-ASIF) class. Specifically, there was no significant difference in radial length, radial angula-
tion, volar tilt, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total ROM, or grip strength
(Level II evidence).
Karantana A, Downing ND, Forward DP, et al. Surgical treatment of distal radial fractures with a volar
locking plate versus conventional percutaneous methods: A randomized controlled trial. J Bone Joint
Surg Am. 2013;95:1737–1744.
This is a prospective, randomized controlled trial comparing percutaneous fixation (n = 64) to that of a
volar locking plate (n = 66). Outcomes were measured with QuickDASH, Patient Evaluation Measure,
EuroQol-D, grip strength, ROM, and radiographic parameters. Patients treated with a volar plate had
quicker earlier recovery, with increased grip strength and anatomic reduction. No functional
advantage was seen beyond 12 weeks postoperatively, and there was no difference in return to
work (Level I evidence).
Williksen JH, Frihagen F, Hellund JC, Kvernmo H, Husby T. Volar locking plates versus external fixation
and adjuvant pin fixation in unstable distal radius fractures: A randomized, controlled study. J Hand
Surg Am. 2013;38:1469–1476.
This is a prospective study of 111 unstable distal radius fractures that were randomized to treatment
with external fixation (EF) using adjuvant pins or with a volar locking plate (VLP). The mean age of the
patients was 54 years (range, 20–84 years). At 1 year, patients were assessed with a visual analog
scale pain score, Mayo wrist score, QuickDASH score, ROM, and radiologic evaluation. At 52 weeks,
patients with VLPs had a higher Mayo wrist score (90 vs. 85), better supination (89 degrees vs.
85 degrees), and less radial shortening (+1.4 mm vs. +2.2 mm). There were more patients with pain
over the ulnar styloid in the EF group (16 vs. 6 patients). For AO type C2/C3, the patients with VLPs
had better supination (90 degrees vs. 76 degrees) and less ulnar shortening (+1.1 mm vs. +2.8 mm).
The complication rate was 30% in the EF group, compared with 29% in the VLP group. Eight (15%)
plates were removed because of complications. The QuickDASH score was not significantly different
between the groups (Level I evidence).
Chung KC, Watt AJ, Kotsis SV, Margaliot Z, Haase SC, Kim HM. Treatment of unstable distal radius
fractures with the volar locking plating system. J Bone Joint Surg. 2006;88:2687–2694.
This is a prospective study of 87 patients who were enrolled after open reduction and internal fixation
with a volar locking plate system. Patients were followed with functional and patient reported
outcome measures. Grip strength of the injured side reached 18 kg versus 21 kg on the uninjured
side. Pinch strength was not significantly different. Flexion of the injured wrist reached 86% of the
contralateral side. Michigan Hand Questionnaire outcomes reached normal scores in most patients
at 6-months postoperatively (Level III evidence).
O’Shaughnessy MA, Shin AY, Kakar S. Volar marginal rim fracture fixation with volar fragment-specific
hook plate fixation. J Hand Surg Am. 2015;40(8):1563–1570.
This is a retrospective study of 26 wrists in 25 patients, treated with a volar hook plate in the manage-
ment of distal radius fractures with a volar marginal rim fragment. Twenty patients had AO type C frac-
tures and 6 had AO type B fractures. All 6 AO type B were B3 fractures. Of the AO type C, 1 had C1,
7 had C2, and 12 had C3. No patients had loss of fixation of the critical volar ulnar corner, and there
was no evidence of carpal subluxation. There were no cases of tendon rupture (Level III evidence).
Richard M, Katolik L, Hanel D, Wartinbee DA, Ruch DS. Distraction plating for the treatment of highly
comminuted distal radius fractures in elderly patients. J Hand Surg Am. 2012;37:948–956.
This is a retrospective review of 33 patients over the age of 60 treated with a dorsal distraction plate.
The DASH questionnaire and radiographic measurements were used. All fractures healed, with mean
of 5 degrees of volar tilt, 20 degrees of radial inclination, and 0.6 mm of positive ulnar variance. Mean
flexion was 46 degrees and extension was 50 degrees. The mean pronation and supination were
79 and 77 degrees, respectively. The mean DASH score was 32. The authors concluded that distrac-
tion plating is an effective treatment for comminuted fractures in the elderly (Level III evidence).
Burnier M, Le Chatelier Riquier M, Herzberg G. Treatment of intra-articular fracture of distal radius
fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensito-
metric comparative study of 40 patients. Orthop Traumatol Surg Res. 2018;104(1):89–93.
This prospective study examined the outcome of volar plate fixation in forty patients with similar radius
fracture patterns (type C) and high functional needs. Patients were divided into a fluoroscopic group
(20 patients) and arthroscopic group (20 patients). Pre- and postoperative radiographs and tomodensi-
tometric images were evaluated. The authors observed a statistically significant improvement in reduc-
tion of the radiocarpal step-off and gap in the arthroscopic group (Level III evidence).
CHAPTER 33
Corrective Osteotomy of Radius Malunion
INDICATIONS
• Pain or functional impairment in the setting of radiocarpal or distal radioulnar joint
(DRUJ) malalignment
• There are no fixed radiographic criteria for correction, although symptoms often
present with radial inclination of less than 10 degrees, volar or dorsal tilt greater than
20 degrees, ulnar variance greater than or equal to 2 mm, and articular incongruity
greater than 2 mm.
Contraindications
• Correction of malunion is not indicated in patients with advanced degenerative ar-
thritis, fixed carpal malalignment, and limited functional capabilities.
• In patients with fixed malalignment or advanced arthritis, salvage procedures should
be considered.
• For those with limited functional capabilities, malalignment is often well tolerated
because these patients rarely put a high level of stress across the radiocarpal joint.
Thus no intervention is required.
• Deformity without pain, loss of motion, and decreased grip strength are not indica-
tions for correction.
• The upper extremity is examined for deformity, wrist function, forearm mobility, fin-
ger mobility, grip strength, and instability of the DRUJ and carpal ligaments.
• This patient presents after nonoperative treatment of a distal radius fracture with
pain and difficulty with wrist flexion, extension, and supination (Fig. 33.1).
• In the absence of major nerve dysfunction, early surgical intervention at 6 to 12 weeks
postinjury can be performed through an incompletely ossified fracture callous. This
can minimize the development of soft-tissue contracture and joint stiffness and limit
the duration of impact on the patient.
IMAGING
• Standard imaging (anteroposterior, lateral, oblique) of the wrist is performed.
• Patients may present with a malunion after nonoperative treatment (Fig. 33.2). In
other circumstances, a patient may present after attempted operative fixation. This
will require any internal hardware to be removed (Fig. 33.3).
FIGURE 33.1 Patient has limited motion.
243
244 CHAPTER 33 Corrective Osteotomy of Radius Malunion
FIGURE 33.2 Malunion x-ray.
FIGURE 33.3 X-ray with internal hardware.
• Computed tomography (CT) imaging can provide more information concerning

articular incongruity. Many radiographic programs provide three-dimensional (3D)
reconstruction of CT images (Fig. 33.4).
Surgical Planning
• Anatomy of the malunion determines the approach used to correct the malunion. A
volarly tilted malunion or incongruity of the volar cortex is treated through a volar
approach. Dorsally tilted malunions are treated through either a volar or dorsal ap-
proach. Complex intraarticular malunions may require approaches from both sides.
• Impacted malunions which require more than 1 cm of radial lengthening will often
need an ulnar shortening osteotomy. This can be performed simultaneously or delayed
until the final radial length is established.
• X-rays from the time of the initial injury can help delineate the original fracture pattern.
• X-rays of the opposite uninjured wrist can provide an example of the preinjury
anatomy.
• An osteotomy line is planned at the site of the prior fracture line. The osteotomy is
made parallel to the joint surface in the sagittal plane. An opening wedge osteotomy
is created in most circumstances because of fracture impaction (Fig. 33.5).
SURGICAL ANATOMY
• The goal of radial malunion surgery is to restore preinjury form. Radiographically,
those goals are defined by the appropriate ulnar variance, radial height, radial incli-
nation, and volar tilt (Fig. 33.6A–D).
FIGURE 33.4 Three-dimensional model based on CT images.
5°
5°
35° 30°
5°
25°
9 mm 10° 0 mm
15 mm
FIGURE 33.5 Osteotomy lines.

Radial height
90°
Normal: 11–12 mm
Ulnar
variance
A B
90° Dorsal volar tilt

Radial inclination Normal: 11–12°
90°
Normal: 22–23°
C D
FIGURE 33.6 (A–D) Ulnar variance, radial height, radial inclination, and volar tilt.
• Volarly, the surgeon is cognizant of the location of the radial artery and median nerve
at all times.
• Dorsally, the surgery is approached between the extensor pollicis longus (EPL) and
extensor digitorum communis (EDC). Dorsal sensory branches and veins are pro-
tected and retracted away. The EPL is mobilized and the Lister tubercle is removed
for better plate contact to the radius.
• Corrective osteotomies of distal radius malunions can be done through either a
dorsal or volar approach.
POSITIONING
• The patient is placed supine with the arm on a hand table.
• The ipsilateral iliac crest is prepared if autogenous bone graft is to be used.

Volar • Exposure must be adequate to evaluate the
• Volar exposure is performed through a longitudinal incision between the flexor carpi entire deformity.
• Hohmann retractors should be placed on either
radialis (FCR) and radial artery (Fig. 33.7A). side of the radius to retract soft tissues away
• The flexor pollicis longus (FPL) is swept ulnarly to expose the pronator quadratus, during the osteotomy and plate fixation.
which is then incised in an L-shaped fashion (see Fig. 33.7B).
• The periosteum is stripped to expose the radial deformity.
• The insertion of the brachioradialis is released to decrease the deforming force on EXPOSURES PITFALLS
the malunited fracture and aid with correcting the deformity (see Fig. 33.7C). With the dorsal approach, avoid violating the volar
retinacular sheath of the fourth compartment to
Dorsal protect tendons from subsequent plate contact
and irritation.
• Dorsal exposure is performed between the third and fourth compartments.
• A 6- to 7-cm longitudinal incision is made over the Lister tubercle.
• The EPL is mobilized from the third compartment and retracted away.
• Exposure to the radius is through the floor of the fourth compartment.
EXTRAARTICULAR MALUNION
Step 1: Osteotomy of the Malunion
• After exposing the deformity, the malunion site is visually identified and then con-
firmed under fluoroscopy.
Brachioradialis
is released
FIGURE 33.7 (A) Incision line. (B) Pronator quadratus exposed. (C) Brachioradialis released.
FIGURE 33.8 Osteotomy made with an osteotome parallel to the artic- FIGURE 33.9 Laminar spreader used to disimpact the fracture.
ular surface.
• An osteotomy is made through the prior fracture site with an osteotome or saw. The
osteotomy is made parallel to the articular surface in the sagittal plane (Fig. 33.8).
• For an impacted fracture, the osteotomy site is expanded using a laminar spreader.
The hand is supinated to identify and release the dorsal callus and soft tissues
(Fig. 33.9).
• For patients with prior fixation, the old incision is used and the hardware is removed
A first (Fig. 33.10A–B).
Step 2: Attachment of the Locking Plate

• A volar locking plate is aligned on the distal radial segment (Fig. 33.12).
• The distal rim of the plate is placed parallel to the lunate facet articular surface with
direct contact of the distal end of the plate to the volar cortex (Fig. 33.13).
• Locking screws are used to secure the plate.
B
FIGURE 33.10 (A) Prior incision used to access

the malunion. (B) Hardware removed from the
distal radius.
STEP 1 PEARLS
Kirschner wires (K-wires) placed in the distal
segment parallel to the articular surface can help
confirm the direction and location of the osteotomy
(Fig. 33.11).
STEP 1 PITFALLS
Improper osteotomy orientation will lead to a FIGURE 33.11 K-wires placed.
secondary deformity when the osteotomy is opened.
STEP 2 PEARLS
• Temporarily attach the volar plate to the distal
segment before the osteotomy to aid in quick
fixation after the osteotomy is complete.
• The initial plate orientation should mirror the
deformity to be corrected. For example, in a dor-
sally tilted malunion with loss of radial inclination,
the proximal aspect of the plate will be ulnarly
directed and volarly displaced away from the
radial shaft before correction (see Fig. 33.13).
FIGURE 33.12 Volar locking plate aligned on the distal radius segment.
FIGURE 33.14 Plate secured with screws to the

radial shaft.
FIGURE 33.13 Plate placement.
STEP 2 PITFALLS
• If the plate rim is not parallel to the volar rim
Step 3 of the lunate facet, then radial inclination will
• The proximal portion of the plate is temporarily stabilized to the radial shaft with a not be restored. If the distal end of the plate is
not in direct contact with the volar cortex of
bone clamp, and alignment is checked with fluoroscopy. the distal fragment, then the volar tilt will not
• Distal advancement of the plate along the radial shaft is done to establish the correct be restored.
radial height. The goal is make the radius neutral with the ulna. • Two to four locking screws are placed distally
• The plate is secured with screws to the radial shaft (Fig. 33.14). to provide strength to the distal fragment plate
fixation. If the plate is manipulated after place-
Step 4: Closure ment of a single screw, the screw and plate will
have a higher chance to pull away from the
• Bone grafts with autogenous or cadaveric bone chips are placed into the defect bone, or the plate will rotate out of position.
created by the osteotomy (Fig. 33.15).
• The pronator quadratus is repaired over the plate with 3-0 Vicryl.
STEP 3 PEARLS
• The incision is closed with absorbable suture.
• The patient is placed in a volar short-arm splint. A plate that uses locking screws is necessary
when using the volar plate to reduce the distal
segment. Traditional plates are more prone to
screw loosening.
INTRAARTICULAR MALUNION
• Surgical intervention is made to correct the specific deformity and reestablish
articular congruity. STEP 3 PITFALLS
• Fig. 33.16 shows an example of a volar intraarticular segment malunion. If the plate does not reduce to the radial shaft,
• This patient presents with a volarly subluxed and ulnarly deviated wrist (Fig. 33.17A–C). evaluate and release any scar tissue or fibrous
• The patient has pain and difficulty with wrist extension and supination (Fig. 33.18). callus attached to the distal segment.
STEP 4 PEARLS
• Adequate bone grafting of the entire osteotomy
can be checked under fluoroscopy.
• For defects greater than 1 cm, cortical–
cancellous bone graft can aid stability.
STEP 4 PITFALLS
Bone graft should not be packed beyond the
cortical edges of the radius. This can lead to
prominent bone fragments that cause tendon
irritation and eventual rupture.
FIGURE 33.15 Cadaveric bone placed into the defect.
FIGURE 33.16 Volar intraarticular segment malunion.
Prior
incision
A B C
FIGURE 33.17 (A-C) Volarly subluxed and ulnarly deviated wrist.
FIGURE 33.18 Difficulty with wrist extension and supination.

FIGURE 33.19 Malunion identified with clearly visible prior fracture line
(white arrow pointing to prior fracture line). FIGURE 33.20 Osteotome used to disimpact the prior fracture.
STEP 1 PEARLS
Step 1: Release of Intraarticular Malunion Segments Maintain any nonrestrictive soft-tissue attachments
to the displaced fragment(s). These attachments
• A dorsal or volar approach is selected based on the location of the intraarticular may carry vascular supply to the bone fragments.
malunion.
• A poorly reduced volar fracture is fixed with a volar approach using the prior incision
(see Fig. 33.17A). STEP 1 PITFALLS
• The malunited segments are visually identified (Fig. 33.19) and confirmed with fluo- Avoid damage to the articular surface during the
roscopy. osteotomy.
• An osteotome is used to release the displaced segment (Fig. 33.20).
STEP 2 PEARLS
For this type of malunion, a volar plate using
A volar plate is applied to the radial shaft and the segment is reduced into anatomic variable angle pegs placed under the articular
alignment (Fig. 33.21). surface works well to buttress the volar segment.
Step 3: Distal Screw Placement

• A distal screw is first placed to fixate the reduced malunion segment (Fig. 33.22). STEP 2 PITFALLS
• The remaining screws are placed for further stabilization (Fig. 33.23). The callus underneath the malunion must be
debrided away to enable adequate reduction of the
Step 4: Closure fracture piece.
• The pronator quadratus is repaired over the plate with 3-0 Vicryl.
• The incision is closed with absorbable suture (Fig. 33.24). STEP 3 PEARLS
• The patient is placed in a volar short-arm splint.
Use a variable-angle drill guide to have flexibility in
the angle of screw placement. This can help orient
screws to capture and support small articular
fragments.
STEP 3 PITFALLS
Take care that drilling and screw placement do not
cause iatrogenic fracture of small bone fragments.
A B
FIGURE 33.22 Distal screw placed to fixate the
FIGURE 33.21 Volar plate applied to the radial shaft. reduced malunion segment.
FIGURE 33.23 Remaining screws placed for further stabilization.

FIGURE 33.24 Incision closed with absorbable suture.
INTRAARTICULAR MALUNION OF THE VOLAR ULNAR

CORNER (LUNATE FACET FRAGMENT)
• Surgical intervention is necessary to correct the specific deformity, reestablish ar-
ticular congruity, prevent subluxation of the carpus, and maintain DRUJ congruity.
• Fig. 33.25 shows an example of a volar ulnar corner intraarticular segment malunion.
• This patient presents with a volarly subluxed carpus seen on radiographs and clini-
cally (Fig. 33.26).
• The patient has pain and difficulty with wrist extension and flexion (Fig. 33.27).
FIGURE 33.25 Volar ulnar corner intraarticular segment malunion.
FIGURE 33.26 Volarly subluxed carpus.

FIGURE 33.27 Poor preop motion. STEP 1 PEARLS

• Although the previous volar Henry incision was
used in this case, the volar ulnar approach
(exploiting the interval between the FCU and
palmaris longus superficially and ulnar neuro-
vascular bundle and carpal tunnel contents
deep) should also be considered to permit
direct visualization of the volar ulnar corner
fracture and the sigmoid notch.
• Mobilization of the bony fragments should be
done gently, especially in osteoporotic bone,
because this could lead to increasing bone
fragmentation.
• Ensure that any nonrestrictive soft tissue stays
attached to the displaced fragment(s). These
attachments carry vascular supply to the bone
fragments.
STEP 1 PITFALLS
Avoid damage to the articular surface during the
osteotomy.
STEP 2 PEARLS
Again, gentle and patient elevation with the Freer is
necessary to avoid further fragmentation. Elevating
the fragment will create a void in the subchondral
bone, which should be filled with bone graft or
FIGURE 33.28 Prior volar Henry approach. bone substitute.
Step 1: Release of Intraarticular Malunion Segments STEP 2 PITFALLS

• A dorsal or volar approach is selected based on the location of the intraarticular
The callus at the malunion site must be debrided
malunion. away to enable adequate mobilization and
• A poorly reduced volar ulnar corner fracture is approached using the prior volar reduction of the fracture piece.
Henry approach (Fig. 33.28).
• Prior hardware is identified and removed to better assess the malunion (Fig. 33.29A–B). STEP 3 PEARLS
• Use an osteotome or Freer at the malunion site to gain mobility of the fracture
• Use 2.4-mm plates because these can be bent
fragment. to match radial anatomy and then placed in a
buttress fashion. The plates also have a low
Step 2: Restoration of Articular Congruity profile if they must be placed distally.
• A Freer is used to elevate the mobile fragment and restore both articular congruity • Often, the plates need to be placed distally to
and DRUJ congruity (Fig. 33.30). adequately capture the fragment. To prevent
tendon irritation, it may be helpful to repair the
• Allograft bone is inserted into the subchondral bone defect (Fig. 33.31).
pronator quadratus.
• Additionally, future hardware removal surgery
Step 3: Plate Placement should be discussed with the patient
The plate should be placed in a buttress fashion to permit adequate capture of the preoperatively.
fragment and prevent collapse from the axial loads (Fig. 33.32A–B).
STEP 3 PITFALLS
Step 4: Closure
Ensure that drilling and screw placement does not
• The pronator quadratus is repaired over the plate with 3-0 Vicryl. cause iatrogenic fracture of small bone fragments.
• The incision is closed with absorbable suture.
Plate
Original fracture
line
FIGURE 33.29 (A) Plate identified. (B) Plate removed and original fracture line revealed.
FIGURE 33.30 Articular congruity restored.
Bone graft
FIGURE 33.31 Bone graft inserted into subchondral void.

Plate
FIGURE 33.32 (A-B) Plate placed and buttressing volar ulnar corner fragment.
FIGURE 33.33 Immediate postoperative x-rays.
• The patient is placed in a volar short-arm splint.

• Immediate postoperative x-rays demonstrate improvement in alignment of the
articular surface and correction of the volar carpal subluxation (Fig. 33.33).

• A volar splint remains for 7 to 10 days. Any nonabsorbable sutures are removed.
• Depending on the degree of deformity and stability of the fixation, patients may be
casted or placed in a removable splint.
• Active range of motion (ROM) of the fingers is started immediately.
• The ultimate outcome regarding strength and motion may take up to 12 to 18 months.
Preoperative wrist function will affect the speed of recovery postoperatively.
FIGURE 33.34 Three-month postoperative x-rays.
FIGURE 33.35 Improved range of motion.
POSTOPERATIVE PEARLS • Outcome data suggest that patients will have significant functional improvement
Patients presenting for malunion may be eager to with improved anatomy, but function is not likely to return to the level of the unin-
return to full activity; caution should be stressed jured side.
with these patients about advancing too quickly. • The patient 3 months after correction has x-rays demonstrating a healed previous
osteotomy site with incorporation of the bone graft (Fig. 33.34) and improved ROM
POSTOPERATIVE PITFALLS (Fig. 33.35).
Finger ROM exercises should be started as soon as
possible. Patients presenting with malunion may
already suffer from decreased mobility.
EVIDENCE
Gaspar M, Kho J, Kane P, Abdelfattah HM, Culp RW. Orthogonal plate fixation with corrective osteot-
omy for treatment of distal radius malunion. J Hand Surg Am. 2017;42(1):e1–e10.
This study is a retrospective review of patients who underwent distal radius corrective osteotomy and
90-90 fixation from January 2008 to December 2014. In all, 39 cases (31 extra-articular, 8 combined
intra- and extra-articular) were included. At a mean follow-up of 4 years, significant improvements
were observed in wrist motion, grip strength, pain, radiographic parameters, and QuickDASH scores.
Twelve patients (31%) underwent additional surgery with the most common being plate removal
(7 patients, 3 of 7 of whom removed the radial plate; Level IV evidence).
Luo TD, Nunez Jr FA, Newman EA, Nunez Sr FA. Early correction of distal radius partial articular
malunion leads to good long-term functional recovery at mean follow-up of 4 years. Hand (N.Y.).
2020;15(2):276–280.
This study is a retrospective review of 7 consecutive patients with a mean age of 38 years who under-
went corrective osteotomy via dorsal or combine dorsal volar approach. Mean time from injury to
corrective osteotomy was 10 weeks. At mean follow-up of 44 months, significant improvements in
pain scores, wrist ROM with the exception of pronation, QuickDASH and grip strength were noted.
No patients required secondary procedures, including removal of hardware (Level IV evidence).
CHAPTER 34
Associated Ulnar Fixation (Ulnar Styloid
and Metadiaphyseal Fractures)
INDICATIONS
• Ulnar styloid, ulnar metaphyseal, and ulnar metadiaphyseal fractures may be treated
after reduction and stabilization of distal radius fractures (DRF).
• If rigid fixation of a DRF results in a stable distal radioulnar joint (DRUJ), then
operative fixation of an associated distal ulnar fracture is not mandatory.
• The most common causes of instability of the DRUJ after DRF are dorsal angula-
tion and shortening of the DRF fragments.
• Ulnar fractures require operative repair if there is (1) an unstable DRUJ, (2) an
unstable and/or irreducible fracture, (3) a large intraarticular step-off, or (4) a need
to restore ulnar length and alignment.
Ulnar Styloid Fracture Management

• Ulnar styloid fracture is present in up to 50% to 65% of DRF patients.
• Treat an ulnar styloid tip or midportion fracture nonoperatively because these injuries
are not associated with DRUJ instability (the radioulnar ligament insertion is still intact).
• For an ulnar styloid base fracture, if the DRUJ is stable with or without laxity, treat
nonoperatively.
• In cases of grossly unstable DRUJ with ulnar head subluxation, manage with open
reduction internal fixation.
Ulnar Metaphyseal Fracture Management

• Ulnar metaphyseal fracture (i.e., ulnar head or distal ulnar) is present in up to 6% of
DRF patients.
• Literature has shown that comminuted fractures in elderly patients are often stable
enough (after DRF fixation) for nonoperative management.
• The Biyani Classification delineates the fracture patterns of ulnar metaphyseal
fractures (Fig. 34.1).
Type 1 Type 2 Type 3 Type 4
FIGURE 34.1 Biyani Classification of ulna metaphyseal fractures. Type I: Simple extraarticular fracture
with minimal comminution. Type II: Inverted T- or Y-shaped fracture with an ulnar styloid fragment,
including a portion of the metaphysis. Type III: Fracture of the lower ulnar metaphysis with avulsion
fracture of the ulnar styloid. Type IV: Comminuted fracture of lower ulnar metaphysis, with or without
styloid fracture.
258
CHAPTER 34 Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures) 259
Ulna Metadiaphyseal Fracture Management

The goal of management is to restore ulnar alignment and length and ensure DRUJ
stability. Typically, a displaced fracture should be treated operatively.
Contraindications
• Ulnar styloid fractures with a stable DRUJ do not require fixation.
• Elderly patients with osteoporotic bone and comminuted ulnar head, metaphyseal,
or neck fractures can be managed nonoperatively.
• Perform a complete skin, muscle, and neurovascular examination of the upper ex-
tremity pre- and postreduction.
• Examine the contralateral extremity to compare forearm length (ulnar variance),
range of motion (ROM), and integrity of the DRUJ.
• The carpal tunnel and forearm compartments should be examined for signs and
symptoms of compartment syndrome because fractures of both forearm bones are
typically caused by highimpact injuries.
• Examine for DRUJ instability (Fig. 34.2).
• Assess for joint laxity, subluxation, or dislocation. Joint laxity can be compared
with the contralateral extremity. A palpable clunk with ulnar dislocation suggests
a DRUJ injury.
IMAGING
• Radiographs of the wrist in posteroanterior, lateral, and oblique views should be
obtained.
• Repeat radiographic views of the wrist intraoperatively to ensure restoration of
volar tilt and length of the distal radius after fixation and before examining DRUJ
stability.
Evidence of DRUJ Instability

• Ulna head is subluxed dorsally from the sigmoid notch with the arm in neutral rotation.
• There is widening of the DRUJ on the posteroanterior view.
• Radial displacement of ulnar styloid fragment indicates a pulling force of a detached
radioulnar ligament (Fig. 34.3).
FIGURE 34.2 With the elbow flexed at 90 degrees, stress the ulna volarly and dorsally with the fore-
arm in supination, neutral, and pronation. Repeat the examination with radial deviation of the wrist
(right image). Next, compress the distal radius and ulnar head together and range the wrist from su-
pination to pronation. Ulnar dislocation indicates a DRUJ injury that needs surgical repair.
260 CHAPTER 34 Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)
FIGURE 34.3 The ulnar styloid fragment is being pulled radially (white arrow) indicating the pulling force of
the radioulnar ligament.
SURGICAL ANATOMY
Biomechanical Anatomy
• The distal ulna is the fixed point around which the radius rotates.
• Pronation and supination of the wrist is achieved as the radius rotates around the
ulna via the DRUJ articulation.
• The ulnar styloid base and fovea are the insertion points of the palmar and dorsal
radioulnar ligaments, which are the primary stabilizers of the DRUJ (Fig. 34.4).
• Therefore DRUJ instability may occur with basilar ulnar styloid or intraarticular frac-
tures because this results in disruption of the superficial (distal) attachment limbs of
the radioulnar ligaments.
• The DRUJ may maintain stability if the deep (proximal) limbs remain attached to the
fovea (i.e. ligamentum subcruentum).
Palmar
radioulnar
ligament
Fovea
Articular
disc
Dorsal
radioulnar
ligament
FIGURE 34.4 The palmar and dorsal radioulnar ligaments are the primary stabilizers of the DRUJ. If
the ulnar styloid fragment is proximal to those attachments, the DRUJ may be unstable, necessitat-
ing fixation.
Bony and Ligamentous Relationship

• A palpable, shallow groove on the dorsum of the ulna styloid harbors the extensor
carpi ulnaris (ECU) tendon. This is easily palpated with wrist extension and radial
deviation.
• The extensor retinaculum inserts onto the ulnar and dorsal aspects of the ulna.
Triangular Fibrocartilage Complex

The triangular fibrocartilage complex (TFCC) consists of a central articular disk, menis-
cal homologue, radioulnar ligaments, ulnocarpal ligaments, and ECU tendon sheath.
The radioulnar ligaments of the TFCC attach at the fovea, which is located at the base
of the ulnar styloid.
Critical Structures
The ulnar approach places the dorsal branch of the ulnar nerve at risk. This nerve
branches approximately 6 cm proximal to the ulnar head, passes dorsal to the flexor EXPOSURES PEARLS
carpi ulnaris (FCU), and pierces the deep fascia 5 cm proximal to the pisiform. • Distal extensions of the incision should con-
tinue dorsally, so that the resultant scar does
POSITIONING not correlate with the resting position of the
• Position the patient supine with the affected extremity extended on an arm table. ulnar head on hard surfaces.
• If a TFCC exploration is deemed necessary (after
• The procedure is more easily performed if an assistant holds the elbow flexed at 90
ulnar fixation), the distal aspect of the skin inci-
degrees with the forearm in neutral pronation-supination. sion can be hockey-sticked dorsally enough to
gain access to the fifth to sixth extensor com-
ULNAR APPROACH TO THE ULNAR STYLOID, HEAD, AND partment interval (see Chapter 20 TFCC Repair).
• Release of the ulnar attachments of the exten-
NECK sor retinaculum can aid in fracture visualization
and reduction.
Exposures
• A longitudinal incision is made over the subcutaneous border of the ulnar neck and
shaft (centered on the fracture site; Fig. 34.5). EXPOSURES PITFALLS
• During subcutaneous dissection, the dorsal branch of the ulnar nerve is identified
• Overzealous periosteal stripping should be
and retracted. avoided to preserve the vascular supply to
• The extensor retinaculum is incised. the ulna.
• Dissection is continued sharply between the tendons of the flexor and ECU down to • Avoid circumferential dissection around the
the ulna. ulnar base because this will disinsert the
• Incise the periosteum longitudinally and elevate to expose the fracture. superficial attachment limbs of the radioulnar
ligaments of the TFCC.
• Evacuate the hematoma, irrigate, and clean the fracture fragments.
FIGURE 34.5 The incision over the ulna is centered over the fracture (black arrow). For ulnar styloid
fractures and TFCC exploration and repair, the proposed distal curvilinear incision can be used.
This results in a scar that does not correlate with the resting position of the wrist on a hard surface
(white arrow).
STEP 1 PEARLS ULNAR STYLOID FRACTURE FIXATION WITH TENSION

Because the ulnar styloid is small, avoid multiple
BAND WIRING
passes of K-wire to preserve bone. Step 1: Reduction of Fracture
• Identify the ulnar styloid fragment with the aid of intraoperative fluoroscopy.
• Use an elevator or dental pick to reduce the radially displaced fragment out of the
STEP 1 PITFALLS wrist joint space and into the field of dissection.
Overreducing ulnar styloid fractures, although • Provisionally place a 1.1-mm Kirshner wire (K-wire) just off the midline of the apex
difficult, may increase tension on the TFCC and of the styloid (to permit placement of a second K-wire).
lead to restricted forearm rotation. • Using fluoroscopy, reduce the styloid fragment using the K-wire as a joystick.
• While holding reduction, place a second 1.1-mm K-wire near the apex of the styloid and
drive obliquely to capture the opposite cortex of the ulnar metadiaphysis (Fig. 34.6).
STEP 2 PEARLS • Drive the joystick K-wire into the opposite cortex of the ulnar metadiaphysis.
Use an 18- or 20-gauge needle to guide the
stainless-steel wire through the hole.
Step 2: Placement of Tension Band
• Drill a 1- to 1.5-mm hole (approximately 2 cm proximal from the apex of the styloid)
through the ulnar metadiaphysis.
STEP 2 PITFALLS
• Thread a 26-gauge stainless-steel dental wire through the hole (Fig. 34.7A).
Avoid grasping soft tissue or the dorsal sensory • Create a figure-of-eight loop with the wire by passing distal to the K-wires (see
branch of the ulnar nerve as the wire is placed and Fig. 34.7B).
tightened.
• Pull the figure-of-eight loop taut.
Step 3: Complete Fixation

• Twist the figure-of-eight wire ends in a clockwise the direction until the desired
tension is achieved.
• Visualize reduction under fluoroscopy to ensure that it is maintained with pronation
and supination.
• Cut the wire ends, rosette, and bury toward bone to prevent prominence.
• Using two heavy needle drivers, bend the exposed K-wires 180 degrees and trim
short.
• Face K-wires deep and bury in bone such that they hold the figure-of-eight wire.
A B
FIGURE 34.7 (A) Thread a 26-gauge stainless steel wire through the
proximal hole and then distally in a figure-of-eight fashion around
the K-wires (using an 18-gauge needle for assistance). (B) Tighten
FIGURE 34.6 With the joystick K-wire (black arrow) holding re- the K-wire to reduce the fracture, then cut and expose the K-wire
duction, drive a second K-wire across the fracture fragment. 5 mm outside of styloid and bury it to hold the tension band.
Step 4: Closure
• Reapproximate the periosteum and extensor retinaculum.
• Close the subcutaneous tissue and skin in layers.
• Ensure that the K-wires and tension band wire are not palpable.
ULNAR STYLOID FRACTURE FIXATION WITH CANNULATED

HEADLESS COMPRESSION SCREW
Step 1: Reduction of Fracture
• As described previously, identify and reduce the fracture fragment.
• Hold the fragment reduced with point-to-point reduction forceps (Fig. 34.8).
• Place a single K-wire at the apex of the styloid centered in the bulk of the
fragment.
• Under fluoroscopic guidance, drive a 1.1-mm K-wire obliquely and capture the
opposite cortex of the metadiaphysis of the ulna.
• Confirm adequate reduction.
Step 2: Size Cannulate Headless Compression Screw

• Measure the desired screw length using a second K-wire or the manufacturer’s mea-
suring device. FIGURE 34.8 With a point-to-point holding reduc-
• Advance the K-wire into the radius to avoid inadvertent removal when predrilling. tion, a K-wire is placed across the center of the
fracture. After measuring the length of the com-
• Select the correct drill size for the chosen screw diameter and length, and under
pression screw, send the K-wire out of the far ulnar
fluoroscopic guidance, drill through the far cortex. cortex to prevent inadvertent removal (black arrow).
• Countersink the drill hole.
STEP 1 PEARLS
Step 3: Fixation With Headless Compression Screw
Only large ulnar styloid fracture fragments are
• Pass the driver handle and cannulated headless compression screw over the guide amenable to headless compression screws (typically
wire and advance the screw into position. 2.0–2.5 mm). Fracture fragments must be held in
• Engage the far cortex of the ulna to achieve compression. reduction with forceps/clamp to facilitate precise
• Remove the guide wire. K-wire placement.

• Reapproximate the periosteum and extensor retinaculum. It is important to select a screw that is short enough
• Close the subcutaneous tissue and skin in layers. to bury in the styloid fragment but long enough to
engage the far cortex to achieve compression.
ULNAR METADIAPHYSEAL FRACTURE FIXATION WITH AN
ANATOMIC ULNAR HOOK PLATE STEP 3 PEARLS
• Compression cannot be achieved if the screw
Step 1: Reduction of Fracture threads are bridging the fracture gap.
• Align multifragmentary fractures with point-to-point reduction forceps. • Ensure that the screw sits beneath the surface
• Provisional K-wire fixation may be required if severe comminution exists. of the ulnar styloid to prevent impingement.
• Use a 1.1-mm K-wire to reduce the ulnar styloid fragment to the ulnar head.
STEP 1 PEARLS
• Fixation of a multifragmentary fracture of the
Step 2: Fixate Ulnar Styloid to Ulnar Head Using a 2.0-mm LCP Distal distal ulna can be achieved with a 2.0-mm
Ulnar Hook Plate LCP distal ulnar hook plate. The plate is ana-
• Place the hook plate on the bone by engaging the distal hooks onto the tip of the tomically precontoured and has hooks that grip
ulnar styloid. the styloid process. Therefore fixating the ulnar
styloid to the ulnar head using the plate will
• Secure the plate to the ulnar head with a 2-mm locking screw (Fig. 34.9). facilitate the remainder of the reduction.
• In comminuted metadiaphyseal fractures,
Step 3: Reduce the Ulnar Head to the Ulnar Shaft correct rotational alignment and length must
Use point reduction forceps to grasp the ulna shaft and reduce the ulna head to the be achieved for adequate anatomic fixation.
shaft. • The bone quality in the distal ulna is often poor;
therefore the hook plate is a locking screw de-
sign. Be sure to contour the plate to the fracture.
Step 4: Complete Fixation The first screw should be a cortical screw to
• Drill and insert a nonlocking screw into the oblong hole over the ulnar shaft to reduce bring the plate in tight contact with the bone. If a
the bone to the plate (Fig. 34.10). locking screw is placed first, there may be a gap
• Confirm adequate reduction with fluoroscopy. between the plate and the bone, which may trap
tendons or nerves in the gap during wrist motion.
• Fill the remaining plate holes with locking or nonlocking screws (Fig. 34.11).
STEP 2 PEARLS
Use the drill sleeve for ease of control and
manipulation of the plate.
STEP 2 PITFALLS
• A screw that is too long may penetrate the far
ulnar cortex and enter the DRUJ.
• Unicortical screws are used at the level of the
sigmoid notch.
STEP 4 PEARLS
• The provisional K-wire holding the ulnar styloid to
the ulnar head can be cut short and left in place.
Alternatively, it can be removed, and an additional
screw may be placed between the pointed hooks
on the ulnar styloid to achieve more rigid fixation
with an orthogonally placed screw. FIGURE 34.9 Engage the hooks of the anatomic hook plate into the tip of the ulnar styloid (black
• After final screw placement, check for unre- arrow) and secure the plate to the ulnar head with a cortical screw to bring the plate into contact
stricted pronation and supination of the wrist with the bone (green arrow).
to ensure that no screws are inhibiting the
DRUJ articulation.
A B
FIGURE 34.10 With a reduction clamp holding the plate FIGURE 34.11 (A) The remainder of the screws are placed to attain three points of fixation
to the proximal shaft, place a nonlocking screw in the proximally. (B) Note: unicortical screws were placed in the metadiaphysis to avoid pene-
proximal fragment. tration into the DRUJ (yellow arrow).

• If rigid fixation is achieved:
• Place the patient in a short arm volar resting splint.
• Evaluate the fixation radiographically at 1 week and begin therapy if reduction is
maintained.
• Treat patients based on the needs of their DRF management.
• If the fixation is tenuous and the DRUJ remains unstable:
• Place patient in a sugar-tong splint to block supination and pronation.
• Evaluate fixation radiographically at 1 week and 4 weeks.
• Begin therapy at 4 to 6 weeks, based on DRUJ stability on clinical examination.
• The presence of ulnar styloid fractures does not affect the outcomes of DRF, unless
gross DRUJ instability exists.
• Nonunion occurs in 25% of ulnar styloid fractures.
• Nonunion does not correlate with functional or clinical outcomes and requires no
further treatment if asymptomatic.
• Symptoms related to nonunion occur because of abutment on the carpus, irrita-

tion from the loose body, or development of DRUJ instability.
See Video 34.1
EVIDENCE
Richards TA, Deal N. Distal ulna fractures. J Hand Surg Am. 2014;39(2):385–391.
This review article on distal ulnar fractures summarizes pertinent anatomy and treatment options for
distal ulnar fractures. The authors review fracture classifications, methods of fixation (including
salvage procedures), and the arguments for and against surgical intervention.
Sammer DM, Shah HM, Shauver MJ, Chung KC. The effect of ulnar styloid fractures on patient-rated
outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009;34(9):1595–1602.
The authors performed a prospective cohort study of distal radius fractures treated with volar locking
plate. They omitted patients with an unstable DRUJ and compared 88 patients with ulnar styloid
fractures to 56 without. They found that ulnar styloid fracture presence, size, displacement, and
union did not affect subjective outcomes, which were evaluated with the Michigan Hand Outcomes
Questionnaire.
Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate fixation of a
distal radius fracture? J Bone J Surg. 2019;92: 1–6.
This study evaluated 138 consecutive patients with distal radius fractures who underwent open
reduction and internal fixation and compared the outcomes of patients with and without ulnar
styloid fractures. Seventy-six (55%) patients had styloid fractures, of which 29 were at the ulnar
base. No differences in wrist outcomes were identified between group comparisons, and, therefore,
the authors concluded that associated ulnar styloid fractures in patients who receive stable fixation
of their distal radius has no adverse effect on wrist function and does not need operative fixation.
CHAPTER 35
Forearm Fracture-Dislocations (Galeazzi
and Monteggia)
INDICATIONS
• Radius and ulna fracture-dislocations require operative treatment in the adult population.
• The forearm unit consists of the ulna and radius, which are held together proxi-
mally at the proximal radioulnar joint (PRUJ), at the interosseous membrane (IOM)
along the shaft, and distally at the distal radioulnar joint (DRUJ). Because of their
intimate relationship, displaced proximal or midshaft fractures of one bone may
result in a dislocation of the other.
• Galeazzi fracture-dislocation is characterized by a radial shaft fracture, typically at the
junction of the middle and distal thirds, and dislocation of the DRUJ. Dorsal ulnar
dislocation of the DRUJ results from pronation and wrist extension. Volar ulnar dislo-
cation of the DRUJ (less common) is the result of forced supination or a direct ulna
blow. DRUJ instability arises when the triangular fibrocartilage complex (TFCC) tears
from its foveal attachment or there is an ulnar styloid base fracture (with intact TFCC).
• Operative fixation of the radial shaft fracture typically results in a reduced, stable
DRUJ. After radius fracture fixation, evaluation of DRUJ stability will guide man-
agement as follows:
• If stable: Perform long-arm cast immobilization in slight supination.
• If unstable: Perform DRUJ transfixion.
• If unstable and irreducible DRUJ: Perform (1) open reduction and internal fixa-
tion of styloid fracture, or (2) open removal of interposed soft tissue and TFCC
repair. Protect both repairs with DRUJ transfixion.
• Monteggia fracture-dislocation is characterized by a proximal ulna shaft fracture
with an accompanying dislocation of the PRUJ. The goal of treatment is to maintain
an anatomically reduced radial head, which is best accomplished with restoration of
ulna length and alignment. The Bado Classification describes subtypes of this
fracture-dislocation pattern (Fig. 35.1):
• Type I (60% of fractures, mostly children): Proximal or middle third ulna shaft
fracture (apex anterior angulation) with anterior dislocation of the radial head.
• Type II (15% of fractures, mostly adults): Proximal or middle third ulna shaft frac-
ture (apex posterior angulation) with posterior dislocation of the radial head. The
Jupiter Classification describes subtypes:
• IIA: The ulna fracture involves the distal olecranon and coronoid process.
• IIB: The ulna fracture is at the metaphyseal-diaphyseal junction distal to the
coronoid.
• IIC: The ulna fracture is diaphyseal.
• IID: The ulna fracture extends to the midshaft or distal.
• Type III (20% of fractures): Ulna metaphysis fracture (distal to coronoid process)
with lateral dislocation of the radial head.
• Type IV (5% of fractures): Proximal or middle third ulna and radial head fractures
with dislocation of the radial head in any direction.
Contraindications
• Grossly contaminated wounds require initial washout and debridement before
definitive fixation.
• Hemodynamic instability or life-threatening injuries take precedence before operative
fixation.
266
CHAPTER 35 Forearm Fracture-Dislocations (Galeazzi and Monteggia) 267
A B
C D
FIGURE 35.1 The Bado Classification describes subtypes of Monteggia fracture-dislocations based
on the direction of the radial head displacement (black arrows). (A) Type I – anterior dislocation,
(B) Type II – posterior dislocation, (C) Type III – lateral dislocation, (D) Type IV – dislocation in any
direction with radial head fracture (bolt). (From Perez, EA. Fractures of the shoulder, arm, and forearm.
In Canale ST ed. Campbell’s Operative Orthopaedics. 9th ed. Elsevier; 1998:3031–3126.)
• Perform a complete skin, muscle, and neurovascular examination of the upper ex-
tremity (pre/postreduction and pre/postoperatively).
• Examine the contralateral extremity to compare forearm length, range of motion
(ROM), and integrity of the DRUJ and PRUJ.
• Evaluate the forearm compartments for signs and symptoms of compartment syndrome.
• It is imperative to examine the DRUJ and PRUJ for dislocations after operative repair
of forearm fractures.
IMAGING
• Anteroposterior and lateral plain radiographs of the wrist, forearm, and elbow are
indicated for forearm fractures.
• Galeazzi fracture-dislocation (Figs. 35.2):
• On anteroposterior view, evaluate for an apex medial angulated radius fracture,
radial shortening (typically . 5 mm), and widening of the DRUJ.
• On lateral view, evaluate for an apex dorsal angulated radius fracture and dorsal
dislocation of ulna head.
• Evaluate for ulna styloid base fracture.
• Monteggia fracture-dislocation (Fig. 35.3):
• Evaluate for bony abnormalities.
• Congruency of the radiocapitellar joint is assessed with the radiocapitellar line
(RCL). The RCL (a longitudinal line traveling down the center of the radius) should
pass through the center of the capitellum in all views (in adults).
• If intraarticular involvement (Jupiter type IIA), radial head fractures (Bado type IV),
or severely comminuted fractures are suspected, then computed tomography
(CT) may be helpful.
SURGICAL ANATOMY
Bony Anatomy
• Both radius and ulna have characteristic bows that permit pronation and supination of
the forearm. The morphology of these bones must be respected when performing fixa-
tion, or the patient will experience significant limitations in ROM, dexterity, and strength.
268 CHAPTER 35 Forearm Fracture-Dislocations (Galeazzi and Monteggia)
A B
FIGURE 35.2 Radiograph of Galeazzi fracture-dislocation showing anterior-posterior view with (A) apex
medially angulated radius fracture (yellow arrow), radial shortening, and DRUJ widening (green arrow),
and lateral view showing (B) apex dorsal angulated radius fracture (blue arrow) and dorsal dislocation
of ulna head (red arrow).
A B
FIGURE 35.3 Radiograph of Monteggia fracture-dislocation showing lack of congruency of the radio-
capitellar joint in the (A) anteroposterior view and (B) lateral view. The radiocapitellar line (RCL; yellow
dotted line) is drawn down the shaft of the radius and should pass through the center of the capitel-
lum. This Bado type I shows an ulna fracture with an apex anterior angulation (blue arrow) and anterior
dislocation of the ulna head (red arrow). (From Ring D. Monteggia fractures. Orthop Clin North Am.
2013;44[1]:59–66).
• The radius has a 10-degree radial bow in the coronal midshaft and a 5-degree sag-
ittal bow in the proximal third.
• The ulna has a slight posterior apex bow along its entire length.
• The midportion of the ulna has a triangular cross-section. The posterior apex portion
is largely subcutaneous (and palpable) and separates the extensor and flexor com-
partments.
Articular Anatomy
Distal Radioulnar Joint
See Fig. 35.4 for a depiction of the distal radioulnar joint.
• It involves the synovial joint between the concave sigmoid notch of the radius and
the convex ulna head.
• It is primarily stabilized by the volar and dorsal radioulnar ligaments (component of
the TFCC), and secondarily by the IOM and pronator quadratus (PQ).
Ulnar styloid
Extensor carpi
ulnaris tendon
sheath
Extensor carpi
ulnaris tendon
Dorsal distal Palmar distal Triangular

radioulnar ligament radioulnar ligament (articular)
disk
FIGURE 35.4 The primary stabilizing structures of the triangular fibrocartilage complex (TFCC) are
the palmar and dorsal radioulnar ligaments, which insert onto the base of the ulna styloid. The distal
radioulnar joint (DRUJ) is injured and may be unstable, with injury to these structures or fracture of the
ulnar styloid proximal to their insertion. (From Savoie FH. Triangular fibrocartilage complex injury. In
Giangarra C, Manske E, eds. Clinical Orthopaedic Rehabilitation: A Team Approach. 4th ed. Elsevier:
2017;45–50 and Anatomy of the triangular fibrocartilage complex).
• The TFCC consists of a central articular disk, meniscal homologue, radioulnar liga-
ments, ulnocarpal ligaments, and extensor carpi ulnaris (ECU) tendon sheath. The
radioulnar ligaments of the TFCC attach at the fovea, which is located at the base
of the ulna styloid.
Interosseous Membrane
The IOM disperses axial load forces to the forearm.
Proximal Radioulnar Joint

See Fig. 35.5 for a depiction of the proximal radioulnar joint.
• The synovial joint is formed by the circumferential margin of the radial head that
articulates with the lesser sigmoid notch of the ulna (on the lateral side of the coro-
noid process).
• The annular and quadrate ligament are the primary stabilizers of the PRUJ.
• The annular ligament originates and inserts on the ulna and encircles the radial
head.
• The quadrate ligament is a fibrous band spanning from the inferior border of the
radial notch on the ulna to the neck of the radius.
• A thorough understanding of the muscles and neurovascular structures of the fore-
arm is needed to safely perform open reduction and internal fixation.
Annular ligament
Inferior band of ulnar collateral

Anterior band ligament
Posterior band
FIGURE 35.5 The annular ligament encircles the radial head and maintains the articulation between
the radial notch on the ulna. (From Leela CB. Elbow and forearm. In Standring, S. ed. Gray’s
Anatomy. 41st ed. Elsevier; 2015;837–861).
Galeazzi Fracture-Dislocation Open Reduction Internal

EXPOSURES PEARLS
Fixation
• During the anterior approach, several at-risk
nerves should be protected: EXPOSURES
• The lateral antebrachial cutaneous nerve
(LABC) emerges between the biceps tendon • Anterior (Henry) approach for middle and distal-third radius fractures (Fig. 35.6):
and BR proximally and can be found subcu- • A longitudinal line is drawn, extending from the radial border of the flexor carpi radia-
taneously on the radial side of the volar lis (FCR) at the wrist crease toward the lateral edge of the bicep tendon proximally.
forearm. • The incision is made on this line and centered over the fracture. The length de-
• The radial sensory nerve (RSN) runs deep to
the BR and penetrates the fascial interval pends on the fracture location.
between the BR and extensor carpi radialis • Dissection is performed sharply through skin, subcutaneous tissue, and fascia.
longus tendons in the distal third of the • Identify the radial artery.
forearm. • In the middle and proximal third of the arm, the radial artery is more superficial
• The posterior interosseous nerve (PIN) travels and midline.
deep and within the substance of the supina-
tor muscle (proximal third of the forearm) and • Distally, the radial artery with its venae comitantes is found deep to the bra-
is protected when the forearm is supinated. chioradialis (BR), exiting the interval between the BR and FCR muscle bellies.
Supinating the forearm may require using • Bipolar cautery is used to coagulate perforators to the BR muscle, and the radial
forceps to grab the distal portion of the artery is mobilized (radially in the distal forearm, ulnarly in the proximal forearm).
proximal fracture fragment. • Dissection proceeds deep along the medial edge of the BR. The radial sensory
• The median nerve and palmar cutaneous
branch (distal third of forearm) are ulnar to nerve (RSN) is identified under the BR and retracted radially.
the FCR and should not be visualized during • To expose the midshaft of the radius, the forearm is pronated and radial attach-
dissection. Use blunt retractors to avoid injury. ments of the flexor digitorum superficialis (FDS) and pronator teres (PT) are released
subperiosteally and retracted medially.
• To expose the proximal radius, develop the interval between the BR and PT. Re-
EXPOSURES PITFALLS tract the PT and biceps tendon ulnarly and BR radially. Supinate the forearm and
• Be mindful of excessive retraction during expo- release the supinator muscle subperiosteally from a medial to lateral direction
sure because this can compromise nearby (supination provides protection to the posterior interosseous nerve).
neurovascular structures. • To expose the distal radius, the dissection mirrors that of a distal radius fracture ap-
• Avoid excessive periosteal stripping. proach (See Chapter 32 Fragment-Specific Fixation of Distal Radius Fractures).
• Maintain the IOM between radius and ulna.
PROCEDURE
Step 1: Fracture Reduction
• Apply blunt reduction forceps to the proximal and distal fracture fragments to assist
with anatomic reduction.
Incision
Sensory branch
Flexor pollicis Brachioradialis of radial nerve
longus muscle muscle
Tendon of
Pronator flexor carpi
quadratus radialis muscle
muscle
Flexor digitorum
sublimis muscle
B Flexor carpi
Radial artery radialis muscle
D
Brachioradialis Incision in
muscle periosteum
Flexor pollicis
longus muscle
Radial Flexor digitorum E

C
artery sublimis muscle
FIGURE 35.6 The anterior approach to the radius involves (A) mobilizing the flexor carpi radialis muscle and radial artery ulnarly and the brachioradialis
muscle and radial sensory nerve radially. (B) The arm is then pronated to facilitate release of flexor pollicis longus (FPL) and flexor digitorum superficialis
(FDS) from the periosteum of the radius. (C) The radial artery can be mobilized radially in the distal forearm (yellow arrow) if needed. (D) Elevating the
pronator quadratus distally (not depicted); FPL, and FDS in the midshaft (blue arrow); and pronator teres proximally (not depicted) from the radius will
help with exposing the fracture. (A–C from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020:1369–1458).
• With the fracture segments aligned, apply a point-to-point reduction forceps across STEP 1 PEARLS
the fracture to maintain reduction. Do not obstruct the potential placement of hard- • A lever interposed into the fracture is often
ware (plate and screws) with the reduction forceps. useful for reducing oblique fractures.
• Fluoroscopy can be used during reduction to
assess for the desired length of the radius.
Step 2: Fixation of Fracture With Compression Plating • For complex reductions, pin the DRUJ with a
• For simple midshaft oblique or transverse radius fractures (that are easily held in 1.6-or 2-mm steel pin to set the desired radius
reduction with forceps) a 3.5-mm dynamic compression plate is used to achieve length and ulnar variance. Use the contralateral
interfragmentary compression (Fig. 35.7). arm as a guide.
• The plate should permit placement of three bicortical, nonlocking screws in each
fracture fragment.
• Ensure that the plate is centered over the anterior surface of the bone in the sagittal plane.
• Prebend the plate so that the center is tented 1 to 2 mm above bone. Otherwise,
axial compression from the plate will cause gaping of the fracture on the far cortex.
STEP 2 PEARLS
• If maintaining compression is difficult with for-
ceps, a Verbrugge clamp is useful to grasp
between the last hole of the plate and the
head of a temporarily placed (proximal or
distal to the plate) independent screw.
• For long oblique fractures, attain compression
with a lag screw before plate fixation. The inter-
fragmentary lag screw should be placed per-
pendicular to the fracture plane. A 3.5-mm drill
bit is used to create a gliding hole on the near
cortex, and a 2.5-mm pilot hole through the far
cortex. The lag screw is placed such that 1 mm
protrudes through the far cortex. Ensure that
fracture reduction is maintained throughout.
The plate can then be placed with screws in
neutral position because the plate will not be
used to attain further axial compression.
• For three-part fractures with butterfly frag-
ments, use 2.4-mm bicortical screws to make
the fracture a more manageable two segment.
When plating, do not use aggressive axial FIGURE 35.7 An anteriorly positioned 3.5-mm compression plate on a midshaft radius fracture.
compression techniques. Prebend plate 1 to 2 mm above fracture to facilitate compression of oblique fracture (blue
• For comminuted fractures, bridge the fracture arrow). Place distal screw(s) in a neutral position (green arrow) and then place a proximal screw
with an anatomic plate that accounts for the eccentrically to induce compression (red arrow).
native radial bow.
• If a fracture pattern makes it difficult to attain
six cortices of fixation, bridging the fracture
using a locking plate is helpful.
• For fractures with a distal radius component, • Place two nonlocking bicortical screws in the distal fragment in neutral positions to
consider long anatomic distal radius plates. secure the plate in a centered position over the shaft.
• Place a screw in the proximal fracture fragment in an eccentric position (on the side
of the oblique hole away from the fracture). Tightening this screw facilitates axial
STEP 3 PITFALLS
compression.
Restoring stability to the DRUJ in Galeazzi fracture- • For oblique fractures, a lag screw can be placed across the fracture, and through the
dislocations is best achieved with precise anatomic
plate, if possible, to increase the strength of fixation (Fig. 35.8).
restoration of length, alignment, and rotation of the
radius. Imprecision in radius fixation will lead to • The remaining bicortical, nonlocking screws can be placed in neutral positions so
overtreatment of DRUJ instability. that there are three screws within each fracture fragment.
Step 3: Assessment of Distal Radioulnar Joint

• Have an assistant hold the patient’s forearm in a neutral position with the elbow
flexed at 90 degrees on the arm table.
• Grasp the distal radius and ulna head with separate hands, and alternately apply
dorsal and palmer forces to assess the DRUJ for laxity, subluxation, or dislocation.
FIGURE 35.8 Plate fixation is secured with three Repeat examination with the wrist in radial deviation (this action stabilizes the DRUJ
bicortical screws proximal and distal to fracture if the TFCC is uninjured).
line. Additional strength is attained with a lag • Repeat this examination in full pronation and supination.
screw placed perpendicular to the fracture line.
Step 4: Transfixion Pinning for Unstable Distal Radioulnar Joint
• Reducible but unstable DRUJ without an associated ulna styloid fracture should be
pinned. If irreducible, see Step 5.
• Place the forearm in the rotational position with maximal stability of the DRUJ (ideally
neutral or slight supination).
• Using fluoroscopy, mark the proposed location for entry of a 1.6-mm smooth, stain-
90° less steel pin over the center of the ulna in the coronal plane. The pin should be
placed perpendicular to the long axes of the ulna and radius and proximal to the
DRUJ/sigmoid notch of the radius (Fig. 35.9).
• Drive the pin through both cortices of the ulna and confirm satisfactory placement
radiographically.
FIGURE 35.9 Transfixion pinning from ulna to
radius at the junction of the metadiaphysis. Note • Have an assistant hold reduction of the DRUJ (compress radius and ulna together)
that the 1.6-mm stainless steel pin is perpendic- and drive the pin through both cortices of the radius.
ular to the long axis of the ulnar (blue lines). • Place the second pin 1 to 2 cm proximal.
Step 5: Open Reduction of Distal Radioulnar Joint and Triangular

STEP 4 PEARLS
Fibrocartilage Complex Repair
• It is easier to place pins from ulna to radius
• Irreducible DRUJ dislocations require open reduction of interposed soft tissue and re-
because the pin is more accurately centered
pair of the TFCC. For posterior ulna head dislocations, a dorsal approach is indicated. on the small diameter of the ulna.
• Make a 4-cm dorsal longitudinal incision over the interval between the fifth and sixth • Leave pins accessible from both the ulnar and
extensor compartment (Fig. 35.10A). radial sides to facilitate easy retrieval if pins
• Identify the dorsal cutaneous branch of the ulnar nerve and protect it. break internally. Keep pins buried on the radial
side. Alternatively, if both ends are left ex-
• Sharply incise the extensor retinaculum between the fifth and sixth extensor com-
posed, then cut external pins on one side
partments. before removing (to prevent pulling externally
• Release and retract the extensor digiti quinti (EDQ) radially from the fifth compartment. exposed, unsterile pins through the ulna and
• If a traumatic capsulotomy is not present, make an ulnar-based capsulotomy flap radius).
without injuring the dorsal radioulnar ligament of the TFCC (see).
• Carefully debride, evacuate hematoma, and remove interposed tissue to evaluate
the integrity of the TFCC. STEP 4 PITFALLS
• Inspect the foveal attachment and the palmar and dorsal radioulnar ligaments for The RSN is at risk for injury from pins exiting the
injury. radius. If desired, the surgeon can place an incision
• Use a 1.1-mm Kirschner wire to create two holes (1 cm apart) from the dorsal side over the lateral distal radius, bluntly dissect, and
identify and protect the RSN.
of the ulna (1 cm proximal to the ulnar styloid base) to the fovea (see Fig. 35.10C).
• Pass a 2-0 absorbable monofilament suture on a straight needle through the bone
tunnel (outside-in).
STEP 5 PEARLS
• Pass the needle around the ulnar periphery of the TFCC and through the other bone
tunnel (inside-out). • In Galeazzi fracture-dislocation, a Class 1B
TFCC (ulnar avulsion without styloid fracture) is
• Ensure that the DRUJ is reduced and repair the dorsal radioulnar ligament injury, if present. nearly always present.
• With the ulna head reduced, perform transfixion pinning as described in Step 4. • The ulnomeniscal homolog can be removed from
• With the forearm in a neutral position, tie down the TFCC repair suture(s) at the ulnar its ulnocarpal attachment to better visualize the
neck (see Fig. 35.10D) TFCC.
• Repair the capsule and extensor retinaculum in separate layers with interrupted, • If there is a large ulna styloid fracture contrib-
uting to DRUJ instability, open reduction and
absorbable sutures. internal fixation is indicated (see Chapter 34
Associated Ulnar Fixation).
Dorsal
radioulnar
ligament
EDQ ECU B
A
C D
FIGURE 35.10 Triangular fibrocartilage complex (TFCC) repair. (A) Approach the TFCC through a
dorsal longitudinal incision between the extensor digiti quinti (EDQ) and extensor carpi ulnaris (ECU).
(B) Retract the EDQ radially and create an ulnar-based capsular flap but preserve the dorsal radioul-
nar ligament. (C) Using a Kirschner wire (K-wire), create holes from the dorsal aspect of the ulna
obliquely to the periphery of the TFCC. Pass suture with a straight needle. (D) After transfixion
pinning, tie down the injured portion of the TFCC to complete the repair.

• Patients should be placed in a long-arm splint with the forearm in neutral or slight
supination.
• Obtain wrist x-rays to ensure that the DRUJ remains reduced during the first month
of follow-up.
• For radius fixation and stable DRUJ:
• Use a long-arm splint for 2 weeks followed by a removable short-arm splint.
• Begin hand therapy at 4 weeks.
• For radius fixation with DRUJ transfixion with or without TFCC repair:
• Use a long-arm splint for 2 weeks followed by a long-arm cast until postoperative
week 6.
• Evaluate pin sites every 2 weeks and remove at postoperative week 4 or 6.
• Guided hand therapy is initiated 1 week after pin removal.
• Expected outcomes:
• Radius union and maintenance of DRUJ stability are high, and outcomes are
generally good.
• Pinning of the DRUJ and immobilization in supination yields high success rates
of long-term DRUJ stability.
• Full activity for high-demand patients may not be attained until 4 months postop-
eratively.
• Variable loss of pronosupination and wrist flexion are common.
Reduction and Fixation of Monteggia Fracture-Dislocation

Bado Type I
POSITIONING
Place the patient in lateral decubitus with the affected extremity positioned over the
chest and bolstered to facilitate a posterior approach.
EXPOSURES
• Proximal ulna fractures are approached through a posterior midline incision.
• The incision is placed lateral to the tip of the olecranon at the subcutaneous border
of the ulna (Fig. 35.11).
• The incision may need to be carried proximal to the tip of the olecranon to permit
anatomic plate fixation if the olecranon is involved.
• Extend the incision distally to permit adequate fracture visualization, reduction,
and fixation.
• Sharply dissect through fascia into the interval between the anconeus and flexor
carpi ulnaris (FCU) proximally and ECU and FCU distally.
Extensor carpi ulnaris

Incision
Anconeus

Ulnar nerve
FIGURE 35.11 The approach to the olecranon and proximal ulna is carried through the interval be-
tween the anconeus and flexor carpi radialis (FCR) proximally and extensor carpi ulnaris (ECU) and
flexor carpi radialis (FCR) distally.
• Incise the periosteum at the subcutaneous border of the ulna and expose the frac- EXPOSURES PEARLS
ture by elevating the periosteum medially and laterally.
The posterior midline incision facilitates access to
• If needed proximally, split the triceps insertion longitudinally in line with the the radial head and coronoid tubercle if indicated.
tendon fibers.
• Adequately debride the fracture, evacuate hematoma, remove small fragments not
amenable to fixation, and irrigate thoroughly before reduction. EXPOSURES PITFALLS
Excessive medial dissection places the ulnar nerve
PROCEDURE at risk for injury.
Step 1: Reduce Proximal Ulna Fracture and Radial Head Dislocation

STEP 1 PEARLS
• After exposing the ulna fracture (and before reduction), assess the radial head
through the ulna fracture fragments. Restoration of the anatomic axis and length of
the ulna is a critical step to ensure that the PRUJ
• Reduce the proximal radioulnar joint. If the radial head is fractured (Bado type IV), it remains reduced.
may require plate fixation or resection and replacement with a radial head prosthesis
(not described).
• Extend the elbow and manually manipulate the fracture fragments to obtain reduction. STEP 1 PITFALLS
• Evaluate with an intraoperative radiograph and elevate areas of articular depression If the PRUJ does not reduce after ulna reduction,
to ensure articular congruency. the ulna should be evaluated under fluoroscopy for
• Temporarily stabilize fragments with bone reduction forceps. possible malalignment of fracture fragments.
Step 2: Select Hardware for Fixation

STEP 2 PEARLS
• Plate placement on the ulna is dependent on the location of the fracture (Fig. 35.12).
• For proximal ulna and olecranon fractures, a contoured 3.5-mm dynamic com- If the ulna fracture is oblique, 3.5-mm interfragmentary
pression plate or anatomic plate placed posteriorly (i.e., subcutaneously) be- lag screws placed perpendicular to the fracture line
can assist in reduction and fixation.
tween the ECU and FCU interval is biomechanically preferred.
• The plate must accommodate the natural anterior deviation of the posterior
cortex of the proximal ulna (1–14 degrees).
• The proximal third ulna also has a varus angulation (11–23 degrees) that is
difficult to contour with a traditional straight plate.
• For ulna shaft fractures, a 3.5-mm straight reconstruction plate can be placed under
the muscle on the medial or lateral aspect of the triangular-shaped ulna midshaft.
• Place the plate, temporarily secure with reduction forceps, and assess alignment
with the intraoperative c-arm x-ray.
Extensor Flexor
carpi ulnaris carpi ulnaris
A
ECU
ECU
Fracture Fracture
FCU
FCU
B C
FIGURE 35.12 Plate placement on ulna fractures are dictated by the shape of the ulna and location of the fracture. (A, B) The subcutaneous
border of the ulna is located between the extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU; green arrow) and is the most biome-
chanically preferred plate position but also leads to plate prominence. This position is used in olecranon and proximal ulna fractures. (A, C)
In midshaft ulna fractures, the plate can be positioned medially under the ECU (blue arrow) or FCU (red arrow).
STEP 3 PEARLS
• If using an anatomic plate that extends to the
tip of the olecranon, use the plate hole(s) at
the tip of the olecranon that accommodate or-
thogonally placed screws. A long screw that
bridges the fracture site can provide intramed-
ullary stability to the construct (the “homerun”
screw; Fig. 35.13).
• Ensure radiographic axial alignment and joint
stability.
• Under fluoroscopy, apply varus and valgus
stress to the elbow in extension to ensure
no joint gaping or incongruency of the joint
lines that could indicate subluxation.
• In medial-lateral and anterior-posterior stan-
dard plane views, the proximal radial shaft
axis rests at the center of the capitellum.
• In medial-lateral view, the trochlea humeri
rests in the center of the semilunar notch of
the olecranon and the joint space is even FIGURE 35.13 For proximal ulna fractures, most anatomic plates will have proximal screw holes that
without step-offs. allow for orthogonally placed “homerun” screws (blue arrow) that add stability to the construct. Uni-
• Ensure clinical axial alignment and joint stability: cortical screws should be used in the proximal fragments to avoid intraarticular placement (green ar-
• Ensure that there is free range of extension/ rows). Ensure congruity of the joint in articular fractures (red arrow).
flexion of the elbow and pronation/supina-
tion of the forearm.
• Perform a lateral pivot test by passively supi-
nating the forearm under valgus stress. If the
Step 3: Hardware Fixation
radial head dislocates, a lateral ulnar collateral • For transverse fractures, interfragmentary compression can be attained with com-
ligament reconstruction is indicated. pression plating.
• Place a nonlocking bicortical screw in the proximal fragment in a neutral position
within a plate hole near the fracture.
• If placing a screw in the olecranon, use a cancellous screw with unicortical pur-
chase to avoid intraarticular penetration.
• Distally (on the ulna diaphysis), insert a second 3.5-mm cortical screw in an eccentric
position into the opposite fragment. Tightening the screw will create compression
across the fracture.
• Secure the plate with three or four cortical screws with bicortical purchase distally,
and three to four cortical or cancellous screws with bicortical or unicortical purchase
if there is risk for intraarticular penetration.

• Patients should be placed in posterior splint with the elbow flexed to 90 degrees.
• Remove splint in 7 to 10 days, and if rigid fixation was obtained, begin guided active-
assisted physical therapy. Avoid full elbow flexion until 4 weeks postoperatively.
Outcomes
• Rigid fixation with normal healing is expected in most Monteggia fracture-dislocations.
• Implant loosening, implant failure, nonunion/malunion, and instability are rare.
• PRUJ stability is expected as long as ulnar length was attained.
• Implant removal is sometimes desired because of prominent hardware.
EVIDENCE
Van Duijvenbode DC, Guitton TG, Raaymakers EL, et al. Long-term outcome of isolated diaphyseal radius
fractures with and without dislocation of the distal radioulnar joint. J Hand Surg Am. 2012;37:523–527.
This single institution retrospective cohort compared seven patients with a Galeazzi fracture-dislocation
with ten patients with an isolated diaphyseal fracture. With an average of 19 years follow-up, they
found no difference in Mayo Modified Wrist Score or the Disabilities of the Arm, Shoulder, and Hand
(DASH) questionnaire. The authors concluded that near-anatomic fixation of the radius is the key to a
good outcome in Galeazzi injuries.
Yohe NJ, De Tolla J, Kaye MB, et al. Irreducible Galeazzi fracture-dislocations. Hand (N Y). 2019;14(2):249–252.
This systematic review of literature on Galeazzi fracture-dislocations identified 12 articles (17 cases) of
irreducible injuries, secondary to entrapment of extensor tendons (most commonly ECU) or ulnar
fracture fragments. The authors advocated vigilance in evaluating the DRUJ in Galeazzi injuries
because more than half of irreducible DRUJs were missed in the peri-operative period.
ddsf
SECTION V
Rheumatoid Arthritis and

Degenerative Disease
CHAPTER 36 Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic
Tendon Transfer, and Extensor Tendon Centralization 378
CHAPTER 37 Tendon Transfers for Rheumatoid Tendon Attrition Rupture 285
CHAPTER 38 . Stabilization of Extensor Carpi Ulnaris Tendon Subluxation
with Extensor Retinaculum 297
CHAPTER 39 Correction of Swan-Neck Deformity 304
CHAPTER 40 Treatment of Boutonniere Deformity 312
CHAPTER 41 Metacarpophalangeal Arthroplasty 319
CHAPTER 42 Proximal Interphalangeal Arthroplasty 334
CHAPTER 43 Distal Interphalangeal Joint Arthrodesis (Osteoarthritis) 344
CHAPTER 44 Joint Fusion for Thumb Metacarpophalangeal Instability 345
CHAPTER 45 CMC Fusion for Basal Joint Osteoarthritis 346
CHAPTER 46 Reconstruction for Thumb Carpometacarpal Joint Instability
Using Flexor Carpi Radialis (Littler Procedure) 353
CHAPTER 47 Suspension Arthroplasty for Thumb Carpometacarpal Joint
Arthritis Using Abductor Pollicis Longus 360
CHAPTER 48 Revision Arthroplasty for CMC Joint 368
CHAPTER 49 Distal Ulnar Resection (Darrach Procedure) 380
CHAPTER 50 Sauvé-Kapandji Procedure 386
CHAPTER 51 Hemiresection Ulnar Arthroplasty 393
CHAPTER 52 Total Wrist Arthroplasty 399
CHAPTER 53 Total Wrist Fusion 413
CHAPTER 54 Wrist Denervation 420
277
CHAPTER 36
Metacarpophalangeal Joint Synovectomy, Crossed
Intrinsic Tendon Transfer, and Extensor Tendon
Centralization
INDICATIONS
• Crossed intrinsic tendon transfer is indicated in patients with ulnar subluxation of the
extensor tendon and passively correctable ulnar deviation of the digits because of
rheumatoid arthritis (RA) or traumatic radial sagittal band rupture. The metacarpo-
phalangeal (MCP) joint must be supple and without significant arthritic changes or
subluxation.
• In RA patients, the index finger ulnar common intrinsic tendon is transferred to the
extensor digitorum communis (EDC) of the long finger; the long finger tendon is used
to correct the ring finger; and the ring finger tendon is used for the small finger. Ulnar
deviation of the index finger is corrected, imbricating the radial sagittal band.
• The crossed intrinsic transfer corrects ulnar deviation by decreasing ulnar force on
the donor digit and increasing radial force on the recipient digit.
Contraindications
For patients with significant MCP joint subluxation or arthritis, soft tissue reconstruction
does not adequately stabilize a severely subluxated proximal phalanx. These patients
should undergo silicone MCP arthroplasty (see Chapter 41).
• Clinical examination focuses on the condition of the MCP joint and the position of
the extensor tendon.
• Synovitis presents as swelling over the dorsal MCP joint (Fig. 36.1). Synovitis can
lead to attenuation of the sagittal bands, volar subluxation of the proximal phalanx,
ulnar drift of the fingers, or tendon rupture.
• In RA patients, the extensor tendons often subluxate ulnarly and lie in the intermeta-
carpal space. This is obvious when the patient makes a fist (Fig. 36.2).
• Active and passive range of motion (ROM) is measured. When a patient is unable to
actively extend the MCP joints, it is important to distinguish between tendon sublux-
ation and tendon rupture. The examiner passively extends the MCP joints; if the
tendon is intact but subluxated, the patient can maintain extension. If the tendon is
ruptured, the MCPs fall into flexion when the examiner’s hand is removed.
MCP joint synovitis
FIGURE 36.1
278
CHAPTER 36 Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon 279
FIGURE 36.2
• Intrinsic tightness can occur with chronic ulnar deviation at the MCP joint. Check for
intrinsic tightness by extending the MCP joint and flexing the proximal interphalan-
geal (PIP) joint. In patients with intrinsic tightness, PIP joint flexion will be restricted
with the MCP extended and will improve when the MCP is flexed.
IMAGING
Standard, three-view radiographs of the hand are required to evaluate the MCP joint
(Fig. 36.3).
SURGICAL ANATOMY
• The common intrinsic tendon is formed by the tendons of the palmar and dorsal
interosseous muscles on the ulnar side of the digit and by the interossei and lumbri-
cal tendons on the radial side of the digit. These tendons pass palmar to the axis of
the MCP joint and divide into a medial and lateral band near the midpoint of the
proximal phalanx. The medial band inserts on the central slip and the lateral bands
continue distally and become the terminal tendon (Fig. 36.4A–B). Contraction of the
intrinsic muscles causes MCP joint flexion and interphalangeal (IP) joint extension.
• The sagittal bands originate from the extensor hood, wrap around the metacarpal
head, and insert on the volar plate. They centralize the extensor tendon over the
MCP joint. In RA, synovitis causes attenuation and elongation of the radial sagittal
band and the extensor tendons commonly subluxate ulnarly.

• The patient is positioned supine on the operating room table with the arm extended
on a hand table.
• The procedure is performed under axillary block with sedation or general anesthesia.
• A tendon weaver or mosquito forceps is helpful for the tendon transfer.
FIGURE 36.3
280 CHAPTER 36 Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon
Terminal tendon
Oblique retinacular ligament
Triangular ligament
Transverse retinacular ligament
Central band
Conjoint lateral band
Lateral band of intrinsic tendon

Medial band of intrinsic tendon
Central slip of long extensor tendon
Lateral slip of long extensor tendon
Common intrinsic tendon
Arciform sheet
Deep transverse metacarpal
ligament
Sagittal band
Interosseous tendon
Lumbrical tendon
Long extensor tendon
A Ulnar Radial
Attenuation of the radial portion

of the extensor hood
Extensor tendon
Tightness Extensor tendon

(subluxate ulnarly)
Radial Ulnar
Flexor
tendon
Lumbrical
Common
Interosseous intrinsic Flexor tendon
EXPOSURES PEARLS B muscle tendon (translate ulnarly)
• Take care to preserve the dorsal veins to FIGURE 36.4

reduce postoperative swelling.
• The transverse incision can be reused if silicone EXPOSURES
MCP arthroplasty is indicated in the future.
• A single, dorsal, transverse incision is used to expose the extensor apparatus over
multiple MCP joints (Fig. 36.5).
EXPOSURES PITFALLS
• A dorsal longitudinal or lazy-S incision centered at the joint is used to access a
RA patients have fragile skin. Retract gently with single MCP joint (i.e., for synovectomy without crossed intrinsic transfer; Fig. 36.6).
suture loops to prevent postoperative healing • Skin flaps are elevated at the level of the extensor tendon to expose the intrinsic
issues.
tendons distally.
FIGURE 36.5
A B
FIGURE 36.6
PROCEDURE STEP 1 PEARLS

• When dividing the radial sagittal band, main-
Step 1: MCP Joint Synovectomy tain a 2- to 3-mm cuff on the extensor tendon
• The skin is incised and dissection proceeds rapidly to the extensor hood. The exten- to facilitate repair.
sor tendon is inspected and inflamed synovium is excised. • The interval between the extensor indicis pro-
prius (EIP) and the extensor digitorum commu-
• The radial sagittal band is longitudinally incised and the extensor tendon is retracted
nis (EDC) can be incised to access the index
ulnarly (Fig. 36.7). finger MCP joint. Similarly, the interval between
• The MCP joint is opened and synovectomy is performed (Fig. 36.8). the extensor digiti quinti (EDQ) and EDC can
• The joint is irrigated, inspected, and any remaining synovitis is excised. be incised to access the small finger MCP
joint. We prefer to release the radial sagittal
band and retract both tendons ulnarly.
Dotted line indicates radial

sagittal band incision

Common
intrinsic
tendon
A B
FIGURE 36.9
Ulnar common
intrinsic tendon
Extensor
tendon
Interosseous
muscle
STEP 2 PITFALLS
• The neurovascular bundle lies just volar to the FIGURE 36.10
intrinsic tendon. A right-angle dissector or ves-
sel loop can be passed around the tendon for
gentle retraction.
• Transect the common intrinsic tendon just be- Step 2: Exposure, Division, and Mobilization of the Ulnar Common
fore it divides into the medial and lateral Intrinsic Tendon
bands. If it is cut too proximally, the transfer
• The interosseus tendon is identified by bluntly dissecting along the ulnar aspect of
will not reach the adjacent extensor apparatus
(Fig. 36.10). the MCP joint (see Fig. 36.8).
• The common intrinsic tendon is traced distally, transected at the midpoint of the
proximal phalanx, then mobilized proximally to the MCP joint. Longitudinal release
STEP 3 PEARLS from the extensor apparatus is performed as needed for adequate mobilization
• The index finger ulnar common intrinsic ten- (Fig. 36.9).
don is transferred to the middle EDC; the long
finger tendon is used for the ring finger; and Step 3: Tendon Transfer, Extensor Tendon Centralization, and Radial
the ring finger tendon is used for the small
finger. Ulnar deviation of the index finger is
Sagittal Band Repair
corrected by a double-breasted repair of the • The common intrinsic tendon is passed ulnarly through a subcutaneous tunnel
radial sagittal band. (Fig. 36.11), then through a slit in the adjacent finger extensor tendon.
• Tendons should be handled gently; a tendon • The MCP joint is held in extension and ulnar deviation is corrected by tensioning the
weaver or mosquito forceps is used to pass
tendon transfer; 3-0 braided permanent suture is used to secure the tendon transfer.
the common intrinsic tendon through a slit in
the adjacent extensor tendon. • The radial sagittal band is repaired with the same suture and imbricated to reduce
• Division of the abductor digiti minimi (ADM) is laxity (Fig. 36.12).
sometimes necessary to reduce ulnar force on
the small finger (Fig. 36.13). Care must be Step 4: Closure
taken to avoid injury to the neurovascular • The tourniquet is released, the wound is irrigated, and hemostasis is achieved.
bundle, which lies just volar to the ADM.
• The skin is closed using 4-0 nylon suture (Fig. 36.14).
FIGURE 36.14
FIGURE 36.13

• The patient is placed in a volar splint with the MCP joints extended and in a neutral
position.
• Sutures are removed in 10 to 14 days and the patient is transitioned to a removable
splint for an additional 2 weeks.
• Once the tendon transfer has healed, active motion is started under the care of
a hand therapist. Moderate stiffness is expected after splinting with the MCPs
extended for 3 to 4 weeks.
• Fig. 36.15A–B shows a patient 1 month after right cross intrinsic transfer.
See Video 36.1
FIGURE 36.15
EVIDENCE
Oster LH, Blair WF, Steyers CM, Flatt AE. Crossed intrinsic transfer. J Hand Surg Am. 1989;14:963–971.
This study retrospectively reviews long-term outcomes in 30 patients with inflammatory arthritis who
underwent crossed intrinsic transfer. Mean follow-up time was 12.7 years. Average postoperative
ulnar drift of the fingers was 5 degrees and remained stable over time. Average active arc of motion
for the MCP joint was 47 degrees. There was no difference in outcome when the ulnar lateral band
was sutured to the radial lateral band of the adjacent digit or to the collateral ligament of the adjacent
MCP joint. Crossed intrinsic transfer provides long-term correction of ulnar drift in inflammatory
arthritis (Level V evidence).
Clark DI, Delaney R, Stilwell JH, Trail IA, Stanley JK. The value of crossed intrinsic transfer after
metacarpophalangeal Silastic arthroplasty: A comparative study. J Hand Surg Br. 2001;26:565–567.
The authors review outcomes for 73 rheumatoid hands after MCP joint replacement. Crossed intrinsic
transfer was performed in 28 hands, and outcomes were compared with MCP joint replacement
without cross intrinsic transfer. The treatment groups had similar degrees of preoperative ulnar drift
(crossed intrinsic transfer group mean, 27 degrees; comparative group mean, 29 degrees). At
50-month follow-up, the crossed intrinsic transfer group had statistically less ulnar drift (crossed
intrinsic transfer group mean, 6 degrees; comparative group mean, 14 degrees; p = .01). There
were no other significant differences in outcome (Level IV evidence).
Pereira JA, Belcher HJ. A comparison of metacarpophalangeal joint Silastic arthroplasty with or without
crossed intrinsic transfer. J Hand Surg Br. 2001;26:229–234.
Forty-three patients undergoing silastic interposition arthroplasty of the index, middle, ring, and small
MCP joints for RA were randomized into two cohorts: MCP arthroplasty (1) with or (2) without
crossed intrinsic transfer. There were no differences in patient demographics or preoperative clinical
measurements between groups. Outcomes were analyzed at a mean of 17 months after surgery.
Both groups had reduced ulnar drift and improved grip and pinch strength. There was no difference
in pain or perceived function between treatment groups. The authors conclude that cross intrinsic
transfer does not affect the outcome of silastic interposition arthroplasty of the MCP joint in RA
patients (Level IV evidence).
CHAPTER 37
Tendon Transfers for Rheumatoid Tendon Attrition
Rupture
INDICATIONS
• In rheumatoid arthritis patients, tendon rupture is a result of synovitis or attrition over
a deformed bone. Common bony pathologies include caput ulnae syndrome (dorsal
prominence of the ulna head leading to extensor tendon rupture; Fig. 37.1) and Man-
nerfelt syndrome (flexor pollicis longus [FPL] rupture caused by a volar scaphoid
osteophyte.
• The most ruptured tendon in rheumatoid patients is the extensor digiti minimi (EDM),
followed by the extensor digitorum communis (EDC) tendons to the small finger (SF),
ring finger (RF), middle finger (MF), and index finger (IF; in that order) and the exten-
sor pollicis longus (EPL). On the flexor side, FPL rupture is most common; the flexor
digitorum profundus (FDP) and superficialis (FDS) tendons are rarely involved.
• Direct repair of ruptured tendons is not possible because the tissue quality is poor,
and tendon grafting is not reliable because of proximal myostatic contracture from
months of delayed repair. Tendon transfers are indicated to restore motor function in
rheumatoid patients with attritional tendon rupture. The specific procedure depends
on the number and function of ruptured tendons. Options include end-to-side repair
to an intact adjacent tendon or transfer of an injured tendon to the distal stump of a
ruptured tendon (Table 37.1; Fig. 37.2A–D).
• Bony pathology must be addressed at the time of tendon transfer to prevent pro-
Caput
gressive deformity and rerupture of the reconstructed tendons. Distal ulna excision ulnae
(see Chapter 49: Distal Ulna Resection [Darrach Procedure]) or osteophyte excision
can be performed as part of the procedure.
FIGURE 37.1
• The patient is examined for areas of swelling, tenderness, previous scars, and deformity.
• Examine the wrist and distal radioulnar joint for pain and instability (See Chapter 49:
Distal Ulna Resection [Darrach Procedure]).
• Active and passive range of motion (ROM) of all joints is assessed. Inability to ac-
tively flex or extend a joint raises suspicion for tendon rupture.
• Patients with isolated EDM rupture may be able to extend the SF through the EDC;
however, they will not be able to independently extend the SF with the other fingers
flexed.
• Patients with rupture of the EDC to one finger may be able to extend the finger
through juncturae to adjacent fingers. When more than one EDC is ruptured, the
deformity is more obvious (Fig. 37.3).
• EPL function is tested by placing the patient’s hand flat on a table (palm down) and
asking them to lift the thumb off the table. Intact retropulsion signifies intact EPL
function (Fig. 37.4).
• Lack of finger extension in RA is also sometimes caused by ulnar subluxation of the
tendons over the head of the metacarpal (Fig. 37.5) or, rarely, from posterior interos-
seous nerve palsy caused by elbow synovitis. To differentiate between these causes,
passively extend the finger and ask the patient to hold it in place. Patients with ten-
don rupture or nerve palsy will be unable to maintain extension; however, patients
with extensor tendon subluxation will maintain extension because the extensor ten-
don is centrally relocated over the metacarpophalangeal (MCP) joint. Patients with
tendon rupture will lose the tenodesis effect of finger extension with wrist flexion.
Tenodesis is preserved in nerve palsy.
285
286 CHAPTER 37 Tendon Transfers for Rheumatoid Tendon Attrition Rupture
TABLE
37.1 Number of Ruptured Tendons and Treatment Considerations
No. Impairment Diagnosis Preferred Option Alternative Option
1. Inability to extend small finger Rupture of EDM at ulnar head End-to-side repair of EDM
to EDC to ring finger
2. Inability to extend small and Rupture of EDC to ring and small un- EIP transfer to EDC to ring
ring fingers der extensor retinaculum and EDM and EDM
at ulnar head
3. Inability to extend small, ring, Rupture of EDC to long, ring, and EIP transfer to EDC to ring
and long fingers small under extensor retinaculum and EDM
and EDM at ulnar head End-to-side repair of EDC
to index and long
4. Inability to extend small, ring, Rupture of EIP, EDC to index, long, FDS long to EDC to index ECRL or ECRB can be
long, and index fingers ring, and small under extensor reti- and long considered
naculum, and EDM at ulnar head FDS ring to EDC to ring,
small and
EDM
5. Inability to extend thumb Rupture of EPL at Lister tubercle EIP to EPL ECRL to EPL
EDM to EPL
6. Inability to extend thumb and Rupture of EPL at Lister tubercle, EIP, FDS long to EPL and EDC
small, ring, long, and index EDC to index, long, ring, and small to index
fingers under extensor retinaculum, and FDS ring to EDC long, ring,
EDM at ulnar head small, and
EDM
7. Inability to flex thumb Rupture of FPL in carpal tunnel BR to FPL ECRL to FPL
FDS long to FPL
Thumb IP joint fusion
8. Inability to achieve independent Rupture of FDS PIP joint synovectomy to
flexion of PIP joint prevent rupture of FDP
9. Inability to flex DIP joint Rupture of FDP DIP joint arthrodesis Tenodesis of DIP joint
10. Inability to flex IP joints Rupture of FDS and FDP Staged flexor tendon
reconstruction
BR, Brachioradialis; DIP, distal interphalangeal; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EDC, extensor digitorum communis; EDM,
extensor digiti minimi; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis
longus; IP, interphalangeal; PIP, proximal interphalangeal.
• The EIP and FDS to the RF and MF are often used as donor tendons in patients with
multiple extensor tendon ruptures, and their function must be checked and docu-
mented preoperatively. EIP is intact when independent extension of the IF is possible
with the other fingers flexed (Fig. 37.6). To assess FDS function, all other digits are
blocked, and the patient is asked to flex the finger in question at the proximal inter-
phalangeal (PIP) joint. FDP share a common muscle belly and therefore, independent
flexion of any finger with the others restrained requires an intact FDS tendon.
Similarly, the FDP is assessed by blocking PIP flexion of the possible donor digit in
question and asking the patient to flex the DIP joint (Fig. 37.7A-B).
IMAGING
Standard three-view wrist radiographs are required to evaluate the distal radioulnar
(DRU), midcarpal, and radiocarpal joints.
SURGICAL ANATOMY
• A detailed understanding of the flexor (Fig. 37.8) and extensor (Fig. 37.9) tendon
anatomy is required.
• Tendons in RA can be directly invaded by synovial pannus within tenosynovial sheaths
(extensor retinaculum, carpal tunnel, and digital flexor sheath), or may rupture as a
EDC-Ring
EDM
EDC-Ring
EDM
EIP
B
EDC-
EDC-Ring Long
EDM
EDC-
Index
EIP
EIP
C
FDS-Long
or FDS-Ring
EDC-Ring
EDC-Long
EDC-Index
EDM
or EIP
D
Extensor tendon ruptures FDS-Long
of ring and small fingers and FDS-Ring
result of ischemia caused by pressure from a proliferative synovitis; this results in

regions where the tendon is in close relation to joints (DRU, radiocarpal, PIP joints).
• Attritional rupture frequently affects the EDM at the ulna head, EPL at the Lister
tubercle, and FPL in the carpal tunnel caused by a flexed scaphoid.
• Dorsal ulnar subluxation is commonly described in RA, but this is a misnomer; the
ulna is the fixed axis of the forearm. The radius subluxates volarly, which gives the
impression of dorsal ulna prominence (Fig. 37.10).
Test for EPL:
Index and middle

1. Hand flat on extensor tendon
examination ulnarly subluxed
table
2. Lift thumb off

table “toward
ceiling” Ring and small
finger extensor
tendon rupture
FIGURE 37.4
FIGURE 37.5
EIP testing:
Intact index
finger extension
(independent)
EPL tendon is
ruptured in this
patient
• It is important to identify the cause of the tendon rupture at the time of tendon re-
construction. This may require synovectomy or procedures to address joint instabil-
ity and osteophytes. For example, if the patient has SF extensor tendon rupture, it
is highly likely that other extensors will rupture subsequently (Vaughan-Jackson
syndrome). Tenosynovectomy, distal ulna excision, and tendon reconstruction are
the preferred treatments to prevent progressive disease.

• The patient is positioned supine with the arm extended and hand pronated on a
hand table. An upper arm tourniquet is placed.
• A tendon passer and tendon weaver should be available for tendon transfers. Intra-
operative fluoroscopy, an oscillating saw, and a bur are required if bony resection
(Darrach) is planned.
Juncturae
tendinum Extensor
digiti minimi
Extensor
carpi radialis Extensor
pollicis longus Extensor
Extensor digitorum
pollicis brevis Extensor
Abductor retinaculum
pollicis longus Synovial
Palmar cutaneous sheaths
branch of median
nerve
Flexor digitorum FIGURE 37.9
superficialis Radial artery
Median nerve Distal radioulnar joint

Palmaris longus
(retracted) Volar subluxation Dorsal subluxation
Flexor pollicis of the ECU of the ulnar head
longus
Digital extensor
Flexor carpi tendons
radialis
L C
Brachioradialis
S
Wrist joint
Extensor Rotatory subluxation
carpi ulnaris of scaphoid
FIGURE 37.8
FIGURE 37.10
EXPOSURES
EXPOSURES PEARLS
• A 6-cm longitudinal incision is made over the dorsum of the wrist in line with the MF
Care is taken to preserve the dorsal veins and the
metacarpal to expose the EDC tendons within the fourth compartment. When pres-
superficial sensory nerve branches. The dorsal
ent, previous incisions are used (Fig. 37.11). ulnar sensory nerve pierces the deep fascia of the
• Skin flaps are elevated at the level of the extensor retinaculum (Fig. 37.12). forearm 5 cm proximal to the distal ulnar joint line.
• The extensor retinaculum is incised using a stair-step design to facilitate closure
at the end of the case (Fig. 37.13).
EXPOSURES PITFALLS
• The intercompartmental septae are divided between the extensor compartments;
Rheumatoid skin is fragile and must be handled
this converts the extensors into a single compartment and exposes the total extent
with great care.
of synovitis.

FIGURE 37.13

• Synovectomy is important because it removes
diseased tissue from tendons that will be used Step 1: Synovectomy
for transfer. • A no. 15 blade is used to excise synovitis from the extensor tendons and extensor
• Tenosynovitis can infiltrate the tendon sub- retinaculum (Fig. 37.14A).
stance and cause fraying. Frayed tendon • After removing the synovial tissue, assess the extensor anatomy (see Fig. 37.14B).
should be trimmed.
• Nodules within tendons are excised and tendon In this figure, a suspected EPL rupture was confirmed.
defects are repaired with horizontal mattress
sutures. Step 2: Distal Ulna Excision, Bone Reshaping, and Stabilization
• When indicated, bony prominence removal and stabilization procedures are per-
formed. See Chapter 49 for step-by-step instructions on the Darrach procedure.
• If the patient has already had a Darrach, the distal ulna is reshaped to ensure smooth
contour of the entire raw edge (Fig. 37.15).
A B
FIGURE 37.14
FIGURE 37.15
Radial half of ECU (in hemostat)
A Intact ECU
B
ECU stabilization of ulna
FIGURE 37.16
• To treat ulna instability, advancement of the pronator quadratus and ECU tendino- STEP 2 PEARLS
plasty are performed (Fig. 37.16; see Chapter 49: Step 4).
Reshaping a distal ulna after a previous Darrach
is critical to protect future tendon transfers and
Step 3: Evaluation of the Dorsal Wrist Capsule prevent iatrogenic tendon rupture from a sharp
• The dorsal wrist capsule is sometimes lax as a result of stretch from synovial pres- distal ulna.
sure. It can be imbricated using the braided sutures when necessary. If a simultane-
ous Darrach is performed, the capsule over the distal ulna is closed tightly using
horizontal mattress 3-0 braided sutures.
• After synovectomy and capsular imbrication, the intact extensor tendons can be-
come loose as a result of expansion over time. Tightening the lax extensor tendons
with the braided sutures gives more power to extend the fingers. Tension is set with
all the fingers fully extended because some stretching of the tendon repairs will occur
during therapy.
Step 4: Tendon Transfers

The reconstructive plan depends on the number and function of ruptured tendons (see
Table 37.1). In general, all tendon transfers are secured using braided permanent sutures.
Loss of Small Finger Extension: End-to-Side Small Finger EDC to Ring

Finger EDC
• The EDC to the SF and RF are explored and synovitis is removed (Fig. 37.17).
• A tendon passer is used to pass the SF EDC through the RF EDC. The SF extensor
tendon tension is set with the finger in full extension. The tendon transfer is then
secured using multiple 3-0 Ethibond horizontal mattress sutures and a Pulvertaft
weave (Fig. 37.18).
EPL Rupture: EIP Transfer to EPL

• Incisions are made at the level of the thumb and index metacarpal heads to identify
the ruptured EPL tendon and to harvest the EIP tendon distally (Fig. 37.19).
• The EIP tendon is ulnar to the EDC. It is harvested as distally as possible to gain
length (Fig. 37.20).
Ruptured distal end of small finger EDC End-to-side tendon transfer to ring finger EDC
FIGURE 37.17
FIGURE 37.18
EIP redirected for transfer to EPL

through subcutaneous tunnel
Cut distal EIP
EPL
Ruptured EPL (distal portion) EIP Ruptured EPL (distal portion)
A B
FIGURE 37.21
• The distal incision over the index metacarpal head can be spared in some patients.
An example of this and tension for EIP to EPL transfer is demonstrated in Fig. 37.21.
EIP TO EDC PEARLS Loss of Ring and Small Digit Extension: EIP Transfer to Ring and Small EDC
When both the ring and small extensors are • The EIP tendon is harvested distally (as previously described).
ruptured, an EIP transfer is preferred. End-to-side
• The edges of the ruptured ring and small EDC tendons are freshened until tendon
repair of both the ring and SF extensors to the MF
tendon creates an oblique pull and can result in substance is seen (Fig. 37.22). It is critical to be sure that the ruptured tendon is
abduction of the SF. debrided to tendon substance so that the tenocytes can bridge the tendon juncture.
Suturing of scarred tendon ends will lead to rupture.
• The repair is completed end-to-end with horizontal mattresses under appropriate
tension (Fig. 37.23).
Loss of More Than Three Extensor Tendons: FDS or ECRL/ECRB to EDC

• When more than three extensor tendons are ruptured, the FDS tendons are typically
used as donors. FDS is a “smart” donor tendon in that it is redundant for most func-
tion with FDP, has long excursion (up to 70 mm), and is a powerful motor.
Ruptured ring &

small EDC
EIP
FIGURE 37.23
FIGURE 37.22
• FDS of the MF tendon transfer is accomplished using a chevron incision overlying FDS OR ECRL/ECRB TO EDC PEARLS
A1 pulley and a more proximal incision over the distal forearm (Fig. 37.24).
• A single FDS tendon can be used to power up
• The A1 pulley is incised and the FDS of the MF is transected distally (Fig. 37.25). to three extensor tendons. If more than three
• Using the distal forearm incision, the FDS of the MF is identified and rerouted sub- extensors are ruptured, one should consider
cutaneously around the radial forearm (Fig. 37.26A-C). transfer of both the RF and MF FDS tendons.
• The ruptured tendons are trimmed and 2-0 Ethibond is used to suture distal stumps • When an FDS tendon is used as a motor, a
subcutaneous transfer is preferred to one
together side by side.
through the interosseous membrane to reduce
• In this example, the FDS of the MF was sutured to the EDC of the IF, MF, RF, SF, the likelihood of adhesions. Transfer around
and the EDM and EIP tendons with the MCP joints in full extension using Ethibond the radial side of the forearm is preferred be-
(Fig. 37.27). cause the direction of pull will help correct the
• Extended posture of the digits is appreciated after FDS of the MF transfer is com- ulnar deviation deformity.
pleted (Fig. 37.28).
• The extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) FDS OR ECRL/ECRB TO EDC PITFALLS
may be possible alternatives if the FDS is not available (Fig. 37.29). Nevertheless, EIP does not have enough power to drive more
the excursion for the wrist extensors is only 30 mm, so these are chosen selectively. than one or two digits and is not a good option for
a multiple tendon weave.
Loss of Thumb Flexion: FPL Interposition Graft or FDS to FPL Tendon Transfer
• In most cases, the proximal FPL muscle is still functional, and the tendon can be
repaired with an interposition graft. An incision is made over the FCR tendon in the
distal forearm (Fig. 37.30) and the proximal stump of the FPL is identified just deep
and ulnar to this. The distal stump is identified within the carpal tunnel or at the level
of the thumb A1 pulley (Fig. 37.31). See “Chapter 78: Acute Repair of Extensor Ten-
don Injuries Zones I to VII” for additional details on FPL repair.
• When FDS to FPL transfer is indicated, a Bruner incision is designed over the FPL ten-
don sheath at the level of the thumb MCP joint. Excursion of the FPL should be verified
before donor harvest to confirm that the tendon glides within the tendon sheath.
• A second incision is made over the A1 pulley of the MF or RF to harvest the FDS.
• A proximal incision is designed on the distal forearm over the FCR tendon or over
the carpal tunnel (Fig. 37.30). The cut end of FDS is retrieved in the proximal incision,
then passed distally toward the thumb.
• The FDS is transferred to the FPL stump. If possible, a traditional flexor tendon repair
is performed with a 6- to 8-strand repair. A Pulvertaft weave is appropriate proximal
to the pulley apparatus and provides excellent repair strength.
FIGURE 37.28
A
EDC rupture
EIP intact
A ECRL reflected
FIGURE 37.29
FIGURE 37.26 A–C
FIGURE 37.30
FIGURE 37.27
FIGURE 37.31
• Be sure that the tendon graft or tendon ends are fed through the original sheath.
Errant passing of a clamp to create a new tunnel will cause the tendon to be adher-
ent without the shield provided by the sheath. A small feeding tube can be threaded
gently through the tendon sheath from the A1 pulley to emerge at the wrist. Then the
tendon can be sutured to the feeding tube to guide its gliding into the tendon sheath.
The distal end of the extensor retinaculum

is placed under the extensor tendons Extensor retinaculum over the extensor tendons
A B
FIGURE 37.32
FIGURE 37.33
Step 5: Extensor Retinaculum Reconstruction/Repair

• The distal part of the extensor retinaculum is tunneled under the extensor tendons
to augment the wrist capsular repair (Fig. 37.32).
• The proximal extensor retinaculum is sutured over the extensor tendons to recreate
the retinaculum (Fig. 37.33).
Step 6: Skin Closure and Splinting

• The tourniquet is released and hemostasis is obtained.
• The skin is closed using 4-0 nylon or absorbable monofilament subcuticular suture.
• The patient is placed in a splint with the fingers extended. If a Darrach procedure is
performed, the patient should be splinted in supination to enhance healing of the
distal radioulnar joint (DRUJ) and dorsal wrist capsule.

• The patient is splinted with the fingers in full extension for 4 weeks.
• After 4 weeks, active ROM exercises are initiated under the supervision of a certified
hand therapist.
• The outcome of tendon transfers is generally good for extensor tendon rupture in
RA. Increased extensor lag is observed when more tendons are involved.
• Patients with isolated flexor tendon ruptures in the palm or at the wrist level had
good functional results. Patients with multiple ruptures within the carpal canal had a
worse prognosis.
See Video 37.1
EVIDENCE
O’Sullivan MB, Singh H, Wolf JM. Tendon transfers in the rheumatoid hand for reconstruction. Hand
Clin. 2016;32(3):407–416.
This article reviews treatment options for spontaneous tendon rupture in the rheumatoid hand.
Suzuki T, Iwamoto T, Ikegami H, et al. Comparison of surgical treatments for triple extensor tendon rup-
tures in rheumatoid hands: A retrospective study of 48 cases. Mod Rheumatol. 2016;26(2):206–210.
This is a retrospective study that compares four techniques for treatment of extensor tendon rupture of
the ulnar three fingers in rheumatoid hands. The techniques performed were PL tendon grafting, EIP
tendon transfer, end-to-side transfer with early mobilization, and a combination of end-to-side and
EIP transfers. The combination group had the best mean MP joint extension (-3 degrees), followed
by the end-to-side group (-12 degrees), EIP group (-16 degrees), and PL group (-21 degrees). The
combination end-to-side and EIP transfers yielded the best clinical outcomes, with all cases showing
good results.
Chung US, Kim JH, Seo WS, Lee KH. Tendon transfer or tendon graft for ruptured finger extensor
tendons in rheumatoid hands. J Hand Surg Eur. 2010;35:279–282.
The authors evaluated the outcome of tendon reconstruction using tendon graft or tendon transfer in
51 wrists of 46 patients with RA with extensor tendon ruptures. At a mean follow-up of 5.6 years, the
mean MCP joint extension lag was 8 degrees (range 0–45), and the mean visual analog satisfaction
scale was 74 (range 10–100). Clinical outcomes did not differ significantly between tendon grafting
and tendon transfer. The MCP joint extension lag correlated with the patient’s satisfaction score, but
the pulp-to-palm distance did not correlate with patient satisfaction. The authors concluded that
both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger
extensor tendons in rheumatoid hands.
Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with
rheumatoid arthritis. J Hand Surg Am. 1988;13:860–866.
The authors present 115 flexor tendon ruptures in 43 hands with RA, one hand with psoriatic arthritis,
and one hand with lupus erythematosus. Ninety-one tendons were ruptured at the wrist, 4 ruptures
occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were
caused by attrition on a bone spur, and 30 were caused by direct invasion of the tendon by tenosy-
novium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium.
Patients whose ruptures were caused by attrition regained better motion than those whose ruptures
were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated
ruptures in the palm or at the wrist had the best functional results. Patients with multiple ruptures
within the carpal canal had a worse prognosis. The severity of the patient’s disease and the degree
of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures
by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.
CHAPTER 38
Stabilization of Extensor Carpi Ulnaris Tendon
Subluxation with Extensor Retinaculum
INDICATIONS
• The extensor carpi ulnaris (ECU) tendon is stabilized within the ulnar groove by a
fibro-osseus subsheath lying deep to the extensor retinaculum (Fig. 38.1). Injury to
the subsheath results in volar subluxation of the tendon around the ulna head with
forearm rotation.
• Subsheath injury occurs during hypersupination of the forearm, ulnar deviation and
flexion of the wrist, or active contraction of the ECU muscle.
• Traumatic ECU subluxation is relatively common in young athletes and is often as-
sociated with racquet or stick sports (i.e., tennis, golf, baseball).
• Immobilization in a long-arm or Muenster cast with the forearm pronated and the
wrist slightly extended and radially deviated for 4 to 6 weeks is recommended as
first-line treatment.
• ECU stabilization surgery is indicated in patients with persistent symptoms.
• Volar subluxation of the ECU tendon is also common in patients with rheumatoid
arthritis (RA). With loss of the ECU moment arm, the radial wrist extensors act unop-
posed and contribute to radial wrist deviation and carpal supination. Although ECU
subluxation is rarely symptomatic in RA patients, dorsal repositioning of the ECU
tendon with an extensor retinaculum sling or extensor carpi radialis longus (ECRL)
to ECU tendon transfer improves wrist alignment.
Extensor
retinaculum Intact ECU
(reflected) subsheath
Extensor
digiti minimi Extensor
carpi ulnaris
FIGURE 38.1
297
298 CHAPTER 38 Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum
• Patients complain of a painful snapping sensation over the ulnodorsal wrist.
• The ECU synergy test is performed with the patient’s elbow flexed at 90 degrees and
the forearm in full supination. The examiner grasps the patient’s thumb and index
finger with one hand and palpates the ECU tendon with the other hand. The patient
is asked to radially abduct the thumb against resistance (Fig. 38.2). Patients with
ECU pathology will have pain along the course of the tendon during this maneuver.
If subluxation exists, tendon bowstringing can be seen beneath the skin.
• Supination, ulnar deviation, and wrist flexion creates the greatest angle between the
ECU and the ulna. Patients can often demonstrate subluxation with this position.
• Other sources of ulnar-sided wrist pain, including ulnar styloid fractures, triangular
fibrocartilage complex (TFCC) injuries, ulnar impaction syndrome, and flexor carpi
ulnaris (FCU) tendonitis, must be ruled out. Diagnosis of subsheath tears can be
difficult, even for experienced physicians.
IMAGING
• A plain radiograph of the wrist is required to exclude a fracture or other bony etiology
for ulnar-sided wrist pain.
• Dynamic ultrasound is useful to confirm ECU tendon subluxation if the diagnosis is
unclear.
SURGICAL ANATOMY
• The ECU tendon is stabilized within the ulnar groove by a fibro-osseous subsheath,
which is deep to the extensor retinaculum (Fig. 38.3). This subsheath is unique to
the sixth compartment—the other dorsal compartments are separated only by inter-
vening septae. The subsheath spans the ECU groove over the ulna to stabilize the
ECU, whereas the overlying extensor retinaculum covers the ECU and provides no
restraining function.
• Subsheath disruption can result in one of three ways: radial-sided rupture (Fig. 38.4A),
ulnar-sided rupture (see Fig. 38.4B), or detachment of the periosteum from the ulna in
FIGURE 38.2
continuity with the subsheath (see Fig. 38.4C).
• The dorsal sensory branch of the ulnar nerve runs in the subcutaneous tissue along
the sixth compartment and must be identified and protected during the operation
(Fig. 38.5A–B).

• The patient is positioned supine on the operating table with a hand table extension.
• The surgery is performed with an axillary nerve block and IV sedation under pneu-
matic tourniquet control.
• No special equipment is necessary.
Extensor
3rd compartment retinaculum
5th
2nd compartment
compartment Extensor
carpi ulnaris
ECU subsheath False
6th Rupture Rupture pouch
1st compartment ECU
compartment
Radius A B C
CHAPTER 38 Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum 299
Dorsal sensory
branch of the
ulnar nerve
Extensor digiti
minimi
Extensor carpi
ulnaris
FIGURE 38.7
EXPOSURES
• Lister tubercle is palpated and marked.
• A 5-cm longitudinal incision is made on the dorsal wrist in line with the third meta- EXPOSURES PITFALLS
carpal for full exposure of the ECU tendon sheath and access to the extensor The dorsal sensory branches of the ulnar nerve
retinaculum (Fig. 38.6). must be identified and gently retracted. Multiple
• Full-thickness flaps are elevated off of the extensor retinaculum over the fourth, fifth, branches are often present distally in the operative
field.
and sixth compartments (Fig. 38.7).

• If the torn subsheath is substantial and can be Step 1
closed without tension, it can be repaired
primarily, but this is not usually the case. • The extensor retinaculum is incised over the sixth compartment to expose the sub-
• The ulnar groove can be deepened using a sheath and ECU tendon.
3-mm bur if the groove is too shallow, but this • Inflamed tissue and frayed tendon are debrided (Fig. 38.8A–B).
is often not needed because the extensor
retinaculum sling will stabilize the ECU. Step 2
Deepening of the groove is often done as
an isolated procedure because the sling will A 2-cm wide flap of extensor retinaculum based at the ulnar border of the fifth extensor
displace the ECU radially out of the groove. compartment is elevated. The radial limit of the flap is the radial aspect of the third
compartment (Figs. 38.9A–B and 38.10).

• Care should be taken to not make the flap too • The ulnarly based extensor retinaculum flap is wrapped around the ECU tendon to
short. create a sling (Fig. 38.11A–B). The flap is first passed deep to the ECU tendon with
• The intercompartmental septae must be care- the synovial layer abutting the tendon and then around the dorsal surface of the
fully divided without cutting into the flap or
damaging the underlying tendons. tendon, where it is secured to itself and the adjacent extensor retinaculum with 2-0
Ethibond sutures (Fig. 38.12).
• Ensure that the sling stabilizes the tendon without being overly tight (Fig. 38.13).
Step 4
• The tourniquet is released and careful hemostasis is achieved using bipolar electro-
cautery.
• The wound is closed with 4-0 suture and a sugar-tong splint is applied in neutral
forearm rotation.
FIGURE 38.8
Radial border
of the 3rd Pedicle of the flap
compartment (at the ulnar border of
the 5th compartment)
5th
compartment
ECU
6th
compartment
B
Radius Ulna
Extensor
Ulnar border retinaculum
of the 5th
compartment
ECU
A
Extensor
retinaculum
Ulnar border
of the 5th
compartment
ECU
B
FIGURE 38.11
FIGURE 38.12
FIGURE 38.13

• The patient is seen in the office approximately 2 weeks after surgery. Sutures are removed
and the patient is placed into a sugar-tong splint or long-arm cast with the elbow in 90
degrees of flexion and neutral forearm rotation. Total immobilization time is 4 to 6 weeks.
• See Fig. 38.14 for 6-week follow-up. Range of motion (ROM) improves with time.
• Strenuous activities are avoided for 3 months.
• Patients are permitted to return to manual labor and sporting activities in 6 months.
See Video 38.1
A B
C D
FIGURE 38.14
EVIDENCE
Inoue G, Tamura Y. Surgical treatment for recurrent dislocation of the extensor carpi ulnaris tendon.
J Hand Surg Br. 2001;26:556–559.
The authors reviewed 12 patients with recurrent dislocation of the ECU tendon and identified three
types of fibro-osseous sheath disruption: Type A—sheath is ruptured ulnarly and lies superficial to
the tendon; Type B—sheath is ruptured radially and lies in the ulnar groove beneath the tendon; Type
C—detachment of the periosteum ulnarly is in continuity with sheath, creating a false pouch into
which the tendon can dislocate. Treatment was tailored to the type of disruption: subsheath
reconstruction with extensor retinaculum for type A, direct repair for type B, or reattachment of
the periosteum with suture anchors for type C. All patients had satisfactory results.
Iorio ML, Huang JI. Extensor carpi ulnaris subluxation. J Hand Surg Am. 2014;39:1400–1402.
This article summarizes the treatment of ECU subluxation. The fibro-osseous sheath stabilizes the ECU
during forearm rotation. Injury to the sheath results in subluxation or dislocation of the ECU. Symp-
tomatic patients are treated with cast immobilization for 4 to 6 weeks. If symptoms persist, surgical
exploration is recommended.
Puri SK, Morse KW, Hearns KA, Carlson MG. A biomechanical comparison of extensor carpi ulnaris
subsheath reconstruction techniques. J Hand Surg Am. 2017;42(10):837.e1–837.e7.
This is a cadaveric study comparing the stability of the ECU tendon after three types of reconstruction
techniques: subsheath reconstruction with extensor retinaculum without ulnar groove deepening,
subsheath reconstruction with extensor retinaculum with ulnar groove deepening, and ulnar groove
deepening without subsheath reconstruction. The position of the ECU tendon relative to the radial
side of the ulnar groove was measured in nine combinations of wrist and forearm positions. They
found that ulnar groove deepening did not improve the stability of the ECU tendon compared with
subsheath reconstruction alone. Subsheath reconstruction with extensor retinaculum alone
eliminated ECU dislocation.
Ito J, Koshino T, Okamoto R, Saito T. Radiologic evaluation of the rheumatoid hand after synovectomy
and extensor carpi radialis longus transfer to extensor carpi ulnaris. J Hand Surg Am. 2003;28(4):
585–590.
The authors reviewed 23 rheumatoid patients (28 wrists) who underwent synovectomy and concomitant
ECRL to ECU tendon transfer with a mean follow-up time of 8.8 years. Radial angulation of the wrists
was reduced approximately 10 degrees after surgery. Ulnar translocation of the carpus was
prevented. Mean ulnar drift of the fingers was maintained at the preoperative level. They conclude
that ERCL to ECU tendon transfer effectively stabilizes the wrist and may prevent further ulnar drift
of the fingers in rheumatoid patients.
CHAPTER 39
Correction of Swan-Neck Deformity
INDICATIONS
• The swan-neck deformity is characterized by proximal interphalangeal (PIP) joint
hyperextension and distal interphalangeal (DIP) joint flexion.
• Swan-neck posturing is a result of tendon imbalance; the root cause can be at the wrist
or at the metacarpophalangeal (MCP), PIP, or DIP joints. Tendon imbalance may be
caused by inflammatory arthritis, trauma, tendon rupture, or general ligamentous laxity.
• Possible abnormalities in a swan-neck deformity include (Fig. 39.1):
• Intrinsic muscle shortening
• Volar subluxation of the MCP joint
• Dorsal displacement of the lateral bands
• Laxity of the PIP joint volar plate
• Oblique retinacular ligament laxity
• Mallet deformity with terminal extensor tendon disruption
• Flexor tendon adhesions or lacerations
• Joint stiffness or arthritic joint destruction
• Skin tightness or loss
• The Nalebuff classification system is used to describe the severity of a swan-neck
deformity and is based on the degree of PIP joint stiffness:
• Type 1: PIP joint is flexible in all positions of the MCP joint.
• Type 2: PIP joint flexion is limited in certain positions of the MCP joint.
• Type 3: PIP joint flexion is limited in all positions of the MCP joint.
• Type 4: PIP joint is stiff and arthritic.
• PIP hyperextension and stiffness impair a patient’s ability to make a fist. First-line
treatment includes splinting with the DIP joint in extension and dorsal blocking of the
PIP joint with 40 to 60 degrees of flexion for 8 weeks. Surgery is indicated for
patients who do not respond to nonoperative management, have full passive range
of motion (ROM), and are functionally limited.
Dorsal MCP joint synovitis

Rupture of extensor insertion
onto base of proximal phalanx
Dorsal DIP joint synovitis

Rupture of terminal tendon
Proximal migration of terminal
and oblique retinacular ligament
Volar MCP joint synovitis Volar PIP joint synovitis

Attenuation of volar plate Attenuation of volar plate
Flexor tenosynovitis Attenuation of transverse retinacular ligament
Intrinsic tendon adhesion Dorsal translation of conjoint lateral band
Intrinsic muscle contracture Flexor tenosynovitis
Rupture of flexor digitorum superficialis
FIGURE 39.1
304
• There are multiple surgical techniques available to treat swan-neck deformities de-
pending on the etiology of the problem. The key to a successful repair is to identify
and treat each pathologic structure.
• The goals of surgical repair include: (1) correcting PIP joint hyperextension, (2) improv-
ing PIP joint motion, (3) correcting DIP joint flexion deformity, (4) improving lateral band
“snapping” on PIP joint flexion, and (5) improving extension at the MCP joint.
• Active and passive ROM are assessed independently at the MCP, PIP, and DIP
joints. Special attention is paid to PIP joint motion.
• When passive motion is greater than active motion at the PIP joint, flexor tendon
adhesions may be present.
• In patients with limited PIP joint motion in all MCP positions, examine closely for
adhesions that affect the central extensor and dorsal translocation of the conjoint
lateral bands.
• If ulnar drift is present at the MCP joint, PIP joint motion is assessed with the MCP
joint extended with radial and ulnar inclination. This examines for isolated intrinsic
muscle shortening of the radial or ulnar interosseous muscle.
• The Bunnell test is used to examine for intrinsic tightness. The test is performed
by holding the MCP extended and passively flexing the PIP joint. The MCP is then
flexed. If PIP flexion increases, intrinsic muscle tightness is present. Normally,
MCP extension does not restrict PIP motion and no change in motion is detected
(Fig. 39.2A–C).
IMAGING
• Standard three-view radiographs are used to evaluate the articular surfaces
(Fig. 39.3A–C).
• Patients with articular damage are best treated with arthrodesis or arthroplasty, rather
than soft-tissue reconstruction. In rheumatoid arthritis (RA), the ligamentous support
of the PIP joint is typically poor. PIP fusion is more reliable than silicone arthroplasty.
SURGICAL ANATOMY
• Detailed knowledge of the extensor mechanism is necessary for diagnosis and treat-
ment of swan-neck deformities.
• Three muscles contribute to the extensor mechanism of the finger – the extensor
digitorum communis (EDC), the lumbrical, and the interossei. The EDC runs along
A B C
FIGURE 39.2
306 CHAPTER 39 Correction of Swan-Neck Deformity
A B C
FIGURE 39.3
the dorsum of each finger and is stabilized at the MCP joint by the sagittal bands.
The sagittal bands wrap transversely around the metacarpal head and insert onto
the volar plate and proximal phalanx.
• Distal to the MCP joint, the EDC tendon trifurcates into a central slip and two lateral
slips. The central slip inserts onto the base of the middle phalanx and extends the
PIP joint. The lateral slips contribute to the conjoint lateral bands.
• The lumbrical muscles originate from the flexor digitorum profundus tendons in the
palm and pass volar to the intermetacarpal ligaments at the MCP level. Oblique fi-
bers join the central slip over the proximal phalanx. Distally, the lumbrical inserts
onto the radial conjoint lateral band.
• The dorsal interossei arise from the metacarpals and have two muscle bellies: the
superficial and deep head. The superficial head becomes the medial tendon, which
runs deep to the sagittal band and inserts on the base of the proximal phalanx (it
abducts the digit). The deep head gives rise to the lateral tendon, which passes
superficial to the sagittal band and is more complex. The lateral tendon has trans-
verse, oblique, and distal fibers. Transverse fibers insert on the midproximal phalanx
and help flex the MCP joint. Oblique fibers help extend the PIP joint. Distal fibers of
the lateral tendon insert onto the conjoint lateral band.
• The conjoint lateral bands travel distally to form the terminal tendon, which insert
onto the dorsal base of the distal phalanx and extend the DIP joint.
• The triangular, transverse retinacular, and oblique retinacular ligaments stabilize
the conjoint lateral bands and coordinate motion of the extensor mechanism
(Fig. 39.4A–B).
• Disruption of the terminal tendon at the DIP joint (mallet injury) causes the lateral
bands to migrate proximally, increasing the extension force at the PIP joint.
• Attenuation of the PIP joint volar plate from synovitis, posttraumatic arthritis, or
generalized laxity can cause PIP hyperextension.
• Chronic volar subluxation of the MCP joint from inflammatory arthritis or posttraumatic
contracture increases tension on the EDC and leads to PIP joint hyperextension.
• Carpal collapse at the wrist can cause relative lengthening of the extrinsic tendons.
Intrinsic muscle forces may overpower the extrinsic forces, leading to PIP joint hy-
perextension.

• The patient is placed in the supine position with the arm supported on a hand table.
• A wide-awake, local anesthesia, no tourniquet approach is helpful so that active
motion can be assessed intraoperatively.
• Fluoroscopy, Kirschner wires (K-wires), and bone anchors should be available de-
pending on the chosen technique.
Dorsal interphalangeal
Oblique
Triangular retinacular
ligament ligament
Transverse
retinacular
Proximal interphalangeal ligament
Central
Lateral
slip
band
Sagittal band Metacarpophalangeal Transverse

Proximal retinacular
Central slip interphalangeal ligament
Sagittal
Metacarpophalangeal
band
Dorsal
Dorsal, volar
interphalangeal
interosseous
Dorsal, volar muscles
Terminal
interosseous Lumbrical tendon
muscles Lumbrical muscle
muscle Lateral band Oblique
A retinacular
B ligament
FIGURE 39.4
PROCEDURES PROCEDURE 1 PEARLS

Several techniques are available for correction of a swan-neck deformity depending on If the native lateral band is attenuated proximally,
the etiology, impaired structures, and patient symptoms. Techniques can be combined the distal stump can be sutured to the A2 pulley
to treat multiple structures. or secured directly to the proximal phalanx with a
bone anchor.
Procedure 1: Lateral Band Relocation
Lateral band relocation is indicated when a patient has full, active PIP motion but com- PROCEDURE 1 PITFALLS
plains of “snapping” with flexion. • This procedure is inadequate if there are ad-
• The ulnar lateral band is exposed through a longitudinal midaxial incision centered hesions to the central slip.
about the PIP joint (Fig. 39.5A–B). • For RA patients, the quality of the lateral bands
• The lateral band is divided as proximally as possible at the base of the proximal may be poor and the ligaments may be atten-
uated, precluding the use of this technique.
phalanx and dissected distally beyond the PIP joint (Fig. 39.6A–B).
• The PIP joint is flexed and a blunt instrument is used to create a tunnel volar to the
Grayson and Cleland ligaments, volar to the PIP joint (Fig. 39.7).
• The lateral band is then passed through the tunnel from distal to proximal and su-
tured to the native proximal tendon or, preferably, attached to a stout structure such
as the A2 pulley or to the bone of the proximal phalanx to keep the PIP joint from
hyperextending (Fig. 39.8).
Procedure 2: Release of the PIP Joint

PIP joint release is performed when there is a fixed extension contracture of the PIP
joint, with a normal articular surface. It is indicated in patients with normal articular
cartilage who cannot fully flex the PIP joint independent of the MCP joint position.
Closed capsulotomy can be attempted under anesthesia with gentle, sustained, pas-
sive flexion. If passive flexion is restricted, an open capsulotomy and release of lateral
bands from its attachment to the central tendon is performed.
• A curvilinear incision is made over the dorsum of the finger to expose the PIP joint
and extensor apparatus. In the figure, a suture from prior extensor repair is visible
within the central extensor tendon (Fig. 39.9).
• The interval between the central tendon and the lateral bands is then incised longi-
tudinally (Fig. 39.10).
B
FIGURE 39.5
B
FIGURE 39.6

Parallel incisions between

lateral bands and central slip
FIGURE 39.10
FIGURE 39.9
PROCEDURE 2 PEARLS
• Complete release of the lateral bands proximal
and distal to the PIP joint is necessary to per-
FIGURE 39.11 mit volar migration with flexion.
• Flexion should be tested after release of the
lateral bands because complete dorsal capsu-
lotomy and collateral ligament release is not
• The dorsal PIP joint capsule is incised. Intraoperative flexion of the PIP joint is tested
always necessary.
(Fig. 39.11).
• If flexion is still restricted at the PIP joint, the following maneuvers are performed in
this order: (1) additional release of the dorsal PIP joint capsule, (2) release of the PROCEDURE 3 PEARLS
dorsal portions of the radial/ulnar collateral ligaments from the proximal phalanx, A synovectomy of the flexor tendons can be
and (3) Z lengthening of the central tendon. performed simultaneously.
Procedure 3: Flexor Digitorum Superficialis Tenodesis PROCEDURE 3 PITFALLS

Flexor digitorum superficialis (FDS) tenodesis is performed when the PIP joint has full If possible, avoid dissection in zone 2.
passive motion but requires a PIP restraint. It creates a static, volar checkrein to prevent
hyperextension of the PIP joint.
• A Bruner incision is made over the volar MCP joint and flaps are elevated (Fig. 39.12).
• The flexor sheath is opened proximal to the A1 pulley, and the FDS and flexor digi-
torum profundus (FDP) are identified (Fig. 39.13).
• The FDS tendon is transversely divided about 1 cm proximal to the A1 pulley (Fig. 39.14).
• A small bone anchor is inserted into the lateral aspect of metacarpal bone just
proximal to the neck. The sutures are passed through the divided slip of FDS with
the PIP joint in 30 degrees of flexion (Fig. 39.15).
FIGURE 39.13
FIGURE 39.12
PROCEDURE 4 PEARLS Procedure 4: Intrinsic Muscle Release

• This technique is a priority in patients with Intrinsic muscle release is indicated in patients with intrinsic muscle tightness on ex-
intrinsic muscle contracture limiting PIP joint amination.
motion. • A transverse incision is made at the dorsal base of the proximal phalanx (Fig. 39.16).
• The released intrinsic tendon can be used for
• The extensor hood is identified with blunt dissection.
a crossed intrinsic tendon transfer to correct
ulnar drift, if indicated. • The intrinsic tendons are located at the radial and ulnar aspects of the extensor
mechanism. The MCP joint is extended and the intrinsic tendons are transversely
divided until the PIP joint can be passively flexed (Fig. 39.17).
Procedure 5: DIP Joint Arthrodesis

DIP arthrodesis is considered in patients with a fixed flexion contracture of the DIP joint
(mallet deformity) and swan-neck posturing of the finger. See Chapter 43 Distal Inter-
phalangeal Joint Arthrodesis for additional step-by-step instructions.
Common
intrinsic
tendon
A B
FIGURE 39.17
• DIP joint arthrodesis is performed through a dorsal transverse or T-shaped incision.

• The dorsal capsule and extensor tendons are transversely divided, and the joint
cartilage is removed with a rongeur.
• Fixation is performed with a buried K-wire or headless compression screw to fuse
the joint in extension.

• The hand is immobilized in a splint with the MCP joints extended and PIP joints
FIGURE 39.16
slightly flexed.
• If flexor tenosynovectomy is performed, active motion begins within the first 5 days
under the supervision of a certified hand therapist.
• Dorsal extension blocking should continue for 4 to 6 weeks postoperatively to pre-
vent hyperextension at the PIP joint.
• Soft-tissue reconstructions stretch over time. Most studies show good outcomes at
1 year with gradual recurrence of deformity in the long term.
See Video 39.1
EVIDENCE
Elzinga K, Chung KC. Managing swan-neck and Boutonniere deformities. Clin Plast Surg. 2019;46(3):
329–337.
This article reviews the etiology, anatomy, and treatment options for swan-neck and Boutonniere
deformities.
Fox PM, Chang J. Treating the proximal interphalangeal joint in swan-neck and Boutonniere
deformities. Hand Clin. 2018;34(2):167–176.
This article reviews options for treating the PIP joint in swan-neck and Boutonniere deformities.
de Bruin M, van Vliet DC, Smeulders MJ, Kreulen M. Long-term results of lateral band translocation
for the correction of swan-neck deformity in cerebral palsy. J Pediatr Orthop. 2010;30:67–70.
The authors treated 62 fingers with lateral band translocation and reported an 84% success rate at
1 year, which declined to 60% at 5 years. The authors concluded that lateral band translocation is
not a long-lasting procedure in the treatment of cerebral palsy.
Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and Boutonniere
deformities: Long-term results. J Hand Surg Am. 1993;18:984–989.
Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal capsulotomy and
lateral band mobilization. An initial increase of 55 degrees of motion into flexion was noted, but this
deteriorated over time. Of 15 fingers followed at 3 and 12 months, there was a mean loss of
17 degrees of flexion.
CHAPTER 40
Correction of Boutonniere Deformity
INDICATIONS
• The boutonniere deformity is characterized by flexion at the proximal interphalangeal
(PIP) joint and hyperextension of the distal interphalangeal (DIP) joint.
• Boutonniere deformities are caused by pathology at the dorsal PIP joint. Disruption
of the central slip of the extensor apparatus caused by trauma or synovitis results in
flexion (Fig. 40.1).
• The lateral bands migrate volarly and contract, creating an extension force across
the DIP joint. The oblique and transverse retinacular ligaments also gradually con-
tract, worsening DIP hyperextension.
• Boutonniere deformities can be flexible or fixed. Over time, destruction of the articu-
lar cartilage can lead to significant arthrosis of the PIP joint.
• The Nalebuff stage is based on the passive correctability of the PIP joint and the
condition of the articular cartilage.
• Stage 1: PIP joint synovitis and a slight (10–15 degree), fully correctable extensor lag
• Stage 2: Marked PIP joint flexion (30–45 degrees) that can be fixed or is partially
correctable; joint surface intact
• Stage 3: PIP joint fixed flexion contracture and joint erosion
• For acute, flexible boutonniere deformities, the patient is splinted with the PIP joint
extended and the DIP joint free for 6 weeks. Active and passive DIP range of motion
(ROM) exercises are performed hourly to encourage dorsal migration of the lateral
bands and to stretch the transverse retinacular ligament. After 6 weeks, the patient
is weaned from the splint during the day and performs active PIP flexion exercises.
The splint is worn at night for an additional 6 weeks.
• For chronic boutonniere deformities, serial casting is used to correct PIP flexion. Full
PIP extension is maintained for 6 to 12 weeks and DIP flexion exercises are per-
formed. Operative release of tight collateral ligaments or the volar plate can be
performed if full PIP extension cannot be achieved with therapy alone.
• Surgery is rarely indicated for boutonniere deformities; they are less functionally
debilitating than swan-neck deformities because finger flexion and power grip are
maintained. Do not operate on a functional finger.
• The goal of surgical correction is to increase extensor force across the PIP joint and
decrease extension at the DIP joint. Full passive motion is required before surgery.
Joint releases, when indicated, must be performed before tendon rebalancing.
• Surgical correction is indicated in patients with flexible, nonarthritic joints who are
unresponsive to splinting and have a functional deficit.
• Inspect for scars and swelling at the dorsal PIP joint and examine the posture of the
finger.
Dorsal attenuation
(PIP joint synovitis)
Volar contracture
FIGURE 40.1
312
CHAPTER 40 Correction of Boutonniere Deformity 313
• Active and passive ROM are assessed independently at the metacarpophalangeal

(MCP), PIP, and DIP joints.
• The Elson test evaluates central slip integrity. The PIP joint is held in 90 degrees of
flexion and the patient is asked to extend the finger. A patient with an intact central
slip will generate force at the PIP joint but will be unable to actively extend the DIP.
Conversely, a patient with a central slip injury will be unable to extend the PIP and
the force will be transferred to the DIP joint.
• The Boyes test is performed by holding the PIP joint extended and asking the patient
to flex the DIP. If the extensor mechanism is intact, the patient will be able to flex at
the DIP. If the lateral bands are contracted from injury to the extensor tendon, the
patient will be unable to flex the DIP.
• In rheumatoid arthritis (RA) patients with ulnar drift, PIP motion is assessed with the
MCP joint extended with radial and ulnar inclination to assess for intrinsic muscle
shortening (Fig. 40.2).
IMAGING
• Standard, three-view x-rays are mandatory to evaluate for dislocations, fractures,
and articular wear.
• Patients with significant arthritis are not candidates for soft-tissue reconstruction
and are best treated with arthrodesis or arthroplasty to relieve pain.
SURGICAL ANATOMY
• In RA, boutonniere deformity arises secondary to synovitis at the PIP joint. Pressure
and inflammation from the synovial pannus lead to attenuation of the dorsal capsule
and central slip, creating an extensor lag. As the flexion deformity progresses, the
lateral bands shorten and translocate volar to the axis of the PIP joint, causing hy-
perextension of the DIP joint. The volar plate can also shorten, creating a checkrein
against extension (Fig. 40.3A–B).
• Detailed anatomic knowledge of the extensor and flexor apparatus is important in both
diagnosis and treatment (see Chapter 39 Treatment of Swan-Neck Deformity figures).

• The patient is placed in the supine position with the arm supported on a hand table.
• A wide-awake, local anesthesia, no tourniquet approach is helpful so that active
motion can be assessed intraoperatively.
FIGURE 40.2
314 CHAPTER 40 Correction of Boutonniere Deformity
Transverse
retinacular
A ligament
Attenuation of
the central slip
FIGURE 40.3
• Fluoroscopy, Kirschner wires (K-wires), and bone anchors should be available de-
pending on the chosen technique.
PROCEDURES
Several techniques are available for repair and reconstruction of boutonniere deformi-
ties based on the chronicity and etiology of the central slip injury.
Extensor Tenolysis and Extensor Central Slip Repair

• Extensor tenolysis with central slip repair is indicated in patients with chronic, trau-
matic boutonniere deformities. Repair of the central slip with splinting or pinning of
the DIP joint can resolve the deformity (Fig. 40.4A–B).
• The healed laceration is extended proximally and distally as needed for exposure
(Fig. 40.5).
• Tenolysis is performed and the cut edges of the tendons are identified (Fig. 40.6).
• The tendon is repaired to the remnant stump in standard fashion using 4-0 Ethibond
suture or anchored to the dorsal base of the middle phalanx using a bone anchor
(Fig. 40.7).
• Incisions are closed with 4-0 nylon suture. The PIP and DIP joints are stabilized in
extension with pinning or splinting.
Healed PIP
laceration,
central slip
injury with Laceration
chronic incorporated into
boutonniere surgical incision
deformity (midaxial)
A B

Retracted central slip
Volar Plate Release and Extensor Tenotomy

• Volar plate release is indicated in patients with intrinsic joint tightness of the PIP
joint. This may be combined with an extensor tenotomy to reduce DIP hyperexten-
sion. A transverse tenotomy is performed at the level of the triangular ligaments,
proximal to the attachment of the oblique retinacular ligaments to preserve DIP joint
extension.
• A V-shaped incision is centered over the volar PIP joint and flaps are elevated to
expose the flexor tendon (Fig. 40.8). Care is taken to identify and preserve the neu-
rovascular bundles.
• The A3 pulley is incised longitudinally and the flexor tendons are retracted to expose
the volar plate. The proximal aspect of the volar plate is then incised and the finger
extended (Fig. 40.9).
• The DIP joint is evaluated. If it remains hyperextended, an extensor tenotomy is
performed.
• A longitudinal incision is made over the dorsal middle phalanx to expose the exten-
sor apparatus. The triangular ligament is transversely incised proximal to the oblique
Cut edge of
volar plate
Retracted flexor
tendon

VOLAR PLATE RELEASE AND retinacular ligaments (at the junction of the proximal and middle third of the middle
EXTENSOR TENOTOMY PEARLS phalanx), and the DIP joint is flexed (Fig. 40.10).
Selective pinning of joints may help tendon healing • The skin is closed with 4-0 nylon sutures.
but will contribute to postoperative stiffness. • A K-wire can be placed across the PIP joint to induce stiffness in extension while the
digit is healing (Fig. 40.11).
• The finger is splinted in extension.
VOLAR PLATE RELEASE AND
EXTENSOR TENOTOMY PITFALLS
Tenotomy of the extensors should proceed in a
Central Slip Reconstruction with Centralization of the Lateral Bands
stepwise manner to preserve extension at the DIP • In RA patients, synovitis at the PIP joint leads to attenuation of the central slip over
joint. Some surgeons advocate for terminal tendon time. In this case the central slip typically cannot be repaired primarily and must be
tenotomy to induce a mild mallet deformity because reconstructed using local tissues. Synovectomy is performed, the lateral bands are
this position can be a functional improvement for
centralized, and small, transverse cuts are made distally to lengthen the lateral
patients (Fig. 40.12A–E).
bands and permit DIP flexion.
FIGURE 40.12
• A curvilinear incision is designed over the dorsal PIP joint (Fig. 40.13).
• The extensor apparatus is exposed and the central slip is identified. It is usually
attenuated or ruptured (Fig. 40.14).
• The lateral bands (arrow) and transverse retinacular ligament are identified (Fig. 40.15).
• A synovectomy is performed, taking great care to preserve both the transverse reti-
nacular ligaments and the lateral bands.
• The radial and ulnar transverse retinacular ligaments are released from the volar plate
with a no. 15 blade, then transposed dorsally and sutured together in the midline to
reconstruct the central slip (Fig. 40.16 A–C). Transposition of the transverse retinacu-
lar ligaments dorsally relocates the lateral bands above the axis of rotation of the PIP
joint (Fig. 40.17).
• The posture of the DIP joint is assessed. If the DIP joint remains hyperextended
(arrow), small, transverse cuts are made in the distal lateral bands to provide more
length (Figs. 40.18 and 40.19).
• The skin is closed with 4-0 nylon sutures and the patient is placed into an extension
splint.
Lateral
band
A B
Transverse
retinacular
ligament
C
Middle phalanx
Release of lateral bands

FIGURE 40.19
POSTOPERATIVE CARE Central Slip Reconstruction with Centralization of the Lateral Bands
AND EXPECTED OUTCOMES Pearls
• The patient is seen in the office 10 to 14 days • Joint contractures must be addressed before tendon rebalancing. If there is a con-
postoperatively and sutures are tracture of the PIP joint, a volar approach is used to release the volar plate and ac-
removed.
• K-wires should stay in place for 3 to 4 weeks cessory collateral ligaments to obtain full passive extension.
for healing and positional stability. • Tendon sutures should be placed carefully to set the appropriate tension. A wide-
• The hand is immobilized in a full resting exten- awake approach is useful so that the patient may actively flex and extend the digit
sion splint. and adjustments can be made as needed.
• After pin removal, the patient is transitioned See Video. 40.1
into a dynamic daytime splint and a nighttime
static splint for an additional 4 to 8 weeks.
EVIDENCE
Grau L, Baydoun H, Chen K, Sankary ST, Amirouche F, Gonzalez MH. Biomechanics of the acute
boutonniere deformity. J Hand Surg Am. 2018;43(1):80.e1–80.e6.
The authors sequentially divided the central slip, transverse and oblique fibers of the interosseous
hood, and the triangular ligament on 18 fresh cadaveric hands, then measured extension of the PIP.
They found that division of the central slip from the middle phalanx resulted in decreased extension
at the PIP joint. Extension was further decreased when the transverse and oblique fibers of the inter-
osseous hood were also divided. A boutonniere deformity occurred only when the triangular ligament
was also damaged. They conclude that damage to the central slip alone does not cause a bouton-
niere deformity; the lateral bands must also subluxate volar to the axis of rotation of the PIP joint.
El-Sallakh S, Aly T, Amin O, Hegazi M. Surgical management of chronic boutonniere deformity. Hand
Surg. 2012;17(3):359–364. doi:10.1142/S0218810412500311.
This is a retrospective study of 12 patients with traumatic boutonniere deformities who were treated
with distal extensor tenotomy (proximal to the distal insertion of the oblique retinacular ligaments)
and lateral band dorsalization. Average follow-up time was 33 months. PIP joint extension deficit
improved from 60 degrees preoperatively to 7 degrees postoperatively. Average active flexion at the
DIP joint was 75 degrees after surgery; 92% of patients had excellent or good results long-term.
Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and boutonniere
deformities: Long-term results. J Hand Surg Am. 1993;18:984–989.
Nineteen fingers with rheumatoid boutonniere deformity were treated with central slip reconstruction. The
results were unpredictable, with only modest improvement in PIP extension, which deteriorated over time.
CHAPTER 41
Metacarpophalangeal Arthroplasty
INDICATIONS
• Metacarpophalangeal (MCP) arthroplasty is indicated in patients with chronic pain,
deformity, or functional loss. Arthrodesis is poorly tolerated at the MCP level be-
cause the arc of motion starts at this joint. Implant arthroplasty is the preferred
surgical treatment for arthritic MCP joints.
• There are two common implant options for MCP joints: silicone and pyrocarbon.
Silicone implants act as spacers. They are hinged and rely on the formation of a
capsule around the implant for stability. Pyrocarbon implants are unconstrained (two
parts) and must be supported by normal bone stock and intact surrounding soft tis-
sues. Both types of implants provide excellent pain relief, maintain joint motion,
improve hand appearance, and have high levels of patient satisfaction.
• Silicone implants are indicated for rheumatoid arthritis (RA) patients because the
construct provides stability. Pyrocarbon should not be used in RA patients because
ligament laxity will lead to subluxation of the joints.
• Pyrocarbon arthroplasty is suitable for patients with posttraumatic arthritis or osteoar-
thritis (OA). Strong ligaments provide structural support for this unconstrained implant.
• The MCP joint is examined for edema, deformity, and areas of tenderness. Active
and passive range of motion (ROM) is measured. The joint is stressed in radial and
ulnar deviation to assess collateral ligament stability. The skin is evaluated for integ-
rity and healing potential.
In patients with inflammatory arthritis:
• Ulnar subluxation of the extensor tendons is noted when present (Fig. 41.1).
• Overall finger posture (including presence of swan-neck or boutonniere deformity)
and the condition of surrounding joints are evaluated.
• Volar subluxation of the proximal phalanx on the metacarpal head and ulnar drift of
FIGURE 41.1
the fingers is common in RA patients. If this deformity is passively correctable, ex-
tensor tendon centralization with cross-intrinsic transfer is considered. Arthroplasty
is indicated when passive correction is not possible because the supporting liga-
ment and tendon structures are contracted, which makes soft-tissue releases unten-
able to maintain joint alignment. Joint resection provides relative lengthening of
these contracted structures, thus makes realignment of the digit more predictable
(Fig. 41.2A–B).
• The wrist is carefully evaluated; deformity at the radiocarpal or distal radioulnar joint
(DRUJ) affects distal joints and must be treated first, even if the patient is asymptom-
atic at the proximal joint. Radial deviation at the radiocarpal joint leads to compensa-
tory ulnar drift at the MCP joints. DRUJ instability can result in attritional extensor
tendon ruptures. Failure to correct wrist instability and deformity affects outcomes in
MCP arthroplasty.
IMAGING
• Three views (posteroanterior [PA], oblique, and lateral) of radiographs of the hand are
obtained to evaluate articular congruity and bone stock (Fig. 41.3A–C).
• Implant size can be estimated using measurement tools and templates.
SURGICAL ANATOMY
• The MCP is an asymmetric condylar joint; the ovoid articular surface of the metacar-
pal fits into an elliptical cavity at the base of the proximal phalanx. Motion is permit-
ted in two planes: flexion-extension and radio-ulnar deviation.
319
320 CHAPTER 41 Metacarpophalangeal Arthroplasty
FIGURE 41.2
FIGURE 41.3
• The joint is stabilized by the volar plate, collateral ligaments, and extensor mecha-
nism. The sagittal bands centralize the extensor tendon over the MCP joint and
prevent bowstringing during hyperextension (Fig. 41.4).
• The intrinsic tendons insert onto the lateral bands, which are volar to the axis of
rotation of the MCP joint and act as flexors (Fig. 41.5).
• The metacarpal head is sloped ulnarly and volarly. In RA patients, synovitis attenu-
ates the supporting ligaments and the proximal phalanges slide ulnarly and volarly
on the metacarpal heads. The extensor tendons subluxate into the intermetacarpal
space and contribute to ulnar drift of the digits.
• Chronic MCP subluxation and ulnar drift leads to fibrosis of the intrinsic muscles.
When present, this requires release and cross-intrinsic transfer at the time of MCP
arthroplasty.
• In scleroderma patients, sclerosis of the skin, collateral ligaments, joint capsules,
and tendons results in attenuation of the central slip and volar displacement of
the lateral bands. Flexion at the proximal interphalangeal (PIP) joint leads to com-
pensatory hyperextension at the MCP joint, resulting in a boutonniere deformity
(Fig. 41.6A–C).
Sagittal band Extensor Metacarpophalangeal

joint Central slip
Sagittal band
Dorsal and volar
interosseous
Lumbrical Proximal
muscle interphalangeal
Lateral band joint
Deep transverse
metacarpal ligament
FIGURE 41.5
Proximal Collateral Accessory Volar plate Metacarpal

phalanx ligament collateral
ligament
FIGURE 41.4
Dorsal PIP
skin ulcerations
PIP flexion contracture
with attenuated central
slip and lateral band P1
subluxation MCP joint
hyperextension
P2
P3
Metacarpal
Calcinosis
Calcinosis
FIGURE 41.6

hand table.
• The operation is performed under tourniquet control.
• A rolled towel is placed in the palm for support.
• Implants, implant-sizers, an oscillating saw, and intraoperative fluoroscopy are
required.
EXPOSURES
• A dorsal longitudinal or lazy-S incision centered at the joint is used to access a
single MCP (Fig. 41.7).
• Multiple arthroplasties are performed through a single, dorsal, transverse incision,
which provides ease of access through the same single incision when revision ar-
throplasty is needed in the future. Care is taken to preserve the dorsal veins to re-
duce postoperative swelling (Fig. 41.8).
Silicone Metacarpophalangeal Arthroplasty

INDICATIONS
Indications include:
• Painful destruction or subluxation of the MCP joint that cannot be passively corrected
• RA patients with greater than 15 degrees of ulnar drift and/or greater than 20 degrees
STEP 1 PEARLS of extensor lag
• Patients with inflammatory arthritis have poor • Loss of function because of joint deformity
skin quality and a high rate of wound healing • Low-demand patients with OA
complications. Tissue must be handled with
great care; do not crush the skin with forceps. Contraindications
• The distal radial collateral ligament insertion Contraindications include:
onto the proximal phalanx is preserved. Once
the implant is in place, the radial collateral lig- • Poor wound healing ability, inadequate skin coverage, or active infection at the MCP
ament is repaired to resist lateral force during joint
pinch and reduce recurrence of ulnar drift. • Excessive erosion or fatty replacement of the bone with poor ability to support an
• Care must be taken to avoid injury to volar implant
structures during the osteotomy.
• If the joint remains tight or the finger cannot
be easily reduced into neutral alignment, ulnar PROCEDURE
intrinsic release is performed. If soft-tissue
tightness persists, release the volar plate or Step 1: Joint Exposure and Transverse Osteotomy
resect additional metacarpal bone. We prefer • An extended, transverse incision is made over the dorsal MCP joints. Dissection is
to resect additional metacarpal bone, which is carried down to the extensor tendons using longitudinal spreading to protect the
easier.
dorsal veins and sensory nerves.
FIGURE 41.7
Incision for MCP arthroplasty Incision on the radial

sagittal band
Tendon
Tendon
FIGURE 41.9
FIGURE 41.8
A B C
Osteotomy line is just distal to the

collateral ligament insertion
FIGURE 41.10
• The radial sagittal band is incised at the border of the extensor tendon and the ten-
don is retracted laterally. The joint capsule is incised longitudinally and a synovec-
tomy is performed (Fig. 41.9).
• The collateral ligament is released from its proximal attachment on the metacarpal
head.
• The MCP joint is flexed and an oscillating saw is used to resect the metacarpal head
just distal to the collateral ligament insertion (Fig. 41.10A–C). The MCP joint should
then easily reduce into neutral alignment (Fig. 41.11).
Step 2: Reaming the Medullary Canal FIGURE 41.11
• An awl is used to prepare the medullary canals of the proximal phalanx and meta-
carpal. The medullary canals of the proximal phalanx are prepared first for the index,
middle, and small finger. For the ring finger, the order is reversed because of the STEP 2 PEARLS
narrow canal of the fourth metacarpal; the metacarpal is broached first and the im-
If severe deformity of the proximal phalanx exists,
plant size determined before preparing the proximal phalanx to avoid over-reaming. fluoroscopy can be used to locate the medullary
• On the proximal phalanx, the starting point of the awl is at the junction of the dorsal canal and confirm alignment of the awl.
and middle third of the articular surface. The awl is inserted with a gentle twisting
motion. The smallest distal broach is then inserted straight into the medullary canal
STEP 2 PITFALLS
in the path created by the awl. Orientation of the broach must be maintained during
insertion and withdrawal; typically, the numbered side of the broach is placed paral- Insert the broaches along the central axis of the
phalanx; breaking the dorsal or volar cortex can
lel with the dorsal cortex. If the broach is twisted, it may asymmetrically enlarge the
destabilize the implant.
medullary cavity and create a poor fit with the implant stem. The broach is inserted
1/3
FIGURE 41.12
to its full depth to create enough space for the implant stem. If the implant stem
pops out of the medullary canal, the broached space is too shallow. Broaches are
increased in size until the desired implant size is reached (Fig. 41.12A–B).
• The process is repeated for the metacarpal. With the articular surface removed, the
awl inserts easily into the medullary canal. Broaches are sequentially inserted to their
full depth until the implant size is reached. The largest implant that the medullary
canal will accept is selected for a snug fit (Fig. 41.13A–B).
Step 3: Implant Insertion and Radial Collateral Ligament Repair

• Before implant insertion, the metacarpal is prepared for radial collateral ligament re-
pair. Two 0.035-in (0.89-mm) Kirschner wires (K-wires) are drilled through the dorsal
radial metacarpal cortex at the distal end of the cut bone. A braided 3-0 permanent
A suture is passed through these holes and left untied. This suture is used later to reat-
tach the radial collateral ligament to the metacarpal (Fig. 41.14A–C).
• An implant sizer is selected based on the largest broach size used in Step 2. The sizer
is oriented so that the cavity of the barrel faces volarly (Fig. 41.15). The proximal stem
is inserted first into the metacarpal, then the distal stem into the proximal phalanx.
The stems should fit easily into the broached medullary canals. The transverse barrel
should seat against both osteotomy sites but should not be compressed. There
should be no bony impingement with flexion and extension. If the fit is adequate, the
sizer is removed and the final implant is opened. Correct orientation is verified, and
the implant is inserted in the same sequence using two clean, smooth forceps and a
no-touch technique (Fig. 41.16).
• The joint is held in extension while the soft tissues are repaired. The radial col-
lateral ligament is imbricated using the suture previously placed through the
metacarpal drill holes. The joint capsule is repaired using a braided 3-0 perma-
nent suture (Fig. 41.17A–E). Tight repair of the radial collateral ligament and joint
capsule with the finger extended limits the flexion arc by 10 to 20 degrees but
stabilizes the joint.
Step 4: Centralization of the Extensor Tendons

• The extensor tendon is centralized to reduce recurrence of ulnar drift. In longstand-
ing deformity, the ulnar sagittal band may require release.
• The radial aspect of the extensor hood is imbricated to the radial sagittal band
B
(Fig. 41.18A–D). The MCP is passively flexed and extended to ensure that the
FIGURE 41.13 extensor tendon remains centralized through the arc of motion.
STEP 3 PEARLS
• If the implant stem does not fit into the medul-
lary canals, the implant may be too large or
the broached canal too short. More bone may
need to be resected from the metacarpal.
• If the radial collateral ligament is severely at-
tenuated, a portion of the volar plate is used to
reconstruct the ligament. A distally based flap
from the medial half of the volar plate is raised
and imbricated through the drill holes at the
dorsoradial cortex of the cut end of the meta-
carpal bone.
A B STEP 3 PITFALLS
It is imperative to confirm the orientation of the
implant. The flexion crease of the implant must
be volar (down) to allow for flexion; postoperative
correction is not possible without reoperation.
FIGURE 41.16
A B
Slight radial deviation

of proximal phalanx
after radial collateral
ligament repair
Radial Radial
collateral collateral
ligament ligament
Silicone
arthroplasy
implant
C D E
FIGURE 41.17
Step 5: Incision Closure

• The tourniquet is released and hemostasis is achieved.
• The skin is closed with a few deep absorbable sutures and several horizontal
mattress sutures to gently evert the skin. The patient is splinted with the MCPs
extended.
Pyrocarbon Metacarpophalangeal Arthroplasty

INDICATIONS
• MCPJ pain because of posttraumatic arthritis or osteoarthritis with good soft tissue
support and bone stock.
• Typically, only one joint is affected in OA or posttraumatic conditions.
Contraindications
• Poor wound healing capacity, inadequate skin coverage, or active infection at the
MCP joint
• Dislocated joints with ligamentous shortening or advanced cortical bone loss
• Joints with poor soft tissue support and unreconstructible ligaments
• Inflammatory arthritis
STEP 1 PEARLS
If the radial sagittal band is incised to access the
PROCEDURE
joint, it should be repaired at the end of the case to
centralize the extensor tendon.
Step 1: Joint Exposure
• The skin is incised and dissection is carried down to the level of the extensor tendon.
• Depending on surgeon preference, the radial sagittal band may be released,
or the extensor tendon may be longitudinally split to expose the joint capsule
(Fig. 41.19).
• The capsule is incised longitudinally and synovium and osteophytes are debrided
with a rongeur (Fig. 41.20).
Ulnarly dislocated
extensor tendon
Extensor tendons centralized B Inserted silicone

over the MCP joints arthroplasty implant
Radial sagittal band
Silicone implant
Extensor
tendon
Radial
sagittal
band
Centralization
of dislocated D
C
extensor tendon
FIGURE 41.18

Dorsal third of
metacarpal head Starter awl
Metacarpal
Proximal phalanx
STEP 2 PEARLS
• Identify the borders of the metacarpal bone
to locate the correct entry point for the
starter awl.
• About 2 to 4 mm of bone is removed from the
metacarpal head.
STEP 2 PITFALLS B
• Ensure that the starter awl is inserted parallel FIGURE 41.21

to the axis of the metacarpal. Imprecise posi-
tioning of the awl will cause the osteotomy an-
gle to be off once the cutting guide is placed. Step 2: Metacarpal Osteotomy
• The attachment site of collateral ligaments • The MCP is flexed and the starter awl is inserted into the metacarpal. The entry point
should be verified and protected during the
is at the junction of the dorsal and middle third of the bone and is slightly ulnar to the
osteotomy.
midline (Fig. 41.21A–B). The awl must be inserted parallel to axis of the metacarpal.
• Advance the awl into the midshaft of the metacarpal (see Fig. 41.22A–B).
STEP 4 PEARLS
• The starter awl is removed and the alignment awl/cutting guide is placed into the
• Broaching the medullary canal is difficult in medullary canal. The osteotomy site is just distal to the collateral ligament origin. The
patients with sclerotic bone. If needed, a side-
osteotomy is performed at 27.5-degree volar tilt (see Fig. 41.23A). The dorsal sub-
cutting bur can be used to slightly enlarge the
canal to make room for the broach. chondral bone is scored with the cutting guide in place – the guide and alignment awl
• After inserting the implant, there should be are removed, and the remainder of the cut is made freehand (see Fig. 41.23B).
smooth, passive motion from 0 to 90 degrees.
• The final implants are slightly bigger than the Step 3: Proximal Phalangeal Osteotomy
same-number sizers to achieve a press-fit into
• The starter awl is inserted at the base of the proximal phalanx (Fig. 41.24A–B).
the medullary canal.
• Pyrocarbon implants do not need cement. • The alignment awl/cutting guide is inserted into the proximal phalanx. A 1 to 2 mm
Cementing will make subsequent removal section of bone is removed at a 5-degree dorsal angle with assistance from the cut-
of the implant almost impossible. ting guide (Fig. 41.25).
Step 4: Insertion of the Implants

STEP 4 PITFALLS
• The metacarpal and proximally phalanges are carefully broached to create room for
Pyrocarbon implants are fragile; use the plastic the implant stems (Fig. 41.26A–B).
impactor supplied by the manufacturer to press-fit
• Implant sizers are placed and checked for fit with fluoroscopic guidance. The largest
the stem into the medullary canal.
appropriate implant size is chosen for stability.
Starter should be
parallel to the axis
of the metacarpal bone
One-half to two-thirds
of the length of the
metacarpal bone
Metacarpal
A B
FIGURE 41.22
Proximal
osteotomy
guide
27.5°
Partial osteotomy site
Alignment awl
A B
FIGURE 41.23
• The final implants are inserted and gently press-fit using impactors (Fig. 41.27A–B).
• Final implant position is verified with fluoroscopy (Fig. 41.28A–C).

• The dorsal capsule is repaired over the prosthesis; it can be trimmed as needed for
a snug closure.
• If released, the radial sagittal band is repaired with 3-0 nonabsorbable suture.
• The tourniquet is deflated and hemostasis is achieved.
One-half to
two-thirds of
the length of
the proximal
phalanx
A B
FIGURE 41.24
Distal osteotomy guide
Electrical saw
FIGURE 41.25
B
FIGURE 41.26
Implant
A B
FIGURE 41.27
A B C
FIGURE 41.28
• The skin is closed using 4-0 nonabsorbable sutures.

• The MCP joints are splinted in full extension. The interphalangeal joints can be free.

• The sutures are removed 10 to 14 days postoperatively.
• At the first postoperative visit, a short arm dynamic extension splint is applied with
20 degrees of wrist extension and MCPs in full extension. The IP joints are left free.
Flexion and extension exercises are initiated. Modifications to splinting position are
frequently required depending on the severity of the preoperative deformity and the
patient’s progress after surgery.
• At 6 weeks, patients are gradually weaned from the splint and strengthening is
initiated.
• A nighttime static splint is worn for 2 months.

• Reduced pain and improved appearance of the hand is expected. Normal range of
motion in the MCP joint and grip strength cannot be restored. Patients will typically
gain about 30 to 40 degrees of active motion.
EVIDENCE
Chung KC, Kotsis SV, Burns PB, et al. Seven-year outcomes of the silicone arthroplasty in rheumatoid
arthritis prospective cohort study. Arthritis Care Res (Hoboken). 2017;69(7):973–981.
RA patients with severe MCP joint deformity were divided into two treatment cohorts – (1) silicone
metacarpophalangeal joint arthroplasty (SPMA) plus medical management, and (2) medical manage-
ment alone. Patients were followed over 7 years. Objective measurements included grip and pinch
strength, arc of motion, ulnar drift, and extension lag. Patient-reported outcomes included the Michi-
gan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Patients
were highly satisfied after SMPA. Extensor lag and ulnar drift improved after SMPA, and grip and
pinch strength were stable after surgery. The authors concluded that the benefits of SMPA are main-
tained for at least 7 years. Medically managed patients remained stable in their hand function over
the 7-year study duration.
Chung KC, Burns PB, Wilgis EF, et al. A multicenter clinical trial in rheumatoid arthritis comparing silicone
metacarpophalangeal joint arthroplasty with medical treatment. J Hand Surg Am. 2009;34:815–823.
RA patients with MCP joint deformities were divided into two cohorts: surgery-plus-medical therapy or
medical therapy alone. Outcomes at 1-year follow-up showed significant improvement in hand function
after silicone MP arthroplasty. Surgical patients had significant improvement in appearance, activities of
daily living, and satisfaction. Surgical cases also had reduced ulnar drift and extensor lag after recon-
struction. The change in values for grip strength and pinch strength were not significant.
Chung KC, Kowalski CP, Kim HM, Kazmers IS. Patient outcomes following Swanson Silastic metacar-
pophalangeal joint arthroplasty in the rheumatoid hand: a systematic overview. J Rheumatol.
2000;27:1395–1402.
This systematic review examined 20 articles with comparative data for silicone MP arthroplasty. The
authors found that silicone arthroplasty corrected ulnar drift and improved the appearance of the
rheumatoid hand. ROM at the MCP joint improved modestly. Postoperative arc of motion favored
extension.
Parker W, Moran SL, Hormel KB, Rizzo M, Beckenbaugh RD. Nonrheumatoid metacarpophalangeal
joint arthritis. Unconstrained pyrolytic carbon implants: indications, technique, and outcomes. Hand
Clin. 2006;22:183–193.
Nineteen patients with 21 osteoarthritic MCP joints were treated with pyrocarbon arthroplasty. Average
follow-up time was 14 months. Flexion increased by 13% and extension lag decreased by 28%. Grip
strength improved by about 40%. The visual analog scale of pain (range 0–100) changed from 73 to
8.5. The authors conclude that pyrocarbon arthroplasty is a reasonable option to treat MCP joint
osteoarthritis (Level IV evidence).
Parker WL, Rizzo M, Moran SL, Hormel KB, Beckenbaugh RD. Preliminary results of nonconstrained
pyrolytic carbon arthroplasty for metacarpophalangeal joint arthritis. J Hand Surg Am. 2007;32:
1496-1505.
This study reviews early outcomes of 142 arthritic MCP joints treated with pyrolytic carbon implants.
Patients were followed for an average of 17 months. The pain analog scale (range 0–100) in OA and
RA patients decreased from 73.0 to 8.5 and from 43.1 to 8.9, respectively. Functionality and arc of
motion improved in both OA and RA patients. On postoperative radiographs, all OA joints were
stable. 10.5% of RA joints showed axial subsidence and 16.4% of RA joints showed periprosthetic
erosions (Level IV evidence).
CHAPTER 42
Proximal Interphalangeal Arthroplasty
INDICATIONS
• Implant arthroplasty is indicated for patients with severe pain, deformity, and loss
of motion in the proximal interphalangeal (PIP) joint who have failed nonoperative
treatment (splinting, antiinflammatory medication, steroid injection, and/or hand
therapy).
• Silicone implants may be used in patients with inflammatory arthritis, posttraumatic
arthritis, or osteoarthritis (OA).
• Silicone implants act as spacers after joint resection. They are supported by the
surrounding ligamentous structures and become encapsulated by fibrous tissue
shortly after insertion. The result is reduced pain and maintained range of motion
(ROM).
• Silicone is biologically inert and has many properties that are ideal for small joint
reconstruction. Unlike rigid implants, silicone implants are softer than bone and do
not cause bony resorption.
Contraindications
• PIP joint arthroplasty is contraindicated when there is active infection, ligamentous
instability, severe angular deformity of the bone, or significant periarticular bone loss.
• Implant arthroplasty of the index finger PIP joint can be considered but because of
lateral stress on the joint during pinch, arthrodesis may be preferred in active pa-
tients who require joint rigidity during pinch.
• The fingers are inspected for collinearity and symmetry. Deviation of the finger at the
PIP joint may indicate asymmetric articular compression, ligamentous damage, or
periarticular bone loss (Fig. 42.1).
• Active ROM is assessed (Fig. 42.2 A–C). Implant arthroplasty is effective for treating
pain, which is the major indication. Patients must understand that motion may not
change or may decrease, but pain should improve. Patients with 60 degrees or more
of active PIP motion arc should be discouraged from undergoing implant arthro-
plasty if the pain is tolerable.
FIGURE 42.1
334
FIGURE 42.2
• Passive ROM is evaluated, and the PIP joint is manually stressed in all directions.
The implant relies on the ligamentous support of the PIP joint. If a joint is extremely
unstable, fusion is a more predictable option.
IMAGING
• Standard three-view x-rays are required (Fig. 42.3). The articular surfaces of the
proximal and middle phalanges are examined. Implant arthroplasty is indicated if
there is articular surface damage and joint space loss.
• Bone stock and quality must be sufficient to support an implant. Some patients are
better served with a fusion if the bone quality is poor.
Surgical Anatomy
• The PIP joint is a gliding hinge joint composed of the bicondylar head of the proximal
phalanx and the concave base of the middle phalanx.
• The volar plate, collateral ligaments, and extensor mechanism stabilize the joint on
all sides (Fig. 42.4).
336 CHAPTER 42 Proximal Interphalangeal Arthroplasty
FIGURE 42.3
Proper Central
collateral tendon
ligament
Middle Proximal
phalanx phalanx
Volar plate

FIGURE 42.4
• The volar approach places the digital neurovascular bundles and flexor tendons at
risk. These must be protected during elevation of the skin flaps.
• The A3 pulley is located directly over the proximal interphalangeal joint and must be
divided for joint exposure. The A2 pulley and A4 pulley, which are proximal and distal,
are preserved.
• Shotgun hyperextension of the PIP joint requires release and elevation of the
volar plate and partial release of the collateral ligaments. The typical shotgun ap-
proach is not needed. The volar plate should be detached proximally to expose
the head of the proximal phalanx. Access to the PIP joint is necessary to insert
the implant after sawing just proximal to the head of the proximal phalanx and
then removing it.

• The patient is positioned supine with the arm supported on a hand table. An upper
arm tourniquet is placed.
• The procedure is performed under general or regional anesthesia.
• Preoperative antibiotics are administered.
• Intraoperative fluoroscopy, a narrow oscillating saw, an arthroplasty set with an awl
and broaches, implant sizers, and multiple sizes of final implants must be available.
EXPOSURES
• Dorsal, lateral, and volar approaches to the PIP joint are described in the literature.
Studies have shown favorable results with the volar approach, and this is our preferred
FIGURE 42.5
FIGURE 42.6
technique. It is technically more challenging but achieves better motion and less ex-
tensor lag postoperatively.
STEP 1 PEARLS
• A Bruner incision is designed from the distal interphalangeal (DIP) flexion crease to
the metacarpophalangeal (MCP) flexion crease (Fig. 42.5). Preserve the A2 pulley proximally and the A4 pulley
distally to prevent tendon bowstringing.
• The skin is incised, and the flap is elevated at the level of the flexor tendon sheath
(Fig. 42.6). The neurovascular bundles must be identified and protected.
STEP 2 PEARLS
PROCEDURE Retract the flexor tendons to the radial side while
releasing the ulnar collateral ligament and then to the
Step 1: Release of the Flexor Tendons ulnar side to release the radial collateral ligament.
• The A3 pulley is incised longitudinally along the lateral aspect of the tendon sheath The flexor tendons must always be protected.
(Fig. 42.7).
• The flexor tendons are retracted, and the volar plate is exposed. STEP 2 PITFALLS
Do not cut transversely through the collateral
Step 2: Exposure of the PIP Joint ligament to preserve joint stability; the ligament
• The volar plate is incised transversely proximal to the PIP joint. The incision is curved is released from its attachments to the proximal
along the lateral margins to separate the volar plate from the accessory collateral phalanx. In most instances it is only partially
released and does not require repair.
ligaments. The volar plate is reflected and retracted distally to expose the joint
(Fig. 42.8).
Flexor tendons A3 pulley (in forceps)
Volar plate
Flexor tendons

• A 15-blade is carefully introduced into the joint space, then curved along the lateral
aspect of the proximal phalanx on each side. The maneuver releases the portion of
the collateral ligament that is closest to the joint but preserves the more proximal
attachments.
• The PIP joint is not hyperextended. Use a narrow saw set at a low speed to make
a cut proximal to the head of the proximal phalanx (Fig. 42.9). Be careful not to cut
the extensor tendon. A freer is used to break off the head of the proximal phalanx
and the bone is detached from the collateral ligaments. There will often be osteo-
phytes attaching to the soft tissue, which must be removed to avoid impinging the
implant.
• There is no need for shotgun or hyperextension of the PIP joint because the removal
of the head gives access to the PIP joint. The middle phalanx often has a bone shelf
FIGURE 42.9
dorsally attaching to the extensor tendon that must be removed. Otherwise, it will
block motion.
STEP 3 PEARLS
• The bone cut must be perpendicular to the Step 3: Remove the Articular Surface From the Proximal Phalanx
shaft of the phalanx. An asymmetric cut A sagittal saw is used to remove 2 to 3 mm of the articular surface and bone of the
causes deviation of the finger. proximal phalanx. The amount of bone removed should equal the diameter of the barrel
• Maintain the proximal attachments of the col- of the silicone implant that will fill the space. Inadequate removal of bone will make
lateral ligaments during the bone cut.
• Residual dorsal osteophytes are removed with seating of the implant difficult and will constrict the implant, thus limiting motion.
a rongeur to ensure a completely clear joint
space (Fig. 42.10). Step 4: Broaching the Medullary Canals
• An awl is centered on the articular surface of the middle phalanx. It is inserted with
a gentle twisting motion. Be sure to hyperextend the joint to gain central access to
the sclerotic middle phalanx.
• The distal broach from the arthroplasty set is placed within the path created by the
awl. It is inserted and withdrawn until it can be fully seated. Broaches are increased
in size until the desired implant size is reached. The broach creates a space for the
implant stem and consolidates the medullary bone (Fig. 42.11).
• For the PIP joint, 00 or 0 implants are suitable and, rarely, a #1 implant. The medul-
lary cavity must be broached deeply to fit the stem securely; otherwise, the implant
may dislocate with motion. The smallest broach is a #2, which should be sufficient
to fit the small size implants.
• Attention is then turned to preparing the proximal phalanx. The awl is inserted into
FIGURE 42.10
the medullary canal of the proximal phalanx. It should insert with ease because the
articular surface has been removed and the medullary cavity should be visible.
STEP 4 PEARLS • The proximal broaches are then inserted. Typically, a #2 broach can fit into the proxi-
• There are separate broaches for the proximal mal phalanx medullary cavity, which can seat the #1 or smaller implant (Fig. 42.12).
and middle phalanges. The sizes match the
proximal and distal stems of the implant. Step 5: Sizing and Implant Placement
• The broaches have a specific orientation and
must be inserted without any twisting. The • The distal stem of the sizer is inserted into the middle phalanx, and then the proximal
numbered side of the broach is typically in- stem is placed within the proximal phalanx (Fig. 42.13). The stems should fit easily
serted parallel to the dorsal cortex of the bone. into the medullary canals.
The broach is inserted straight and withdrawn. • The finger is taken through a full arc of motion. The implant should not compress or
Twisting may enlarge or distort the medullary
buckle.
cavity asymmetrically.
STEP 4 PITFALLS
• The broach must be inserted to its full depth.
Failure to create a deep enough medullary
cavity will cause the implant to dislodge during
postoperative rehabilitation.
• Ensure that the broach is inserted in the center
of the bone. Do not penetrate the cortex with
the broach; this causes implant malposition.

FIGURE 42.13
FIGURE 42.14
Implant A3 pulley ( in forceps)
FIGURE 42.16
FIGURE 42.15
• Once satisfied with the fit, the trial implant is removed and the final implant is opened. STEP 5 PEARLS
• The final implant is placed with a no-touch technique using two clean, smooth for- Sedation can be lightened to enable the patient to
ceps. The implant is oriented so that the cavity of the silicone barrel is open to the perform active motion with the trial implant to test
volar surface (Figs. 42.14 and 42.15). the fit.

• If the collateral ligaments were fully released, they are repaired with 4-0 absorbable
If the implant buckles or compresses during
sutures. movement, the implant may be too large, the
• The volar plate is replaced over the volar joint and secured with 4-0 absorbable broached canal may not be deep enough, or more
sutures. bone may need to be removed from the proximal
• The A3 pulley is repaired (Fig. 42.16). phalanx.
• The skin is closed with 4-0 nylon sutures (Fig. 42.17), and the patient is placed in a
dorsal blocking splint with the PIP in slight flexion.

• A supervised active ROM therapy protocol is initiated 3 to 5 days after surgery.
• Sutures are removed 2 weeks postoperatively.
• After 6 weeks, patients can increase their activity.
• Photos are shown of a patient 6 months after silicone PIP arthroplasty of the small
finger with excellent results (Fig. 42.18A–C).
FIGURE 42.17
FIGURE 42.18
• Patients can expect stable to slightly improved ROM, increased grip and pinch
strength, and less pain postoperatively. Most patients are highly satisfied (84%) and
would have the surgery again (91%).
• There is an 11% to 15% risk of implant failure at 5 years. Up to 20% of patient re-
quire revision surgery.
Revision Pip Joint Arthroplasty

INDICATIONS
• Revision PIP joint arthroplasty is indicated for symptomatic implant fracture, disloca-
tion, recurrent pain, or infection.
• Challenges during revision arthroplasty include excessive scar formation, distorted
anatomy, and soft tissue and bony deficiency. We prefer to approach a revision PIP FIGURE 42.19
arthroplasty through a dorsal incision to avoid the scarred tissue planes volarly.
Surgical Anatomy
The dorsal aspect of the PIP joint is stabilized by the central slip of the extensor appa-
ratus. The lateral bands have attachments to the central slip, then continue distally to
the terminal tendon. The extensor tendon must be split longitudinally to expose the joint.
EXPOSURES
• A longitudinal or lazy-S incision is designed over the dorsal surface of the PIP joint
(Fig. 42.19).
• The skin is incised and flaps are raised at the level of the extensor tendon (Fig. 42.20).
FIGURE 42.20
PROCEDURE
• The extensor tendon is split longitudinally and elevated to expose the PIP joint im- Rather than splitting the extensor apparatus
plant (Fig. 42.21). longitudinally, the joint can also be exposed via a
Chamay approach (Fig. 42.22A–C). This approach
• The central slip is mobilized radially and ulnarly. preserves the central slip and the attachments of
the lateral bands to the central slip. A distally based
Step 2 triangular flap is designed with the apex extending
• The finger is flexed 90 degrees to access the joint and the previous implant is re- proximally. The extensor apparatus is repaired at
moved using a freer. the end of the procedure. Although this approach
provides wide exposure, we do not use it because
• Osteophytes are removed with a rongeur. of concern for stretching out of the extensor
• If revision arthroplasty is being performed for implant dislocation, adjustments are tendon repair.
made to prevent recurrent dislocation. Options include bony shortening, deepening
of the broached canals, or changing of the implant size.
FIGURE 42.21
Reflected extensor
tendon
Proximal
interphalangeal
joint
Central extensor
tendon
Lateral band
A B C
FIGURE 42.22
Step 3
• A trial implant is placed within the medullary canals in the same process as was
previously described for primary arthroplasty.
• The finger is taken through a full arc of motion to ensure a proper fit.
• The final implant is selected and inserted using clean instruments and a no-touch
technique. Ensure that the silicone barrel is open to the volar surface to permit
flexion (Fig. 42.23).
Step 4
• The extensor tendon is closed with 3-0 braided nonabsorbable suture (Fig. 42.24).
• The skin is closed with 4-0 nonabsorbable suture.

FIGURE 42.25
• The patient is placed in a splint with 30 degrees of MCP flexion and 10 degrees of
flexion at the PIP joint.

• Patients begin a supervised early active motion protocol 3 to 5 days after surgery.
• Sutures are removed 2 weeks postoperatively.
• Photos are shown of a patient 6 weeks after revision silicone PIP arthroplasty of the
left middle finger with excellent results (Fig. 42.25).
• Full PIP extension is not expected after surgery; most patients have 10 to 15 degrees
of extension lag. The goal is to achieve maximal flexion.
See Video 42.1
EVIDENCE
Naghshineh N, Goyal K, Giugale JM, et al. Proximal interphalangeal joint silicone arthroplasty for os-
teoarthritis: Midterm outcomes. Hand (NY). 2019;14(5):664–668.
The authors reviewed 45 silicone PIP joint arthroplasties for nonrheumatic arthritis with a mean follow-
up of 42 months. They measured ROM, grip and pinch strength, Disability of the Arm, Shoulder, and
Hand (DASH) scores, and patient satisfaction with respect to pain, deformity, function, and strength.
ROM did not change after surgery. Postoperative grip and pinch strength improved significantly. Pain
scores improved from 7.4 to 1.9 on a visual analog scale from 1 to 10, and patient satisfaction was
high (84%). The overall complication rate was 37%, with 20% of patients requiring revision surgery.
The authors concluded that silicone arthroplasty is a good option for osteoarthritis of the PIP joint.
Lans J, Notermans BJW, Germawi L, Lee H, Jupiter JB, Chen NC. Factors associated with reoperation
after silicone proximal interphalangeal joint arthroplasty. Hand (NY). 2019:1558944719864453.
doi:10.1177/1558944719864453. Epub ahead of print.
This study retrospectively reviews all adult patients who underwent silicone PIP arthroplasty over
15 years. It includes 91 patients who underwent 114 arthroplasties for inflammatory, posttraumatic,
or degenerative arthritis. The overall reoperation rate was 14%. Non-Caucasian race, smoking, and
posttraumatic arthritis were identified as risk factors for reoperation. The 1-, 5-, and 10-year implant
survival rates were 87%, 85%, and 85%, respectively.
Yamamoto M, Malay S, Fujihara Y, Zhong L, Chung KC. A systematic review of different implants and ap-
proaches for proximal interphalangeal joint arthroplasty. Plast Reconstr Surg. 2017;139(5):1139e-1151e.
This is a systematic review of 40 studies reporting on the outcomes of implant arthroplasty for proximal
interphalangeal joint osteoarthritis. The mean postoperative range of motion was 58 degrees for sili-
cone arthroplasty through a volar approach and 51 degrees for surface replacement arthroplasty
through a dorsal approach. Mean gain in ROM was 17 degrees and 8 degrees, respectively. Postop-
erative extensor lag was 5 degrees with the volar approach and 14 degrees with the dorsal approach.
The revision rate was 6% for silicone arthroplasty and 18% for surface replacement arthroplasty at
a mean follow-up of 41.2 and 51 months, respectively. The authors conclude that silicone implant
arthroplasty using a volar approach results in the best range of motion, less extensor lag, and fewer
complications compared with other implant designs and surgical approaches.
CHAPTER 43
Distal Interphalangeal Joint Arthrodesis

This chapter includes the following video that has been prepared by the authors:
Video 43.1 – Distal Interphalangeal Joint Arthrodesis.
KEY CONCEPTS
• Distal interphalangeal joint (DIP) arthrodesis is indicated in patients with intractable
pain or instability after failure of nonoperative management. Many patients with DIP
arthritis present with mucous cysts. Cyst excision may correct a nail deformity, skin
changes, or a draining wound but will not improve joint pain. Fusion is a reliable op-
tion when pain causes functional limitations.
• The DIP joint is most functional in a straight or slightly flexed position. Five degrees
or less of flexion is generally appropriate for fusion. It is important, however, to dis-
cuss this with the patient preoperatively. Additional flexion may be advantageous for
certain activities.
• The key to a successful fusion is opposition of cancellous bone at the fusion site
with minimal motion to promote fusion.
• Intraoperative fluoroscopy is needed to confirm compression of bone and appropri-
ate placement of pins or hardware.
• The bone surfaces should be contoured to maximize cancellous bone opposition in
reduction before fixation.
• Small plates, screws, or percutaneous pins can be used for fixation. We prefer using
Kirschner wires (K-wires) for the ease of fusion and no retained hardware.
• K-wires are driven antegrade from the DIP joint through the distal phalanx. Position-
ing is confirmed on fluoroscopy. The joint is reduced, and then the wire is driven
retrograde into the middle phalanx.
• The patient is placed in a DIP joint splint that permits hand and proximal interpha-
langeal (PIP) joint motion. K-wires are left in place for about 6 weeks to facilitate
bony healing. A longer period of fixation may be necessary for patients with poor
bone stock or slow healing.
FIGURE 43.6 Reduction of the joint surface and position of the Kirschner wires are confirmed with
fluoroscopy.
344
CHAPTER 43
Distal Interphalangeal Joint Arthrodesis
INDICATIONS
• Distal interphalangeal (DIP) joint arthrodesis is indicated in patients with intractable
pain or instability after failure of nonoperative management.
• Many patients with DIP arthritis present with mucous cysts. Cyst excision may correct
a nail deformity, skin changes, or a draining wound, but it will not improve joint pain.
• Fusion is a reliable option when pain causes functional limitations.
• Patients may present with stiffness, pain, instability, or an angular deformity (Fig. 43.1).
• Subluxation, dislocation, or osteophytes may be present at the joint.
• Inspect for mucous cysts and changes in the nail bed.
• Assess range of motion (ROM) and pinch strength.
• Joint destruction and intractable tenderness are clear indications for joint fusion.
IMAGING
• Obtain standard anteroposterior (AP) and lateral radiographs of the affected digits
(Fig. 43.2).
• Assess the surrounding bone quality; poor bone stock makes fusion more difficult.
SURGICAL ANATOMY
• The DIP joint is most functional in a straight or slightly flexed position. Five degrees
or less of flexion is generally appropriate for fusion. Nevertheless, it is important to
discuss this with the patient preoperatively. Additional flexion may be advantageous
for certain activities.
• The key to a successful fusion is opposition of cancellous bone at the fusion site
with minimal motion to promote fusion.
• Joint surface destruction creates laxity in the collateral ligaments and instability of
the joint.
• Osteophytes are a hallmark sign of arthritis. Significant osteoarthritis at the DIP joint
may result in Heberden nodes with swelling and inflammation.
FIGURE 43.1
344.e1
344.e2 CHAPTER 43 Distal Interphalangeal Joint Arthrodesis
FIGURE 43.2
EXPOSURES PEARLS POSITIONING AND EQUIPMENT

• Limit horizontal incisions over the joint in case • The patient is positioned supine on the operating room table with a hand table extension.
there is delayed wound healing postoperatively. • Preoperative antibiotics are not needed.
• The extensor tendon should not be divided in • A standard tourniquet or finger tourniquet may be used.
line with the skin incision. At the end of the
• Intraoperative fluoroscopy is needed to confirm compression of bone and appropri-
case, it is repaired separately for additional
support and coverage of the joint. ate placement of pins or hardware.
EXPOSURES
EXPOSURES PITFALLS
• A T-shaped incision is made on the dorsum of the finger over the DIP joint. Sufficient
Avoid injury to the germinal matrix to prevent nail exposure is necessary to remove osteophytes, release soft tissue contracture, and
abnormalities.
excise mucous cysts when present (Fig. 43.3).
• Skin flaps are raised at the level of the paratenon (Fig. 43.4).
STEP 2 PEARLS • The skin is retracted, and the terminal tendon is divided proximal to the joint, then
• Flexing the joint provides easier access to the elevated distally off of the bone (Fig. 43.5).
articular surfaces.
• The bone surfaces should be contoured to
maximize cancellous bone opposition in reduc- PROCEDURE
tion before fixation.
Step 1: Joint Preparation for Arthrodesis
• The joint line is confirmed with a Freer elevator.
• The radial and ulnar collateral ligaments are released to gain access to the joint for
removal of the articular cartilage.
Extensor tendon
cut proximal to joint

CHAPTER 43 Distal Interphalangeal Joint Arthrodesis 344.e3
STEP 2 PITFALLS
• Failure to release soft-tissue contractures may
limit positioning or reduction of the joint for ar-
throdesis.
• Failure to completely remove the cartilage sur-
face on either bone may result in nonunion.
Extensor tendon
elevated from
proximal to distal
FIGURE 43.5
• A fine rongeur is used to completely remove the articular cartilage from both the
distal and middle phalanx in the DIP joint.
STEP 3 PEARLS
Step 3: Alignment and Joint Fixation
• Small plates, screws, or percutaneous pins can be used for fixation. We prefer using The volar plate may tent the joint apart, preventing
compression of the bones for arthrodesis.
Kirschner wires (K-wires) for the ease of fusion and no retained hardware. Adequate release is necessary if this occurs.
• K-wires are driven antegrade from the DIP joint through the distal phalanx. Position-
ing is confirmed on fluoroscopy. The joint is reduced, then the wire is driven retro-
grade into the middle phalanx. STEP 3 PITFALLS
• Two 0.045-in (1.14-mm) K-wires are used. • Avoid multiple drillings that will create holes in
• Reduction of the joint surface and position of the K-wires are confirmed with fluo- the bones and cause premature wire loosening.
• Use of a single K-wire may result in rotation or
roscopy (Fig. 43.6A–B).
malunion.
Step 4: Skin Closure
• The tourniquet is released and hemostasis is obtained.
• The extensor tendon is repaired to maintain the balance of the intricate extensor
mechanism and provide additional soft tissue coverage (Fig. 43.7).
• Skin is closed with 4-0 nylon suture and a volar resting splint is applied (Fig. 43.8).

• The patient is seen in the office 10 days after surgery for suture removal.
• The patient is placed in a DIP joint splint that permits hand and proximal interpha-
langeal (PIP) joint motion.
FIGURE 43.6
344.e4 CHAPTER 43 Distal Interphalangeal Joint Arthrodesis
FIGURE 43.8
FIGURE 43.7
• K-wires are left in place for about 6 weeks to facilitate bony healing. A longer period
of fixation may be necessary for patients with poor bone stock or slow healing.
• X-rays are used to confirm pin position and bony healing (see Fig. 43.6).
See Video 43.1
EVIDENCE
Neukom L, Marks M, Hensler S, Kündig S, Herren DB, Schindele S. Silicone arthroplasty versus screw
arthrodesis in distal interphalangeal joint osteoarthritis. J Hand Surg Eur Vol. 2020;45(6):615–621.
This study compares outcomes after silicone arthroplasty and screw arthrodesis for treatment of DIP
arthritis. ROM, pain, patient satisfaction, and hand appearance were reviewed at a mean of 4.4 years
after surgery. Mean DIP ROM for arthroplasty patients was 28 degrees with an extension deficit of 17
degrees. Pain was low in both arthroplasty and arthrodesis patients at 0.2 and 0.6 out of 10, respec-
tively. Patients from both groups were highly satisfied, but arthroplasty patients were less satisfied
with their hand appearance. In all, 21% of arthroplasty patients and 15% of arthrodesis patients
underwent reoperation during the study period.
Patel A, Damodar D, Dodds SD. Dorsal Plate Fixation for Distal Interphalangeal Joint Arthrodesis of the
Fingers and Thumb. J Hand Surg Am. 2018;43(11):1046.e1–1046.e6.
The authors describe a surgical technique for DIP arthrodesis with a dorsal plate. The ideal position
of arthrodesis is slight flexion to improve power, fine pinch, and grip. Dorsal plate fixation allows for
fusion in a more ideal position compared with straight, intramedullary implants.
Dickson DR, Mehta SS, Nuttall D, Ng CY. A systematic review of distal interphalangeal joint arthrodesis.
J Hand Microsurg. 2014;6:74–84.
This is a systematic review of techniques and complications in DIP joint arthrodesis. Fixation tech-
niques included K-wires, headless compression screws, and cerclage wires. There was no difference
in infection rate. Compression screws had higher union rates (not significant) but were more expen-
sive and had higher complications compared with other techniques. The authors conclude that there
is no clear advantage for a specific fixation technique.
Teoh LC, Yeo SJ, Singh I. Interphalangeal joint arthrodesis with oblique placement of an AO lag screw.
J Hand Surg Br. 1994;19:208–211.
The paper described arthrodesis of the interphalangeal joint using a single interfragmentary screw
placed laterally and obliquely across the joint. The technique offers better control of the desired an-
gle of fusion. The fusion rate was 96% at an average of 8.2 weeks.
Uhl RL, Schneider LH. Tension band arthrodesis of finger joints: A retrospective review of 76 consecu-
tive cases. J Hand Surg Am. 1992;17:518–522.
The authors present a series of 76 tension-band arthrodesis procedures in 63 patients using parallel
wire fixation with tension-band technique. Radiographic fusion was achieved at a mean of 12 weeks.
Overall fusion rate was 99%. Technical problems included nonparallel pin placement and penetration
of the wire tips, causing painful impingement of the soft tissues.
CHAPTER 44
Joint Fusion for Thumb Metacarpophalangeal
Instability

This chapter includes the following video: Video 44.1 – Thumb Metacarpophalangeal
Fusion.
KEY CONCEPTS
• Thumb metacarpophalangeal (MCP) joint fusion is indicated in patients with symp-
tomatic arthritis or instability. Patients with carpometacarpal joint destruction often
have compensatory hyperextension of the thumb MCP joint and will have pain with
gripping, twisting, and key pinch. A normal thumb has a subtle degree of passive
hyperextension at the MCP joint but should not collapse or hyperextend during key
pinch —this is a sign of MCP instability.
• Several fixation techniques are available for thumb MCP joint fusion, including
Kirschner wires (K-wires), headless compression screws, and miniplates. We prefer
to use a 2.0-mm T-plate and screws when bone stock is adequate. For rheumatoid
patients, we prefer K-wire fixation because the bone is porous, and this makes
screw fixation insecure.
Radial collateral
ligament
Radial nerve
sensory branch
Extensor pollicis brevis

Ulnar collateral
ligament
Adductor pollicis aponeurosis

FIGURE 44.2 The intrinsic muscles of the thumb (flexor pollicis brevis and abductor pollicis brevis)
insert onto the radial sesamoid and have attachments to the extensor mechanism to provide
dynamic support.
345
CHAPTER 44
Joint Fusion for Thumb Metacarpophalangeal
Instability
INDICATIONS
Thumb metacarpophalangeal (MCP) joint fusion is indicated in patients with symptom-
atic arthritis or instability.
• Patients may complain of pain, swelling, stiffness, or decreased grip strength.
• Patients with carpometacarpal joint destruction often have compensatory hyperexten-
sion of the thumb MCP joint and will have pain with gripping, twisting, and key pinch.
• A normal thumb has a subtle degree of passive hyperextension at the MCP joint but
should not collapse or hyperextend during key pinch, which is a sign of MCP insta-
bility (Fig. 44.1).
IMAGING
Standard three-view radiographs (anteroposterior, oblique, and lateral) are required to
evaluate the articular anatomy and bony quality.
SURGICAL ANATOMY
• The thumb MCP joint has characteristics of both a condyloid and a hinge joint.
• There is little inherent stability in the bony anatomy; the joint is dependent on soft
tissue constraints, including the ligamentous complex and musculotendinous
attachments.
• The paired proper and accessory collateral ligaments stabilize the joint on the radial
and ulnar aspects. The proper collateral ligaments originate from the lateral condyles
of the metacarpal and insert onto the volar third of the proximal phalanx. The acces-
sory collateral ligaments originate from the metacarpal (volar to the proper ligament)
and insert onto the volar plate and the sesamoid bones. The proper collateral liga-
ments are tight in flexion, and the accessory collateral ligaments are tight in extension.
• The adductor pollicis originates from the second and third metacarpals and inserts
at the thumb MCP joint. The adductor aponeurosis courses obliquely across the
MCP joint and inserts onto the extensor apparatus distal to the sagittal band.
• The fibrocartilaginous volar plate forms the floor of the capsuloligamentous complex.
• The intrinsic muscles of the thumb (flexor pollicis brevis and abductor pollicis brevis)
insert onto the radial sesamoid and have attachments to the extensor mechanism to
provide dynamic support (Fig. 44.2).
FIGURE 44.1
345.e1
345.e2 CHAPTER 44 Joint Fusion for Thumb Metacarpophalangeal Instability
Radial collateral
ligament
Radial nerve
sensory branch
Extensor pollicis brevis

Ulnar collateral
ligament
Adductor pollicis aponeurosis

FIGURE 44.2

• The patient is positioned supine on the operating room table with a hand table
extension.
• Preoperative antibiotics are administered.
• Intraoperative fluoroscopy is required to confirm opposition of bone and placement
of pins or hardware.
EXPOSURES
• A 5-cm longitudinal incision is designed on the dorsum of the thumb centered at the
MCP joint (Fig. 44.3).
• The skin is incised, and the subcutaneous tissue is elevated to expose the extensor
pollicis longus (EPL) and extensor pollicis brevis (EPB) tendons (Fig. 44.4).
• A longitudinal incision is made in the interval between the tendons to expose the
EXPOSURES PEARLS
dorsal capsule.
Identify and protect the superficial radial sensory • The dorsal capsule is incised, and capsular flaps are elevated radially and ulnarly to
nerve branches.
expose the MCP joint (Fig. 44.5).
EPB EPL
FIGURE 44.3 FIGURE 44.4 FIGURE 44.5

CHAPTER 44 Joint Fusion for Thumb Metacarpophalangeal Instability 345.e3

• Complete removal of cartilage and sclerotic
Step 1: Preparation of the MCP Joint bone is accomplished when there is punctate
• The thumb MCP joint is flexed to expose the articular surfaces of the proximal pha- bleeding from the underlying cancellous bone.
lanx and metacarpal head. • An alternative to the cup-in-cone technique is
• The articular surfaces are completely removed to promote fusion. We prefer the to make straight cuts with a sagittal saw. A
5-mm oscillating saw is used to remove ap-
“cup-in-cone” technique. A rongeur is used to remove cartilage from the metacarpal
proximately 1 to 2 mm of bone from the meta-
head (cone) and the base of the proximal phalanx is shaped to accept the metacar- carpal head and the base of the proximal pha-
pal head (cup; Fig. 44.6). This increases the contact area between the bones at the lanx. Cuts must be precise because
fusion site. irregularities can cause angular or rotational
• The fusion angle of the thumb MCP joint should be between 0 and 15 degrees. deformities.
Step 2: Fixation
STEP 1 PITFALLS
Several fixation techniques are available for thumb MCP joint fusion including Kirsch-
Incomplete removal of the articular cartilage,
ner wires (K-wires), headless compression screws, and miniplates. We prefer to use
particularly over the hard-to-reach volar condyle,
a 2.0-mm T-plate and screws when bone stock is adequate. For rheumatoid patients, will prevent bony union.
we prefer K-wire fixation because the bone is porous, and this makes screw fixation
insecure.
Plate Application
• The plate is prebent to the desired fusion angle (0 to 15 degrees).
• The plate is positioned along the central axis of the thumb metacarpal with the “T”
portion over the base of the proximal phalanx. This is confirmed radiographically.
• The first hole is drilled on the metacarpal, just proximal to the fusion site. A 1.3-mm
drill bit is used.
• Screw length is determined with a depth gauge and a 1.5-mm screw is placed loosely.
• The position of the distal portion of the plate is confirmed radiographically and a
screw is placed in the proximal phalanx just distal to the fusion site (Fig. 44.7). Prepared joint
surfaces
• The remaining screw holes are drilled, and all screws are tightened to complete the
fixation (Fig. 44.8).
• Three screws should be placed proximal and three distal to the fusion site.
FIGURE 44.6

345.e4 CHAPTER 44 Joint Fusion for Thumb Metacarpophalangeal Instability
Fixation with K-Wires

• Two 0.045-in (1.14-mm) K-wires are driven from the thumb metacarpal to the distal
subchondral bone of the proximal phalanx.
• The wires can be started at the metacarpal head and driven retrograde first to assist
STEP 2 PITFALLS in trajectory across the fusion site, then passed antegrade into the proximal phalanx.
• The osteotomy site should be compressed Fixation with Headless Compression Screw
after fixation is applied. If it is not compressed,
the hardware should be removed and replaced • A guidewire is driven retrograde from the center of the metacarpal head. Aim to exit
to ensure that the bony edges are in direct the dorsal cortex of the metacarpal approximately 2 cm from the fusion site.
apposition. • Fluoroscopy is used to confirm the fusion angle and position of the guidewire along
• If a compression screw is used, it must be
the central axis of the metacarpal.
advanced collinearly along the guidewire.
Excessive force or levering on the dorsal cortex • The K-wire is advanced antegrade within the medullary canal of the thumb proximal
of the metacarpal will result in fracture. phalanx into the distal subchondral bone.
• Screw length is estimated using the manufacturer’s guide; 4 mm is typically sub-
tracted from the measured length to ensure that all threads are buried within the
bone.
• A hand reamer is used to drill over the guide wire in preparation for screw placement.
• The appropriately sized compression screw is advanced along the guidewire.
• After confirming proper screw placement, the wire is removed.
Step 3: Closure
• The joint capsule is closed over the hardware with 4-0 Ethibond sutures.
• The skin is closed using 4-0 nylon sutures (Fig. 44.9).
• The patient is placed into a short-arm, thumb spica splint.

• The patient is seen in the office 10 to 14 days postoperatively and sutures are
removed.
• The patient is placed into a custom thermoplastic splint or cast.
• K-wires are typically removed after 6 weeks.
• The splint is left in place until there is radiographic evidence of union. In the absence
of complication, this usually occurs between 8 and 12 weeks.
FIGURE 44.9 • Gradual range of motion and strengthening are initiated after union.
See Video 44.1
EVIDENCE
Letzelter JP III, Ahmad R, Tagliarino J, Woeckener J, Bello R, Melamed E. Hand function following
simulated fusion of thumb metacarpophalangeal and interphalangeal joints. Hand (NY). 2020;
1558944720906495. doi:10.1177/1558944720906495.
The authors used orthoses to simulate fusion of the thumb MCP and interphalangeal (IP) joints, then
evaluated function with lateral and tip pinch strength, the Jebsen-Taylor Hand Function test, and the
Grooved Pegboard test. The mean lateral pinch strength was significantly greater in the nonsplinted
group (8.3 kg) compared with the MCP (6.3 kg) and IP-splinted (5.7 kg) groups. Mean tip pinch
strength was also significantly higher in the nonsplinted group than in MCP- and IP-splinted thumbs
(4.6 kg vs. 4.1 and 3.9 kg). There was no difference in the Jebsen-Taylor or Grooved Pegboard test
between the 3 groups. They conclude that MCP joint fuses decreases lateral and tip pinch strength
by 24% and 10%, respectively, compared with a healthy, nonsplinted thumb. A fused IP joint will
decrease lateral and tip pinch by 31% and 16%, respectively.
Lutsky KF, Edelman D, Lebowitz C, Matzon JL, Beredjiklian PK. Union rates and complications after
thumb metacarpophalangeal fusion. Hand (NY). 2019;14(6):803–807.
This study compares results after thumb MCP fusion using tension band wiring (TBW) or plate and
screw fixation (PS). A total of 56 thumb MP joints were fused during the 7-year study period. Mean
age was 60.9 years and mean follow-up was 32.4 months. The average flexion angle was 16.5 de-
grees for the TBW group and 12.8 degrees for the PS group. The overall union rate was 95% and
overall complication rate was 21%. The most common complication in the TBW group was painful
hardware, requiring removal. The PS group had more delayed unions and nonunions. The authors
conclude that alignment is similar with both techniques, but delayed unions and nonunions are more
common with the locking plate and screw technique.
Rasmussen C, Roos S, Boeckstyns M. Low-profile plate fixation in arthrodesis of the first metacarpo-
phalangeal joint. J Hand Surg Eur Vol. 2011;36:509–513.
The authors retrospectively reviewed 51 patients who underwent arthrodesis of the thumb MCP joint
using a low-profile titanium miniplate. Bony union was achieved in 98% of patients. Average follow-up
CHAPTER 44 Joint Fusion for Thumb Metacarpophalangeal Instability 345.e5
was 52 months (13 to 92 months). Complications included hardware failure (<1%), prominent hard-
ware (6%), and tendon adhesions (<2%). Forty-five patients completed a satisfaction questionnaire.
Nineteen judged the surgery to be excellent, 16 deemed it good, 9 described it as fair, and
1 described it as poor. Twenty of 24 working patients returned to work at an average of 5.7 weeks
after surgery. The remaining four retired because of rheumatoid comorbidities. Satisfaction did not dif-
fer based on angle of fusion.
Hagan HJ, Hastings H. Fusion of the thumb metacarpophalangeal joint to treat posttraumatic arthritis.
J Hand Surg Am. 1988;13:750–753.
The authors retrospectively reviewed 18 patients who underwent thumb MCP fusion with K-wire fixa-
tion for posttraumatic arthritis. At an average follow-up of 18 months, all patients were satisfied.
All patients went on to union at an average of 60 days follow-up. Pain was improved in all patients;
however, mild pain and difficulty picking up small objects was present in 78% of patients. Position
of fusion and preoperative MCP motion did not affect results. Key pinch was significantly increased.
Complications included pin-tract infections and prominent hardware.
CHAPTER 45
Carpometacarpal Joint Fusion for Basilar Arthritis
INDICATIONS
• Initial management options for thumb basilar joint arthritis include activity modifica-
tion, nonsteroidal antiinflammatory drugs (NSAIDs), splinting, therapy, and cortico-
steroid injections. Surgery is indicated in patients who continue to have severe pain
or poor function despite nonoperative management.
• The Eaton-Littler classification describes four stages of arthritis based on a true
lateral radiograph of the trapeziometacarpal (TM) joint (Fig. 45.1A–D). This classifica-
tion system is helpful to define the radiographic staging but does not correlate with
the patient’s clinical presentation and the surgical treatment options.
• Stage I: Normal or slightly widened TM joint space, TM subluxation of up to one-
third of the articular surface, normal articular contours
• Stage II: Decreased TM joint space, TM subluxation of up to one-third of the
articular surface, osteophytes or loose bodies less than 2 mm
• Stage III: Markedly decreased TM joint space, TM subluxation of greater than one-third
of the articular surface, osteophytes or loose bodies equal to or greater than 2 mm
• Stage IV: Pantrapezial arthritis with involvement of the scaphotrapezial (ST) joint;
or less commonly, the trapeziotrapezoid or trapezioindex metacarpal joint
• Surgical options for treatment of TM disease include: (1) Anterior oblique ligament
reconstruction (see Chapter 46), (2) trapeziectomy with or without ligament recon-
struction and tendon interposition (see Chapter 47), (3) TM arthrodesis, and (4) TM
joint replacement arthroplasty. There are many variations in surgical technique for
each of these options. The goals of surgery are to stabilize the thumb, reduce pain,
and maintain strength and motion.
• Carpometacarpal (CMC) arthrodesis is indicated in young, active patients with stage
II or III disease who require a strong, stable thumb (i.e., manual laborers over the age
of 60 years old).
Contraindications
• One contraindication is pantrapezial arthritis (stage IV disease) because CMC fusion
does not address pain from the scaphotrapeziotrapezoid (STT) joint.
• Another is severe osteopenia because it precludes adequate bony fixation.
• Metacarpophalangeal (MCP) joint instability or hyperextension greater than 30 degrees
is another contraindication; avoid fusing both the MCP and CMC joints. These patients
are better served with trapeziectomy and MCP arthrodesis.
A B C D
FIGURE 45.1
346
CHAPTER 45 Carpometacarpal Joint Fusion for Basilar Arthritis 347
Extension
Radial
deviation
FIGURE 45.2
• The thumb is inspected for swelling and erythema. Resting posture of the CMC and
MCP joint is noted (Fig. 45.2).
• Active and passive range of motion (ROM) and joint laxity are assessed. Early dis-
ease typically presents with joint laxity, whereas stiffness is a sign of late disease.
• Areas of tenderness around the base of the thumb are noted.
• The grind test is performed by axially loading and rotating the thumb metacarpal
(Fig. 45.3A). This motion creates pain and crepitus in arthritic TM joints because of
friction between the eroded joint surfaces (see Fig. 45.3B).
• Objective motion measurements include radial/palmar abduction and active/passive
MCP joint motion. Key pinch is recorded and compared with the opposite hand.
Pinch strength is often diminished, and functional hand width may be narrowed.
• Patients must be evaluated for concomitant pathology. More than one-third of pa-
tients with CMC arthritis also have carpal tunnel syndrome. De Quervain disease,
trigger thumb, and flexor carpi radialis (FCR) tenosynovitis can all present with pain
at the base of the thumb and must be ruled out.
IMAGING
• Standard three-view (posteroanterior, oblique, and lateral) hand radiographs are
mandatory. True anterior-posterior (Robert’s) and lateral (Bett’s) views of the TM joint
are also useful (Fig. 45.4).
• Radiographs guide surgical decision-making; however, findings do not always cor-
relate with patient symptoms. The decision to proceed with surgery is based on the
patient’s level of discomfort, not imaging.
SURGICAL ANATOMY
• The thumb CMC joint is a biconcave-convex saddle joint. From the dorsal view, the
base of the thumb metacarpal is V-shaped (Fig. 45.5).
• The deep branch of the radial artery passes across the anatomic snuff box over the
ST joint, then into the hand between the two heads of the first dorsal interosseous
muscle. It runs volarly between the heads of the adductor pollicis muscle to become
the deep palmar arch. The deep branch of the radial artery must be identified and
protected during a dorsal approach to the TM joint.
• Branches of the superficial sensory radial nerve (SSRN) run in the subcutaneous tissue
adjacent to the first dorsal compartment and along the dorsal thumb. Traction injury or
inadvertent division of nerve branches causes persistent pain at the incision (Fig. 45.6A–B).
348 CHAPTER 45 Carpometacarpal Joint Fusion for Basilar Arthritis
First metacarpal
Dorsal
Trapezium
A B
Volar
FIGURE 45.5 The carpometacarpal (CMC) joint is a biconcave-convex saddle joint. From the dorsal
view, the base of the thumb metacarpal is V-shaped. (From Halilaj E, Moore DC, Laidlaw DH, et al.
The morphology of the thumb carpometacarpal joint does not differ between men and women, but
changes with aging and early osteoarthritis. J Biomech. 2014;47[11]:2709–2714.)
Superficial branch
of radial nerve
Flexor carpi Abductor pollicis
radialis Trapezium longus
Radial
artery Flexor carpi
radialis
Incision
Flexor pollicis
longus
Volar ligament
Palmar branch Palmaris
A of median nerve longus B Hamate
FIGURE 45.6 (From Calandruccio JH. Arthritic hand. Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed.
Elsevier; 2020: 3756–3818.e6)

extension.
• The procedure is performed under axillary block with sedation or general anesthesia
using an upper arm tourniquet.
• Fluoroscopy, an oscillating saw, and bony fixation hardware are required. Kirschner
wires (K-wires), a locking plate, headless compression screws, or staples can be
used depending on availability and surgeon preference. We prefer to use a 2.0-mm
locking T-plate.
EXPOSURES
A 4-cm longitudinal incision is made on the dorsal hand midway between the abductor
pollicis longus (APL) and extensor pollicis longus (EPL) tendon, centered at the TM joint
(Fig. 45.7; see also Fig. 45.6A).
PROCEDURE
Step 1: Approach to the CMC Joint
• The skin is incised, then tenotomy scissors are used to bluntly dissect the soft tissue.
SSRN branches and the radial artery are identified and protected (Fig. 45.8). Small
dorsal veins and branches of the radial artery are cauterized as needed.
• The CMC joint capsule is incised longitudinally along the midaxis of the thumb meta-
carpal.
• Periosteal flaps are elevated to expose the ST joint, trapezium, and metacarpal base.
• Proliferative synovium is debrided with a rongeur.
• A Freer elevator is used to identify the ST and TM joints. The articular surfaces on
the proximal trapezium and distal scaphoid are inspected. If ST degeneration is
FIGURE 45.7
STEP 2 PEARLS noted, TM arthrodesis is contraindicated because the scaphoid will still impinge on
the eroded ST joint. Therefore a different technique is chosen.
• Healthy, cancellous bone must be exposed on
both the metacarpal base and trapezium for
the fusion to unite. Step 2: Preparation of the Metacarpal and Trapezium
• The V-shaped osteotomy enables the metacar- An oscillating saw is used to remove the articular surface from the base of the thumb
pal base to key in with the trapezium to pro- metacarpal (Fig. 45.9). A matching V-shaped osteotomy is made in the distal trapezium
vide stability and increase the surface area of
to increase the contact between the bones. The metacarpal and trapezium should then
fusion.
fit together nicely. If the cuts are perfect, bone graft is not necessary. Gaps from sub-
chondral cysts or imperfect cuts are packed with cancellous allograft.
STEP 3 PEARLS
Step 3: Bony Fixation
Ideally, the TM joint is fused in approximately
20 degrees of radial abduction and 40 degrees of • A 0.045-inch K-wire is used to temporarily stabilize the joint and check positioning.
palmar abduction. The thumb should be opposable • A 2.0-mm locking T-plate is selected and contoured. The horizontal portion of the
to all four digits. Reproducible positioning of the plate is positioned over the trapezium. A cortical screw is drilled and placed centrally
thumb is difficult, but thankfully, most patients in the trapezium to stabilize the plate to the bone. At least three locking screws are
compensate for small differences in the fusion used in the metacarpal shaft. Additional locking screws are placed laterally in the
angle through increased motion at the MCP and
STT joints. trapezium (Fig. 45.10A–B). The use of locking screws provides additional rigidity to
the fixation because nonunion is a common complication of the fusion procedure for
this joint.
Step 4: Incisional Closure

• The joint capsule is closed with 4-0 absorbable suture (Fig. 45.11).
• The tourniquet is deflated, and the wound is checked for hemostasis.
• The skin is closed with 4-0 monofilament suture.
POSTOPERATIVE CARE AND EXPECTED OUTCOME

• The patient is placed into a short arm thumb spica splint and seen in the office in
2 weeks for suture removal.
A B
FIGURE 45.10A–B
FIGURE 45.11
A B
FIGURE 45.12
• Splinting is continued for 6 to 8 weeks to permit the fusion to heal, then gentle active
ROM is initiated (Fig. 45.12).
• Manual labor is permitted 4 months after surgery.
• Overall, more than 90% of patients are satisfied.
• The risk for radiographic nonunion is 10% to 20%, but many patients have improve-
ment in symptoms despite incomplete union.
• Peritrapezial arthritis develops over time but does not typically affect overall pain,
function, or patient satisfaction.
See Video 45.1
EVIDENCE
Hartigan BJ, Stern PJ, Kiefhaber TR. Thumb carpometacarpal osteoarthritis: Arthrodesis compared with
ligament reconstruction and tendon interposition. J Bone Joint Surg Am. 2001;83(10):1470–1478.
The authors reviewed outcomes for 141 thumbs treated with TM arthrodesis or ligament reconstruction
and tendon interposition (LRTI). Mean follow-up time was 69 months. There was no difference in
pain, function, or satisfaction between the two groups. The LRTI group had more motion in opposi-
tion and ability to flatten the hand, whereas the arthrodesis group had greater lateral and chuck pinch
strength. The arthrodesis group had a higher incidence of complications (nonunion), but this did not
affect the overall outcome.
Raven EE, Kerkhoffs GM, Rutten S, Marsman AJ, Marti RK, Albers GH. Long term results of surgical
intervention for osteoarthritis of the trapeziometacarpal joint: Comparison of resection arthroplasty,
trapeziectomy with tendon interposition and trapezio-metacarpal arthrodesis. Int Orthop. 2007;
31(4):547–554.
The authors compare TM arthrodesis with trapeziectomy with or without ligament reconstruction in
74 thumbs. Baseline patient characteristics (age and Eaton stage) were similar between groups.
Mean follow-up time was over 8 years. There was no difference in pain, strength, Disabilities of the
Arm, Shoulder, and Hand (DASH) scores, or patient satisfaction, but the arthrodesis group had more
complications and reoperations.
Taylor EJ, Desari K, D’Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and silastic
replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg Br.
2005;30(1):45–49.
This study compares TM arthrodesis, trapeziectomy with or without ligament reconstruction, and silas-
tic trapezial replacement for treatment of basilar joint arthritis in 83 thumbs. There was no difference
in clinical outcomes between groups. The arthrodesis group had a higher complication rate than
either of the other two groups studied and a 19% reoperation rate.
CHAPTER 46
Reconstruction for Thumb Carpometacarpal
Joint Instability Using Flexor Carpi Radialis
(Littler Procedure)
INDICATIONS
• Anterior oblique ligament reconstruction (Littler procedure) is indicated in patients with
Eaton-Littler stage I or early stage II trapeziometacarpal (TM) disease with painful in-
stability or diminished thumb function who have failed nonoperative management
(Table 46.1).
• Painful carpometacarpal (CMC) joint instability without significant articular wear is
often seen in young patients with connective tissue disorders, such as lupus or
Ehlers-Danlos Syndrome.
• The Littler procedure can also be used for patients with ongoing instability after
traumatic TM dislocation.
Contraindications
Articular wear at the TM or scaphotrapeziotrapezoid (STT) joints. Trapeziectomy is not
performed during this procedure; pain from arthritic joints will continue unless the pa-
tient has early-stage disease in which instability may be a feature. In these situations,
the ligament reconstruction can be augmented by interposing an artificial dermal matrix
to cushion the joint.
• Resting position of the TM joint is noted. Thumb adduction with dorsoradial sublux-
ation of the metacarpal base is often observed. In advanced disease, stiffness leads
to compensatory metacarpophalangeal (MCP) joint hyperextension.
• Patients are typically tender at the volar aspect of the TM joint regardless of disease
stage. Tenderness over the scaphotrapezial (ST) joint indicates advanced disease.
• Axial loading and distraction forces are applied to test pain with loading and
offloading (see Fig. 45.3A). The grind test is performed by compressing and rotating
the thumb metacarpal base on the trapezium. This motion creates pain and crepitus
in an arthritic joint because of friction between the eroded surfaces (see Fig. 45.3B).
TABLE
46.1 Eaton-Littler Classification System
Stage Radiographic Characteristics
Stage I Normal or slightly widened trapeziometacarpal (TM) joint; TM subluxation up
to one-third of articular surface; Normal articular contours
Stage II Decreased TM joint space; TM subluxation up to one-third of articular
surface; Osteophytes or loose bodies , 2 mm
Stage III Decreased TM joint space; TM subluxation . one-third of articular surface;
Osteophytes or loose bodies $ 2 mm
Stage IV Involvement of the scaphotrapezial, trapeziotrapezoid, or trapezoid-index
metacarpal joint
353
354 CHAPTER 46 Reconstruction for Thumb Carpometacarpal Joint Instability Using Flexor Carpi Radialis (Littler Procedure)
Palmaris longus

FIGURE 46.1
Patients who have pain with the grind test are not candidates for the Littler proce-
dure but may benefit from CMC arthrodesis (see Chapter 45) or trapeziectomy (see
Chapter 47).
• Laxity in the basilar joint is noted; earlier disease presents with laxity.
• Objective measurements include radial/palmar abduction and active/passive motion.
Key pinch is recorded and compared with the opposite hand.
• The Littler procedure uses a slip of flexor carpi radialis (FCR) tendon to reconstruct
the anterior oblique ligament. FCR is palpable when the patient flexes and radially
deviates the wrist (Fig. 46.1).
• Patients must be evaluated for concomitant carpal tunnel syndrome and tendinopathies.
• See Chapter 45 for additional details.
IMAGING
• Standard posteroanterior (PA), lateral, and oblique x-rays of the TM joint are
required.
• The CMC stress view is a PA radiograph of both TM joints as the patient pushes the
thumbs together. The metacarpal base subluxes laterally in patients with TM insta-
bility (Fig. 46.2).
SURGICAL ANATOMY
• The thumb CMC joint is a semiconstrained, biconcave-convex saddle joint supported
by 16 surrounding ligaments. Seven of these ligaments are thought to be directly
FIGURE 46.2
CHAPTER 46 Reconstruction for Thumb Carpometacarpal Joint Instability Using Flexor Carpi Radialis (Littler Procedure) 355
responsible for joint stability: the deep anterior oblique ligament (DAOL, or beak liga-
ment), superficial anterior oblique ligament, dorsoradial ligament, ulnar collateral ligament,
posterior oblique ligament, intermetacarpal ligament, and dorsal intermetacarpal ligament.
• The beak ligament is the key stabilizer of the TM joint. It serves as a pivot point
during pronation and prevents dorsoradial dislocation of the metacarpal base
(Fig. 46.3A–B).
• The FCR muscle originates on the medial epicondyle of the humerus and inserts onto the
index metacarpal base. In the forearm, it lies radial to the flexor digitorum superficialis and
II
Hook of Flexor carpi radialis I

hamate Volar ligament
Abductor pollicis longus
Pisiform
Trapezium
Tubercle of
scaphoid
IML
DRL
DIML
APL POL
DAOL
SAOL
DT-II MC
DRL
POL DTT
B
FIGURE 46.3
palmaris longus tendons and ulnar to the radial artery. The palmar cutaneous branch of
the median nerve is 1 mm ulnar to the FCR tendon in the distal forearm.
• The abductor pollicis longus (APL) tendon is located within the first dorsal compart-
ment and inserts on the radial aspect of the thumb metacarpal base.
ST joint, then into the hand between the two heads of the first dorsal interosseous
muscle. It runs volarly between the heads of the adductor pollicis muscle to become
the deep palmar arch. The deep branch of the radial artery must be identified and
protected at the dorsal aspect of the TM joint.
• Branches of the superficial sensory radial nerve (SSRN) run in the subcutaneous tissue
adjacent to the first dorsal compartment and along the dorsal thumb. Traction injury or
inadvertent division of nerve branches causes persistent pain at the incision (Fig. 46.4).

• The operation is performed under axillary block or general anesthesia with an upper
arm tourniquet.
• The patient is placed in the supine position with a hand table extension.
• A small bur or gouge is needed to create a tunnel in the base of the thumb metacar-
pal. A Hewson suture passer or looped 24-gauge wire is helpful to pass the tendon
through the bone tunnel.
EXPOSURES
• A modified Wagner approach is used. The incision is at the junction of the glabrous
and nonglabrous skin along the thenar eminence and extends to the ulnar aspect of
the FCR tendon at the wrist crease.
• The FCR tendon is exposed proximally though several 1-cm transverse incisions to
the musculotendinous junction (Fig. 46.5).
PROCEDURE
Step 1: Approach to the Carpometacarpal Joint
• The skin is incised and dissection proceeds toward the TM joint using a no. 15
blade. A dorsal skin flap is elevated to expose the metacarpal base. Care is taken to
locate and protect branches of the SSRN.
Superficial branch of
radial nerve
Tendon sheath of 1st Extensor
dorsal compartment pollicis
brevis
Abductor
pollicis
longus
FIGURE 46.6
• The APL tendon is identified and gently retracted dorsally to expose the insertion of STEP 1 PEARLS
the thenar muscles on the metacarpal base. The thenar muscles are elevated extra-
The radial artery passes over the ST joint, and
periosteally to expose the TM and ST joints. The stretched beak ligament can be seen. care must be taken to identify and protect it before
• The ST and TM joint capsules are incised longitudinally. A transverse arthrotomy at the aggressive joint manipulation.
TM joint is performed. Proliferative synovium is debrided with a ronguer (Fig. 46.6).
• The articular surfaces are examined by applying longitudinal traction and rotating the
STEP 1 PITFALLS
thumb. If the joint surfaces are worn, trapeziectomy is required.
• The space between the APL and the extensor pollicis brevis (EPB) tendons is in- The trapezium is not resected in this procedure.
cised. The tendons are retracted to each side and the dorsal branch of the radial Pain from arthritic joint surfaces or residual
osteophytes will not improve.
artery is identified and retracted proximally.
• The periosteum over the dorsum of the metacarpal base is longitudinally incised to
expose the dorsal cortex. A Freer elevator is used to clear the trapezium.
• A small bur or gouge is used to create a tunnel through the base of the metacarpal
in a dorsal-volar direction. The tunnel is perpendicular to the axis of the thumbnail
and 1 cm distal to the metacarpal base. Aim volarly just distal to the insertion of the
beak ligament and parallel to the articular surface.
Step 2: Flexor Carpi Radialis Harvest

• The FCR tendon is identified in the proximal aspect of the Wagner incision at the STEP 2 PEARLS
wrist crease. The palmar cutaneous branch of the median nerve is just ulnar to the Keep the tendon in moistened gauze to prevent
FCR tendon and must be protected. desiccation.
• The tendon sheath is incised and the tendon is dissected proximally and distally.
• Traction is applied on the distal part of the FCR to identify the course of the tendon
in the forearm. Transverse incisions are made every few centimeters to the muscu- STEP 2 PITFALLS
lotendinous junction, approximately 8 cm from the wrist crease (Fig. 46.7). Rupture of the tendon graft or remnant FCR tendon
• The radial half of the FCR tendon is harvested from proximal to distal. It is important can occur intraoperatively or postoperatively. Care
to follow the fibers so that the tendon is not inadvertently transected. Do not slide should be taken to harvest an even graft.
the scissors; cut along the fibers to maintain the integrity and thickness of the ten-
don. The proximal portion of the FCR tendon graft is passed from incision to incision
in the subfascial plane (Fig. 46.8).
• The radial half of the FCR tendon is dissected proximally to its insertion on the index
metacarpal base.

FIGURE 46.9 The FCR tendon slip is delivered through the metacarpal base in a volar to dorsal
direction.
STEP 3 PEARLS
Step 3: Beak Ligament Reconstruction
• It is unnecessary to pin the TM joint because • A suture passer or looped wire is passed through the bone tunnel in the base of the
the tendon provides adequate stability after
postoperative splinting. thumb metacarpal from dorsal to volar. The FCR tendon slip is then delivered
• The FCR can be pulled tightly because tendon, through the metacarpal base in a volar to dorsal direction (Fig. 46.9).
unlike ligament, stretches over time. • The TM joint is extended and abducted to seat the metacarpal base against the
trapezium.
• Once the TM joint is reduced, the FCR tendon is pulled tight. The tendon is secured
to the periosteum of the dorsal cortex using 3-0 braided suture.
• The free end of the FCR tendon is passed deep to the APL tendon, then looped
around the remaining portion of the FCR. The sheath over the FCR is sutured tightly
using 3-0 braided sutures to prevent bow-stringing of the FCR tendon. Finally, the
tendon graft is passed across the TM and ST joints and secured to the APL with 3-0
braided suture. This reconstruction reinforces the volar, dorsal, and radial aspects of
the TM joint capsule (Fig. 46.10A–C).
II
APL
Tubercle
Scaphoid
Radius
FCR
A C
FIGURE 46.10 (A–C) The tendon graft is passed across the TM and ST joints and secured to the APL with 3-0 braided suture.
FIGURE 46.11
Step 4: Closure
• The joint capsule is repaired over the tendon reconstruction using 3-0 braided
permanent sutures.
• The thenar muscles are reattached to the periosteum with 3-0 braided sutures.
• The tourniquet is deflated and hemostasis is ensured.
• Skin incisions are closed with 4-0 nonabsorbable sutures (Fig. 46.11).

• The thumb is immobilized in a short arm thumb spica cast for 4 to 6 weeks, then
gentle active motion is initiated. Strengthening begins 8 to 12 weeks after surgery.
• CMC joint stiffness typically lasts for 4 to 6 weeks but may persist up to 4 months
after restrictions are lifted.
• Studies show excellent pain relief, restoration of pinch strength, and no radiographic
degeneration at 15-year follow-up; 90% of patients are satisfied.
See Video 46.1
EVIDENCE
Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometa-
carpal joint: A long-term assessment. J Hand Surg Am. 1984;9:692–699.
This study reviews outcomes for the first 50 anterior oblique ligament reconstructions. Intractable pain
and instability were the primary indications for surgery. The radiographic appearance of each joint
was examined pre- and postoperatively; 95% of patients with stage I or II disease had good or excel-
lent pain relief. There was no progression of arthritis on follow-up radiographs 13 years postopera-
tively. They conclude that ligament reconstruction restores stability and prevents joint degeneration in
patients with stage I or II TM disease.
Lane LB, Henley DH. Ligament reconstruction of the painful, unstable, nonarthritic thumb carpometa-
carpal joint. J Hand Surg Am. 2001;26:686–691.
This study reviews 37 cases of ligament reconstruction in nonarthritic TM joints performed between 1980
and 1996. Follow-up ranged from 1 to 17 years with an average of 5.2 years. All patients had stage I or
II TM disease with pain before surgery, and 65% were unable to work. Patients had improved joint sta-
bility, improved pinch strength, and excellent pain relief postoperatively. All patients returned to work.
There was no clinical or radiologic evidence of osteoarthritis in any patient at final follow-up.
Rust PA, Tham SKY. Ligament reconstruction of the trapezial-metacarpal joint for early arthritis: A pre-
liminary report. J Hand Surg Am. 2011;36:1748–1752.
This retrospective study evaluated six women (ages 31–46 years) treated with reconstruction of the inter-
metacarpal and reverse anterior oblique ligament using a strip of FCR tendon. Postoperative evaluation at
an average of 18 months (range, 12–28 months) consisted of an interview, examination, and computed
tomography (CT) scan. The visual analog pain score, rest pain, and activity pain improved significantly
after surgery. Tip and lateral pinch strength measured 92% compared with the contralateral thumb, and
CT showed improved alignment of all joints. The authors conclude that ligament reconstruction reduces
pain, increases strength, and improves joint alignment in patients with painful TM joint instability.
Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis.
Cochrane Database Syst Rev. 2009;4:CD004631.
This systematic review examines nine studies with seven surgical interventions for treatment of thumb
basilar joint arthritis (trapeziectomy, trapeziectomy plus ligament reconstruction and tendon interposi-
tion arthroplasty, trapeziectomy plus tendon interposition arthroplasty, trapeziectomy plus ligament
reconstruction, Artelon [Artimplant, Sweden] joint resurfacing, arthrodesis, and joint replacement).
No major differences were found in postoperative pain, physical function, patient global assessment,
or range of motion. In one study, the Artelon spacer had improved key pinch compared with
trapeziectomy plus ligament reconstruction and tendon interposition arthroplasty. Simple
trapeziectomy had significantly fewer complications than the other procedures.
CHAPTER 47
Trapeziectomy and Abductor Pollicis
Longus Suspensionplasty
INDICATIONS
• Carpometacarpal (CMC) arthritis is one of the most common conditions treated by
hand surgeons. Surgery is indicated in patients who continue to have severe pain or
thumb dysfunction despite nonoperative management.
• Patients with Eaton stage III or IV trapeziometacarpal (TM) disease have damage to the
articular cartilage (see Chapter 46, Table 46.1). Joint salvage procedures do not provide
predictable pain relief for these patients. Surgical options for advanced disease include:
(1) trapeziectomy with or without ligament reconstruction and tendon interposition, (2)
arthrodesis (see Chapter 45), and (3) TM joint replacement arthroplasty.
• Candidates for trapeziectomy and abductor pollicis longus (APL) suspensionplasty
are low-demand patients with a painful, eroded basilar joint or diminished thumb
function. Complete trapeziectomy is the key factor in pain relief. The APL to extensor
carpi radialis longus (ECRL) tendon transfer stabilizes the thumb metacarpal base
and reduces metacarpal subsidence into the trapeziectomy space.
• The thumb is inspected for swelling and erythema. Resting posture is noted, paying
special attention to metacarpal adduction, first webspace contractures, and meta-
carpophalangeal (MCP) joint hyperextension (zigzag deformity; Fig. 47.1).
• Active and passive range of motion (ROM) and joint laxity are assessed.
• Areas of tenderness around the base of the thumb are noted.
• The grind test is performed by axially loading and rotating the thumb metacarpal. This
motion creates pain and crepitus in arthritic TM joints because of friction between the
eroded joint surfaces (see Chapter 45, Fig. 45.3A–B).
FIGURE 47.1
360
CHAPTER 47 Trapeziectomy and Abductor Pollicis Longus Suspensionplasty 361
• Objective motion measurements include radial/palmar abduction and active/passive

MCP joint motion. Key pinch is recorded and compared with the opposite hand.
Pinch strength is often diminished and functional hand width may be narrowed.
• Patients must be evaluated for concomitant pathology. More than one-third of pa-
tients with CMC arthritis also have carpal tunnel syndrome. When indicated, carpal
tunnel release should be performed at the time of CMC arthroplasty; trapeziectomy
alone does not decompress the carpal tunnel. De Quervain disease, trigger thumb,
and flexor carpi radialis (FCR) tenosynovitis all present with pain at the base of the
thumb and must be ruled out.
IMAGING
• Standard three-view (posteroanterior, oblique, and lateral) hand radiographs are
mandatory. True anterior-posterior (Robert’s) and lateral (Bett’s) views of the TM joint
are also useful (Fig. 47.2).
• Radiographs guide surgical decision making; however, findings do not always cor-
relate with patient symptoms. The decision to proceed with surgery is based on the
patient’s level of discomfort and dysfunction, not imaging.
SURGICAL ANATOMY
• The thumb CMC joint is a semiconstrained saddle joint supported by 16 surrounding
ligaments. The beak ligament is the key stabilizer of the TM joint. It serves as a pivot
point during pronation and prevents dorsoradial dislocation of the metacarpal base
(see Chapter 46, Fig. 46.3A–B).
• The APL tendon lies within the first dorsal compartment and inserts on the radial
aspect of the thumb metacarpal base.
• The FCR tendon is located just ulnar to the radial artery in the distal forearm. The
tendon enters a fibro-osseous tunnel just proximal to the trapezium, then turns and
inserts on the index metacarpal base. Small slips of the FCR tendon also insert onto
the middle metacarpal base and the trapezial tuberosity. Care must be taken to
avoid injury to the FCR during trapeziectomy.
scaphotrapezial (ST) joint, then into the hand between the two heads of the first
dorsal interosseous muscle. It runs volarly between the heads of the adductor pol-
licis muscle to become the deep palmar arch. The deep branch of the radial artery
must be identified and protected during a dorsal approach to the TM joint. The deep
palmar arch gives off a small branch to the volar aspect of the ST joint that should
be identified and secured during the operation (Fig. 47.3).
• Branches of the superficial sensory radial nerve (SSRN) run in the subcutaneous
tissue adjacent to the first dorsal compartment and along the dorsal thumb. Traction
injury or inadvertent division of nerve branches can lead to persistent pain at the
incision Fig. 47.4.
• For additional information, see Chapter 46.
FIGURE 47.2
362 CHAPTER 47 Trapeziectomy and Abductor Pollicis Longus Suspensionplasty
Mainly ulnar artery
Mainly
radial
artery
Superficial
palmar arch
Deep palmar radial nerve
arch Extensor
Tendon sheath of 1st
brevis
Ulnar artery Abductor
Radial artery
pollicis
longus

Care must be taken to identify and protect the radial • The operation is performed under axillary block or general anesthesia with an upper
artery and SSRN branches. The dorsal branch of arm tourniquet.
the radial artery is found at the proximal aspect of • Preoperative antibiotics are administered.
the incision over the ST joint; it should be mobilized
and retracted proximally. The SSRN is adjacent to • The patient is positioned supine with the arm extended on a hand table. A rolled
the first dorsal compartment in the distal forearm. towel is placed under the palm for support.
Terminal branches run over the anatomic snuff box • Fluoroscopy, an oscillating saw, osteotomes, and a tendon weaver should be available.
to supply the dorsal radial hand.
EXPOSURES
• A 3- to 4-cm longitudinal skin incision over the anatomic snuff box, midway between
the APL and the extensor pollicis longus (EPL) tendons exposes the ST joint, trape-
zium, and thumb metacarpal base (Fig. 47.5).
• The APL tendon is approached through a chevron incision over the first dorsal com-
partment at the level of the radial styloid.

The interval between the trapezium and the
scaphoid must be identified with a Freer so that Step 1: Approach to the Carpometacarpal Joint
one does not inadvertently resect a portion of • The skin is incised over the anatomic stuff box, then tenotomy scissors are used to
scaphoid. If the space is obscured by osteophytes, bluntly dissect the soft tissue. SSRN branches and the radial artery are identified
the mini c-arm can be used.
FIGURE 47.5
FIGURE 47.6 The SSRN branches and radial artery are protected. FIGURE 47.7 Joint capsule exposed.
FIGURE 47.8 ST joint, trapezium, and metacarpal base are exposed.
2nd metacarpal
A B
FIGURE 47.9
and protected (Fig. 47.6). Small dorsal veins and branches of the radial artery are Trapezium
cauterized as needed.
• The CMC joint capsule is exposed (Fig. 47.7) and incised longitudinally. Periosteal FCR
flaps are elevated to expose the ST joint, trapezium, and metacarpal base (Fig. 47.8).
• Proliferative synovium is debrided with a rongeur. Bone
• A Freer elevator is used to identify the ST and TM joints (Fig. 47.9A–B). saw
Radius
Step 2: Trapeziectomy
• Once the trapezium is completely exposed, an oscillating saw is used to divide it into
longitudinal thirds. The cuts are made parallel to the FCR tendon, which is immedi-
ately deep to the trapezium in its fibro-osseous tunnel (Fig. 47.10). FIGURE 47.10
Osteotomy
lines
A B
C D
FIGURE 47.11
STEP 2 PEARLS • The cuts are distracted with a small osteotome or Freer elevator (Fig. 47.11A–C). The
After the trapezium is excised, the FCR tendon trapezium is then removed with a ronguer (see Fig. 47.11D). Ensure that all osteo-
is inspected for injury. Partial tendon lacerations phytes and bone chips are removed (Fig. 47.12).
can be repaired with 3-0 braided nonabsorbable • Fluoroscopy is used to ensure complete trapezial resection.
sutures.
Step 3: Abductor Pollicis Longus Tendon Harvest
STEP 2 PITFALLS • A chevron incision is made over the dorsal radial wrist. The SSRN is identified and
Incomplete trapeziectomy and residual osteophytes retracted and the first dorsal compartment is exposed.
can cause persistent postoperative pain or • The first dorsal compartment is incised to expose the APL tendon (Fig. 47.13A). A
recurrent osteoarthritis. Feel for osteophytes and radial slip of the APL tendon is chosen for the suspensionplasty and is divided at the
remove them using a rongeur. The trapezoid- musculotendinous junction (see Fig. 47.13B). It is carefully separated from the ulnar
metacarpal joint needs to be inspected for arthritic slips using tenotomy scissors to cut along the fibers. Sliding the scissors increases
change. Residual postoperative pain may be
caused by undetected wear in this joint. If this the risk for unintentional tendon injury or division.
joint is arthritic, the distal half of the trapezoid can • The distally based APL tendon slip is passed from the proximal incision to the distal
be resected. Because this joint is nonmobile and incision through a subcutaneous tunnel using a mosquito (see Fig. 47.13C).
inherently stable, no interpositional material needs
to be inserted into the residual space.
STEP 3 PEARLS
• It is not necessary to completely release the
extensor pollicis brevis (EPB) tendon or any
subsheaths within the first dorsal compartment
unless the patient has symptoms of De
Quervain tenovaginitis.
• A radial slip of APL is selected because ulnar
traction on this slip will adduct the thumb
metacarpal base and correct radial subluxation.
FIGURE 47.12
APL
APL divided
A B
APL passed through

subcutaneous
tunnel
FIGURE 47.13
ECRL
FIGURE 47.14
Step 4: Abductor Pollicis Longus Suspensionplasty

• The ECRL tendon lies deep and ulnar to the EPL. ECRL is exposed through the distal
incision and used as an anchor point for the APL suspensionplasty (Fig. 47.14).
• The APL slip is passed volar to the EPB and EPL, then a tendon weaver is used to
pass the APL through the ECRL just proximal to its insertion on the base of the index
metacarpal. The APL is maximally tensioned to position the base of the thumb meta-
carpal adjacent to the index metacarpal base. A 3-0 braided nonabsorbable suture is
used to secure the tendon weave and set the tension. Two additional passes are made
through the ECRL tendon and secured with horizontal mattress sutures (Fig. 47.15).
• Any extra APL tendon is trimmed and sutured into an anchovy with 4-0 braided
absorbable sutures (Fig. 47.16). The tendon anchovy is placed within the trapeziec-
tomy space for padding and support. It later incorporates into the scar.
Step 5: Incisional Closure

• Joint capsule is closed with 4-0 absorbable suture.
• The skin is closed with 4-0 dermal sutures and a running subcutaneous absorbable
monofilament suture.

• The thumb is immobilized in a short-arm thumb spica splint. After the postoperative
splint is removed, a thermoplast thumb spica splint is applied. Light strengthening
exercises and unrestricted passive ROM are initiated 4 weeks after surgery.
EPB
APL radial Woven juncture

slip
ECRL
APL (ECRB not
shown)
FIGURE 47.15
FIGURE 47.16
• Grip and pinch strength initially decrease but then improve to the preoperative level
by 6 months. At 1 year postoperatively, grip and pinch strength exceed preoperative
measurements. Most patients are satisfied and have reduced pain by 3 months
postoperatively.
EVIDENCE
Chang EY, Chung KC. Outcomes of trapeziectomy with a modified abductor pollicis suspension arthro-
plasty for the treatment of thumb carpometacarpal joint osteoarthritis. Plast Reconstr Surg. 2008;
122:1–12.
This study compares APL suspensionplasty with FCR ligament reconstruction in the treatment of CMC
arthritis. The loss of CMC space was 38% at 1 year for APL suspensionplasty compared with preopera-
tive measurements. Most thumbs were stable and had no additional loss of height beyond the first
postoperative year. Grip strength was improved in both cohorts. The Michigan Hand Questionnaire
showed improvements in activities of daily living, work, patient satisfaction, and pain. Shorter tourniquet
times were reported for APL suspensionplasty compared with FCR ligament reconstruction.
Field J, Buchanan D. To suspend or not to suspend: A randomised single blind trial of simple trapeziectomy
versus trapeziectomy and flexor carpi radialis suspension. J Hand Surg Eur Vol. 2007;32:462–466.
This is a prospective randomized controlled trial comparing trapeziectomy alone to trapeziectomy with
FCR suspension in 65 patients with stage III or IV CMC arthritis. Patients who underwent trapeziec-
tomy alone had increased radial abduction 1 year after surgery, but there were no significant differ-
ences in palmar abduction, first webspace span, grip strength, pinch strength, pain, or patient satis-
faction between groups. The trapeziectomy and ligament reconstruction group had a higher incidence
of complex regional pain syndrome and volar forearm scar adherence. They conclude that ligament
reconstruction offers no definite advantages over simple trapeziectomy and may have a higher compli-
cation rate.
Sirotakova M, Figus A, Elliot D. A new abductor pollicis longus suspension arthroplasty. J Hand Surg
Am. 2007;32:12–22.
This study reviews outcomes in 104 CMC arthroplasties with APL suspension. At 12 months, 91% of
patients had excellent pain relief. Tip pinch, key pinch, and grip strength increased by 46%, 19%,
and 41%, respectively, from preoperative values. Patients also showed improvement in ROM and
reduced hand disability at 6 months after surgery.
Wajon A, Vinycomb T, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint)
osteoarthritis. Cochrane Database Syst Rev. 2015;(2):CD004631.
This is a systematic review of outcomes after surgical treatment of CMC arthritis. Seven surgical proce-
dures were identified -trapeziectomy with ligament reconstruction and tendon interposition (LRTI),
trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthro-
plasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). In total, 670 patients
were reviewed. Trapeziectomy with LRTI did not have additional risks or benefits compared with tra-
peziectomy alone.
CHAPTER 48
Revision Carpometacarpal Joint Arthroplasty
INDICATIONS
• Carpometacarpal (CMC) joint arthroplasty with trapeziectomy with or without liga-
ment reconstruction provides predictable pain relief for most patients. Revision CMC
arthroplasty is indicated in patients with persistent or recurrent basilar thumb pain
or instability who are at least 1 year out from their primary procedure and have failed
symptomatic management.
• Patients must be counseled that revision procedures are less predictable than pri-
mary CMC arthroplasty. Multiple surgeries are sometimes necessary. The primary
goal of revision surgery is pain relief; functional improvement is secondary.
• A successful revision CMC arthroplasty depends on identification of the source of
pain. Common reasons for failure include subsidence of the first metacarpal with
bony impingement on the scaphoid or trapezoid, untreated or progressive scapho-
trapezoidal (ST) arthritis, superficial sensory radial nerve (SSRN) neuroma, untreated
metacarpophalangeal (MCP) joint laxity or arthritis, and unrecognized concomitant
pathology (carpal tunnel syndrome or tendinopathy). Treatment must be tailored to
the reason for failure.
• Subsidence of the thumb metacarpal after primary arthroplasty is common and not
usually functionally significant. Not all patients with collapse deformities require revi-
sion surgery; many patients will adapt or compensate. Revision surgery is indicated
for intolerable pain or instability.
APPROACH TO REVISION CMC JOINT ARTHROPLASTY

• Revision CMC arthroplasty requires thoughtful planning. The surgical treatment plan
must address each source of pain (Table 48.1).
• There are a few critical questions to ask:
• What is the cause of recurrent symptoms (mechanical pain, neuropathic pain,
instability)?
• What surgery has been performed?
• What options are available?
TABLE
48.1 Sources of Pain and Suggested Treatments
Cause of Symptoms Suggested Treatment
Subsidence of thumb metacarpal Revision basilar joint arthroplasty or thumb-index
metacarpal arthrodesis (salvage)
MCP joint instability or arthritis MCP joint capsuloplasty or arthrodesis
Superficial sensory radial nerve injury Neurolysis or excision of neuroma and nerve grafting
Scaphotrapezoidal arthritis Proximal hemi-trapezoidectomy
Second CMC joint arthritis Distal hemi-trapezoidectomy
Carpal tunnel syndrome Carpal tunnel release
De Quervain tenovaginitis First dorsal compartment release
FCR tendonitis Debridement or tenotomy
Complex regional pain syndrome Referral to pain management
CMC, Carpometacarpal; FCR, flexor carpi radialis; MCP, metacarpophalangeal
368
CHAPTER 48 Revision Carpometacarpal Joint Arthroplasty 369
• The goals of revision CMC arthroplasty are to:

• Restore stability of the CMC joint
• Restore length of the thumb ray
• Correct hyperextension of the MCP joint
• Address MCP, ST, and second CMC (index metacarpal-trapezoid) joint arthritis
• Treat neuropathic pain
• Treat concomitant carpal tunnel syndrome or tendinopathies
• There are many options to restore thumb length and stability, including revision ar-
throplasty with a different tendon or technique, and suspensionplasty with suture
tape, endo-buttons, bone anchors, or tenodesis screws. Our preferred technique is
to create a sling under the base of the thumb metacarpal using a slip of abductor
pollicis longus (APL) and suture tape. Thumb-to-index metacarpal arthrodesis is
considered when soft tissue suspension techniques are exhausted.
• The thumb CMC joint is assessed for range of motion (ROM), stability, function, and pain.
Pain with axial loading suggests symptomatic metacarpal subsidence with bony im-
pingement on the trapezoid or scaphoid. Patients with ST arthritis have pain in the ana-
tomic snuff box. Areas of hypersensitivity, burning pain, a Tinel sign along the scar, or pain
proximal to the CMC joint may indicate a SSRN neuroma or nerve entrapment in scar.
• The MCP joint is assessed for posture, ROM, stability, and pain. Compensatory
MCP joint hyperextension is common in patients with CMC arthritis and is easily
identified with tip-to-tip pinch. MCP joint osteoarthritis develops over time and con-
tributes to patient dissatisfaction after basilar joint surgery.
• Objective measurements should include radial/palmar abduction and active/passive
MCP joint motion. Key pinch should be recorded and compared with preoperative
values and the opposite hand.
• Many patients have concomitant carpal tunnel syndrome or tendinopathy. Patients
must be evaluated for numbness, palmar pain, triggering on interphalangeal (IP) joint
flexion, and pain along the first dorsal compartment, flexor carpi radialis (FCR) ten-
don, or A1 pulley. These conditions contribute to pain at the base of the thumb and
should be treated at the time of revision CMC surgery.
IMAGING
• Standard anteroposterior (AP), lateral, and oblique radiographs of the hand are used
to evaluate the bony anatomy. The location of the thumb metacarpal base and any
impingement on the scaphoid or trapezoid is noted. Residual trapezium and other
osteophytes are identified. The ST joint is carefully evaluated because unrecognized
or progressive ST arthritis can cause ongoing pain. The MCP joint is also evaluated
for arthritis and hyperextension (Fig. 48.1).
• Image-guided injection of local anesthetic with steroid into the ST or second CMC
Hyperextension
at MCP joint
FIGURE 48.1
370 CHAPTER 48 Revision Carpometacarpal Joint Arthroplasty
Thumb
metacarpal
subsiding
proximally
joint can be helpful to localize the source of the pain.

• Ultrasound is considered if the patient complains of burning or electrical-type pain
proximal to the CMC joint or has a Tinel sign on examination. Ultrasound-guided
anesthetic injection of SSRN neuromas can confirm the diagnosis.
SURGICAL ANATOMY
• After trapeziectomy, the thumb metacarpal may subluxate dorsally and subside
proximally (Fig. 48.2).
• The CMC joint flexes and adducts because of forces from the flexor pollicis longus
(FPL) and thenar intrinsics.
• The moment arms that affect the MCP joint with pinch increasingly favor extension.
The IP joint develops extensor lag because of MCP joint hyperextension.
• Proximal subsidence of the thumb metacarpal may result in metacarpal impinging
onto the scaphoid (Fig. 48.3) or trapezoid.
• With progressive CMC collapse, there is loss of length of the thumb ray; loss of
extension, abduction, and opposition; loss of strength; and sometimes pain.

extension.
• A tourniquet and fluoroscopy are required.
• Depending on the technique used, Kirschner wires (K-wires) and a wire driver, head-
less compression screws, low-profile plates and screws, bone anchors, and/or te-
nodesis screws and suture tape may be necessary.
Abductor Pollicis Longus Suspension With Tenodesis

Screw
INDICATIONS
An indication for this procedure is failed primary CMC arthroplasty with symptomatic
first metacarpal subsidence.
Contraindications
A contraindication is attenuation or scarring of the APL tendon from use in previous
surgery.
EXPOSURES STEP 1 PEARLS

• The previous incision is used if possible and extended as needed. If this does
If nerve injury is suspected from a previous surgery,
not provide adequate exposure, a 4-cm longitudinal skin incision is designed SSRN branches are carefully explored. Neurolysis
over the base of the thumb metacarpal midway between the APL and EPL ten- is sufficient if nerve branches are intact but
dons (Fig. 48.4). trapped in scar. Neuromas are buried proximally
• A chevron incision over the first dorsal compartment at the level of the radial styloid into a muscle.
allows access to the APL tendon proximally.
STEP 1 PITFALLS
PROCEDURE
SSRN nerve branches can be difficult to identify in
Step 1 scarred tissue planes. Dissection should proceed
with caution. If nerve injury is identified at the time
• The skin is incised sharply, then blunt dissection is used to expose the joint capsule of surgery, repair is performed.
(Fig. 48.5). Branches of the SSRN and the dorsal branch of the radial artery are
identified and protected.
• The joint capsule is incised longitudinally, and the base of the thumb metacarpal is STEP 2 PEARLS
exposed (Fig. 48.6).
There is no need to fill the hemi-trapezoidectomy
• Scar, synovitis, and osteophytes are debrided from the arthroplasty space with a defect with interposition material. The joint is rigid
rongeur. Any hardware is removed and soft tissue reconstructions from previous and will not collapse.
surgeries are taken down.
Step 2
The ST and second CMC joints are inspected for wear. An osteotome is used to per-
form a hemi-trapezoidectomy if needed; 3 mm of the proximal or distal trapezoid is
removed and the joint space is left open.
Radial artery
FIGURE 48.6
Trough
Harvest a 2 mm × 4 cm
slip of APL tendon
Step 3
A bur is used to create a 2- to 3-mm trough in the base of the first metacarpal in the
radial-ulnar plane (Fig. 48.7).

If the APL tendon was used in the primary surgery • A chevron incision is made over the first dorsal compartment at the level of the radial
or is unsuitable for any reason, the procedure may styloid. The SSRN is identified and protected.
be performed using a 2-mm by 5-cm free tendon • The first dorsal compartment sheath is opened along its length and the APL tendon
graft from the extensor carpi radialis longus (ECRL)
or FCR and suture tape (Arthrex Internal Brace™). is identified. A radial slip of APL tendon is divided proximally at the musculotendi-
Two tenodesis screws are used; one is placed in nous junction. Tenotomy scissors are used to harvest a distally based slip of tendon,
the base of the first metacarpal at the radial corner, taking care to maintain the integrity and thickness of the tendon (Fig. 48.8).
midline in the AP plane, and the second is placed • The APL tendon slip is passed from the proximal incision to the distal incision in the
in the base of the second metacarpal as described subcutaneous plane using blunt dissection and a mosquito.
in step 5 (Fig. 48.10).
• The cut end of the APL tendon is prepared with a looped whip stitch (Fig. 48.9A–B).
Step 5
• The thumb metacarpal is distracted, and the base of the index metacarpal is identi-
fied with a Freer elevator.
• We prefer to use the Arthrex 3.5 DX SwiveLock® SL tenodesis screw to anchor the
APL tendon into the base of the second metacarpal. Suture tape adds support to
the sling but is not mandatory. The following steps are specific to this system; how-
ever, any tenodesis screw or bone anchor may be used. Passing suture and the APL
tendon through a bone tunnel over the index metacarpal is another option. The goal
is to create a sling under the base of the thumb metacarpal for support.
A 1 cm whip stitch B
FIGURE 48.9 (Part B from Noyes, FR, Barber-Westin, SD. ACL primary reconstruction: Diagnosis,
operative techniques, and clinical outcomes. In Noyes, FR, ed. Noyes’ Knee Disorders: Surgery,
Rehabilitation, Clinical Outcomes. Saunders; 2017: 137–220.) FIGURE 48.10
A B
FIGURE 48.11
• A guidewire is placed into the radial base of the thumb metacarpal just proximal STEP 5 PEARLS
to the APL insertion (Fig. 48.11A).
• Keeping the tendon moist with saline irrigation
• The 3.5-mm cannulated drill and drill guide are placed over the guidewire. The will help it glide smoothly on the fork tip.
drill guide has a depth stop at 1 cm. The metacarpal is drilled to the stop (see • There is no need to pull on the APL tendon or
Fig. 48.11B). suture tape once they are threaded though the
• The drill and guidewire are removed, and irrigation is used to remove bony debris. fork tip. The ligament reconstruction will auto-
• Suture tape is draped over the fork tip on the SwiveLock device. tension as the screw seats.
• Suture tape adds support to the sling but is not
• Slow, firm pressure is applied to the SwiveLock device until the anchor body mandatory. If it is not available, there is no
contacts the bone. The pear-shaped knob is turned to advance the screw until it need to drill the base of the thumb metacarpal;
is fully seated (Fig. 48.12A–B). a single tenodesis screw is used to secure the
• A second guidewire is placed into the base of the index metacarpal midway be- tendon to the base of the index metacarpal.
tween the volar and dorsal cortices and approximately 5 mm distal to the second
CMC joint (Fig. 48.13A).
• The index metacarpal is drilled to the stop, then the drill and guidewire are re- STEP 5 PITFALLS
moved and the drill hole is irrigated (see Fig. 48.13B). Ensure that the thumb metacarpal is distracted
• The slip of previously harvested APL tendon and the suture tape are threaded and fully adducted against the second metacarpal
base before seating the tenodesis screw. Improper
through the fork tip on the SwiveLock device. An assistant distracts and fully ad-
positioning of the thumb metacarpal leads to
ducts the thumb metacarpal against the second metacarpal. The device is in- incorrect tensioning of the ligament suspension.
serted into the hole drilled in the index metacarpal base. The APL tendon should If the anchor is not available, a cortical window
seat in the trough created in the base of the first metacarpal (see Fig. 48.10). over the index radial metacarpal can be created.
• Slow, firm pressure is applied to the SwiveLock device until the anchor body con- Then the sutures with the APL tendon are passed
through the bone tunnel and tied securely over the
tacts the bone. The knob is turned to advance the tenodesis screw (Fig. 48.14).
opposite ulnar cortex.
• Excess tendon and suture tape are trimmed.
Suture tape
drilled into
thumb
metacarpal
A B
B
FIGURE 48.12
A B
FIGURE 48.13
FIGURE 48.14
Step 6
• The joint capsule is closed with 4-0 braided absorbable suture.
• Hemostasis is obtained and the skin is closed with 4-0 deep dermal sutures and skin
sutures.
POSTOPERATIVE CARE
• The thumb is immobilized in a short-arm thumb spica splint for 6 weeks.
• Light strengthening and unrestricted passive ROM are initiated 6 weeks after surgery.
• Full activity is permitted after 3 months.
Metacarpophalangeal Joint Capsuloplasty/Volar Plate

Advancement
INDICATIONS
One indication for this procedure is MCP joint hyperextension less than 30 degrees
(Fig. 48.15).
Contraindications
There are a few contraindications for this procedure:
• MCP joint hyperextension of greater than 30 degrees
• Fixed MCP joint deformity
• Symptomatic MCP joint arthritis
FIGURE 48.15
EXPOSURES
A volar zigzag incision is made at the level of the MCP joint (Fig. 48.16).
STEP 1 PEARLS
PROCEDURE
The radial and ulnar digital nerves to the thumb must
Step 1 be identified and gently retracted.
• The skin is incised sharply, then blunt dissection is used to expose the flexor tendon
sheath. Care is taken to preserve the neurovascular bundles.
• The A1 pulley is identified and divided, and the FPL tendon is retracted laterally (Fig. 48.17).
Step 2
• The volar plate is exposed and a distally based U-shaped incision is made in the
volar plate.
• The volar plate is elevated as a flap from proximal to distal.
• At the metacarpal neck, a Freer is used to expose the bone and a Mitek Mini suture
anchor is placed.
• It is optional to place a 0.045-inch K-wire obliquely across the MCP joint in 30 degrees
of flexion to protect the soft tissue repair (Fig. 48.18).
• The volar plate flap is advanced proximally and secured with the suture anchor so
that the MCP joint is in 30 to 40 degrees of flexion.
Step 3
The skin is closed using nylon sutures, and a dorsal blocking splint is placed with the
MCP joint in 30 degrees of flexion.
FIGURE 48.18

The splint (and pin if used) are removed 4 weeks after surgery. The joint is protected
from hyperextension forces until 8 weeks postoperatively.
Metacarpophalangeal Joint Arthrodesis

See Chapter 44 Joint Fusion for Thumb Metacarpophalangeal Instability for exposures,
procedure, and postoperative care information.
INDICATIONS
Indications for this procedure include MCP joint hyperextension greater than 30 de-
grees, fixed hyperextension deformity, instability, and symptomatic MCP joint arthritis.
Intermetacarpal Arthrodesis – Thumb to Index Metacarpal

Base Fusion
INDICATIONS
It is a salvage procedure for failed revision soft tissue or implant arthroplasty.
EXPOSURES
The previous incision is used if possible and extended as needed (Fig. 48.19). If this
does not provide adequate exposure, a 4-cm longitudinal skin incision is designed over
the base of the thumb metacarpal midway between the APL and EPL tendons.
PROCEDURE
Step 1
• The skin is incised sharply, then blunt dissection is used to expose the joint capsule.
Branches of the SSRN and the dorsal branch of the radial artery are identified and
protected.
• The joint capsule is incised longitudinally and the base of the thumb and index meta-
carpals are exposed.
• Scar, synovitis, and osteophytes are debrided from the arthroplasty space with a
rongeur. Any hardware is removed and soft tissue reconstructions from previous
surgeries are taken down.
Step 2
STEP 3 PEARLS The radial portion of the ECRL is elevated off the base of the index metacarpal and a
If desired, the thumb and index metacarpal bases burr is used to expose cancellous bone on the opposing surfaces of the index and
can be fused to the trapezoid to increase the area thumb metacarpals.
of bony contact. Cancellous bone is exposed on
opposing articular surfaces and a second headless Step 3
compression screw is placed between the thumb
• The thumb metacarpal is distracted out to length and temporarily pinned with a 0.045-inch
metacarpal base and the trapezoid (see Fig. 48.21).
K-wire (Fig. 48.20A). Positioning is checked on fluoroscopy (see Fig. 48.20B).
Scar from previous

incision
FIGURE 48.19
Temporary K-wire
A B
FIGURE 48.20
First screw
Second screw
FIGURE 48.21
• A headless compression screw is advanced over the K-wire into first and second
metacarpal bases (Fig. 48.21).
• An autograft from the distal radius or proximal ulna is packed into the fusion site
(Fig. 48.22A–B).
Step 4
• The joint capsule is closed with 4-0 absorbable suture (Fig. 48.23).
• The skin incision is closed with 4-0 deep dermal sutures and interrupted horizontal
mattress sutures.

• The patient is immobilized in a thumb spica splint postoperatively. The patient is
seen in the office 2 weeks after surgery for suture removal. A thumb spica cast is
applied for an additional 6 weeks or until the fusion has healed on imaging.
• Light strengthening exercises and ROM exercises are permitted after the fusion has
healed.
• Full activity as tolerated is permitted after 3 months.
• Many patients will have reduced pain and some will have improved function after
revision CMC arthroplasty, but results are less predictable than for primary surgery.
• Patients should be counseled that they may require more than one revision surgery.
A B
FIGURE 48.22
FIGURE 48.23
EVIDENCE
Cooney WP III, Leddy TP, Larson DR. Revision of thumb trapeziometacarpal arthroplasty. J Hand Surg
Am. 2006;31(2):219–227.
The authors reviewed trapeziometacarpal joint arthroplasties performed at their institution over a 12-year
period. Fifteen of 606 patients had revision procedures for treatment of mechanical pain related to
instability or bony impingement. Revision procedures included soft-tissue interposition alone or with
ligament reconstruction and neurolysis when indicated. About 75% of patients had a good or
satisfactory outcome after revision surgery based on an objective grading scale. The method of
soft tissue revision (with or without ligament reconstruction) did not affect the outcome. Nerve
involvement was a predictor of worse outcome.
Papatheodorou LK, Winston JD, Bielicka DL, Rogozinski BJ, Lourie GM, Sotereanos DG. Revision of
the failed thumb carpometacarpal arthroplasty. J Hand Surg Am. 2017;42(12):1032.e1–e7.
The authors analyzed 32 patients with failed primary CMC arthroplasty. Metacarpal subsidence with pain
was the primary reason for failure. Revision procedures included soft tissue interposition with or with-
out ligament reconstruction and distraction pinning, partial trapezoid excision for ST joint arthritis, and
MCP joint arthrodesis for hyperextension. Mean follow-up was 57 months. All patients had good (27 of
32) or fair (5 of 32) functional outcomes with reduced pain and increased grip and key pinch strength.
Conolly WB, Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpo-
metacarpal joint of the thumb. J Hand Surg Br. 1993;18(4):533–539.
In an 8-year period, 17 patients underwent revision surgery for failed CMC osteoarthritis of the thumb.
Primary procedures included trapeziectomy, silastic arthroplasty, and arthrodesis. Reasons for failure
included subsidence of the thumb metacarpal with pain or instability, dislocation or painful sublux-
ation of silastic implants, and nonunion or progressive ST arthritis, respectively. The type of revision
procedure varied and was tailored to the patients’ needs. Nine patients (53%) had complete relief of
pain; three (18%) had mild persistent pain and stiffness; and five (29%) had no pain relief or func-
tional improvement after revision CMC surgery.
Renfree KJ, Dell PC. Functional outcome following salvage of failed trapeziometacarpal joint arthro-
plasty. J Hand Surg Br. 2002;27(1):96–100.
This study reviews outcomes in 15 patients who underwent revision trapeziometacarpal joint arthroplasty
at a single institution over an 11-year period. Primary surgeries included trapeziectomy combined with
ligament reconstruction and soft tissue interposition using a variety of techniques (FCR, APL, PL, or
fascial allograft), a silicone trapezial implant, and an Ashworth-Blatt prosthesis. Patients who failed
primary arthroplasty subsequently underwent a mean of four revision operations for continued pain or
instability. There was a 27% complication rate for revision surgery at 5 years with injury to the SSRN
being most common. All attempts at scaphoid-metacarpal fusion failed. Workers’ compensation
patients had worse outcomes. Twelve patients were contacted an average of 5 years after their last
revision procedure; despite the high complication rate and need for multiple surgeries, 75% of
patients reported overall satisfaction and improved function.
CHAPTER 49
Distal Ulnar Resection (Darrach Procedure)
INDICATIONS
• The goal of surgical treatment of distal radioulnar joint (DRUJ) arthritis is to eliminate
the articulation between the distal ulna and the sigmoid notch. Options include dis-
tal ulna resection (Darrach procedure) or hemi-resection (Bowers procedure; see
Chapter 51), DRUJ arthrodesis (Sauvé-Kapandji procedure; see Chapter 50), and
ulna head replacement.
• The Darrach procedure is indicated in low-demand patients with chronic DRUJ pain
or instability from posttraumatic arthritis, osteoarthritis (OA), or rheumatoid arthritis
(RA).
• DRUJ incongruity is common after intraarticular distal radius fractures, and malunion
can lead to persistent pain. Elderly patients may benefit from distal ulna resection.
Contraindications
• There is a theoretical risk for ulnar translation of the carpus after excision of the ulna
head. Some authors recommend DRUJ arthrodesis (Sauv-Kapandji procedure) in
younger and high-demand patients to reduce this risk; however, studies show no
difference in long-term, functional outcomes. Risk factors for ulnar translation of the
carpus include increased radial slope (23 degrees) and destruction of the ulnar
corner of the distal radius.
• Young patients with DRUJ incongruity after a distal radius malunion may be better
treated with a radial osteotomy.
• There are many structures around the wrist that can cause pain, such as the DRUJ, the
triangular fibrocartilage complex (TFCC), lunotriquetral (LT) ligament, extensor carpi
ulnaris (ECU), flexor carpi ulnaris (FCU), and pisotriquetral joint. The goal is to delineate
the exact location and cause of pain. Each structure has a specific treatment.
• The patient is asked to identify the point of maximal tenderness, and this is con-
firmed with palpation.
• Active and passive range of motion (ROM) are assessed for wrist flexion/extension,
radio-ulnar deviation, and pronation/supination. Any tenderness or crepitus with
motion is documented.
• The ECU and FCU tendons are palpated. Tenderness and swelling indicate tendini-
tis. Palpate for ECU subluxation during forearm rotation.
• An ulnocarpal stress test is performed by ulnarly deviating and axially loading the
wrist. Pain may indicate ulnar impaction syndrome.
• To perform the fovea test, palpate at the ulnar side of the wrist between the FCU and
ulnar styloid. Pain is highly sensitive for TFCC tears.
• LT instability is identified with the LT shear test. The lunate is stabilized between the
examiner’s thumb and index finger, and the triquetrum is sheared against the lunate
in a dorsal-palmar direction with the examiner’s other hand.
• Pain with compression of the distal forearm indicates DRUJ pathology.
• DRUJ stability is checked in all forearm positions. An unstable DRUJ clunks as the
ulna head dislocates and reduces during forearm rotation. Compression across the
joint may accentuate the clunk. Any abnormal translation of the ulna on the radius
indicates instability, and this should be compared with the contralateral side.
• Caput ulnae syndrome is characterized by weakness, pain with forearm rotation, stiff-
ness, dorsal prominence of the ulna head (which is typically reducible with painful
crepitus), and bulging of the synovial bursae of the ECU and other extensor compart-
ments. This is sometimes seen in RA patients and is treated with a Darrach procedure.
380
FIGURE 49.1
IMAGING
• Standard posteroanterior (PA), oblique, and lateral views of the wrist are mandatory
(Fig. 49.1).
• Ulnar variance is measured on the PA film.
• Findings that suggest instability include widening of the DRUJ, an ulnar styloid base
fracture, a fleck fracture from the fovea, and more than 5 mm of ulnar-minus variance
compared with the contralateral wrist. DRUJ instability is accentuated in a lateral
stress view; the patient holds a 5-lb weight with the forearm in pronation and the
x-ray beam is directed cross-table.
• Carpal alignment is carefully evaluated. Suspicion of carpal dissociation should be
investigated using arthroscopy or magnetic resonance imaging (MRI). When indi-
cated, carpal stabilization is performed during the same surgery with a Darrach.
• Computed tomography (CT) scans of both wrists in pronation-supination and neutral
position are useful when the diagnosis is unclear. CT scans can evaluate sigmoid
notch competency and morphology, congruency of the ulnar head, and DRUJ arthritis.
• MRI is useful to identify tears of the TFCC or lunotriquetral ligaments and other soft
tissue pathology. Dynamic imaging can reveal the lesion and instability of the DRUJ
or ulnocarpal joint.
SURGICAL ANATOMY
• The dorsal sensory branch originates from the ulnar nerve about 6.4 cm proximal to
the ulna head (8.3 cm from the proximal edge of the pisiform). It divides into longi-
tudinal and transverse branches over the ulnar side of the wrist, which course dor-
sally to the ulnar styloid. These branches must be protected during exposure of the
ulna head.
• The ulna head articulates with the sigmoid notch of the distal radius to form the
DRUJ. The sigmoid notch is shallow and flatter than the ulna head. At the midrange
of motion, just 40% to 60% of the ulna head is seated within the sigmoid notch. This
makes the DRUJ inherently unstable.
• The DRUJ is stabilized by surrounding soft tissue structures. The TFCC is located
on the ulnar aspect of the wrist between the ulna and the proximal carpal row and
consists of a triangular fibrocartilaginous disc and supporting ligaments. The dorsal
and volar radioulnar ligaments originate from the sigmoid notch of the radius and
converge at the base of the ulnar styloid. The TFCC is the primary stabilizer of the
DRUJ. Secondary stabilizers are the interosseous membrane, pronator quadratus
muscle, ECU tendon and its subsheath, ulnocarpal ligaments, and DRUJ capsule.
Any operation on the DRUJ should maintain these soft tissue structures to provide
stability. Aggressive dissection and periosteal stripping must be avoided.
• In RA patients, the ECU subluxes volarly and the extensor digiti minimi (EDM) tra-
verses the head of the ulna dorsally. All anatomic structures should be identified and
realigned.
382 CHAPTER 49 Distal Ulnar Resection (Darrach Procedure)
Longitudinal incision is designed over the

prominence head of ulna
A B
Dorsal sensory branch of ulnar nerve

FIGURE 49.2

Some surgeons design the incision over the ulna • The patient is positioned supine with the arm extended and hand pronated on a
styloid and approach the ulna head volar to the hand table.
ECU tendon. The sensory branch of ulnar nerve is • A nonsterile upper arm tourniquet is placed.
retracted dorsally.
• The procedure is performed under general anesthesia or a regional block with seda-
tion. Nerve blocks are preferred in RA patients, who often have cervical spine insta-
EXPOSURES PITFALLS bility and are difficult to intubate safely.
Minimize trauma to the extensor tendons by leaving • Intraoperative fluoroscopy, an oscillating saw, and a bur should be available.
the paratenon intact and avoiding exaggerated
retraction. EXPOSURES
• A curvilinear incision is designed over the ulna head (Fig. 49.2).
• Tenotomy scissors are used to bluntly dissect the soft tissue and protect the super-
ficial veins and dorsal sensory branch of the ulnar nerve.
• The ulna head is exposed between the fifth compartment (EDM) and sixth compart-
ment (ECU; Fig. 49.3).
PROCEDURE
STEP 1 PEARLS
• Preservation of the periosteum or styloid Step 1: Periosteal Flap Elevation and Osteotomy
process will not influence the results. • The DRUJ capsule and periosteum are incised longitudinally just ulnar to the fifth
• Outcomes are better when the minimal dorsal compartment septum and elevated radially and ulnarly to expose the head of
amount of ulna head is resected (just to the
level of the sigmoid notch). The pronator qua- the ulna.
dratus is an important stabilizer of the ulna, so • The osteotomy site is marked proximal to the sigmoid notch with a 45-degree incli-
preserving its attachment improves outcomes. nation (Fig. 49.4). Approximately 2 cm of distal ulna is resected with an oscillating
saw.
FIGURE 49.3
A B
FIGURE 49.4
Step 2: Ulna Head Resection STEP 2 PITFALLS
• A Freer elevator is used to extract the ulna head from the surrounding tissue. A no. 15 Sharp edges of the cut distal ulna may cause
blade is used to divide the soft tissue attachments. tendon rupture postoperatively. The end of the distal
ulna must be smoothed with a rongeur or a file.
• Synovectomy is performed, as necessary.
• A rongeur is used to remove and shape the edges of the remaining bone, especially
at the dorsal lip of the distal end of the ulna. The goal is to remove sharp corners
and areas that may impinge during forearm rotation.
Step 3: Imbrication of the Dorsal Capsule

• After removal of the ulna head, the forearm is pronated and supinated to test the
stability of the distal ulna. There should be no impingement or clicking with motion.
• If the ulna is stable, the dorsal capsule is tightly imbricated with 2-0 braided perma-
nent sutures. As the sutures are tied, the ulna is reduced volarly to prevent dorsal
subluxation. After imbrication, there should be no dorsal prominence of the distal
end of the ulna when fully supinating the wrist.
Step 4: Ulna Head Stabilization (ECU Tendinoplasty and Dorsal

Advancement of Pronator Quadratus)
• If the distal ulna is unstable after ulna head resection, stabilization is performed
with an ECU tendinoplasty with or without dorsal advancement of the pronator
quadratus.
• A 3-mm hole is burred in the dorsal cortex of the distal ulna (Fig. 49.5).
• A distally based slip of ECU is harvested from the radial side of the tendon (Fig. 49.6).
FIGURE 49.5
FIGURE 49.6
384 CHAPTER 49 Distal Ulnar Resection (Darrach Procedure)
Capsule
Pronator quadratus
FIGURE 49.7
ECU FCU
FIGURE 49.8
FIGURE 49.9
STEP 4 PITFALLS • The ECU slip is passed through the medullary canal and out the burred hole in the
Dorsal pronator quadratus muscle advancement dorsal ulna. It is sutured to itself with nonabsorbable sutures while the ulna stump is
is often not possible in RA patients because reduced volarly and the wrist is extended and ulnarly deviated at 15 degrees (Fig. 49.7).
the muscle is very flimsy. In this case, ECU • An adjunctive stabilization procedure is dorsal advancement of the pronator quadra-
tendinoplasty alone is sufficient. tus. The ulnar edge of pronator quadratus muscle is divided and advanced dorsally,
then sutured to the joint capsule. This supports and stabilizes the dorsal aspect of
the distal ulna (Fig. 49.8).
• The dorsal capsule is imbricated as described in Step 3 (Fig. 49.9).
Step 5: Incision Closure and Hemostasis

• The tourniquet is released and hemostasis is ensured.
• The skin incision is closed with 4-0 absorbable sutures (Fig. 49.10).
• For distal ulna resection alone, the wrist is immobilized in a short-arm splint with the
fingers free. When ECU stabilization is performed, the patient is placed in a long-arm
splint for 4 weeks.

• The patient is seen in the office 7 to 10 days postoperatively.
• A removable splint is worn for 6 weeks. Early finger ROM is encouraged.
• The patient can begin wrist motion exercises 6 to 8 weeks after the operation.
FIGURE 49.10
• The Darrach procedure relieves pain and provides predictable, long-term function.
Average range of motion is 85/78 degrees in pronation-supination, 41/45 degrees in
flexion-extension, and 14/19 degrees in radial-ulnar deviation.
• Studies show no difference in outcome when comparing the Darrach to the Sauvé-
Kapandji procedure.
See Video 49.1
EVIDENCE
Yayac M, Padua FG, Banner L, et al. Treatment outcomes in patients undergoing surgical treatment for
arthritis of the distal radioulnar joint. J Wrist Surg. 2020;9(3):230–234.
The authors compared outcomes for 121 patients who underwent surgical treatment for DRUJ arthritis.
Patients were grouped for analysis by procedure type: distal ulnar head resection, DRUJ arthrodesis,
or ulnar head replacement. Overall, 25% of patients had persistent pain and 20% had limited ROM
after surgery. Four percent of patients required revision procedures. They found no difference in
postoperative pain, ROM, rate of complications, or number of revision procedures when comparing
groups.
Carl HM, Lifchez SD. Functional and radiographic outcomes of the Sauvé-Kapandji and Darrach proce-
dures in rheumatoid arthritis. J Hand Microsurg. 2019;11(2):71–79.
This is a retrospective study comparing outcomes after Darrach or Sauvé-Kapandji procedures in RA
patients with DRUJ arthritis. The Darrach procedure was performed on 13 wrists, and the Sauvé-
Kapandji procedure was performed on 11 wrists during the 8-year study period. Mean follow-up was
1.3 years. Pain, function, and ROM improved postoperatively in both groups. There was no differ-
ence in the degree of ulnar translocation.
Grawe B, Heincelman C, Stern P. Functional results of the Darrach procedure: A long-term outcome
study. J Hand Surg Am. 2012;37A:2475–2480.
The authors reviewed 99 Darrach procedures performed for traumatic or posttraumatic DRUJ pathol-
ogy; 27 patients were available for final follow-up. Final average visual analog scale scores for pain
(0–4), pain with activity (0–4), overall satisfaction (0–4), and wrist stability (0–10) were 0.1, 0.6, 3.7,
and 1.5, respectively. Mean wrist range of motion was 85 degrees/78 degrees in pronation-supina-
tion and 41 degrees/45 degrees in flexion-extension. About half of patients had radioulnar impinge-
ment on dynamic radiography, but none were symptomatic. The authors conclude that the Darrach
procedure provides predictable long-term pain relief and function in patients with posttraumatic
DRUJ arthritis.
CHAPTER 50
Sauvé-Kapandji Procedure
INDICATIONS
• The Sauvé-Kapandji procedure consists of fusion of the distal radioulnar joint
(DRUJ) and resection of a short segment of ulna proximal to the joint to preserve
forearm motion. It eliminates the painful articulation between the ulna and sigmoid
notch and maintains normal anatomic alignment of the wrist. When intact, triangular
fibrocartilage complex (TFCC) function is preserved.
• The Sauvé-Kapandji procedure is indicated in patients with DRUJ dysfunction who
are at risk for ulnar carpal translation from inflammatory arthritis or traumatic radio-
carpal ligament injuries.
• Although outcomes are equivalent compared with distal ulna resection, the Sauvé-
Kapandji procedure is preferred in young and high-demand patients.
• Integrity of the TFCC is not a prerequisite for this procedure but may be advanta-
geous.
Contraindications
• Insufficient bone stock at the distal ulna or a grossly deformed ulna head that could
cause tendon irritation is a contraindication.
• Positive ulnar variance is suitable for the shelf arthroplasty procedure as described.
• Prior radial head resection, especially with a history of an Essex-Lopresti injury with
disruption of the interosseous membrane that can further destabilize the forearm
axis.
See Clinical Examination in Chapter 49 Distal Ulna Resection (Darrach Procedure).
IMAGING
See Imaging in Chapter 49.
SURGICAL ANATOMY
See Surgical Anatomy in Chapter 49.
POSITIONING
See Positioning in Chapter 49.
EXPOSURES
• A curvilinear incision is designed over the ulna head between the extensor digiti
minimi (EDM) and extensor carpi ulnaris (ECU) tendons (Fig. 50.1).
FIGURE 50.1
386
FIGURE 50.2
• The soft tissues are bluntly dissected, taking care to preserve dorsal veins and pro-
tect the dorsal sensory branch of the ulnar nerve (Fig. 50.2).
PROCEDURE
Several modifications to the Sauvé-Kapandji procedure have been described. We pre-
fer the shelf arthroplasty technique, in which the distal ulna is rotated 90 degrees and
inserted into a hole drilled in the sigmoid notch. This provides a large surface area for
fusion. The following steps describe the shelf arthroplasty technique.
Step 1: Ulna Head and DRUJ Exposure

• A longitudinal incision is made on the ulnar side of the EDM through the extensor
retinaculum and periosteum.
• The periosteum and extensor retinaculum are elevated radially and ulnarly to expose
the ulna head and DRUJ (Fig. 50.3).
Step 2: Ulna Head Resection

• An oblique osteotomy is performed 30 mm proximal to the distal end of the ulna
or 10 mm proximal to the sigmoid notch of the radius with an oscillating saw STEP 2 PEARLS
(Fig. 50.4A–B). Removal of the articular surface is adequate while
• A Freer is used to extract the distal ulna, and the soft tissue attachments are sharply fashioning the removed ulna to fit into the trough
divided. Synovectomy is performed if necessary. in the sigmoid notch. Be sure that the ulna is fully
seated into the radius for additional stability.
• The sigmoid notch is exposed (Fig. 50.5).
Flap of extensor retinaculum and periosteum
FIGURE 50.3
30 mm
A B
FIGURE 50.4
388 CHAPTER 50 Sauvé-Kapandji Procedure
STEP 3 PEARLS
FIGURE 50.5
The diameter of the drilled hole should match the
diameter of the proximal (cut) end of the ulna.
• The articular surfaces of the ulna head and sigmoid notch of the radius are denuded
of articular cartilage using a rongeur or 3-mm bur.
STEP 3 PITFALLS
Be sure to centralize your drill hole on the sigmoid Step 3: Shelf Osteotomy on Sigmoid Notch
notch. Do not penetrate the subchondral bone of Intraoperative fluoroscopy is used to identify the proper position for shelf osteotomy.
radiocarpal joint or the volar or dorsal cortices of
A 10-mm diameter hole is created in the sigmoid notch of the radius with a 3-mm bur
the radius.
(Fig. 50.6A–C).
C
FIGURE 50.6
Step 4: Placement of Ulna Head STEP 4 PEARLS

• The resected portion of the ulna is rotated 90 degrees and inserted into the hole
• The gap between the ulna head and the ulna
drilled in the sigmoid notch. shaft must be at least 1 cm; this reduces the
• The ulna graft is impacted into the subchondral and cancellous bone of the radius. chance of reossification.
The shelf that is created should be 12 to 15 mm long. • An antirotation Kirschner wire (K-wire) can be
• A guidewire is placed through the center of the ulna head to stabilize the ulna graft placed within the graft (in addition to the
to the radius. Location and length are verified on fluoroscopy. A cortical cannulated screw) if desired. It is removed 3 weeks post-
operatively. We do not routinely do this.
screw is inserted into the guide wire and is used to fixate the ulna graft with the ra-
dius (Fig. 50.7A–D).
• Ulna graft contouring is performed. Sharp edges are removed with a rasp or rongeur STEP 5 PEARLS
(Fig. 50.8). The pronator quadratus fascia can be interposed
over the end of the ulna shaft to stabilize the
Step 5: Ulna Stabilization stump and prevent reossification across the gap
After fixation of the ulna graft, forearm and wrist range of motion is tested. If there is impinge- (Fig. 50.9).
ment or instability, additional contouring is performed and stabilization of the ulnar stump is
indicated. See Step 4 of Chapter 49 Distal Ulna Resection (Darrach Procedure).
A B
12-15 mm
C D
FIGURE 50.7
FIGURE 50.8
Dorsal Pronator quadratus Extensor carpi ulnaris
Extensor carpi
ulnaris tendon
sheath
Final appearance
FIGURE 50.9
Step 6: Wrist Capsule and Wound Closure

• The periosteal flaps are imbricated tightly over the ulna (Fig. 50.10).
• The ECU tendon is relocated over the dorsum of the ulna graft. When there is obvi-
ous subluxation of the ECU tendon during forearm rotation, a retinacular flap can be
used to suspend the ECU tendon (Fig. 50.11).
• The skin is closed with 4-0 monofilament absorbable sutures (Fig. 50.12).
• The patient is placed in a well-padded, long-arm splint with the forearm in neutral
and the fingers free.

• The patient is seen in the office 10 to 14 days after surgery.
• Early postoperative x-rays are shown (Fig. 50.13).
Distal
Retinaculum flap
ECU
ECU
Ulna
head
Proximal
FIGURE 50.12
FIGURE 50.13
• After removal of the long-arm splint, a removable short-arm splint is continued for
another 3 to 4 weeks or until there is radiographic evidence of fusion.
• When ECU tendinoplasty for distal ulna stabilization is performed, the wrist is im-
mobilized in a long-arm splint for 4 weeks, followed by a short-arm splint for another
2 weeks.
• Light strengthening exercises are started 8 weeks after surgery. Heavy lifting and
forceful forearm torque should be avoided for 3 months.
• Patients can expect good pain relief and maintained motion.
• About 20% of patients experience a complication. Reoperation is sometimes neces-
sary for revision osteotomy, excision of heterotopic ossification, or hardware removal.
See video 50.1
EVIDENCE
Munaretto N, Aibinder W, Moran S, Rizzo M. Sauvé-Kapandji remains a viable option for distal radioul-
nar joint dysfunction. Hand (NY). 2020;1558944720966725. Epub ahead of print.
This is a retrospective review of 35 Sauvé-Kapandji procedures performed over a 20-year period with a
minimum of 1-year follow-up. Postoperative wrist extension, pronation, and supination were unchanged.
Wrist flexion was decreased by about 10 degrees compared with preoperative measurements. All
DRUJs successfully fused radiographically. There was one case of ulnar translation (3%) and 4 major
complications (11%). The authors conclude that the Sauvé-Kapandji procedure provides excellent pain
relief, improved grip strength, and maintained wrist motion for patients with DRUJ dysfunction.
Giberson-Chen CC, Leland HA, Benavent KA, Harper CM, Earp BE, Rozental TD. Functional Outcomes
After Sauvé-Kapandji Arthrodesis. J Hand Surg Am. 2020;45(5):408–416.
This study evaluates patient-reported outcomes after the Sauvé-Kapandji procedure for treatment of
DRUJ instability or arthritis. 57 patients underwent the procedure during the 10-year study period.
Surgical indications included posttraumatic arthritis (n = 35), rheumatoid arthritis (10), osteoarthritis
(7), Madelung deformity (3), psoriatic arthritis (1), and giant cell tumor of the bone (1). The mean
QuickDASH (Disability of the Arm, Shoulder, and Head) score decreased from 52 before surgery to
28 1 year postoperatively. The mean QuickDASH score at final follow-up significantly improved in
patients with osteoarthritis and inflammatory arthritis. Supination improved after surgery (48 to 74 degrees),
and wrist flexion, extension, and pronation were unchanged. 21% of patients had complications,
including revision osteotomy (7%) and hardware removal (7%). All DRUJs united radiographically.
Verhiel SHWL, Özkan S, Ritt MJPF, Chen NC, Eberlin KR. A comparative study between Darrach and
Sauvé-Kapandji procedures for post-traumatic distal radioulnar joint Dysfunction. Hand (NY).
2019;1558944719855447. Epub ahead of print.
The authors retrospectively reviewed 85 patients with posttraumatic DRUJ arthritis who underwent ei-
ther a Darrach (n = 57) or a Sauvé-Kapandji (n = 28) procedure. They found no significant difference
in patient-reported function, pain, or satisfaction when comparing the two procedures at a median of
8.4 years postoperatively. 30% of Darrach patients and 50% of Sauvé-Kapandji patients had compli-
cations. Instability of the ulnar stump (n = 10) and dorsal sensory branch of the ulnar nerve symp-
toms (n = 8) were the most common complications. Sauvé-Kapandji patients had more reoperations
for excision of heterotopic ossification. The authors conclude that the Darrach and Sauvé-Kapandji
procedures have comparable long-term results for the treatment of posttraumatic DRUJ arthritis.
Fujita S, Masada K, Takeuchi E, Yasuda M, Komatsubara Y, Hashimoto H. Modified Sauvé-Kapandji
procedure for disorders of the distal radioulnar joint in patients with rheumatoid arthritis. J Bone
Joint Surg Am. 2005;87:134–139.
The authors modified the conventional Sauvé-Kapandji procedure to create an osseous shelf in patients
with poor bone quality of the distal ulna. The modified procedure involves resecting the distal part of
the ulna, making a drill hole in the sigmoid notch, rotating the resected portion of the ulna 90 de-
grees, inserting it into the drilled hole, and fixing it with an AO cancellous screw. Osseous union was
achieved in all cases. Wrist pain resolved or decreased in all patients. The mean total arc of forearm
rotation increased from 144 degrees preoperatively to 167 degrees at follow-up. The mean carpal
translation index did not change after the operation.
CHAPTER 51
Hemiresection Ulnar Arthroplasty
INDICATIONS
• Matched hemiresection ulnar arthroplasty is indicated in patients with distal radioul-
nar joint (DRUJ) pain from posttraumatic arthritis, osteoarthritis (OA), or inflammatory
arthritis with an intact triangular fibrocartilaginous complex (TFCC).
• The premise of hemiresection arthroplasty is that the DRUJ articulation is eliminated,
but the TFCC and ulnocarpal ligaments are maintained.
• The procedure is technically simple, maintains ulnar length, preserves ulnar-sided
wrist stability, and permits full pronation and supination. In addition, there is no need
for prolonged immobilization postoperatively.
• The procedure was introduced to avoid the complications associated with other
ablative procedures (Darrach and Sauvé-Kapandji), such as ulna stump instability,
impingement of the ulna and radius, and ulnar translation of the carpus.
• This procedure is ideal for those with DRUJ arthritis on radiograph and DRUJ pain
with pronation/supination.
Contraindications
• TFCC pathology: There is no advantage to hemiresection arthroplasty over distal
ulna resection (Darrach) if the TFCC is not intact.
• In the case of ulnocarpal abutment with greater than 2 mm positive ulnar variance,
mechanical abutment will persist unless a concomitant ulnar shortening is per-
formed.
• Comprehensive evaluation of the wrist is necessary to identify all sources of ulnar-
sided wrist pain.
• Patients may complain of pain, swelling, stiffness, or decreased grip strength. Some
patients can identify the location of pain as dorsal and directly overlying the DRUJ.
• The ulna compression test confirms the presence of DRUJ arthritis; the radius and
ulna are compressed at the DRUJ with the elbow in 90 degrees of flexion and the
forearm in neutral. Arthritis or synovitis will manifest as pain.
• Crepitus and pain can be appreciated while compressing the DRUJ and passively
rotating the forearm to the extremes of pronation and supination.
• Stability of the TFCC must be confirmed clinically. The aim of this operation is to
remove the impingement of the arthritic ulna with the sigmoid notch. In rheumatoid
patients, the DRUJ is typically unstable, which is a contraindication to performing
this operation. With OA, the TFCC is typically intact and stabilizes the DRUJ, which
makes partial excision of the articulating ulna an ideal operation to remove the
source of pain.
• For additional details, see Chapter 49 Distal Ulna Resection (Darrach Procedure).
IMAGING
• Standard three-view wrist x-rays are mandatory (Fig. 51.1). Careful attention is paid
to the articular surfaces of the sigmoid notch and the ulna head. Narrowing of the
DRUJ and ulna head osteophyte formation are common. Osteophyte formation
typically begins at the proximal aspect of the ulna head; the sigmoid notch is spared
early in the disease process.
• Bilateral wrist x-rays are sometimes helpful to compare ulnar variance and to deter-
mine whether malunion or carpal malalignment exists in the setting of prior trauma.
• Computed tomography (CT) scan aids in diagnosing incongruity of the sigmoid
notch in the setting of prior trauma or if the diagnosis is unclear.
393
394 CHAPTER 51 Hemiresection Ulnar Arthroplasty
FIGURE 51.1
SURGICAL ANATOMY
• The DRUJ is formed by the sigmoid notch of the radius and the ulna head. The ra-
dius of curvature of the sigmoid notch is 20% greater than the ulna head. Motion
through the DRUJ consists of both gliding and rotation (Fig. 51.2).
• The DRUJ is stabilized by ligaments and the fibrocartilage of the volar and dorsal
rims of the sigmoid notch. The shape of the sigmoid notch in the coronal plane can
be quite variable.
• The extrinsic stabilizers of the DRUJ include the TFCC, pronator quadratus (PQ),
extensor carpi ulnaris (ECU), and interosseous membrane.
• The TFCC refers to all the soft tissues and support structures that span the DRUJ
and ulnocarpal joints. The TFCC includes the triangular fibrocartilage (TFC, or ar-
ticular disk), meniscus homologue, palmar and dorsal radioulnar ligaments, ulnar
collateral ligament, ulnotriquetral ligament, ulnolunate ligament, ECU subsheath,
and prestyloid recess.
• The main stabilizers of the DRUJ are the palmar and dorsal radioulnar ligaments.
These ligaments extend from the palmar and dorsal distal margins of the sigmoid
notch and converge in a triangular configuration to attach to the ulna. Each radioul-
nar ligament divides in the coronal plane into a deep limb that inserts into the ulnar
fovea and a superficial limb that inserts into the midportion of the ulnar styloid.
• See Chapter 49 for additional details.

hand table.
• A nonsterile upper arm tourniquet is placed.
• The procedure is performed under general anesthesia or a regional block with sedation.
• Intraoperative fluoroscopy and an oscillating saw should be available.
U R
Sigmoid notch
FIGURE 51.2
Dorsal sensory branch of ulnar nerve

FIGURE 51.3
FIGURE 51.4
• A curvilinear incision is designed over the DRUJ between the fifth and sixth extensor Identify and protect the dorsal ulnar sensory
compartments (Fig. 51.3). nerves. There are usually several branches that
course dorsal to the ulnar styloid.
• The extensor retinaculum is exposed by blunt dissection of the soft tissue, taking
care to preserve the veins and dorsal sensory branch of the ulnar nerve (Fig. 51.4).
PROCEDURE
Step 1: Exposure of the DRUJ
• A longitudinal incision is made through the extensor retinaculum and dorsal capsule
between the EDM and ECU, and the tendons are retracted.
• Capsular flaps are elevated radially and ulnarly to expose the ulna head and DRUJ
(Fig. 51.5).
Step 2: Hemiresection of the Ulna

• Fluoroscopy is used to confirm the osteotomy site (Fig. 51.6). The osteotomy angle
should match the shape of the sigmoid notch.
• A 5-mm sagittal saw is used to remove the articular portion of the ulna head. It may
be necessary to remove between 4 and 7 mm of bone, depending on the size of the
ulna. It is important to expose the underlying cancellous bone to promote healing to
the surrounding soft tissue after resection (Fig. 51.7).

FIGURE 51.7
STEP 2 PITFALLS • Pronate and supinate the forearm to be sure that there is no impingement at the
sigmoid notch. Typically, the dorsal corner of the ulna will rub against the sigmoid
Do not violate the ulnar fovea or ligamentous
stabilizers of the TFCC. notch in full supination. A rongeur is used to remove more bone, if necessary, to
create a smooth arc of motion.
• Interpositional materials such as tendon do not need to be placed into the bone void
after resection.
Step 3: Closure
• The wrist capsule is tightly imbricated with 3-0 Ethibond suture (Fig. 51.8). Capsular
tissue can be interposed between the radius and ulna, if desired.
• The skin is closed with 4-0 absorbable monofilament suture (Fig. 51.9).
• The patient is placed into a long-arm splint with the forearm in neutral.

• The patient is seen in the office 10 to 14 days postoperatively and is fitted for a
custom, thermoplastic, long-arm splint.
• At 3 weeks, the long-arm splint is exchanged for a short-arm splint.

FIGURE 51.10
FIGURE 51.11
• Gradual strengthening begins 8 weeks after surgery.

• At 12 weeks, restrictions are lifted, and the patient may use their extremity as tolerated.
• Figs. 51.10 and 51.11 show radiographs and range of motion 6 weeks postoperatively.
See Video 51.1
EVIDENCE
Nawijn F, Verhiel SHWL, Jupiter JB, Chen NC. Hemiresection interposition arthroplasty of the distal
radioulnar joint: A long-term outcome study. Hand (NY). 2019;1558944719873430. Epub ahead of
print.
This study reviews long-term patient-reported outcomes in patients who underwent hemiresection in-
terposition arthroplasty of the DRUJ. 66 patients were included. The mean interval between surgery
and follow-up questionnaire was 8.6 years. The mean QuickDASH (Disabilities of the Arm, Shoulder,
and Head) score was 31.0 ± 20.2. The mean score on the Hemiresection Interposition (HIT) arthro-
plasty questionnaire was 2 ± 2. The median numeric rating for pain was 1 (interquartile range [IQR],
0–3), and the median numeric rating for satisfaction was 9 (IQR, 8–10). The complication rate and
reoperation rate were 14% and 8%, respectively. They conclude that most patients are satisfied after
HIT arthroplasty. Patients with inflammatory arthritis had higher satisfaction and lower pain scores.
Patients who had prior trauma, prior surgery, or DRUJ subluxation were less satisfied. Men, older
patients, and posttraumatic patients had more pain postoperatively. Posterior interosseous nerve
neurectomy was associated with improved pain scores.
Ahmed SK, Cheung JP, Fung BK, Ip WY. Long term results of matched hemiresection interposition ar-
throplasty for DRUJ arthritis in rheumatoid patients. Hand Surg. 2011;16(2):119–125.
This is a retrospective review of 51 rheumatoid wrists treated with matched hemiresection interposition
arthroplasty over an 18-year period. 31% of patients had extensor tendon ruptures at the time of
their initial surgery. Average follow-up time was 4.5 years. There was no statistically significant
change in pronation or supination after surgery. Grip strength increased from 6.1 kg before surgery
to 11.5 kg after surgery. 84% of patients had complete relief of ulnar-sided wrist pain, and another
14% had reduced pain postoperatively. They conclude that matched hemiresection arthroplasty pro-
vides excellent pain relief and maintains motion in rheumatoid patients with DRUJ arthritis.
CHAPTER 52
Total Wrist Arthroplasty
INDICATIONS
• Total wrist arthroplasty (TWA) is indicated in low-demand patients with severe wrist
pain who require some motion. Potential candidates include patients with osteoar-
thritis (OA), posttraumatic arthritis, and sometimes rheumatoid arthritis (RA).
• Although new implant designs show promise, TWA is fraught with complications in-
cluding stiffness, infection, tendon attenuation, and hardware loosening, dislocation,
or failure. Fastidious precision is mandatory in placing the current implant design
because of the multiple steps in inserting the implant.
• Pain relief after TWA is typically inferior to wrist fusion, and few patients achieve
functional wrist motion postoperatively.
• The patient must understand the risks and benefits of TWA and must commit to a
lifetime of restricted activities imposed by having an artificial wrist.
Contraindications
• Young or active patients with high-demand occupations or activities (sports, farming,
manual labor, etc.)
• Poor bone stock caused by osteopenia, osteoporosis, or rheumatoid disease
• Poor skin or soft tissue quality
• Tendon imbalance or spasticity that would limit postoperative mobility or create
abnormal joint loading
• Prior wrist infections or infected hardware
• Elicit a detailed history of the patient’s functional demands, activities, occupa-
tion, hobbies, and home circumstances. High-demand activities hasten implant
failure.
• The hand and wrist are inspected for previous scars, erythema, swelling, and deformity.
Signs of active inflammatory disease or infection may be a contraindication to wrist
replacement.
• Finger, wrist, and forearm range of motion (ROM) are assessed. Any contracture or
spasticity should be identified preoperatively; imbalance of forces about the wrist
can cause abnormal loading of the implant.
• The carpus and distal radioulnar joint (DRUJ) are examined for subluxation and dis-
location, which suggest inherent wrist instability.
• RA patients are prone to tendon and soft tissue imbalances and must be examined
carefully. Evaluate the quality of the skin and the capacity for wound healing after implant
placement. Systemic therapy for rheumatoid disease must be optimized before surgery.
• Patients are immobilized in a wrist splint and instructed to wear it full time for a trial
period. Arthroplasty is considered for those who find immobilization intolerable.
IMAGING
• Standard three-view wrist radiographs are mandatory to determine the extent of
wrist destruction. If there is well-preserved bone stock and most of the carpal joints
are severely affected (Fig. 52.1), then total wrist arthroplasty is an option.
• Computed tomography (CT) scan or wrist arthroscopy are indicated when the extent
of intercarpal or radiocarpal arthrosis is unclear.
• When the radiocarpal or intercarpal joints are spared, other options, such as proxi-
mal row carpectomy or four-corner fusion (see Chapter 27 Salvage Procedures for
Scaphoid Nonunion), is preferable to total wrist arthroplasty or arthrodesis.
399
400 CHAPTER 52 Total Wrist Arthroplasty
FIGURE 52.1
• Rheumatoid wrists should be evaluated with great care; radiographs may not show
the true extent of arthrosis or osteopenia. In RA patients with radiocarpal arthritis
without midcarpal joint involvement, radiolunate or radioscapholunate fusion can be
considered to maintain some motion.
• Implant size can be estimated from preoperative wrist radiographs.
SURGICAL ANATOMY
• The implant described in this chapter is the Integra Freedom Wrist Arthroplasty Sys-
tem. The design consists of components to replace the distal radius and the proximal
carpal row. The radial component has a stem that is inserted into the intramedullary
canal. The carpal component consists of a titanium plate that is fixed into the carpal
bones with a central peg and two screws. A convex ultra-high-molecular-weight
polyethylene (UHMWPE) bearing is locked onto the carpal plate and articulates with
the concave surface of the distal radial component.
• The carpal component is fixated with two variable-angle screws, and a central stem
is inserted into the capitate. Screws are passed through the scaphoid, trapezoid,
and second carpometacarpal (CMC) joint radially and through the hamate ulnarly.
EXPOSURES PEARLS The ulnar screw should not be passed through the mobile fourth or fifth CMC joints.
• The posterior interosseous nerve is located on The radial component articular surface is inclined 40 degrees to give the option to
the floor of the fourth extensor compartment. If preserve the ulna head.
desired, a 1-cm portion of nerve is excised • Older implants with ball-and-socket or hinge designs are prone to wrist imbalance
proximal to the radiocarpal joint for postopera-
and implant dislocation postoperatively. Newer designs use a broad articulation to
tive pain control. This may not be necessary,
however, and it is not routinely performed. reduce these risks.
• If there is significant DRUJ arthritis, a Darrach
procedure can be performed before radiocar- POSITIONING AND EQUIPMENT
pal joint manipulation by incising the capsule • The patient is positioned supine with the arm extended and hand pronated on a
over the distal ulna and resecting the distal
hand table.
ulna at a 45-degree oblique apex-ulnar angle
(Fig. 52.7). The resected ulna bone is saved • The operation is performed under regional block or general anesthesia.
for bone graft. (For more information, see • Preoperative antibiotics are given.
Chapter 49). • A nonsterile, upper arm tourniquet is placed.
• If the head of the ulna is preserved, care • Intraoperative fluoroscopy, an oscillating saw, and the wrist implant system are
should be taken to preserve the triangular
required.
fibrocartilage complex (TFCC) during elevation
of the dorsal wrist capsule flap.
EXPOSURES
• A dorsal, longitudinal incision is designed extending from the midshaft of the third
EXPOSURES PITFALLS metacarpal to about 4 cm proximal to the wrist crease (Fig. 52.2).
Avoid creating rents in the extensor retinaculum • Flaps of skin and subcutaneous tissue are elevated to expose the extensor reti-
during its elevation by staying under the septum naculum (Fig. 52.3). The dorsal sensory branches of the radial and ulnar nerves are
separating the compartments, especially at Lister preserved within the skin flaps. If necessary, dorsal veins may be ligated, but this
tubercle.
increases postoperative edema.
FIGURE 52.2
FIGURE 52.3
FIGURE 52.4
• A radially based extensor retinaculum flap is designed (Fig. 52.4). A longitudinal

incision is made through the retinaculum over the extensor carpi ulnaris (ECU),
and then the retinaculum is carefully elevated to the septum between the first and
second compartments. The intercompartmental septa are taken down to create a
single, continuous retinacular flap (Fig. 52.5).
• Extensor tenosynovectomy is performed, if needed.
• The integrity of the extensor carpi radialis brevis and longus are confirmed. They are
used later for extensor centralization.
• The extensor tendons are retracted to expose the joint capsule.
• The dorsal wrist capsule is raised as a distally based, rectangular flap. The dorsal DRUJ
capsule and the periosteum over the distal 1 cm of the radius are included to create a
longer flap for closure. The radial and ulnar sides of the flap are the floors of the first (or
second) and sixth extensor compartments, respectively. The purpose of the capsular
flap is to provide soft tissue coverage and stout support for the implant (Fig. 52.6).
PROCEDURE
Step 1: Preparation of the Radius
• The wrist is hyper-flexed to expose the articular surface of the distal radius. The
radial template is aligned with the dorsal, radial edge of the articular surface, and the
Extensor retinaculum flap

FIGURE 52.5
Rectangular flap
of wrist capsule
Radius
Distally based dorsal wrist capsular flap
FIGURE 52.6
notch is used to mark the Kirschner wire (K-wire) insertion site. This is typically be-
low the Lister tubercle, in the dorsal ulnar quadrant of the scaphoid fossa, and about
5 mm volar to the dorsal lip of the distal radius.
• The drill guide is used to place a 0.054-inch K-wire at the marked spot (Fig. 52.8).
Use fluoroscopy to ensure that the guidewire is centered in the radial medullary
canal on both PA and lateral views.
• A 3.5-mm cannulated drill is placed over the guidewire and drilled to the highest
laser mark near the end of the flutes. The drill and K-wire are removed, and the radial
Ulna head
Dorsal capsular flap

(in forceps)
FIGURE 52.7
0.054-inch guidewire Distal radius articular surface
STEP 1 PEARLS
• The articular surface of the distal radius may
be distorted by chronic wear, trauma, or inflam-
mation. If the radial template does not fit with
the articular surface, the start point for the
guidewire is estimated and then positioning is
confirmed (and adjusted) with fluoroscopy.
• The Lister tubercle may need to be removed
with a rongeur to permit full seating of the
cutting block (Fig. 52.10).
• Resect the minimum amount of radial articular
FIGURE 52.8 surface to preserve the stability of the soft
tissue envelope around the implant.
• If the DRUJ is preserved, then the radial oste-
otomy should not violate the sigmoid notch.
intramedullary guide rod is inserted into the drilled hole. Positioning is confirmed
STEP 1 PITFALLS
with fluoroscopy.
• The radial feeler and cutting block are mounted on the guide rod and positioned to Avoid injury to the volar structures during the
osteotomy. Intact radiocarpal ligaments provide
remove the articular surface (Fig. 52.9A). K-wires are used to stabilize the cutting
soft tissue stabilization of the implant. Inadvertent
guide block against the radius. The radius is scored with the saw to mark the oste- injury to flexor tendons or the median nerve is also
otomy line. The radial feeler and guide rod are then removed (see Fig. 52.9B). possible and must be avoided.
• The radial osteotomy is performed with an oscillating saw. To complete the cut, the
cutting guide may need to be removed.
STEP 2 PEARLS
• Remove any prominent areas and osteophytes using a rongeur.
• To achieve proper implant alignment, the broach
Step 2: Trial Radial Component Implantation is inserted slightly dorsal in the metaphysis to
avoid tracking along the palmar metaphyseal
• After the radial osteotomy is complete, the intramedullary guide rod is reinserted. flare that will cause tilt of the implant.
• The appropriately sized box punch is mounted on the rod and slid down flush • After the trial radial component is inserted, soft
against the bone, centered within the medullary canal (Fig. 52.11). A mallet is used tissue tension around the wrist can be esti-
to drive the box punch into the medullary canal until its collar becomes flush with mated by reducing the radiocarpal joint. If nec-
essary, additional bone can be removed from
the osteotomy-cut cortex. Remove the box punch and guide rod and remove any
the distal radius to reduce tension. This should
remaining box chips with a curette. only be done, however, after distal component
• Attach the size 1 broach to the handle and insert the nose into the radial canal. En- implantation.
sure that the broach is directly centered within the medullary canal (Fig. 52.12). Drive
the broach with a mallet until the dorsal collar is flush with the bone. Sequentially STEP 2 PITFALLS
increase the broach size up to the desired implant size.
A very large lunate fossa defect will result in poor
• A trial implant is inserted and tapped with an impactor until fully seated. Position is
implant support.
confirmed with fluoroscopy.
Alignment
guide
Radial
Radial cutting bar
cutting block
B
A
FIGURE 52.9 (A-B) The radial guide bar is slid over the rod until it abuts the radius. The radial cutting guide block is mounted
onto the guide bar and slid into proper position. It is positioned to guide the saw cut just beneath the articular surface. As the
cutting block is held aligned with the dorsal surface of the radius, two or three 1.1-mm Kirschner wires (K-wires) are inserted
through the holes in the cutting block and drilled into the distal radius. The cutting block has four rows of three holes spaced
2 mm apart. By using the middle holes in the rows, the cutting block can be adjusted proximally or distally, if necessary.
Lister tubercle
FIGURE 52.10
Box punch Cut edge of radius
FIGURE 52.11 The alignment rod is reinserted into the medullary canal of the radius. The proper size
broach head is inserted into the broach handle and set to the position marked for either “standard”
or “minimal” broaching. The broach is slid over the alignment rod and its sides are aligned parallel to
the sigmoid notch and volar rim of the radius. Using a mallet, the broach is driven into the distal ra-
dius until its collar is flush with the cortex.
Line of carpal
osteotomy
FIGURE 52.12 Using a mallet, the broach is driven into

the distal radius until its collar is flush with the cortex. FIGURE 52.13
K-wire fixation
Lunate excision
FIGURE 52.14
Step 3: Preparation of the Carpus and Trial Component Insertion STEP 3 PEARLS
• Attention is then turned to preparation of the carpus. The lunate is completely ex- • The axial distraction test is critical. If the joint
cised. The distal osteotomy passes through the scaphoid waist, the head of the is markedly lax, the implant is likely to dislo-
capitate, the proximal 1.5 mm of the hamate, and the midtriquetrum (Fig. 52.13). cate postoperatively. A larger polyethylene
implant is inserted to add more volume to the
• If the scaphoid and triquetrum are mobile, they will interfere with the osteotomy wrist and impart stability.
procedure and are temporarily pinned to the capitate. This K-wire should be placed • If extrinsic tendon flexion contracture is pres-
volarly within the bones to avoid the osteotomy line (Fig. 52.14). ent, step-cut lengthening of the flexor carpi
• The carpal sizer is placed just distal to the level of resection and centered on the ulnaris and flexor carpi radialis can be per-
long axis of the capitate. Size is determined by the line that most closely matches formed to achieve the tendon balance.
up with the center of the proximal pole of the hamate. This corresponds with the
ulnar screw insertion size. The appropriate carpal drill guide is used according to the
selected implant size.
Long finger
metacarpal bone
Satellite plate
Capitate
Drill guide
plate
2.5-mm drill
B
A
FIGURE 52.15 (A–B) In applying the modular drill guide, the barrel is pressed against the capitate head and the saddle is
placed onto the third metacarpal shaft over the skin. The sleeve for the guidewire is inserted in the drill guide barrel. The
1.4-mm guidewire is drilled through the capitate and into the third metacarpal. The sleeve and drill guide are removed se-
quentially.
• The modular drill guide is used to center the carpal stem within the capitate. The bar-
rel is pressed against the head of the capitate and the saddle is placed onto the third
metacarpal shaft over the skin (Fig. 52.15A). The sleeve for the guidewire is inserted
in the drill guide barrel. The 0.54-in guidewire is drilled through the capitate and into
the base of the third metacarpal (see Fig. 52.15B). The sleeve and drill guide are re-
moved sequentially. The position of the guidewire is confirmed with fluoroscopy.
• A cannulated drill with a 3.5-mm drill bit is introduced over the guidewire and the
capitate tunnel is created (Fig. 52.16). The depth of the drill hole corresponds to the
implant size and is marked with laser lines on the bit.
• The longitudinal K-wire and cannulated drill are removed. The carpal guide bar is
inserted into the capitate hole and the carpal resection guide is mounted and pinned
(Fig. 52.17).
• The osteotomy is performed with an oscillating saw (Fig. 52.18).
• The K-wires and carpal resection guide are removed. The appropriately sized carpal
reamer is used to prepare the capitate drill hole to accept the trial implant. The flange
on the carpal reamer must abut the capitate. If the reamer does not sit flush with the
capitate, drill the hole deeper and ream again.
• The trial carpal component is inserted into the capitate drill hole. The dorsal edge of
the carpal component must be flush with the dorsal cortex of the capitate.
FIGURE 52.16 The 3.5-mm cannulated drill for the minimal hole or the 4.5-mm cannulated drill for
the standard hole is placed over the guidewire, and a hole is made in the capitate to the proper
depth marked on the drill bit (approximately 20 to 22 mm).
Cutting guide
FIGURE 52.17 The appropriate carpal guide bar, for either a standard or minimal hole diameter, is
inserted into the capitate hole to its full depth. The carpal cutting guide block is mounted onto the
guide bar and slid into proper position.
Cut surface of the carpal bones
FIGURE 52.18 The guide block is positioned to guide the saw cut through the proximal 1 mm of the
hamate, which will pass through the capitate head, scaphoid waist, and midtriquetrum.
• Screws are inserted on the radial and ulnar holes of the carpal component. The
metacarpal alignment guide is placed with the distal plate sitting on the index meta-
carpal and the proximal plate sitting on the radial hole. A 30- to 35-mm long, 2.5-mm
wide drill hole is drilled into the trapezoid across the CMC joint of the index meta-
carpal. A 4-mm screw is inserted into the radial screw hole (Fig. 52.19).
• The metacarpal alignment guide is placed on the axis of the ring metacarpal and the
hamate. The 2.5-mm drill bit is used to drill into the triquetrum and the hamate. Do
not cross the carpometacarpal joint (Fig. 52.20). A 4-mm screw that is 20 mm in
length is inserted into the triquetrum and the hamate.
• Intraoperative fluoroscopy is used to confirm the proper placement of the screws
and the carpal component.
• The trial polyethylene central component is attached to the carpal component. This
will snap into place when properly positioned on the carpal component (Fig. 52.21).
• The radial and carpal trial prostheses are reduced, and wrist motion and stability are
tested. Approximately 35 degrees of flexion, 35 degrees of extension, and 10 de-
grees of radial/ulnar deviation are expected. Some soft tissue tightness is expected
in full extension.
Step 4: Final Implant Placement

STEP 4 PEARLS
• After the wrist is stabilized and balanced, the trial components are removed.
• Several small holes are drilled in the dorsal cortex of the distal radius about 3 mm The final implant can be inserted with or without
bone cement. Usually, there is no need to use the
proximal to the osteotomy line; 2-0 Ethibond sutures are placed through the holes
bone cement.
and used later to anchor the dorsal capsular flap (Fig. 52.22).
Trial implant of
carpal component
Diameter: 4 mm Diameter: 4 mm
Length: 20 mm Length: 30-35 mm
Trial screw Trial screw

FIGURE 52.19 The trial carpal component is inserted into the capitate drill hole. The dorsal edge of
the carpal component must be flush with the dorsal cortex of the capitate.
Radial screw into 2nd MC Ulnar screw in hamate
A B
FIGURE 52.20 (A–B) The modular drill guide is applied with its barrel in the radial hole of the trial carpal component and its saddle on
the second metacarpal shaft over the skin. A 2.5-mm hole is drilled across the scaphoid, trapezoid, and second CMC joint to a
depth of 30 mm to 35 mm. A similar technique is used for the ulnar side, with a few important differences. The saddle is placed on
the fourth metacarpal shaft over the skin. The mobile fourth metacarpal must be held elevated (fourth CMC extended) while drilling to
ensure that the hole is not directed volarly. The hole is drilled through the hamate but does not cross the mobile fourth CMC joint. Its
depth is typically 20 mm, but a small wrist may accommodate only 15 mm.
The trial polyethylene central component
A B
FIGURE 52.21
FIGURE 52.22 Drill holes on the dorsal cortex of the radius for securing the dorsal joint capsule later.
Carpal component Radial component

FIGURE 52.23 The polyethylene implant was then placed; a standard implant was used; and the pa-
tient had about 30 degrees extension, 30 degrees of flexion, and 10 degrees of radial ulnar deviation.
The standard implant was quite suitable, and a #3 implant could be placed. The permanent implant
with a radial component and distal carpal component inserted with 4.5-mm screw was then inserted
across the scaphoid into the second metacarpal, and a 17.5-mm screw was placed into the
hamate.
• The articular surfaces are removed from the triquetrum, capitate, hamate, scaphoid,
and trapezoid, and previously resected bone is packed into the spaces to achieve
intercarpal fusion.
• The final implants are placed and the proper screws are inserted (Figs. 52.23 and 52.24).
The positions of the implants are confirmed using fluoroscopy (Fig. 52.25). Final ROM
and stability are assessed before closure.
Polyethylene component
FIGURE 52.24 The bone graft was harvested from the excised distal ulna and packed between the
scaphoid and the capitate and the capitate and hamate. There was a slight crack of the dorsal cor-
tex over the radius, which was also packed with bone graft. Polyethylene implant was inserted and
patient had a good position of the implant on x-ray.
A B
FIGURE 52.25
STEP 5 PEARLS
Step 5: Joint Capsule and Retinacular Closure
• If the joint capsule is too tight to completely • The dorsal joint capsule is secured to the distal radius using the previously placed
cover the prosthesis, the distal part of the
extensor retinaculum can be divided and Ethibond sutures. The sutures should be tied with the wrist in full flexion to ensure
passed under the extensor tendons to full support of the wrist joint, even with stretching of the capsule (Fig. 52.26).
cover the remaining defect. • The extensor retinaculum is closed over the extensor tendons (Fig. 52.27).
• If the extensor tendons are ulnar to the axis of
the wrist, extensor tendon repositioning is per- Step 6: Skin Closure
formed, meaning that a partial slip of the ECRL
tendon is looped around the extensor tendons • The tourniquet is released and hemostasis ensured.
(except the ECU) to pull radially. The tendon loop • The skin is closed with a 4-0 monofilament suture (Fig. 52.28).
is then sutured to the ECRL tendon insertion; • The patient is placed in a short-arm splint with the fingers free.
this will suspend the extensor tendons radially.
• The patient is seen in the office 10 to 14 days postoperatively.
• A removable wrist splint is worn for an additional 4 to 6 weeks.
• During the splinting period, the patient will start active flexion, extension, pronation,
and supination exercises several times a day.
Dorsal Capsule repair
ECRL
repair
FIGURE 52.26 The second compartment tendon migrated into the saw guide, and the patient had
laceration of the extensor carpi radialis longus tendon that was repaired using a Kessler repair, 2-0
Ethibond, and a horizontal mattress of 2-0 Ethibond repair for additional stability in a 6-strand repair.
The partial rent over the extensor carpi radialis brevis tendon was also repaired this way.
FIGURE 52.27 The extensor retinaculum was then placed over the
content of the fourth and fifth compartment and sutured to the exten-
sor retinaculum over the sixth compartment using 3-0 Ethibond suture. FIGURE 52.28
• At 8 weeks, strengthening and passive exercises can begin.

• At 12 weeks, unrestricted activity is permitted, but the patient is cautioned against
repetitive loading and manual labor.
• Patients should expect a lifetime of functional restrictions to prevent hardware com-
plications.
See Video 52.1
EVIDENCE
Fischer P, Sagerfors M, Jakobsson H, Pettersson K. Total wrist arthroplasty: A 10-year follow-up.
J Hand Surg Am. 2020;45(8):780.e1–780.e10.
This is a prospective study of 136 total wrist arthroplasties implanted between 2005 and 2009. The
authors assessed implant survival and radiographic loosening at 5-year and 10-year follow-up.
Secondary outcomes were motion, grip strength, pain, and patient-reported function. Implant
survival was 92% with revision as the primary endpoint, and 75% when nonrevised, radiographically
loose implants were included as failures. At 10-year follow-up, patients with surviving implants
had preserved wrist ROM, improved grip strength, decreased pain, and improved patient-reported
function compared with preoperative values.
Honecker S, Igeta Y, Al Hefzi A, Pizza C, Facca S, Liverneaux PA. Survival rate on a 10-year follow-up
of total wrist replacement implants: A 23-patient case series. J Wrist Surg. 2019;8(1):24–29.
The authors review 23 cases of total wrist arthroplasty performed with the Stryker ReMotion implant.
The most common indication was RA (n = 19), and the average patient age was 55 years of age. The
average implant survival rate was 95.7% at 4-year follow-up, 91.3% at 6-year follow-up, and 69% at
10-year follow-up. QuickDASH (Disabilities of the Arm, Shoulder, and Head) scores, pain, wrist exten-
sion, and grip strength improved postoperatively. There was no change in wrist flexion, pronation, or
supination. Complications included infection and implant displacement, which were salvaged by
implant replacement or arthrodesis.
Yeoh D, Tourret L. Total wrist arthroplasty: a systematic review of the evidence from the last 5 years.
J Hand Surg Eur. 2015;40:458–468.
This article compares outcomes for several commercially available total wrist implants. In total, 405 total
wrist arthroplasties were reviewed using 7 different implants. RA was the most common indication.
The Motec implant had the best postoperative DASH scores. Only the Maestro implant achieved a
functional range of motion postoperatively. Universal 2 had the highest implant survival rates (100% at
3–5 years), whereas Elos had the lowest (57% at 5 years). Biaxial had the highest complication rates
(68.7%), and Remotion had the lowest (11%). The authors conclude that wrist arthroplasty preserves
some motion but has high complication rates compared with wrist fusion. Functional scores improved
and were maintained over the mid- to long-term. The evidence does not support the widespread use
of arthroplasty over arthrodesis, and careful patient selection is essential.
Cavaliere CM, Chung KC. A systematic review of total wrist arthroplasty compared with total wrist
arthrodesis for rheumatoid arthritis. Plast Reconstr Surg. 2008;122:813–825.
This is a systematic review comparing outcomes for total wrist fusion and total wrist arthroplasty. Total
wrist fusion provided more reliable pain relief. Complication and revision rates were higher for total
wrist arthroplasty. Satisfaction was high in both groups. Of the 14 studies who reported on motion
after total wrist arthroplasty, only 3 showed postoperative motion in the functional range. In this era of
cost-conscious medical care, expensive interventions must demonstrate superior outcomes. Existing
data do not support widespread application of total wrist arthroplasty for the RA wrist.
CHAPTER 53
Total Wrist Fusion
INDICATIONS
• Total wrist fusion is indicated in patients with pain or instability after failure of non-
operative management and motion-preserving procedures.
• Wrist fusion is preferred when multiple joints (i.e., the radiocarpal and midcarpal
joints) are involved. If disease is isolated to a single joint, motion-preserving proce-
dures, such as a proximal row carpectomy or partial wrist arthrodesis, can be con-
sidered (Fig. 53.1).
• Total wrist fusion is a treatment option for patients with osteoarthritis (OA),
posttraumatic arthritis, inflammatory arthritis, Keinböck disease, scapholunate
advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC)
wrist, and ligamentous instability. It is a salvage for failed partial fusions or
arthroplasty.
• Other indications include traumatic segmental bone loss of the distal radius and
carpus, reconstruction after segmental tumor resection, and paralysis of the wrist.
• Pain relief and stability are prioritized at the expense of wrist motion. A detailed his-
tory of the patient’s functional demands, activities, occupation, hobbies, and home
circumstances is mandatory. A preoperative trial of splinting to simulate loss of mo-
tion can help set patient expectations.
Wrist arthritis
Pain and instability
Contraindications to limited procedures Intact motion

- Limited motion <30 degrees >30 degrees
- Soft tissue issues
- High risk for failure w/ other surgery Tolerable?
Single joint
Total wrist Diffuse arthritis
arthritis
arthrodesis
Patient tolerates Intolerance to

immobility immobility
Candidate for Sparing of capitate Lunate fossa spared,

arthroplasty? and lunate fossa capitate involved
Total wrist Proximal row Limited fusion

arthroplasty carpectomy procedures
FIGURE 53.1
413
414 CHAPTER 53 Total Wrist Fusion
Contraindications
• Arthrodesis is contraindicated in patients with active infection or uncontrolled inflammation.
• The hand and wrist are examined for previous scars and areas of tenderness,
edema, and deformity (Fig. 53.2).
• The carpus and distal radioulnar joint (DRUJ) are assessed for subluxation and dis-
location, which suggest inherent wrist instability.
• Range of motion (ROM) is evaluated and documented for individual joints.
• A thorough nerve examination is performed to rule out concomitant carpal tunnel
or Guyon canal syndrome, which can occur because of synovitis within the carpal
canal or with dislocation of the carpus.
IMAGING
• Standard, three-view radiographs of the wrist are mandatory to evaluate the joint
surfaces, carpal alignment, and bone quality. SLAC and SNAC patterns are often
seen in patients with posttraumatic arthritis and should be noted preoperatively
(Fig. 53.3).
• Well-controlled rheumatoid patients typically have localized joint erosions with main-
tained joint spaces. As the disease progresses, radiocarpal arthrosis develops and
the carpus translates ulnarly and subluxes volarly. If the midcarpal joint is preserved,
radiolunate or radioscapholunate fusion can be considered. Patients with advanced
rheumatoid disease have pancarpal arthrosis and significant bone loss. Total wrist
fusion is the only predictable surgery for these patients (Fig. 53.4).
• Computed tomography (CT) scans provide detailed information on the radiocarpal,
midcarpal, and intercarpal joints and are indicated when the extent of arthrosis is
unclear on plain films.
SURGICAL ANATOMY
• There are eight carpal bones organized into two rows. The scaphoid, lunate, trique-
trum, and pisiform constitute the proximal carpal row. The distal row includes the
FIGURE 53.2
trapezium, trapezoid, capitate, and hamate. The proximal carpal articulates with the
radius proximally, and the distal carpal row articulates with the metacarpal bases dis-
tally. The articulation between carpal rows is called the midcarpal or intercarpal joint.
• The wrist is composed of the distal radioulnar joint (DRUJ), the radiocarpal joint, and
the midcarpal joint. The DRUJ is a pivot joint; the ulnar head articulates with the
sigmoid notch on the distal radius and allows pronation and supination of the fore-
arm. The radiocarpal joint is an ellipsoid joint formed by the distal end of the radius
and the proximal carpal row. It allows for wrist flexion/extension and radial/ulnar
deviation. The lunate and triquetrum make only intermittent contact with the ulna on
maximal ulnar deviation.
• Flexion occurs mostly through the midcarpal joint (60% midcarpal, 40% radiocar-
pal), whereas extension occurs mostly through the radiocarpal joint (66% radiocar-
pal, 34% midcarpal).
• 90% of radial deviation occurs through the midcarpal joint. The radiocarpal and
midcarpal joint contribute equally to ulnar deviation.
• Total wrist fusion requires union of the radiolunate, radioscaphoid, scaphocapitate,
lunocapitate, and capitometacarpal joints. If ulnar impingement is a concern, the
triquetrum can be excised at the time of fusion. The hamatocapitate and trapezoido-
metacarpal joints are immobile and do not need to be fused.

• The procedure is performed under regional block or general anesthesia. Preopera-
tive antibiotics are administered.
• The patient is positioned supine with the arm extended on a hand table. A rolled
towel is placed in the palm for support.
• An upper arm tourniquet is used.
• Fixation can be performed using pins, staples, plates, and screws or intramedullary
rods. When there is adequate bone stock, we prefer to use a 3.5-mm precontoured
wrist fusion plate with 3.5-mm screws for the radius and 2.7-mm screws for the
carpus and metacarpal.
EXPOSURES
• A dorsal longitudinal incision is designed over the third ray, extending from the third
metacarpal base to 3 to 4 cm proximal to the radiocarpal joint (Fig. 53.5). In patients
EPL tendon in
3rd dorsal compartment
Wrist capsular flaps

elevated and retracted
EPL tendon
EXPOSURES PEARLS
FIGURE 53.9
• In patients with active synovitis, synovectomy
is performed to reduce pain and inflammation
(Fig. 53.10). with severe deformity, it can be difficult to identify bony landmarks; the incision
• If desired, a posterior interosseous neurectomy should follow a line from the long finger metacarpal base, through the lunocapitate
can be performed. The nerve is found on the joint, and across the lunate fossa of the radius (Fig. 53.6).
floor of the fourth extensor compartment and
can be divided proximal to the radiocarpal joint • Dissection is carried down to the level of the extensor retinaculum, taking care to
for pain control. We do not do this routinely. preserve dorsal sensory branches of the radial and ulnar nerves. If necessary, dorsal
• Maintain a thick capsular flap to provide veins are ligated, but this contributes to postoperative edema (Fig. 53.7).
coverage of the plate. • Flaps are elevated at the level of the extensor retinaculum. The third extensor com-
• When the DRUJ is arthritic, it should be ad- partment is incised obliquely (in line with the extensor pollicis longus [EPL] tendon),
dressed before radiocarpal joint manipulation.
A Darrach procedure (see Chapter 49) or and the EPL is transposed radially over the retinaculum (Fig. 53.8).
matched hemiresection arthroplasty (see • The interval between the second and fourth extensor compartments is incised lon-
Chapter 51) is performed by incising the cap- gitudinally and the extensor tendons are retracted to expose the joint capsule.
sule over the distal ulna and resecting a portion • The dorsal wrist capsule is incised in a straight line through this same interval and is
of bone. The resected bone is saved and used elevated radially and ulnarly to expose the carpal bones (Fig. 53.9).
for graft.
• The periosteum is elevated off the dorsal radius and the middle finger metacarpal.
FIGURE 53.10
Area of bone resection

for fusion
3rd metacarpal
Radius
FIGURE 53.12
FIGURE 53.11 STEP 1 PEARLS

• The wrist should be assessed to confirm that
the joints are reducible and that alignment is
PROCEDURE preserved.
• The radius and carpus should not be signifi-
Step 1: Preparation of the Dorsal Bone cantly shortened. Preserving wrist height
• The dorsal cortex of the radius, carpus, and metacarpals are exposed for plate maintains tendon length and digital motion.
placement (Fig. 53.11).
• Lister tubercle and the dorsal lip of the radius are removed to allow the plate to sit STEP 1 PITFALLS
flush against the bone (Fig. 53.12). Failure to properly reduce the carpus makes
• A fine rongeur is used to remove the articular surfaces of the radiocarpal and mid- plate positioning difficult. Precontoured plates
carpal joints. Cortical bone from the dorsal aspect of the scaphoid, lunate, capitate, typically come with a dorsal bend of 15 degrees
and third carpometacarpal joint is also removed (about one-fourth of the volar-dorsal to match the contour of the wrist and to maximize
postoperative function. Many plating systems are
depth). Any removed bone is kept for grafting.
available (Fig. 53.13).
Step 2: Plate Selection
Choose a plate and position it on the dorsal radius, carpus, and third metacarpal, pay-
ing particular attention to rotation. If the wrist is shortened, a contoured plate will not
lie flush against the bones, and a straight plate is used instead.
Locking plate
for wrist fusion
FIGURE 53.13
Step 3: Bone Grafting and Fixation of the Plate

STEP 3 PEARLS • The denuded articular surfaces are packed with bone graft from previously removed
• Expose enough of the metacarpal so that the bone (such as distal ulna), iliac crest, or the distal radius. Cancellous allograft is
plate can be positioned centrally. preferred, particularly when using a contemporary plating system.
• Alternative sources of bone graft are the • The plate is applied to the dorsum of the radius, carpus, and middle finger metacar-
olecranon and proximal tibia.
• Locking screws are used in patients with poor pal. Typically, 3.5-mm screws are used on the radius and 2.7-mm screws are used
bone stock. When using the locking plate, the for the carpus and metacarpal.
first screws in the metacarpal and radius should • First, the plate is affixed to the middle finger metacarpal in neutral rotation using a
be cortical (nonlocking) screws to close the gap 2.7-mm cortical screw. It is not yet tightened fully (Fig. 53.14).
between the plate and the bone. Otherwise the • The wrist is reduced and checked for rotation. The plate is then fixed to the dorsal
gap will trap the extensor tendons, leading to
tendon ruptures. Then, locking screws can be radius with a 3.5-mm cortical screw and the metacarpal screw is tightened.
placed. If desired, the cortical screws can be re- • Use fluoroscopy to assess plate and screw position.
placed with locking screws once all of the • The remaining plate holes are then filled with screws. Three screws are placed in the
screws are in place. The plate must lie flush metacarpal, and at least three screws are placed into the radius (Fig. 53.15).
against the bone to avoid interposition of the ex- • Any remaining bone graft is packed into open joint spaces and beneath the plate
tensor tendons which can cause tendon rupture.
• In patients with poor soft tissue coverage, (Fig. 53.16).
Steinmann pins can be used instead of plates • Ensure full forearm rotation and passive digital ROM after plate application.
and screws (Fig. 53.17).
Step 4: Soft Tissue Repair, EPL Transposition, and Closure
STEP 3 PITFALLS
• The capsular flap is repaired over the plate using figure-of-eight 3-0 suture (absorb-
able or permanent suture is acceptable). If the capsule is not mobile, a partial ulnar
Malrotation is the most common problem with
cut over the ulnar flap may advance the ulnar flap radially to cover part of the plate
plate fixation. The optimal arthrodesis position
is slight wrist extension and ulnar deviation with and bone graft. The ECRB and ECRL can be mobilized off of the metacarpal bases
neutral rotation. for additional soft tissue coverage over the plate, when needed. Soft tissue coverage
shields the extensor tendons from the hardware to prevent tendon rupture.
• The extensor retinaculum is closed, leaving the EPL transposed over the retinaculum
(Fig. 53.18).
• The tourniquet is then released and hemostasis obtained.
• The skin is closed and a volar wrist splint is applied. (Fig. 53.19).

• The patient is seen in the office 2 weeks after surgery for suture removal. If the in-
traoperative fixation is stable, the patient is fitted for a removable splint, which must
be worn full-time for a total of 4 to 6 weeks, except for hygiene. If the bony fixation
is tenuous, the patient is placed in a cast.
• Gentle digital ROM and edema control are initiated at the first postoperative visit.
• Strengthening exercises begin 12 weeks after surgery.
• Postoperative radiographs should show consolidation of the prepared articular sur-
faces with stable hardware (Fig. 53.20). Lucency around the screws indicates hard-
ware loosening.
• Patients should be prepared for a long recovery of up to 1 year.
• Patients can expect a stable, pain-free wrist with full digital motion and forearm rotation.

FIGURE 53.17
Extensor
pollicis longus
Dorsal view of titanium

Repaired
wrist fusion plate extensor retinaculum
FIGURE 53.18
FIGURE 53.16
• Strength increases for about a year after surgery. Patients ultimately achieve about
80% grip strength of the dominant hand. FIGURE 53.19
• Patients adapt to the fusion in about 3 to 6 months; they can complete most light
activities during the accommodation period.
See Video 53.1
EVIDENCE
Berber O, Garagnani L, Gidwani S. Systematic review of total wrist arthroplasty and arthrodesis in wrist
arthritis. J Wrist Surg. 2018;7(5):424–440.
This systematic review compares functional benefit, secondary outcomes, and adverse events for wrist
arthroplasty versus total wrist arthrodesis for the treatment of end-stage wrist arthritis. Forty-three
studies were reviewed: 17 on arthrodesis, 24 on arthroplasty, and 2 matched cohort studies. In total,
there were 669 arthrodesis surgeries on 603 patients and 1371 arthroplasty surgeries on 1295 pa-
tients. Functional benefit based on Disabilities of the Arm, Shoulder, and Hand) DASH and Patient
Rated Wrist Evaluation (PRWE) scores, postoperative pain, and grip strength improved with both inter-
ventions. ROM after arthroplasty improved to a functional level in only 2 of 24 studies. Complication FIGURE 53.20
rates were higher after arthroplasty (0.2%–9.5%) than arthrodesis (0.1%–6.1%).
CHAPTER 54
Wrist Denervation
INDICATIONS
• Wrist denervation is indicated in patients with chronic pain but preserved motion
after exhausting nonoperative treatments. Patients are candidates for denervation if
they have pain from primary degenerative or inflammatory arthritis, osteonecrosis
(Kienböck or Preiser disease), or traumatic conditions, such as scaphoid nonunion
advanced collapse (SNAC) or scapholunate advanced collapse (SLAC) wrist, liga-
mentous instability, or sequelae of distal radius fractures.
• Transecting articular nerve branches reduces pain without causing major motor or
sensory deficits. Although theoretically possible, neuropathic arthropathy (Charcot
joint) has not been reported in the wrist.
• Wrist denervation can be performed in isolation or can be combined with other pro-
cedures.
• Patients must be counseled that denervation does not treat the underlying disease
and arthritis will progress. This procedure is best suited for low-demand, younger
patients who are expected to have slow disease progression. Additional surgery may
be necessary if denervation does not provide adequate pain relief or if pain recurs
over time.
• This operation should not be viewed as a salvage procedure but as an alternative
treatment of chronic wrist pain. It has no effect on the ability to proceed with subse-
quent operations, such as partial or complete wrist arthrodesis, proximal row car-
pectomy (PRC), or arthroplasty.
Contraindications
• Correctable wrist conditions (i.e., scaphoid nonunion without significant arthritis)
should be treated by addressing the underlying problem.
• Pain that is nonanatomic or proximal to the wrist (i.e., diffuse distal forearm pain) will
persist after wrist denervation.
• Patients with limited preoperative motion are better served with a PRC (see
Chapter 27) or wrist arthrodesis (see Chapter 53).
• Between 1 to 2 mL of local anesthetic is sequentially injected around each of the
articular nerve branches. Blockade is performed in the specific order listed here and
Lister tubercle improvement is assessed after each injection. If pain improves after blockade, the
nerve is targeted with surgery.
• Posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN). The in-
FIGURE 54.1 jection point is 1-cm ulnar and 3-cm proximal to Lister tubercle (Fig. 54.1). The
needle is inserted vertically until resistance from the interosseous membrane is
felt. Then it is withdrawn 2 mm, and local anesthetic is injected around the PIN.
The needle is then advanced through the interosseous membrane and another
1 to 2 mL of local anesthetic is injected around the AIN. If PIN/AIN blockade is
effective, there is no need to perform another injection.
• Dorsal sensory branch of the ulnar nerve (DSBUN). The needle is inserted verti-
cally at the border of the ulnar styloid and local anesthetic is injected just above
the bone.
• Superficial sensory branch of the radial nerve (SSRN). Local anesthetic is injected
about 3 cm proximal to the wrist crease around the radial vessels; be sure to
aspirate before injecting. The needle is then directed dorsally and the subcutane-
ous tissues proximal to the radial styloid are infiltrated (See Chapter 1 Anesthesia
of the Hand, Fig. 1.8).
420
IMAGING
• Three-view radiographs of the wrist are required to evaluate the bony anatomy.
• Magnetic resonance imaging (MRI) is considered if soft tissue injury (triangular fibro-
cartilage complex [TFCC] tear, ligamentous injury) or osteonecrosis (Kienböck dis-
ease) is suspected.
SURGICAL ANATOMY
• The wrist is innervated by articular branches from the AIN, PIN, SSRN, DSBUN,
lateral antebrachial cutaneous nerve (LABCN), and palmar cutaneous branch of the
median nerve (Fig. 54.2A–B).
• The PIN emerges from the proximal edge of the supinator and travels between the
superficial and deep extensor muscles, then along the interosseous membrane in
the forearm. It supplies motor branches to the wrist and finger extensors and con-
tinues distally as a sensory nerve. It terminates in the radial floor of the fourth exten-
sor compartment (Fig. 54.3A).
• The AIN provides motor branches to the flexor pollicis longus and index and middle
flexor digitorum profundus muscles. It travels along the anterior interosseous mem-
brane in the forearm just radial to the anterior interosseous artery. It innervates the
pronator quadratus, then terminates as a sensory branch to the wrist capsule
(Fig. 54.3B).
• The SSRN travels with the radial artery in the middle third of the forearm, then
emerges between the brachioradialis and the first dorsal compartment distally. It
gives off several branches that perforate the extensor retinaculum and an articular
branch at the level of the radial styloid (Fig. 54.4).
• The DSBUN originates from the ulnar nerve 6 to 8 cm proximal to the ulnar styloid.
Articular fibers course toward the wrist capsule at the level of the ulnar head.

• The patient is positioned supine with the arm extended on a hand table.
• The procedure is performed under axillary block with sedation or general anesthesia
with an upper arm tourniquet.
SSRN
Radial artery
and veins
LABCN
PIN FCR
SSRN DSBUN
AIN
A B
FIGURE 54.2 From Wu, CH, Strauch, RJ. Wrist Denervation: Techniques and Outcomes. Orthop Clin North Am. 2019;
50(3):345–356.
422 CHAPTER 54 Wrist Denervation
Anterior Distal
interosseous radioulnar joint
artery
Ulna
Radius
Interosseous
membranes
Posterior
interosseous
nerve
Anterior
interosseous artery
Anterior interossesous
nerve
Pronator quadratus
Interosseous SSRN
N DSBUN
Posterior interosseous membranes
nerve
FIGURE 54.3
FIGURE 54.4
EXPOSURES PEARLS • Standard hand surgery instrumentation, loupe magnification, and bipolar cautery are
Direct excision of the PIN and AIN and avulsion required.
of articular fibers from the SSRN and DSBUN
are performed through a single dorsal incision. EXPOSURES
We do not routinely perform perivascular A 3-cm to 4-cm longitudinal incision is made dorsally between the distal radius and the
adventitial stripping of the radial or ulnar arteries ulna. (Fig. 54.5).
or direct excision of recurrent articular branches
as advocated by other authors. Partial wrist
denervation (PIN and AIN neurectomy) is often PROCEDURE
enough to reduce wrist pain. If multiple nerve
blocks are needed, resection of additional nerve Step 1: PIN Neurectomy
branches through separate incisions may be • The skin is incised and the subcutaneous tissue is dissected. The extensor reti-
required (Fig. 54.6A–C).
naculum is identified and incised along the ulnar border of the third compartment.
• The fourth compartment is opened, and the extensor tendons are retracted ulnarly,
exposing the PIN on the radial floor of the fourth compartment (Fig. 54.7).
• The PIN is mobilized and a 1-cm resection neurectomy is performed with cautery (Fig. 54.8).
FIGURE 54.5
SSRN DSBUN
A B C
FIGURE 54.6

424 CHAPTER 54 Wrist Denervation
STEP 2 PEARLS Step 2: AIN Neurectomy

• The AIN is located radial to the anterior inter- • The interosseous membrane is incised longitudinally to expose the AIN (Fig. 54.9).
osseous artery and must be carefully mobilized • The nerve is mobilized, and a 1-cm segment is resected as distally as possible
to prevent bleeding. (Fig. 54.10).
• AIN resection is performed distally to avoid
denervating the pronator quadratus muscle.
Step 3: Undermining of Subcutaneous Tissue
• The subcutaneous tissue is separated from the underlying fascia and joint to avulse
STEP 2 PITFALLS dorsal articular branches from the SSRN and DSBUN.
Avoid injury to the anterior interosseous artery. • A hemostat is placed from the incision toward the point location of the dorsal ulna
If the vessel is transected, it should be tied or branch. The hemostat is spread and moved back and forth to undermine the subcu-
clipped, and hemostasis must be ensured after taneous tissue (Fig. 54.11).
release of the tourniquet. Latent bleeding of this
• A similar technique is used for the branches of the superficial radial branches and
artery can cause a compartment syndrome of the
deep flexor space. its distal branch over the first intermetacarpal space (Fig. 54.12).
Step 4: Wound Closure

• The extensor retinaculum is closed with 3-0 nonabsorbable suture.
• The skin is closed with 4-0 suture.
• Xeroform and a soft dressing are applied.


• The patient is placed in a soft dressing and seen in the office in 10 to 14 days for
suture removal.
• Gentle active motion is permitted once the incisions are healed.
• Most patients return to work within 4 weeks.
• About 75% of patients have reduced wrist pain. Improvement is seen within 4 weeks
of surgery and plateaus 1 year postoperatively.
• Wrist denervation does not treat the underlying pathology and arthritis will progress.
Some patients have recurrent pain or loss of function over time and may require a
secondary procedure, such as PRC or arthrodesis.
See Video 54.1
EVIDENCE
Braga-Silva J, Román JA, Padoin AV. Wrist denervation for painful conditions of the wrist. J Hand Surg
Am. 2011;36:961–966.
This is a retrospective review of 49 isolated wrist denervations performed using Wilhelm’s technique.
Average pain improvement was 68% at 1 month; 79% of patients had improvement in pain, grip
strength, and range of motion 1 year postoperatively. Radiologic evaluation 5 years after surgery
showed worsened disease in 34 patients.
Gay A, Harbst K, Hansen DK, Laskowski ER, Berger RA, Kaufman KR. Effect of partial wrist denervation
on wrist kinesthesia: Wrist denervation does not impair proprioception. J Hand Surg Am.
2011;36:1774–1779.
This is a double-blinded, randomized controlled trial with 80 healthy subjects (ages 20–54 years) evalu-
ating the effect of partial wrist denervation on wrist kinesthesia. Volunteers were divided in two
groups: (1) nerve (AIN and PIN) blockade with lidocaine, and (2) control (saline injected). They show
that kinesthesia is not impaired by AIN and PIN nerve blockade in both active and passive motion.
Grafe MW, Kim PD, Rosenwasser MP, Strauch RJ. Wrist denervation and the anterior interosseous
nerve: Anatomic considerations. J Hand Surg Am. 2005;30:1221–1225.
This study investigates the anatomy of the AIN in 10 cadavers. The AIN has an average of 4.2 motor
branches to the pronator quadratus (PQ) located from 24 to 38 mm proximal to the ulnar head. They
conclude that resecting a distal segment of the AIN (2 cm proximal to the ulnar head) targets the
articular branches and preserves the motor branches to the PQ.
Hofmeister EP, Moran SL, Shin AY. Anterior and posterior interosseous neurectomy for the treatment
of chronic dynamic instability of the wrist. Hand. 2006;1:63–70.
This is a prospective that evaluates the effectiveness of AIN/PIN neurectomy in 50 wrists. They com-
pare preoperative improvement with nerve blockade to outcome after neurectomy. Improvement of
pain with preoperative injections was not predictive of postoperative pain improvement. Increased
grip strength after nerve blockade did correlate with improved grip strength after surgery. AIN/PIN
neurectomy should not be performed in patients who have no improvement in pain or grip strength
after nerve blockade.
ddsf
SECTION VI
Nerve Conditions
CHAPTER 55 Open Carpal Tunnel Release 427
CHAPTER 56 Endoscopic Carpal Tunnel Release 433
CHAPTER 57 Revision Carpal Tunnel Release and Coverage
Using a Hypothenar Fat Pad Flap 440
CHAPTER 58 Procedures for Ulnar Compressive
Neuropathy 446
CHAPTER 59 Posterior Interosseous Nerve (PIN) Exploration and
Decompression 459
426
CHAPTER 55
Open Carpal Tunnel Release
INDICATIONS
• Signs and symptoms of carpal tunnel syndrome (CTS) include paresthesias, pain or
numbness in the median nerve distribution (volar thumb, index, middle and radial
one-half of ring finger), nocturnal neuropathic symptoms, and/or thenar muscle
weakness or wasting.
• Carpal tunnel release is indicated for those who have failed to achieve improvement
with respect to the duration or distribution of finger/thumb numbness using conser-
vative measures such as splints, ergonomic adjustment, and steroid injections.
Contraindications
In patients with diabetes and hemoglobin A1c levels greater than 8%, carpal tunnel
release may increase the risk for postoperative wound infection and increase the
chances of neuropathy related to poor glucose control. Therefore tight glucose man-
agement should be in place before contemplating carpal tunnel surgery.
• CTS is a clinical diagnosis determined by physical examination and supported by
electrodiagnostic or radiographic testing.
• Patients typically complain of numbness along the tip of the thumb, index, and
middle fingers and the radial half of the ring finger, as well as nocturnal neuropathic
pain that awakens the patient from sleep. They may also describe symptoms during
repetitive fine-motor activities (typing) or specific positioning (driving).
• Sensation along the distribution of the median nerve should be assessed using light
touch and with a two-point discriminator. Comparison with the contralateral side is
often useful if this side is normal.
• The Semmes-Weinstein monofilament test detects a sensory threshold, which is the
weakest stimulus that a patient can detect. It is more sensitive than two-point dis-
crimination and can detect early changes among patients with chronic nerve com-
pression.
• Patients with advanced nerve compression may present with weakness and atrophy
of the median-nerve-innervated thenar musculature, including abductor pollicis brevis,
flexor pollicis brevis, and the opponens pollicis muscles, resulting in weakness of
palmar abduction of the thumb. Test the contralateral thumb for comparison.
• Provocative maneuvers produce compression of the median nerve and are de-
signed to simulate the activities that produce symptoms of carpal tunnel syndrome.
These can be performed at the bedside and include the Tinel sign, Durkan test, and
Phalen test.
• Phalen test: The patient’s wrists are placed in flexion for 1 minute. A positive test
will elicit the onset of numbness in the median nerve distribution (see Fig. 55.1A)
• Tinel sign: Tapping across the distal wrist crease and proximal palm elicits pain
and tingling in the median nerve distribution. A positive test signals attempted
nerve regeneration at the site of compression (Fig. 55.1B).
• Durkan test or carpal compression test: The examiner places pressure across the
proximal palm for approximately 30 seconds. A positive test will elicit the onset
of numbness in the median nerve distribution (Fig. 55.2).
• The CTS-6 is a validated checklist used to assist with the clinical diagnosis of CTS
(Table 55.1). A score of greater than 12 corresponds to a 0.80 probability of having
CTS. The six items on the checklist are:
1. Numbness over the median nerve innervated digits (3.5 points)
2. Nocturnal numbness (4 points)
427
428 CHAPTER 55 Open Carpal Tunnel Release
B
Median nerve
FIGURE 55.1 (A) Phalen test and (B) Tinel test. From Reider B,
Davies GJ, Prevencher MT. Forearm nerve entrapments. In: FIGURE 55.2 Durkan test. From Lowe, W. Sug-
Orthopaedic Rehabilitation of the Athlete: Getting Back in the gested variations on standard carpal tunnel syn-
Game. Saunders; 2015:573–582. drome assessment tests. J Bodyw Mov Ther.
2008;12(2):151–157.
3. Thenar atrophy and/or weakness (5 points)

TABLE Carpal Tunnel Syndrome- 6
4. Positive Phalen test (5 points)
55.1 (CTS–6) 5. Loss of two-point discrimination (4.5 points)
Numbness over median nerve innervated 6. Positive Tinel sign (4 points)
digits (3.5 points)
Nocturnal numbness (5 points) IMAGING
Thenar atrophy and/or weakness • Nerve conduction studies (NCS) with electromyography (EMG) can confirm the di-
(5 points) agnosis of CTS and identify additional areas of compression and neuropathy. A
distal median nerve sensory latency longer than 3.5 ms and motor latency longer
Positive Phalen test (5 points)
than 4.5 ms with symptoms are confirmatory of CTS. Fasciculations and fibrillations
Loss of two-point discrimination of the thenar muscle on EMG indicates muscle denervation and advanced compres-
(4.5 points) sion of the median nerve. The distal median nerve motor latencies with values of
Positive Tinel sign (4 points) 5.0 ms or more are suggestive of CTS.
• Ultrasound can be used to determine the size of the median nerve and evaluate for
space-occupying lesions, if suspected. Cross-sectional measurements greater than
10 mm2 or measurement of the difference in cross-sectional area above and within
the carpal tunnel (2 mm2 threshold) can be used to assist in the diagnosis of CTS.
Ultrasound is also useful to evaluate mobility and deformity of the nerve.
• Magnetic resonance imaging (MRI) is rarely needed but may help diagnose CTS by
measuring the median nerve cross-sectional area, signal intensity, and palmar bow-
ing of the flexor retinaculum.
SURGICAL ANATOMY
• The carpal canal is a fibro-osseous canal that is bordered by the hamate, triquetrum,
and pisiform ulnarly, and the scaphoid and trapezium radially. The roof of the carpal
canal is formed by the flexor retinaculum, which is contiguous with the antebrachial
fascia in the forearm. Within the flexor retinaculum, the transverse carpal ligament
arises from the scaphoid tubercle and trapezium and extends to the pisiform and
hook of hamate bones.
• The median nerve lies just deep to the tendons of the flexor digitorum superficialis
(FDS) and palmaris longus (PL), and ulnar to the flexor carpi radialis (FCR) within
the forearm. It runs through the radial aspect of the carpal canal and then divides
Deep branch of
ulnar nerve
Motor branch of
median nerve
Transverse carpal ligament,

Volar carpal ligament
Palmar cutaneous
branch of median nerve
Median nerve
FCU
Radial artery Ulnar nerve
FCR PL Ulnar artery
FPL FDS
FIGURE 55.3 Wrist anatomy.
into the recurrent motor branch, proper digital nerves, and common digital nerves
(Fig. 55.3).
• The palmar cutaneous branch originates from the radial aspect of the median nerve
approximately 5 cm proximal to the wrist crease. It travels underneath the ante-
brachial fascia between FCR and PL up to 0.8 cm proximal to the wrist crease, at
which point it penetrates the fascia.
• The recurrent motor branch varies in its course; it can be extraligamentous (46%),
subligamentous (31%), or transligamentous (23%; Fig. 55.4).
A B C
FIGURE 55.4 (A) Extraligamentous (most common). (B) Subligamentous. (C) Transligamentous.
EXPOSURE PEARLS
It is often not necessary for the incision to
cross the wrist crease for primary carpal tunnel The procedure is performed under tourniquet control and can be done under regional
release. If the incision needs to be extended anesthesia, intravenous regional (Bier block) anesthesia, or local anesthesia. The
proximally to identify the median nerve to perform patient is positioned supine with the affected extremity on a hand table.
other procedures (e.g., perilunate dislocation,
compartment syndrome, flexor tendon rupture, and EXPOSURES
implant removal) or for reoperation in patients with
recurrent or persistent carpal tunnel syndrome, its A 3-cm longitudinal incision is started distal to the wrist flexion crease and 6 mm ulnar
angle to the flexor crease of the wrist should be to the thenar crease in the proximal palm (Fig. 55.5).
created as a zigzag going ulnar, rather than at right
angles, to avoid scar contracture. PROCEDURE
EXPOSURE PITFALLS Step 1: Division of the Palmar Fascia
• To prevent motor nerve branch laceration, both After incising the skin, sharply dissect through the subcutaneous fat down to the longi-
the skin and flexor retinaculum incisions must tudinal fibers of the palmar fascia (Fig. 55.6). Divide the palmar fascia sharply using a
be made along the ulnar border of the carpal no. 15 blade.
canal.
• Remain as perpendicular to the skin as possible Step 2: Division of the Transverse Carpal Ligament
to avoid veering radial or ulnar off midline and
risking injury to the palmar cutaneous nerve • Once the palmar fascia has been incised, the fibers of the transverse carpal ligament
branch or the ulnar neurovascular bundle. are visualized, and any overlying tissue can be swept away using a surgical sponge
and Adson forceps.
• The transverse carpal ligament is divided centrally using a no. 15 blade under direct
STEP 1 PEARLS
visualization, layer by layer, until the median nerve is visualized (Fig. 55.7). Use
• Handheld Ragnell retractors can be placed for tenotomy scissors to release the neve distally; visualization of the sentinel fat pad
radial, ulnar, proximal, and distal visualization.
• Carefully incise the tissue layer by layer to indicates that distal release is complete.
prevent inadvertent injuries. • Use the short tenotomy scissors to complete the release proximally (Fig. 55.8); en-
• During the identification of the palmar fascia, a sure that the antebrachial fascia is included. Any constricting bands that remain are
prominent palmaris brevis may be encountered divided (Fig. 55.9).
and should be preserved if possible.
• If the hypothenar or thenar muscles are en-
countered ulnar or radial to the midline palmar
Step 3: Closure
fascia, adjust accordingly. After confirming that the decompression of the median nerve is adequate, close the
• The palmar fascia forms the floor of the Guyon wound with a single layer of 4-0 horizontal mattress suture (Fig. 55.10). Absorbable or
canal and should be visualized just beneath nonabsorbable sutures may be used depending on surgeon preference.
the subcutaneous adipose tissue. If the inci-
sion and/or dissection is carried too ulnarly, WIDE AWAKE, LOCAL ANESTHESIA, NO TOURNIQUET
then these fibers will not be seen, and dissec-
tion could proceed directly into the Guyon CARPAL TUNNEL RELEASE
canal, placing the ulnar neurovascular bundle • Wide awake carpal tunnel release can be performed in an office setting if the patient
at risk for injury. is cooperative and calm. Patients are not required to fast (NPO) before the procedure.
Pisiform
Incision Wrist
crease
Recurrent
motor Br
Kaplan’s
cardinal Palmar
line fascia
FIGURE 55.6 After sharply dissecting through skin and subcutaneous

FIGURE 55.5 Surgical landmarks and incision markings for carpal tun- tissues, place three retractors and identify the palmar fascia. This is
nel release. incised longitudinally.
STEP 2 PEARLS
• Look for the “washboard” appearing transverse-
carpal ligament with transverse oriented stout
fibers for release.
• Release is confirmed by performing a “lift test”
in which the tips of the scissors are closed and
slid underneath the transverse carpal ligament.
The scissors are elevated volarly and should
slide without tension in the upward direction.
No. 15 blade used
to make a nick in
the TCL
STEP 2 PITFALLS
FIGURE 55.7 No. 15 blade used to make a nick in the transverse car-
• Stop dissection distally once the sentinel fat
pal ligament (TCL).
pad is seen to prevent injury to the superficial
arch.
• Proximal release of the antebrachial fascia
should be done perpendicular to the wrist
crease under direct visualization to prevent
injury to the palmar cutaneous branch of the
median nerve.
Scissors dividing
the transverse
carpal ligament
proximally
FIGURE 55.8 Scissors dividing the transverse carpal ligament proximally.
TCL released,
revealing median
nerve and flexor Skin closure
tendons
FIGURE 55.9 Transverse carpal ligament (TCL) released, revealing me-

dian nerve and flexor tendons. FIGURE 55.10 Skin closure.
• The wide awake procedure is shorter in duration and less costly. Patients express a
high level of satisfaction.
• The procedure can be accomplished with around 15 to 20 cc 1% lidocaine mixed
with 1:100,000 epinephrine buffered with 8.4% bicarbonate in a 10:1 ratio. A
27-gauge needle is used to perform a field block but is not injected into the median
nerve directly. Allow 20 to 30 minutes for optimal anesthetic and hemostatic effect.
• Technical steps are similar to the open release previously described.
• See additional information about the wide awake approach in Chapter 77: Wide
Awake Approach for Tendon Transfers.

• A bulky dressing consisting of gauze, web roll, and an elastic bandage is applied.
Patients can remove the dressing at 3 days postoperatively. Light handwashing is
allowed thereafter, and the patient is advised to apply Vaseline and a soft dressing
until sutures are removed at the 2-week follow-up.
• Light activity (typing/texting) is encouraged when comfortable. Patients should have
a final office visit at 4 weeks postoperatively, unless they have an ongoing need for
occupational therapy.
• Strenuous activity, sports, and heavy lifting should be avoided within 6 weeks post-
operatively.
• Patients can experience pillar pain, which is defined as pain and tenderness along
the thickened palmar incision where the divided transverse carpal ligament is at-
tached. Patients are encouraged to aggressively massage the area once the sutures
are removed.
See Video 55.1
EVIDENCE
Graham B, Regehr G, Naglie G, Wright JG. Development and validation of diagnostic criteria for carpal
tunnel syndrome. J Hand Surg. 2006;31A:919.e1–919.e7.
These two studies describe the creation and validation of a clinical diagnostic checklist for carpal tunnel
syndrome in the absence of using EMG/NCS.
Lalonde DH. Latest advances in wide awake hand surgery. Hand Clin. 2019;35:1–6.
McKee ED, Lalonde DH, Toma A, Dickson L. Achieving optimal epinephrine effect in wide awake hand
surgery using local anesthesia without a tourniquet. Hand. 2015;10:613–615.
These two studies demonstrate the feasibility of wide-awake techniques for accomplishing carpal tun-
nel release in the office setting.
CHAPTER 56
Endoscopic Carpal Tunnel Release
Kevin C. Chung
INDICATIONS EXAMINATION PEARLS

Indications are similar to those described for open carpal tunnel release (Chapter 55). The wrist is examined for stiffness, specifically with
extension, because the wrist must be extended for
CLINICAL EXAMINATION correct cannula placement (Fig. 56.1).
The clinical examination is similar to that described for open carpal tunnel release
(Chapter 55).
IMAGING
Preoperative testing, including electrodiagnostic testing and adjunct imaging tests, are
similar to those described for open carpal tunnel release (Chapter 55).
SURGICAL ANATOMY
The surgical anatomy is similar to that described for open carpal tunnel release
(Chapter 55).
POSITIONING FIGURE 56.1 Wrist is extended for cannula

• Endoscopic carpal tunnel release (ECTR) is performed under tourniquet control with placement.
the patient in supine position and the affected extremity on a hand table.
• ECTR should be performed under local anesthesia.
EXPOSURES PEARLS
ONE-PORTAL TECHNIQUE
During the visualization of the antebrachial fascia,
Exposures small veins may be present in the subcutaneous fat
• The entry portal should be made at a point that is 1.5 cm radial and 0.5 cm proxi- layer. These veins should be retracted or cauterized
to prevent hematoma formation after surgery.
mal from the proximal pole of the pisiform (Fig. 56.2). A 1-cm incision is designed
Incision
Proximal pole
of pisiform 0.5 cm
1–1.5 cm
FIGURE 56.2 Entry portal incision site.
433
434 CHAPTER 56 Endoscopic Carpal Tunnel Release

of median nerve FCR FCU
PL Palmar cutaneous
branch of
ulnar nerve
FIGURE 56.3 Incision is created ulnar to the palmaris longus tendon.
transversely along the distal wrist flexion crease between the flexor carpi radialis
and flexor carpi ulnaris tendons. The incision is created just ulnar to the palmaris
longus tendon, if present (Fig. 56.3).
• The antebrachial fascia is visualized and blunt dissection is performed using tenot-
omy scissors to expose the fascia circumferentially. The fascia is sharply incised
longitudinally.

The trajectory of the tunnel and dissection points
toward the third webspace, and the dissection Step 1
proceeds along the ulnar aspect of the carpal Short tenotomy scissors are used to gently dissect underneath the antebrachial fascia,
tunnel. and the tips of the scissors are elevated to the rigid surface of the flexor retinaculum
(Fig. 56.4).
STEP 2 PITFALLS
Step 2
With excessive force, the hook of the hamate • Dilators are sequentially introduced into the carpal canal (from smallest to largest) to
may push the tip of the obturator radially and
inadvertently injure the median nerve. enlarge the tunnel.
• A Freer elevator or a synovial separator is inserted into the carpal tunnel to
sweep away any adherent synovial membranes from the undersurface of the
flexor retinaculum.
Release forearm
fascia using
tenotomy scissors
FIGURE 56.4 Forearm fascia is released with tenotomy scissors.

Agee
Carp
al Tun
el Re
lease
Syste
m
Hook of
hamate
Median nerve
FIGURE 56.5 Viewing window is oriented volarly to visualize the flexor retinaculum.

• The wrist is placed in extension, and the cannula system, including the endoscope • Beyond the distal edge of the flexor retinacu-
and blade, is inserted into the wrist. The viewing window is oriented volarly to visu- lum, the palmar fat pad is visualized. Care is
alize the flexor retinaculum (Fig. 56.5). taken to avoid deploying the blade in this area
to avoid injuring the superficial arterial arch
• The distal edge of the flexor retinaculum is identified. The median nerve, flexor ten-
and common digital nerves (Fig. 56.9).
dons, and vessels should be away from the field of view and the working space of • It is unnecessary to incise the palmar
the knife (Fig. 56.6). aponeurosis.
• The cannula should be removed and reinserted, if needed, to achieve this view. • With the use of a clear cannula, the position of
• The blade is deployed within the cannula system, and the distal aspect of the flexor the median nerve or other tissues can be iden-
tified circumferentially.
retinaculum is incised (Fig. 56.7). The incision is completed from distal to proximal
to ensure a complete release (Fig. 56.8).

• The tourniquet is deflated, and gentle compression is held for 5 minutes to prevent
hematoma formation.
• The skin is closed with a simple layer of 5-0 nonabsorbable sutures.
TCL
(transverse fibers)
Fat pad
FIGURE 56.6 Distal edge of the flexor retinaculum is identified.

Probe knife
V-shaped aspect
Hook of
Remaining fibers
hamate
Ulnar artery
and nerve
Radial Cut edge of transverse
artery carpal ligament
Pisiform
Distal fat pad
Median
nerve Blade
Scope
FIGURE 56.7 The distal aspect of the flexor retinaculum is incised. FIGURE 56.8 Incision is completed from distal to proximal.
FIGURE 56.9 Avoid injuring the superficial arterial arch and common digital nerves.
TWO-PORTAL TECHNIQUE
Exposures
Exposure to create the proximal portal is similar to the one-portal technique.
PROCEDURE
Step 1
• A Freer elevator or a synovial separator is inserted into the carpal tunnel to sweep
any adherent synovial membranes off the undersurface of the flexor retinaculum
(Fig. 56.10).
• The exit portal is located on the intersection of the Kaplan cardinal line and the ulnar
FIGURE 56.10 Freer elevator is inserted into the border of the middle finger (Fig. 56.11). A skin incision is made from the starting
carpal tunnel. point and extended in the proximal and radial directions.
1 cm
Incision = 0.5 cm
FIGURE 56.11 Exit portal is incised at the intersection of the Ka- FIGURE 56.12 Cannula is placed in the proximal inci-
plan cardinal line and ulnar border of middle finger. sion and advanced through the exit portal in the palm.
FIGURE 56.13 Identifying the distal edge of the flexor retinaculum.
Step 2
• The cannula assembly is placed within the proximal incision and gently advanced
through the exit portal in the palm. The hand is then stabilized (Fig. 56.12).
• The endoscope is inserted proximally and a small probe is inserted distally to iden-
tify the distal edge of the flexor retinaculum (Fig. 56.13).
• A triangle knife is used to make an insertion hole for the probe hook knife. Then the
probe hook knife is used to release the flexor retinaculum distally (Fig. 56.14A–B).
• The endoscope is then placed in the distal portal, and the probe hook knife is intro-
duced proximally to release the proximal flexor retinaculum (Fig. 56.15A–B).
• The cannula system is removed, and the antebrachial fascia is released through the
proximal incision with tenotomy scissors.
A B
FIGURE 56.14 (A–B) Triangle knife makes a hole for the probe hook knife to release the flexor retinaculum
distally.
Blade insertion hole
A B
FIGURE 56.15 (A–B) Probe hook knife releases the proximal flexor retinaculum. FIGURE 56.16 Skin closure.

• The tourniquet is deflated, and gentle compression is held for 5 minutes to prevent
hematoma formation.
• The skin is closed with a simple layer of 5-0 nonabsorbable sutures (Fig. 56.16).

• The bulky dressing is removed 2 days after surgery.
• No immobilization is required and patients can use their hands as they please. ECTR
patients usually return to work and daily activities earlier than open carpal tunnel
release patients.
ACKNOWLEDGMENT
Thanks to Michiro Yamamoto, MD, PhD, and Takanobu Nishizuka, MD, PhD, Depart-
ment of Hand Surgery, Nagoya University Graduate School of Medicine, for the pictures
in this chapter.
EVIDENCE
Atroshi I, Hofer M, Larsson GU, Ranstam J. Extended follow-up of a randomized clinical trial of open
vs endoscopic release surgery for carpal tunnel syndrome. JAMA. 2015;314:1399–1401.
The authors compared 12-year results among 65 patients randomized to open carpal tunnel release
and 63 patients who underwent two-portal technique ECTR. Outcomes were assessed using the
Carpal Tunnel Questionnaire, Disabilities of the Arm, Shoulder and Hand (DASH), and satisfaction
with treatment. At long-term follow-up, there were no significant differences observed between
groups with respect to patient-reported and functional outcomes (Level II evidence).
Means Jr KR, Dubin NH, Patel KM, Pletka JD. Long-term outcomes following single-portal endoscopic
carpal tunnel release. Hand (N Y). 2014;9:384–388.
To evaluate the long-term outcomes and recurrence rates after single-portal ECTR, the authors exam-
ined 115 patients preoperatively and postoperatively using the Carpal Tunnel Questionnaire. Patients
experienced notable improvement in symptoms after the procedure, with sustained results at 10-year
follow-up (Level IV evidence).
Sayegh ET, Strauch RJ. Open versus endoscopic carpal tunnel release: A meta-analysis of randomized
controlled trials. Clin Orthop Relat Res. 2015;473:1120–1132.
The authors conducted a systematic review and compiled the results of 21 randomized, controlled trials
(1859 procedures) comparing endoscopic and open carpal tunnel release. Patient-reported outcomes,
functional outcomes, reoperation, interval to return to work, and operative time were assessed. The au-
thors concluded that there were no differences in nerve injury by endoscopic technique. Endoscopic
techniques had a longer learning curve, slightly higher rate of transient neurapraxia, and higher associ-
ated costs (Level I evidence).
CHAPTER 57
Revision Carpal Tunnel Release and Coverage
Using a Hypothenar Fat Pad Flap
INDICATIONS
The indications for revision carpal tunnel release (CTR) include persistent, recurrent, or
new symptoms after initial release.
Persistent Carpal Tunnel Syndrome

• Incomplete release of the transverse carpal ligament or secondary site of median
nerve compression is the most common indication, accounting for around 43% of
patients who undergo revision CTR.
• Incomplete release is associated with an acute worsening of carpal tunnel symp-
toms secondary to a more concentrated area of compression.
• Persistent symptoms can be secondary to a diagnosis of diabetic neuropathy, cervical
radiculopathy, or more proximal compression (Pronator syndrome).
Recurrent Carpal Tunnel Syndrome

• Recurrent carpal tunnel syndrome is diagnosed if symptoms reappear after at least
6 months of temporary relief after primary CTR.
• Recurrent symptoms can be secondary to perineural adhesions or reconstitution of
the transverse carpal ligament, which leads to fibrosis around the median nerve.
New Symptoms
• New symptoms immediately after surgery can result from iatrogenic nerve injury.
CLINICAL EXAMINATION PEARLS
This includes partial or complete transection of the median nerve, recurrent motor
• Carpal tunnel syndrome may also be mimicked branch, or palmar cutaneous branch of the median nerve.
by more proximal or alternate sites of nerve
compression. Examples include median nerve CLINICAL EXAMINATION
compression in the forearm between the two
heads of the pronator teres muscle, the fibrous • A thorough history, including the onset, duration, fluctuation, character, and change of
arch of the flexor superficialis, thickening of symptoms, both before and after initial CTR, is critical to understanding the etiology
the bicipital aponeurosis, cervical radiculopa- of symptoms.
thy, or ulnar neuropathy. • Patients may exhibit hand weakness or inability to oppose or palmar abduct the
• Systemic peripheral neuropathy, including meta-
bolic conditions such as diabetes mellitus or thumb.
amyloidosis, or peripheral neuropathy conditions • The previous surgical scar location and healing are assessed to see whether they are
such as Charcot-Marie-Tooth, may also present small, or too distal or ulnar to the ideal incision site.
with persistent symptoms that will not be solely • The presence of persistent symptoms without improvement after an initial CTR sug-
alleviated by release of the carpal canal. gests an incomplete release of the flexor retinaculum or the antebrachial fascia
• A Phalen test will be positive in patients who
have inadequate decompression or secondary proximally.
traction neuritis, given that the pathology is at • In contrast, recurrent symptoms after initial temporary pain relief for several months
the carpal canal. Patients with more proximal (typically 6 months or longer) are most often caused by scar formation, synovial tis-
nerve compression, however, do not typically sue proliferation, reformation of the flexor retinaculum, or recurrent tenosynovitis.
present with reproducible symptoms with wrist • New symptoms include palmar or digital dysesthesias, positive Tinel’s sign, or the-
flexion alone.
nar muscle dysfunction.
IMAGING
• Electromyography and nerve conduction studies should be performed in all patients
who present with recurrent or persistent carpal tunnel syndrome to confirm thenar
muscle innervation or denervation. Additionally, electrodiagnostic studies can iden-
tify the presence of an alternative location of compression or polyneuropathy related
to systemic causes. These test results can also be compared with prior tests.
440
CHAPTER 57 Revision Carpal Tunnel Release and Coverage Using a Hypothenar Fat Pad Flap 441
• Ultrasound can aid in diagnosis by demonstrating an area of transition in the diam-

eter of median nerve and/or transection of the nerve.
SURGICAL ANATOMY
• The clinical anatomy relevant for patients undergoing revision CTR is similar to that
for primary carpal tunnel syndrome (Chapter 55).
• The hypothenar fat pad lies on and partially within the Guyon canal. The hypothenar
muscles and overlying adipose tissue are vascularized by several perforating vessels
that arise from the ulnar artery in the Guyon canal. Arterial perforators arise at 1-cm
intervals beginning from the distal wrist crease (Fig. 57.1).
• The ulnar digital nerve of the small finger runs deep to the distal third of the fat pad
after branching from the ulnar nerve in the Guyon canal.
• The roof and part of the radial wall of the Guyon canal consist of the palmaris brevis
muscle fascia and the volar carpal ligament. The hook of the hamate makes up the
remainder of the radial wall of the Guyon canal. This palpable landmark indicates the EXPOSURES PEARLS
radial edge of the Guyon canal.
The dissection should start in unscarred normal
tissue proximal to the carpal tunnel in the wrist to
POSITIONING first identify the median nerve in a normal plane.
The procedure is performed under tourniquet control with the patient in the supine Identify all structures in the region, then proceed
position and the extremity abducted with the hand on a hand table. along the normal median nerve distally into the
rigid scar tissue. Using a no. 15 blade along
EXPOSURES anatomic planes, the scar tissue can be separated
readily from the nerve and the surrounding flexor
Although the incision for revision CTR ideally lies 5 mm ulnar to the thenar crease, tendons. Gentle pressure with the blade against
prioritize use of the prior incision. Make sure to avoid the motor branch and the ulnar dense scar tissue will facilitate release without
nerve when developing the plane and extend the incision distally to the Kaplan cardi- injuring the nerve. This is often safer than blunt
nal line. A Bruner-style incision toward the ulnar side of the wrist is used for proximal dissection with scissors if the normal places are
distorted by scar.
extension (Fig. 57.2).
Step 1 To reduce the volume in the carpal tunnel,

tenosynovectomy of the flexor tendons in the
• The skin incision is created, and the median nerve is identified proximally under- carpal tunnel may be performed among patients
neath the antebrachial fascia in nonscarred tissue. with proliferative synovitis, which may exacerbate
compression because of mass effect.
Common digital nerve
Recurrent thenar branch
X Hypothenar fat pad
FCU tendon
Median nerve
Radial artery Ulnar nerve
Ulnar artery
FCR tendon
FIGURE 57.1 Green arrows mark the perforators from the ulnar artery that supply the hypothenar fat
pad. Typically, the dissection stops once the ulnar neurovascular bundle is identified, noted by the X.
There is no need to skeletonize the vessels or perforator; further dissection risks injury to the pedicle.
FCR, Flexor carpi radialis; FCU, flexor carpi ulnaris.
442 CHAPTER 57 Revision Carpal Tunnel Release and Coverage Using a Hypothenar Fat Pad Flap
Extended release incision
line
nal
Site of the palmar
i
card
cutaneous branch
X
lin’s
Kap
FIGURE 57.2 Planned incision for extended carpal tunnel release. Kaplin’s cardinal line marks the
approximate location of the superficial palmar arch (black dashes). Incorporate previous incisions in
the palm and zigzag (arrow) across the wrist crease ulnarly to avoid injuring the palmar cutaneous
branch (red X).
Ulnar Hypothenar Median nerve

neurovascular fat pad adherant to TCL
bundle
B
A
FIGURE 57.3 (A) Cross-sectional view of the median nerve during revision carpal tunnel release. (B) Release of the transverse carpal lig-
ament (black arrows) and flexor retinaculum. The median nerve lies deep, encased in scar (red arrow). TCL, Transverse carpal ligament.
• As the dissection proceeds toward the palm, the median nerve is often densely
scarred to the flexor retinaculum and surrounding tissue (Fig. 57.3) Sharp dissection
using a no. 15 blade is performed to expose the median nerve entirely along its
volar surface and to release all points of compression circumferentially.
• The median nerve typically lies radially and volarly within the carpal canal and is
often densely adherent to the radial leaf of the flexor retinaculum. External neurolysis
is performed to free the nerve of all surrounding adhesions, taking care to avoid in-
jury to critical branches, including the motor branch of the median nerve, the palmar
cutaneous branch more proximally, and the common digital nerves. Among patients
who have persistent symptoms related to incomplete release at the distal aspect of
the flexor retinaculum, the nerve will assume an hourglass-like appearance, or pseu-
doneuroma, because of distal compression (Fig. 57.4).
Step 2: Hypothenar Fat Pad Flap Elevation

• A hypothenar fat pad flap is used to restore a smooth nerve gliding surface with
well-vascularized soft tissue, free of scar in the carpal canal. This provides vascular-
ized coverage over the median nerve, particularly among patients with recurrent
carpal tunnel syndrome and significant perineural fibrosis. It also prevents the di-
vided transverse carpal ligament from healing and across the median nerve, which
would cause compression.
• This procedure can be performed within the same extended carpal tunnel release
incision.
• Skin hooks are placed along the ulnar skin edge. Thick skin flaps are elevated
sharply in the subdermal plane using a no. 15 blade, leaving the superficial surface
of hypothenar fat pad exposed. Care is taken to avoid disrupting the subdermal
FIGURE 57.4 The thickened transverse carpal ligament is released (black arrow). The median nerve
has been released from surrounding scar (green rectangle). Note that the nerve appears hemorrhagic
and flattened (white arrow). The nerve is dilated proximal and distal to the area of compression,
giving the “hourglass” appearance.
Superficial
Skin flap surface of
plane of HFPF
dissection
Skin flap plane

of dissection
Superficial
surface
of HFPF
B
A
FIGURE 57.5 (A–B) Skin hooks are used to retract the skin. Flaps are elevated off the hypothenar fat pad in a level below the dermal
plexus to preserve the blood supply to overlying skin. After the skin has been elevated in an ulnar direction, the superficial surface of
the hypothenar fat pad flap will be exposed. HFPF, Hypothenar fat pad flap.
plexus, which may result in skin necrosis (Fig. 57.5). Flap elevation is continued to
the ulnar border of the hand. STEP 2 PEARLS
• After the superficial surface of the hypothenar fat pad is completely exposed, the
• During flap inset, place all sutures and then tie
digital nerves to the ring and small finger will be seen distally and the ulnar nerve and them sequentially at the end to avoid obscur-
artery will be seen proximally. Next, the deep surface of the flap must be mobilized ing your view.
off the hypothenar musculature, with gentle spreads between the fat pad flap and • In addition to the hypothenar fat pad flap, other
the hypothenar muscles to mobilize the fatty tissue for transposition. Use a forcep regional flap options include the abductor digiti
to test the mobility of the flap to reach across the canal to radial leaflet and release minimi flap, a reversed forearm fascial flap
based on the perforators of the ulnar or radial
additional fibrous attachments with gentle spreads as needed. artery or based on the proper arteries, if addi-
• The contents of the carpal canal are retracted ulnarly with a Ragnell. Then the tional soft tissue coverage is needed.
pedicled fat pad flap is transposed radially and sutured volar to the median nerve • Synthetic nerve wraps may be used instead of
and dorsal to (underneath) the radial leaf of the transverse carpal ligament using autologous flap coverage. These commercially
interrupted absorbable horizontal mattress sutures. The hypothenar fat pad flap is available collagen-absorbable neural protective
sheaths can prevent scar adhesion onto the
“dunked” underneath the radial leaflet and care is taken to ensure tension-free cov- median nerve. These are sutured to the
erage over the median nerve (Fig. 57.6). epineurium and wrapped loosely around the
nerve with some laxity. To date, however, a
Step 3: Skin Closure direct comparison of the outcomes among
After confirming that the decompression of the median nerve and hemostasis were patients who have undergone revision CTR
with synthetic or autologous median nerve
performed adequately, the wound is closed with interrupted nonabsorbable skin coverage has not been performed.
sutures.
444 CHAPTER 57 Revision Carpal Tunnel Release and Coverage Using a Hypothenar Fat Pad Flap
Fat pad inset over

Radial the MN and dorsal
leaflet to radial leaflet
Fat pad inset over

the MN and dorsal
to radial leaflet
Radial leaflet
B
A
FIGURE 57.6 (A) Hypothenar flap mobilized and inset over the median nerve (MN). (B) Hypothenar fat pad flap mobilized and transposed
to cover the median nerve. It is sutured deep to the radial leaflet of the transverse carpal ligament using horizontal mattress sutures.

• The hand is placed in a well-padded, plaster-based volar resting splint, with fingers
free for immediate range of motion. Sutures are removed at 2 weeks and patients
have an orthoplast splint fabricated at this time.
• Splinting and wrist immobilization are preferred for a 2-week period postoperatively
because of the extensive dissection of the median nerve and bowstringing of the
nerve that may occur if early wrist flexion is initiated.
• After extended CTR and hypothenar fat pad flap treatment for recurrent carpal tunnel
syndrome, patients can expect improvement in their paresthesias and pain. Sensation
and pinch/tripod/grip strength gradually improve over the first year postoperatively.
See Video 57.1
EVIDENCE
Strickland JW, Idler RS. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syn-
drome. J Hand Surg. 1996;21A:840–848.
Plancher KD, Idler RS, Lourie GM, Strickland JW. Recalcitrant carpal tunnel: The hypothenar fat pad
flap. Hand Clinics. 1996;12:337–349.
The authors describe the anatomic basis and surgical technique used to harvest a hypothenar fat pad
flap. They performed a retrospective review of the flap used to treat 62 hands. The mean follow-up
was 33 months with excellent results in the resolution of recalcitrant carpal tunnel syndrome among
worker’s compensation and nonworker’s compensation patients.
Lauder A, Mithani S, Leversedge FJ. Management of recalcitrant carpal tunnel syndrome. J Am Acad
Orthop Surg. 2019;27:551–562.
The authors provide an excellent review of recalcitrant carpal tunnel syndrome and management options.
Jones NF, Ahn HC, Eo S. Revision surgery for persistent and recurrent carpal tunnel syndrome and for
failed carpal tunnel release. Plast Reconstr Surg. 2012;129:683–692.
The authors performed a retrospective review of 50 patients who underwent revision CTR (55 procedures).
Thirty-four hands underwent endoscopic release and 21 hands underwent open release. The most com-
mon presentation of persistent symptoms was because of incomplete release of the distal flexor retinac-
ulum. All patients were noted to have circumferential fibrosis and scarring of the median nerve.
Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ. A systematic review of the literature on the
outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plast Reconstr Surg.
2013;132:114–121.
The authors performed a systematic review of the evidence regarding the treatment of recurrent carpal
tunnel syndrome, including all articles from 1946 to 2012. The authors compared 294 patients who
underwent vascularized flap coverage over the affected median nerve with 364 patients who under-
went release without additional flap coverage. They identified that patients who underwent vascular-
ized flap coverage with external neurolysis were more likely to have resolved or improved symptoms
after surgery compared with patients who did not undergo flap coverage.
Zieske L, Ebersole GC, Davidge K, Fox J, Mackinnon SE. Revision carpal tunnel surgery: A 10-year
review of intraoperative findings and outcomes. J Hand Surg Am. 2013;38:1530–1539.
The authors performed a retrospective cohort study of 87 patients (97 extremities) who underwent
revision CTR. Among all patients who underwent revision CTR, incomplete release and scarring of
the median nerve were the most common intraoperative findings. Nerve injuries were noted more
commonly among patients who presented with new symptoms, rather than recurrent or persistent
symptoms. Patients with recurrent symptoms were more likely to have diabetes and had a longer
time interval between revision surgery and the index procedures. Encouragingly, postoperative hand
function (pinch and grip strength, pain) improved after surgery, but these gains were less pronounced
among patients with persistent symptoms or who had undergone multiple procedures.
Lattre T, Brammer S, Parmentier S, Van Holder C. Hypothenar fat pad flap surgery for end stage and
recurrent carpal tunnel syndrome. Hand Surg Rehabil. 2016;35:348–354.
The authors present 1-year functional and patient-reported outcomes after extended CTR and hypothenar
fat pad flap in eight patients with recurrent carpal tunnel syndrome. Patients experienced statistically
significant improvement in Semmes-Weinstein Monofilament testing, grip, tripod and pinch strength,
and Boston Carpal Tunnel Questionnaire scores at the 1-year timepoint.
Athlani L, Haloua JP. Strickland’s hypothenar fat pad flap for revision carpal tunnel syndrome: Prospec-
tive study of 34 cases. Hand Surg Rehabil. 2017;36:202–207.
This article is a prospective study examining 34 patients who underwent extended carpal tunnel release
and hypothenar fat pad flap for recurrent carpal tunnel syndrome. Grip strength improved 72% to
86% of contralateral arm, VAS pain improved from 6.4 to 1.4 postoperatively, QuickDASH (Disabilities
of the Arm, Shoulder, and Hand) scores improved by approximately 41 points, and patients resumed
their activities of daily living by 5 weeks.
CHAPTER 58
Procedures for Ulnar Compressive Neuropathy
INTRODUCTION
• The ulnar nerve is a mixed motor and sensory nerve. Compression leads to a con-
stellation of symptoms that vary depending on the location. The two most common
areas of compression include the elbow (the “cubital tunnel”) and the wrist/palm (the
“Guyon canal”).
• Because the area of compression determines the surgical approach, it is critical to
use the physical examination in conjunction with nerve conduction studies and elec-
tromyography to distinguish compression of the ulnar nerve at the elbow from com-
pression at the wrist.
• Occasionally, compression is present at both the elbow and wrist, necessitating
both cubital tunnel and Guyon canal releases.
• There is a “ladder” of procedures that the surgeon must consider when treating cubital
tunnel syndrome at the elbow: Start with in situ decompression for initial management,
progress to a hybrid subcutaneous/intramuscular transposition for recurrent or persis-
tent cubital tunnel syndrome, and finally consider submuscular transposition for patients
who fail the aforementioned treatments.
• Ulnar nerve subluxation at the elbow is a special circumstance, for which transposi-
tion of the nerve is performed as the initial operation.
Release of the Guyon Canal

INDICATIONS
• The various etiologies of ulnar nerve compression at the Guyon canal are illustrated
in Table 58.1. Nonsurgical treatment is suitable for patients with mild symptoms re-
lated to repetitive trauma or activities that cause prolonged compression of the ulnar
palm, such as jackhammering, long-distance cycling, or weightlifting.
• Surgical exploration is indicated for patients with intrinsic muscle loss, compressive
masses, or symptoms that persist or worsen over 2 to 4 months of conservative
treatment.
TABLE
58.1 Etiology of Compression at the Guyon Canal
Soft-tissue compression • Ganglia emanating from the triquetrohamate, pisotriquetral,

ulnocarpal, and midcarpal joints (most common cause)
• Tumors
• Dupuytren nodules and cords
Trauma • Repetitive vibratory trauma or prolonged compression
of the ulnar palm (second most common cause)
• Fracture of the hook of the hamate, pisiform, or base of
the metacarpals of the little and ring fingers
Arthritic, synovial, endocrine, • Rheumatoid arthritis

and metabolic conditions • Osteoarthritis
• Diabetes mellitus
• Chronic renal failure
• Alcoholism
• Hypothyroidism
Iatrogenic injury • Laceration of the ulnar nerve has been reported in the
course of tendon transfers and carpal tunnel releases.
446
CHAPTER 58 Procedures for Ulnar Compressive Neuropathy 447
• Compression at the Guyon canal is not associated with ulnar dorsal hand numbness
because the dorsal sensory branch takes off proximal to the wrist.
• Patients with ulnar neuropathy at the wrist present with pain; paresthesia of the ulnar
palm, small finger, and ulnar half of the ring finger; weakness of grip; and difficulty
with finger abduction and adduction, leading to hand “clumsiness.”
Clinical Signs
• The Froment sign occurs when paralysis of the adductor pollicis and first dorsal in-
terosseous (IO) muscle innervated by the deep branch of the ulnar nerve results in
weakness of thumb key pinch. This sign is demonstrated by thumb interphalangeal
(IP) joint flexion via median nerve innervated flexor pollicis longus (FPL) when at-
tempting key pinch (Fig. 58.1).
• The Jeanne sign is also related to the paralysis of the adductor pollicis and first
dorsal IO muscle and manifests as thumb metacarpophalangeal joint (MCPJ) hyper-
extension with attempted pinch. If present, the stability of the volar plate should be
assessed because this may also contribute to MCPJ hyperextension.
• The Wartenberg sign occurs when paralysis of the third palmar IO muscle results in
an abduction deformity of the small finger secondary to unopposed action of the
radial nerve innervated extensor digiti minimi.
• Intrinsic muscles are responsible for flexion of the MCPJ and extension at the IP joints.
A clawing deformity of the hand occurs when the intrinsic muscles are paralyzed, and
the extrinsic flexor and extensors are still functional. This is characterized by hyperex-
tension at the MCPJ of the ring and small fingers and flexion at the IP joints. In con-
trast, the index and middle finger lumbricals are median nerve innervated, enabling the
patient to compensate for the denervation of the IO muscles; preserved lumbrical
function prevents hyperextension at the MCPJs of these digits (Fig. 58.2).
• With the Tinel sign, tapping across an area of suspected nerve injury or compression
elicits pain and tingling in the nerve distribution. A positive test signals attempted
nerve regeneration at the site of compression and is helpful to distinguish other
neuropathies.
IMAGING
• Wrist anteroposterior (AP), lateral, and carpal tunnel view plain radiographs are helpful
to evaluate for hamate fracture. Evaluation of space-occupying lesions (ganglions, lipo-
mas, giant cell tumors, other cysts) and fractures of the hook of the hamate can be
identified using computed tomography (CT) scanning or magnetic resonance imaging.
Hyperextension
at the MCP
Normal Ulnar nerve palsy
Flexion
at the IP
Positive
Froment sign Difficulty
crossing
fingers
FIGURE 58.1 Positive Froment sign (From Amin, RM and Ingari, JV.
“Procedure 58: Submuscular ulnar nerve transposition.” In Lee D and FIGURE 58.2 Characteristic findings of ulnar nerve compression; there
Neviaser R, eds. Operative Techniques: Shoulder and Elbow Surgery. is clawing of the small finger and an inability to cross fingers on the left.
Elsevier: 2018.) IP, Interphalangeal; MCP, metacarpophalangeal.
448 CHAPTER 58 Procedures for Ulnar Compressive Neuropathy
• Compression at the wrist can lead to sensory only, motor only, or sensory and motor
changes on electrodiagnostic studies. These tests should be performed for all pa-
tients to confirm the diagnosis, evaluate alternate sites of compression, and provide
prognosis for recovery based on the presence or absence of denervation.
• Typical abnormalities on electromyogram and nerve conduction studies (EMG/NCS)
include delayed motor signal to the abductor digiti minimi and first dorsal IO muscles
and/or fasciculation upon needle insertion into these muscles.
SURGICAL ANATOMY
• The ulnar nerve is a terminal branch of the medial cord, C8-T1. In the upper arm, it
travels posteromedial to the brachial artery in the proximal part of the upper arm,
posterior to the medial intermuscular septum, and anterior to the medial head of the
triceps muscle.
• The floor of the Guyon canal is composed of the transverse carpal ligament and
hypothenar muscles; the roof is the volar carpal ligament, which is a continuation of
the forearm fascia. The ulnar border is composed of the pisiform and pisohamate
ligament proximally and the abductor digiti minimi muscle distally. The radial border
consists of the hook of the hamate.
• The ulnar nerve within the Guyon canal branches into superficial (sensory) and deep
(motor) branches.
• Ulnar nerve compression at Guyon canal can occur at three locations, with corre-
sponding clinical manifestations:
• Zone 1 includes compression of the nerve proximal to its bifurcation into super-
ficial and deep branches. The topography of the nerve includes motor fascicles
deep and sensory fascicles superficial. This is the most commonly affected area
and compression here results in both motor and sensory symptoms.
• Zone 2 includes compression of the deep motor branch that courses through the
pisohamate hiatus between the pisohamate arch and ligament around the hook
of hamate. Compression here results in palsy to the ulnar two lumbricals and the
IO muscles, with possible sparing of the hypothenar muscles.
• Zone 3 includes compression of the superficial branch as it crosses the palmar
fascia. Compression results in decreased sensory innervation to the volar small
finger and the ulnar side of the ring finger as well as loss of palmaris brevis func-
tion, which infrequently is noticeable (wrinkling of the ulnar palm).
Release of the Guyon Canal

POSITIONING
The procedure is performed under tourniquet control with the patient in the supine
position with the arm abducted and the hand placed on a hand table.
EXPOSURES PITFALLS EXPOSURES

Immediately beneath the skin, a crossing sensory An S- or Z-shaped incision is used across the volar wrist crease to avoid scar contrac-
cutaneous branch from the ulnar nerve may ture. The incision is marked 5 to 7 mm ulnar to the thenar crease, and the length is
emerge in the distal part of the incision. If present,
usually 4 to 5 cm (Fig. 58.3). The distal forearm portion of the incision should lie over
it should be identified and protected.
the flexor carpi ulnaris (FCU) tendon.
PROCEDURE
STEP 1 PEARLS
• Palpate the pisiform ulnarly and the hamate Step 1: Identify the Ulnar Nerve in the Distal Forearm
radially. The incision should be placed between • Incise the skin in the distal forearm and elevate skin flaps off the FCU tendon.
these two bony landmarks in the palm. In the Once the tendon is identified, dissect along the radial side of the fascia and
distal forearm, center the incision over the FCU.
• Identify the ulnar nerve in the distal forearm retract the tendon ulnarly. Along the radial side of the FCU tendon, the ulnar
and trace distally toward the area of compres- neurovascular bundle will be seen surrounded by fat; the nerve is ulnar to the
sion at the wrist and palm. artery (Fig. 58.4).
• It is not necessary to circumferentially dissect • Once identified in the distal forearm, carry the dissection distally through the subcu-
around the nerve; doing so risks devascular- taneous tissues into the palm, incising the antebrachial fascia and the volar carpal
ization.
ligament (roof).
Along FCU
Zig zag across wrist crease
FIGURE 58.3 Incision design. FCU, Flexor carpi ulnaris.
Ulnar nerve
III
II I
Ulnar artery
A
Superficial sensory
branch of Hamate
ulnar nerve
Zone 3
Zone 2
Motor branch of
ulnar nerve Transverse
Pisohamate ligament carpal ligament
Pisiform
Palmar carpal
Zone 1 ligament
Ulnar nerve
B Ulnar artery
FIGURE 58.4 (A–B) The transverse volar ligament is released to reveal the underlying neurovascular
bundle. Dissection is continued distally to release the motor (Zone 2) and sensory nerve (Zone 3)
branches.
Step 2: Release of the Deep Branch STEP 2 PEARLS

Trace the ulnar nerve into the palm distally. Retraction of the main nerve in the ulnar • Keep the release ulnar to the hook of hamate;
direction will facilitate identification of the nerve bifurcation (see Fig. 58.4A). The deep the carpal canal lies along the radial side.
motor branch starts ulnar and curves radially, deep to the superficial branch around • In redo procedures, more extensive dissection
the hook of hamate. The deep motor branch passes below the tendinous fascial edge is required to ensure adequate release of all
compressive overlying structures and neuroly-
of the hypothenar muscles; release these overlying bands (and some muscle) using sis of individual branches. An example of this
tenotomy scissors. Avoid injury to any small vascular branches traveling with the is demonstrated in Fig. 58.5.
nerve.
Step 3: Release of the Superficial Branch

The superficial branch is identified at the proximal area of nerve bifurcation. Trace it
distally under the fibrous arch of the hypothenar muscles and release all compressive
bands.
Step 4: Closure
Release the tourniquet, close the skin with nylon sutures, and place a soft dressing.
Ulnar artery
Deep motor Common digital nerve

4th webspace
Ulnar artery
Sensory nerve
to ulnar SF
A Ulnar nerve B
FIGURE 58.5 (A–B) Revision Guyon canal release with extensive neurolysis of ulnar nerve and branches into the palm.

Remove the dressing 2 or 3 days after surgery and initiate wrist and finger range-of-
motion (ROM) exercises. Remove the sutures after 10 to 14 days.
Cubital Tunnel Syndrome

INDICATIONS
• Compression at the elbow is the second most common compression neuropathy of
the upper extremity.
• Mild or moderate cubital tunnel syndrome can be treated conservatively. Because the
cross-sectional area of the cubital tunnel decreases 30% to 40% with elbow flexion,
patients should avoid this position. Patients can be taught elbow position modifications
to avoid compression of the nerve during daily activity. Night splints that hold the elbow
in extension are recommended; however, compliance is poor with these devices.
• Decompression of the ulnar nerve at the elbow is indicated for patients who present
with slowed conduction velocity (,50 m/s or a difference of 10 m/s between above
to below elbow conduction velocity). Advanced nerve compression (evidenced by
intrinsic muscle atrophy and hand weakness), failure of nonoperative management,
and ulnar nerve subluxation at the elbow are other indications for surgery.
• Many procedures have been performed for ulnar nerve decompression at the elbow,
including in situ release (most common), medial epicondylectomy, and subcutane-
ous, intramuscular, or submuscular transposition.
• In the absence of subluxation, many surgeons approach cubital tunnel syndrome
with in situ release first; if symptoms are persistent or recurrent, transposition tech-
niques are performed.
• Patients with minimal adipose tissue across the medial forearm are better treated
with intramuscular transposition so that the nerve is protected by the flexor pronator
mass. Because there is the potential for increased morbidity during dissection, sub-
muscular transposition is reserved for patients who failed anterior transposition and
present with severe perineural scarring and symptoms.
CLINICAL EXAMINATION PEARLS • Patients who fail primary cubital tunnel release are classified as:
• Persistent: Experienced incomplete or no relief after cubital tunnel release
• If a Tinel sign or subluxation of the ulnar nerve at
the elbow is detected, examine the contralateral • Recurrent: Experienced a period of relief followed by the return of symptoms related
upper extremity for comparison to determine the to scar and perineural adhesions
need for transposition at both elbows. • New: Related to the creation of a new iatrogenic point of compression or injury
• Distinguish cubital tunnel from medial epicon- to the nerve
dylitis (“golfer’s elbow”) based on history (pain
• During revision cases, the surgeon must also be prepared to manage potential medial
with wrist flexion, pronation, and valgus stress)
and physical examination (no subluxation or antebrachial cutaneous nerve neuromas that may have occurred related to nerve injury
Tinel at elbow over ulnar nerve). Consider in the initial operation.
ultrasound to evaluate the flexor-pronator
mass if the diagnosis of medial epicondylitis CLINICAL EXAMINATION
is in question. Occasionally, both diagnoses
• Assess the patient for the Tinel, Froment, Wartenberg, and other clinical signs dis-
may be present in the same patient.
cussed in the Guyon canal release section.
• Compression at the elbow leads to paresthesia and numbness in the small finger,
along the ulnar aspect of the ring finger, and along the ulnar dorsal hand (secondary
to the dorsal sensory branch).
• The examiner can detect nerve subluxation over the medial epicondyle by palpating
over the cubital tunnel as the patient flexes and extends the elbow. On occasion, the
triceps fascia can snap along the medial epicondyle during elbow flexion and may
lead to the misperception of subluxation and misdiagnosis.
• Motor defects associated with “low” ulnar nerve compression include weakness and
atrophy of the intrinsic muscles of the hand, including the third and fourth lumbricals,
dorsal and volar interossei, hypothenar muscles, deep head flexor pollicis brevis,
and adductor pollicis related to the motor branch of the ulnar nerve.
• Lesions proximal to the bifurcation of the origins of the motor branches to the FCU
and flexor digitorum profundus (FDP) of the ring and little fingers are considered
“high.” These manifest with weakness of ring and small finger FDP function and
decreased sensation along the dorsal ulnar hand.
• Compression of the superficial sensory branch leads to worsened two-point dis-
crimination and alteration of the sensory threshold to the volar small finger and ulnar
half of the volar ring finger.
IMAGING
• AP and lateral elbow radiographs are evaluated for heterotopic ossification around
the cubital tunnel related to prior trauma and nonunion as a result of compression.
• Additionally, ultrasound of the ulnar nerve at the elbow is used to detect changes in
caliber of the nerve above and below the cubital tunnel and subluxation of the nerve
during flexion and extension.
• Anconeus epitrochlearis is an accessory muscle that is present in up to 28% of the
population and can result in ulnar nerve compression at the elbow (Fig. 58.6). The
existence of an anconeus epitrochlearis or ulnar nerve subluxation can be evaluated
using ultrasound.
• Electrodiagnostic studies should be performed for all patients to confirm the diagnosis,
evaluate the alternate sites of compression, and provide prognosis for recovery based
on the presence of denervation. Normal forearm motor nerve conduction velocity is
greater than 48 m/s. Greater than 10 m/s of condition velocity slowing between above
and below elbow sensory conduction measurements indicates nerve compression. In
addition, a decline in amplitude of more than 20% compared with the unaffected side
may indicate nerve compression.
FIGURE 58.6 Anconeous running from medial epicondyle to olecranon, forming arch over cubital tunnel.
SURGICAL ANATOMY
• At the elbow, the ulnar nerve lies in the cubital tunnel and runs deep into the forearm,
between the humeral and ulnar heads of the FCU.
• The following areas of ulnar nerve compression must be identified and released during
cubital tunnel surgery: arcuate ligament of Osborne (most critical), arcade of Struthers,
medial intermuscular septum, deep fascia of FCU, flexor digitorum superficialis (FDS),
and FDP.
• During cubital tunnel release, avoid injury to the medial antebrachial cutaneous nerve,
which also diverges from the medial cord and supplies several branches around the
medial epicondyle. Injury to these branches may result in symptomatic neuroma forma-
tion and postoperative pain. The proximal crossing branch runs approximately 1.8 cm
proximal to the medial epicondyle, whereas the distal crossing branch lies about
3.1 cm distal to the medial epicondyle. If the incision is made posterior to the medial epi-
condyle and closer to the olecranon, this nerve should not be seen and can be avoided.
• The ulnar nerve gives off the dorsal cutaneous branch in the forearm, 5 to 8 cm
proximal to the wrist, before entering the Guyon canal.
POSITIONING
• The procedure can be performed with local, regional, or general anesthesia.
• Place a sterile tourniquet on the proximal upper extremity. The affected arm should
be supinated with the elbow joint in 90-degree flexion.
• Set the elbow joint on a stack of surgical towels or a bump to supinate the arm
easily.
SURGICAL APPROACH FOR PRIMARY ULNAR NERVE

EXPOSURES PEARLS COMPRESSION AT THE ELBOW
• Place the incision between the olecranon and • Either an in situ decompression or transposition can be performed as a primary
the medial epicondyle, favoring a slight poste- procedure to treat ulnar nerve compression at the elbow.
rior position to avoid creating scar irritation • For patients with nerve subluxation over the medial epicondyle or with clinical and
and to reduce the risk for injury to the medial electrodiagnostic evidence of severe compression who have multiple comorbidities,
antebrachial cutaneous nerve.
transposition may be more suitable as a primary option.
• The following sections will describe in-situ decompression and our preferred hybrid
subcutaneous/intramuscular transposition. Subcutaneous transposition is an addi-
tional option that may be suitable for patients with a large amount of subcutaneous
tissue at the medial elbow.
In Situ Decompression
EXPOSURES
Flex the elbow and mark a 3-cm curvilinear incision between the olecranon and medial
epicondyle (Fig. 58.7). Take care to avoid injury to the medial antebrachial cutaneous
nerve by designing the incision more posteriorly.
Medial epicondyle
Incision
Olecranon
FIGURE 58.7 Incision marked approximately halfway between the medial epicondyle and olecranon.
PROCEDURE STEP 1 PEARL
Step 1: Division of the Arcuate Ligament of Osborne • In large forearms with excessive soft tissue,
palpate the underlying nerve to confirm the
• Incise the skin using a no. 15 blade, then switch to tenotomy scissors and dissect location of the dissection.
down through the subcutaneous tissues. The nerve may be easily palpated just • Identify and protect the medial antebrachial
posterior to the medial epicondyle to confirm its location. cutaneous nerve branches that are in the sub-
• There will be a tough fibrous fascia between the medial epicondyle and olecranon; cutaneous fat over the muscle fascia and are
at risk for transection and neuroma formation.
this is the arcuate ligament of Osborne. The fibers of the ligament that run perpen-
dicular to the long axis of the forearm are sharply divided (Fig. 58.8).
STEP 2 PEARLS
Step 2: Distal and Proximal Release • One should not release the nerve circumferen-
• Use a handheld retractor to retract the skin distal and proximal. Release all the dis- tially because this risks devascularization and
will detach the stabilizing posterior fascia layer,
tal fascial bands by incising the aponeurosis between two heads of the FCU and leading to nerve subluxation.
proximal fascial bands with the release of the ligament of Struthers (Fig. 58.9). • Avoid excess division of FCU muscle fibers
• Carefully incise the arcade of Struthers with scissors, with gentle downward retrac- during distal fascial release.
tion of the ulnar nerve to create open space between the nerve and the arcade; • Identify ulnar nerve motor branches to the FCU
alternatively, a Freer can be placed between the ligament and the nerve, and then and protect these during fascial release.
• Inspect the ulnar nerve proximally and distally
the ligament can be released over the Freer. to ensure that there are no compressive bands.
• If the ulnar nerve is not transposed, the medial
Step 3: Examination of the Ulnar Nerve for Subluxation intramuscular septum does not need to be re-
Once the nerve is completely released, its position is examined through elbow flexion sected because the ulnar nerve will not cross
and extension. If subluxation is noted, additional procedures such as subcutaneous or over the septum.
intramuscular anterior transposition of the ulnar nerve may be performed. If there is no
subluxation, proceed to hemostasis and closure. STEP 2 PITFALLS
Take care to completely release the nerve distally
and proximally over the anterior surface. One of the
most common intraoperative findings on revision
cubital tunnel surgery is a kinked ulnar nerve distally.
Ulnar nerve
Medial intermuscular
septum
Arcade of
Struthers
Osborne’s
fascia released
Medial epicondyle
Osborne fascia
Ulnar
nerve Olecranon
Motor branch to
B FCU muscle Arcade of
A
FCU FCU
FIGURE 58.8 (A–B) Osborne fascia extends from the medial epicondyle to the olecranon. This is released to reveal the ulnar nerve underneath. FCU,
Flexor carpi ulnaris.
Ulnar nerve
released
FIGURE 58.9 Handheld retractors are used to expose the compressive structures proximally and
distally; the ligament of Struthers and compressive flexor carpi ulnaris (FCU) fascia are released.
STEP 4 PEARLS
Hemostasis is achieved and a layered skin closure is performed. A bulky dressing is
• Hematoma formation may cause severe scar
formation and lead to poor outcomes because applied. There is no need for splinting.
of surrounding inflammation. Thus thorough
hemostasis is necessary. POSTOPERATIVE CARE AND EXPECTED OUTCOMES
• The deep layer is closed with interrupted • The dressing is removed and elbow active ROM is initiated after 3 days.
absorbable sutures and the superficial layer
• If nonabsorbable sutures were placed, they are removed after 14 days.
can be closed with either running absorbable
or nonabsorbable sutures depending on the • Strenuous activity, contact sports, and heavy lifting are avoided for 6 weeks after
quality of the skin. surgery.
Hybrid Subcutaneous/Intramuscular Anterior

EXPOSURES PEARLS Transposition
Expose the surface of the flexor-pronator mass
thoroughly to create a fascial flap to support the EXPOSURES
ulnar nerve in a subcutaneous position.
• Ensure that the tourniquet is as high as possible on the arm.
• The incision should be of appropriate length to permit circumferential neurolysis of
EXPOSURES PITFALLS the ulnar nerve and anterior transposition over the medial epicondyle (Fig. 58.10).
• Care should be taken to avoid injury to the medial antebrachial cutaneous nerve.
The medial antebrachial cutaneous nerve has several
branches running supralaterally to inferomedially.
Protect these sensory nerves throughout the PROCEDURE
operation with identification using gentle spreads of
the tenotomy scissor. Step 1: Elevation of Skin Flaps
• The incision is extended to 5 cm by elevating subcutaneous flaps over the length of
STEP 2 PEARLS the incision.
There is a venous plexus posterior to the medial • If a medial antebrachial cutaneous nerve neuroma is identified, consider performing
intermuscular septum. Gentle exploration and frequent a regenerative peripheral nerve interface (RPNI) around the nerve end after neurec-
coagulation are necessary to avoid hematoma. tomy (Fig. 58.11).
Step 2: Proximal Site Decompression

STEP 2 PITFALLS
• Identify an area of soft, unscarred tissue where the nerve is clearly delineated and
Because the arcade of Struthers exists proximally begin releasing all overlying structures going from proximal to distal, including the
(it arises an average of 8 cm proximal to the medial
ligament of Struthers and Osborne and FCU fascia, and perform circumferential
humeral epicondyle), the tourniquet may disrupt its
exploration. Place a sterile tourniquet as proximally neurolysis of the nerve (Fig. 58.12).
as possible. • Resect a portion of the medial intermuscular septum to permit transposition and
avoid iatrogenic kinking of the transposed nerve (see Fig. 58.12).
STEP 3 PEARLS
Step 3: Nerve Transposition
• If the posterior motor branches prevent the • Proximally, perform neurolysis and dissect the ulnar nerve from its bed with accom-
ulnar nerve from being transposed sufficiently,
perform intraneural neurolysis to separate the panying vessels starting in an unscarred area. A vessel loop or penrose can be
motor branches. placed under the nerve to provide gentle traction during dissection.
• If a clear plane between the nerve and scar • Continue the neurolysis distally and identify and preserve the motor branches to the
cannot be identified, leave a small amount of FCU and FDP. Intraneural dissection is frequently needed to release the first branch
scar as a cuff on the nerve to prevent injury. to the FCU so that the ulnar nerve can be transposed (Fig. 58.13).
• If the epineurium appears tight, an epineurot-
omy may be necessary to decompress the • The nerve is then gently transposed anterior to the medial epicondyle.
blood supply.
Medial epicondyle
MABC neuroma
Prior in continuity
incision
Olecranon
FIGURE 58.10 The prior incision is used and extended distally and
proximally as needed. FIGURE 58.11 eMdial antebrachial cutaneous (MABC) neuroma identified.
Start of intraneural dissection
Medial
intermuscular
septum Ulnar nerve
Ulnar nerve First branch to FCU
FIGURE 58.13 Neurolysis of the ulnar nerve proceeds from proximal to

FIGURE 58.12 Perform neurolysis from proximal to distal. A portion of distal. Intraneural dissection is required to release the first motor
the medial intermuscular septum is resected to permit smooth lie of the branch of the flexor carpi ulnaris (FCU) and allow transposition of the
nerve after transposition. ulnar nerve anterior to the medial epicondyle without kinks.
Flexor-pronator mass
fascial sling
stair-step design
Neurolysis
of ulnar nerve
FIGURE 58.14 Ulnar nerve circumferentially released from surrounding scar. Stair-step fascial sling
designed to create hammock for nerve.
Step 4: Flexor-Pronator Z-Plasty Fascia Sling Formation STEP 3 PITFALLS

• The flexor-pronator origin is identified, and a step-cut incision is created within the • Anterior transposition may cause an additional
fascia to create limbs of approximately 5 cm in length (Fig. 58.14). compression point. The overall course of the
• The fascia overlying the flexor-pronator muscle is elevated. transposed ulnar nerve should be checked
thoroughly.
• A smooth transverse intramuscular groove is created using a no. 15 blade. All intra-
• The ulnar nerve bifurcates into motor branches
muscular septations in the vicinity are divided and/or excised to create a smooth of FCU and FDP muscles distal to the outlet of
bed of vascularized tissue for the nerve to lie free of compression. the cubital canal.
• The fascial flaps are transposed and loosely closed over the nerve using 3-0
Ethibond suture, taking care not to constrict or kink the nerve (Fig. 58.15).
STEP 4 PITFALLS
Step 5: Skin Closure Because the edge of the fascia may become another
• Deflate the tourniquet and achieve hemostasis. Check the ulnar nerve vascularity. compression point, the space under the fascia must
be generous to accommodate the new course of the
• A layered skin closure is performed, and a soft dressing is applied. nerve. A Freer or other instrument should freely pass
underneath the sling to ensure adequate space and
POSTOPERATIVE CARE AND EXPECTED OUTCOMES no compression (see Fig. 58.15).
A soft dressing is placed for 2 to 3 days. After that, patients can begin gentle ROM
exercises.
REVISION PROCEDURES FOR ULNAR NERVE COMPRESSION

AT THE ELBOW
These procedures are reserved for patients who have undergone either an in situ de-
compression or subcutaneous transposition and present with persist symptoms attrib-
utable to ulnar nerve compression.
Fascial sling
RPNI to MABC
Flexor-
pronator
muscle
Ulnar nerve
A
B
FIGURE 58.15 (A–B) The ulnar nerve is transposed underneath the fascial sling. Care is taken to ensure that there are no kinks along the
nerve and that the fascial sling is not too tight or compressive. A mosquito is passed underneath the fascial sling to demonstrate the space
beneath. A regenerative peripheral nerve interface (RPNI) is performed to treat the neuroma in continuity of the medial antebrachial cutaneous
(MABC) nerve.
HYBRID SUBCUTANEOUS/INTRAMUSCULAR
EXPOSURES PITFALLS TRANSPOSITION
• The ulnar nerve is usually surrounded by scar. • This is performed in patients who have previously undergone in situ decom-
In addition, the position of the nerve may be
shifted because of the adhesion and prior pression.
transposition procedures. Sharp dissection • The previous incision is extended proximally and distally as needed for full
with a no. 15 blade, layer by layer, facilitates exposure.
exposure and tissue planes. • See the section “Hybrid Subcutaneous/Submuscular Transposition” for details.
• The incision should be longer than the original to
accommodate the dissection and transposition. Submuscular Anterior Transposition
EXPOSURES
This step is similar to hybrid subcutaneous/intramuscular transposition (please refer
to Hybrid Subcutaneous/Intramuscular Transposition) with the exception that the
incision is longer.
PROCEDURE
STEP 1 PITFALLS Step 1: Ulnar Nerve Identification and Neurolysis
Caution is taken to avoid injury to the distal Perform the exploration in normal, unscarred planes to identify and protect the ulnar
branches of the ulnar nerve, including the branches
nerve, then sequentially trace the nerve proximally and distally, releasing it from the
to the FCU and FDS upon initial exposure.
surrounding scarred tissue. Thorough circumferential external neurolysis is performed
and surrounding scar tissue is resected if possible.
Step 2: Confirm Complete Decompression

This step is similar to subcutaneous anterior transposition (please see “Hybrid Subcu-
taneous/Intramuscular Transposition”).
Step 3: Muscular Flap Elevation

• The flexor-pronator mass is identified 1 to 2 cm distal to the medial epicondyle, and
STEP 3 PEARLS
a plane is gently dissected underneath the flexor-pronator mass to elevate the
In the distal upper arm, the brachial artery and muscle. The brachial artery and median nerve are identified, protected, and gently
median nerve run side by side between the biceps
retracted laterally as the dissection proceeds underneath the muscle.
and brachialis muscles. Identify and protect these
structures during the exploration. • The dissection is carried toward the medial epicondyle, and a step-cut incision is
created in the muscle fascia to separate the flexor-pronator mass from the medial
epicondyle, leaving a small cuff of fascia for approximation after nerve transposition
STEP 3 PITFALLS
(Fig. 58.16A). The muscle is then gently elevated and reflected distally. Deep to the
Identify a plane under the flexor-pronator muscle muscle lies the ulnar collateral ligament. This should be left down.
mass before completely incising the muscle to • The ulnar nerve is transposed in a submuscular position and made to lie anterior to
avoid disrupting the medial collateral ligament.
the median nerve (see Fig. 58.16B).
Ulnar nerve
FIGURE 58.16 (A) A step-cut is made in the flexor-pronator fascia to create an anterior distally-based
myofascial flap and a posterior proximally-based fascial flap. (B) Flaps are elevated to create a trough
in the muscle bed into which the ulnar nerve is transposed. (C) The fascial flap ends are sutured
together to prevent posterior subluxation of the ulnar nerve and to lengthen the musculofascial unit.
(Distal is to the left and proximal to the right.)
Step 4: Flexor-Pronator Step-Cut Sling Formation

The flexor-pronator mass is loosely reapproximated over the nerve using 3-0 Ethibond
sutures, taking care not to compress or kink the neurovascular structures (see
Fig.58.16C).

The skin is closed in layers using absorbable sutures.

Immobilize the elbow at 70 degrees of flexion for 4 weeks, then remove the splint and
initiate gentle ROM exercises.
See Videos 58.1–58.3
EVIDENCE
Davidge K, Ebersole GC, Mackinon SE. Pain and function following revision cubital tunnel surgery.
Hand. 2019;14:172–178.
A retrospective cohort study examined findings and outcomes after revision cubital tunnel surgery
among 50 patients with 52 revision cubital tunnel surgeries. A kinked ulnar nerve distally or obstructive
medial intermuscular septum proximally were the most commonly encountered problems. All patients
underwent transmuscular transposition with significant improvement in pain and quality of life.
Grandizio LC, Maschke S, Evens PJ. The management of persistent and recurrent cubital tunnel
syndrome. J Hand Surg. 2018;43:933–940.
This is an excellent review of the presentation, etiology, and management of persistent and recurrent
cubital tunnel syndrome.
CHAPTER 59
Radial Nerve Decompression
INTRODUCTION
• Radial neuropathy can result from direct trauma or compression anywhere along the
radial nerve’s course, from the brachial plexus through the spiral groove, radial tunnel,
posterior interosseous nerve (PIN), or superficial branch of the radial sensory nerve.
• Three types of radial nerve decompression may arise in the forearm: PIN syndrome,
radial tunnel syndrome, and compression of the radial sensory nerve in the distal
forearm, otherwise known as Wartenberg syndrome.
• PIN syndrome is a purely motor paralysis caused by PIN compression, which
affects the motor function of muscles innervated by the PIN.
• The addition of pain in the lateral forearm without distal sensory loss is known as
radial tunnel syndrome.
• Wartenberg syndrome is diagnosed when a patient solely has sensory complaints
in the region of the radial sensory nerve. This is likely a result of entrapment of the
radial sensory nerve distal to the radial tunnel, between the extensor carpi radialis
longus (ECRL) and brachioradialis (BR) tendons, as the nerve transitions from
deep to superficial.
INDICATIONS
• Patients with radial tunnel syndrome classically present with pain and tenderness
at the lateral proximal forearm that is exacerbated with resistance of long finger
extension and resisted forearm supination. In contrast, patients with PIN com-
pression present with neurologic motor weakness without associated lateral
forearm pain.
• The presence of space-occupying lesions, such as ganglion cysts or tumors, may
also cause compression of the radial nerve in the forearm (Fig. 59.1).
Axial T1 Sagittal T1 Coronal STIR
A B C
FIGURE 59.1 MRI showing a lipoma in the radial tunnel. (A) Axial T1. (B) Sagittal T1. (C) Coronal STIR. MRI, Magnetic resonance imaging; STIR, short
tau inversion recovery.
459
460 CHAPTER 59 Radial Nerve Decompression
CLINICAL EXAMINATION PEARLS • Conservative management, including treatment of concomitant lateral epicondylitis,
rest, activity modification, antiinflammatories, and corticosteroid injections, is indi-
• The most important differential diagnoses to
consider are radial tunnel syndrome and lateral cated for patients with early compressive symptoms without evidence of space-
epicondylitis. The pain associated with lateral occupying lesions.
epicondylitis is proximal and more posterior/
ulnar, located directly over the lateral epicon- CLINICAL EXAMINATION
dyle. The pain from radial tunnel syndrome is
• Patients with PIN compression present with spontaneous weakness of the finger
distal to the lateral epicondyle in the proximal
forearm, directly ulnar to the BR. Most patients extensors. Wrist extension is preserved with radial deviation because the ECRL
are tender when deep palpation is applied to comes off the radial nerve before the radial tunnel, and the extensor carpi ulnaris
this region, but patients with radial tunnel (ECU) comes off the PIN proper, resulting in ulnar-sided weakness only.
syndrome have more significant and • Patients with radial tunnel syndrome have focal tenderness over the radial tunnel,
asymmetric tenderness.
which exists on the longitudinal line from the radial head to the midpoint of the wrist,
• The Maudsley test is useful for differentiating
lateral epicondylitis from radial tunnel syn- 3.5 to 7.5 cm distal to the radial head.
drome. A positive test describes pain in the
region of the lateral epicondyle during resisted IMAGING
extension of the long finger and is indicative of • For patients with PIN compression, nerve conduction studies may reveal slowed
lateral epicondylitis. The use of local anesthetic
conduction velocity or reduced amplitudes of nerve conduction. Nevertheless, nerve
is also helpful to confirm the diagnosis of
lateral epicondylitis. Temporary total pain relief conduction studies in patients with PIN compression are frequently normal because
after lidocaine injection into the lateral epicon- it is difficult to capture nerve velocities using surface electrodes given the depth of
dyle may further confirm the diagnosis of the PIN from the skin. Compression entirely affects the motor component of the
lateral epicondylitis. radial nerve. Therefore because the superficial sensory radial nerve is not involved,
• Trauma, proliferative rheumatoid synovitis,
sensory nerve action potentials should be unaffected on nerve conduction studies.
mononeuritis, and Parsonage-Turner syndrome
may cause symptoms similar to PIN compres- Electromyography may demonstrate diminished recruitment, increased insertional
sion. Lateral elbow and forearm pain may also activity, fibrillation, and polyphagia because of denervation and peripheral reinnerva-
be caused by cervical radiculopathy, elbow tion among PIN-innervated muscles.
arthritis, avascular necrosis of the capitellum, • For patients with radial tunnel syndrome, electrodiagnostic studies are typically normal.
medial collateral ligament instability, or lateral
• If a space-occupying lesion is suspected, such as a lipoma, ganglion cyst, other
antebrachial cutaneous neuropathy.
tumors, or other pathology in the radiocapitellar joint, then additional tests, including
radiographs or magnetic resonance imaging (MRI), should be performed.
• Although electrodiagnostic studies are inconclusive for radial tunnel syndrome, they
may be useful for ruling out C5 radiculopathy
SURGICAL ANATOMY
• The radial nerve arises from the posterior cord of the brachial plexus, with contribu-
tion from the C5, C6, C7, C8, and T1 roots. It lies posterior to the axillary artery and
travels with the profunda brachii through the triangular interval into the posterior
compartment of the arm, through the spiral groove between the medial head and
lateral head of the triceps until it reaches the lateral intermuscular septum. The nerve
then enters the lateral intermuscular septum and courses distally between the bra-
chialis and lateral head of the triceps, giving off two sensory nerves: the posterior
cutaneous nerves of the arm and forearm. It travels distally in the lateral intermus-
cular septum until it enters the anterior compartment of the arm between the bra-
chialis and BR, roughly 2 to 3 cm proximal to the lateral epicondyle.
• After the triceps branches, the first muscles innervated by the radial nerve proper
are the anconeus, BR, and ECRL, all of which receive innervation proximal to the
lateral epicondyle and radial tunnel. Within the radial tunnel, it then branches into the
nerves to supinator (usually two branches), the PIN, the nerve to the extensor carpi
radialis brevis (ECRB), and the radial sensory nerve (Fig. 59.2).
• The PIN courses between the superficial and deep head of the supinator muscle
along the dorsal forearm and then branches to the extensor digitorum communis
(EDC), ECU, extensor digiti quinti (EDQ), abductor pollicis longus (APL), extensor
pollicis longus and brevis (EPL and EPB), and the extensor indicis proprius (EIP; see
Fig. 59.2).
• The radial tunnel originates at the radiocapitellar joint (RCJ) and runs distally be-
tween the deep and the superficial heads of the supinator. Five points of compres-
sion exist within the radial tunnel: the fibrous bands proximal to the radial head, the
radial recurrent vessels (leash of Henry), the fibrous edge of ECRB, the arcade of
Frohse, and the distal supinator. The lateral wall of the radial tunnel consists of the
CHAPTER 59 Radial Nerve Decompression 461
Brachioradialis
Extensor carpi
radialis longus
Radial nerve
Superficial Posterior
sensory branch interosseous
of radial nerve nerve
Supinator
Extensor
carpi radialis
brevis
Extensor
digitorum
communis
Abductor Extensor carpi
pollicis ulnaris
longus Extensor digiti
quinti minimi
Extensor
pollicis
longus
Extensor
pollicis
brevis Extensor indicis
proprius
FIGURE 59.2 Anatomy of the radial nerve and posterior interosseus nerve. Note that the BR and
ECRL nerves come off before the radial tunnel, and that the ECRB nerve and radial sensory nerve
comes off before the PIN enters the supinator muscle. BR, Brachioradialis; ECRB, extensor carpi ra-
dialis brevis; ECRL, extensor carpi radialis longus; PIN, posterior interosseous nerve.
BR, the ECRL, and the ECRB muscles, whereas the medial wall consists of the bi-
ceps tendon and the brachialis. Its floor is formed by the capsule of the RCJ that
continues distally to the deep head of the supinator muscle (Fig. 59.3).
POSITIONING STEP 1 PEARLS
The procedure is performed under tourniquet control and regional block, or general • Ask the patient to flex the elbow in mid-prono-
supination in the preoperative holding bay to
anesthesia, with the patient placed in supine position. The hand and forearm are pro-
identify the BR, and mark the incision ulnar to
nated on the operating table. Prophylactic antibiotics are not indicated. the BR, between the BR and ECRL.
• The incision needs to be quite proximal, start-
RADIAL NERVE DECOMPRESSION ing 1 cm distal to the elbow crease (Fig. 59.4).
Step 1: Marking
A 6-cm straight longitudinal incision is designed along the posterolateral proximal fore- STEP 2 PITFALLS
arm, between the BR and ECRL.
• The LABC nerve is located on the deep fascia,
typically in this region of dissection.
Step 2: Incision Through Skin to Deep Fascia • The interval between the BR and ECRL can be
• Incise the skin and dissect straight down to the deep fascia. identified in two ways. First, the BR is more
• Protect the lateral antebrachial cutaneous (LABC) nerve. red in color because it has less overlying fas-
cia. Second, there may be a fat stripe between
• Identify the interval between the BR and ECRL and open the deep fascia through the
these two muscles (Fig. 59.5).
length of the incision.
Arcade of
Supinator Brachioradialis
Fröhse
Radial
nerve Radial sensory
nerve
ECRL
ECRB
ECU EDC
Posterior
interosseous nerve
FIGURE 59.3 The radial tunnel originates at the RCJ and runs distally between the deep and the superficial heads of the supinator. Five points of com-
pression exist within the radial tunnel: the fibrous bands proximal to the radial head, the radial recurrent vessels (leash of Henry), the fibrous edge of the
ECRB, the arcade of Frohse, and the distal supinator. The lateral wall of the radial tunnel consists of the BR, the ECRL, and the ECRB muscles, whereas
the medial wall consists of the biceps tendon and the brachialis. Its floor is formed by the capsule of the radiocapitellar joint that continues distally to the
deep head of the supinator muscle. ECRB, Extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, exten-
sor digitorum communis; RCJ, radiocapitellar joint.
BR
FIGURE 59.4 Have the patient flex the elbow with neutral pronosu-
pination to make the BR readily visible, then place your mark ulnar,
ECRL
between the BR and ECRL. The incision starts just distal to the an-
tecubital crease and extends distally 6 cm. BR, Brachioradialis;
ECRL, extensor carpi radialis longus.
FIGURE 59.5 The radial tunnel is easily found by identi-

fying the radial sensory nerve, which exists between
the BR and ECRL muscles in the midforearm. BR, Bra-
chioradialis; ECRL, extensor carpi radialis longus.
Step 3: PIN Identification

STEP 3 PEARLS • After opening the deep fascia, bluntly dissect between the BR and ECRL. This will
The nerves in the radial tunnel have consistent provide direct access to the radial sensory nerve (Fig. 59.6).
orientation: The radial sensory nerve is large and • Ligate or cauterize any crossing vessels seen on the way down.
longitudinally oriented, and it is and the easiest • Trace the radial sensory nerve proximally to identify the PIN (Fig. 59.7).
branch to find first. Roughly parallel and ulnar to it
is the smaller nerve to the ECRB. The PIN is found Step 4: PIN Release
next, moving further ulnar. It is the largest nerve in
the radial tunnel and oriented 45 degrees to the After identifying the PIN in the radial tunnel, the structures of compression are identified
radial sensory nerve. It dives beneath the ECRB and and released: the leash of Henry or the radial recurrent vessels proximal to the supina-
then underneath the supinator. Finally, two branches tor are ligated or cauterized. The first tendinous leading edge overlying the PIN is the
to the supinator are typically found most proximally ECRB fascia. Releasing this will expose the more substantial tendinous leading edge of
and ulnarly, oriented at 90 degrees to the radial
the supinator, known as the arcade of Frohse. This is divided throughout its course to
sensory nerve and 45 degrees to the PIN (Fig. 59.8).
ensure complete release of compression (Fig. 59.9).
CHAPTER 59 Radial Nerve Decompression 463
Radial sensory nerve Superficial radial sensory branch
BR
BR
ECRL
ECRL
Posterior interosseous nerve

FIGURE 59.7 The radial sensory nerve is followed proxi-
FIGURE 59.6 After opening the deep fascia, mally to enter the radial tunnel and identify the PIN. PIN,
bluntly dissect between the BR and ECRL. This Posterior interosseous nerve.
will lead directly to the radial sensory nerve, a key
landmark for finding the radial tunnel. BR, Bra-
chioradialis, ECRL, extensor carpi radialis longus.
STEP 4 PEARLS
ECRL BR • The origin of the ECRB may be divided from
ECRB (in the lateral epicondyle to treat concomitant
pickups) lateral epicondylitis.
• The dissection plane between the BR and
ECRL should be smooth. If the dissection is
difficult, reassess the anatomy to ensure that it
is proceeding in the correct plane.
• The interval between the EDC and ECRB can
also be accessed to ensure complete release
A of the supinator fascia because it provides the
most robust exposure of this fascia (see
BR Fig. 59.8A–C).
muscle
Radial Nerve to
sensory ECRB
nerve
2 nerves to STEP 4 PITFALLS
supinator
Hematoma formation may cause severe scarring
from inflammation. Complete hemostasis is required.
ECRL PIN
muscle
ECRL muscle ECRB muscle,

retracted
PIN, traveling
Release the under leading
supinator fascia edge of supinator
over the dotted (arcade of
line to Fröhse)
decompress PIN
EDC muscle,
retracted muscle
FIGURE 59.8 Cadaver dissection: Different intervals exist for decompressing the radial tunnel. (A)
The easiest is found between the BR and ECRL, between which the radial sensory nerve is found
and can be traced proximally into the radial tunnel. Between the ECRL and ECRB provides a similar
operative exposure. (B) Radial tunnel viewed between the BR and ECRL. Cadaver dissection; leash
of Henry not a distinct structure here. (C) The interval between the ECRB and EDC provides expo-
sure of the supinator muscle and the arcade of Frohse. BR, Brachioradialis, ECRB, extensor carpi
radialis brevis; ECRL, extensor carpi radialis longus; EDC, extensor digitoris communis;
PIN, posterior interosseous nerve.
Incised arcade of Fröhse
Incised ECRB
fascia
Supinator
BR
ECRB
ECRL

FIGURE 59.9 The fascia of ECRB and supinator (arcade of Frohse) is released, decompressing the
PIN. The radial recurrent vessels (leash of Henry) are also released if compressive. ECRB, Extensor
carpi radialis brevis; PIN, posterior interosseous nerve.

• Close the skin in layers with absorbable suture.
• Apply a soft dressing with no immobilization.

• Remove the dressing 2 days postoperatively.
• No immobilization is required. Early active and passive range of motion exercise is
recommended.
• The patient may return to light exercises at the end of the first month and full and
unrestricted duty after 2 months.
See Video 59.1
EVIDENCE
Bolster MA, Bakker XR. Radial tunnel syndrome: Emphasis on the superficial branch of the radial
nerve. J Hand Surg Eur Vol. 2009;34:343–347.
The authors reported 12 cases of radial tunnel syndrome for which the superficial branch of the radial
nerve was decompressed, and 11 of 12 patients experienced relief postoperatively, as measured by
the Disabilities of Arm, Shoulder, and Hand (DASH). This study indicates that pain relief in patients
with radial tunnel syndrome can be achieved by surgical decompression of the superficial branch of
the radial nerve (Level IV evidence).
Ochi K, Horiuchi Y, Tazaki K, et al. Surgical treatment of spontaneous posterior interosseous nerve
palsy: A retrospective study of 50 cases. J Bone Joint Surg Br. 2011;93:217–222.
The authors retrospectively reviewed 38 patients with spontaneous PIN palsy with 21-month follow-up.
Outcomes were evaluated using the Medical Research Council muscle power scale. In this cohort,
younger patients experienced significantly better outcomes compared with older patients after inter-
fascicular neurolysis. Furthermore, a preoperative delay of less than 7 months was associated with
improved results among younger patients. In contrast, time to surgery had no effect for older
patients (Level IV evidence).
Wu P, Yang JY, Chen L, Yu C. Surgical and conservative treatments of complete spontaneous posterior
interosseous nerve palsy with hourglass-like fascicular constrictions: A retrospective study of
41 cases. Neurosurgery. 2014;75:250–257.
In this study, 41 patients with complete spontaneous PIN palsy with hourglass-like fascicular constric-
tion detected by preoperative ultrasound were treated by interfascicular neurolysis, neurorrhaphy,
and autografting. In this cohort, outcomes were favorable with neurolysis alone for patients with
mild-to-moderate PIN constriction, but poor for patients with severe constriction. In contrast,
patients with severe constriction experienced superior outcomes with neurorrhaphy or autografting.
Uniformly, outcomes are poorer among individuals ages 50 years and older (Level IV evidence).
Urch EY, Model Z, Wolfe SW, Lee SK. Anatomical study of the surgical approaches to the radial tunnel.
J Hand Surg Am. 2015;40(7):1416–1420.
The authors performed 10 cadaver dissections for each of three approaches to the radial tunnel. Most
sites of compression (fibrous bands of the radial head, the leash of Henry, the origin of the ECRB,
and the arcade of Frohse) were visualized using the interval between the BR and ECRL; however the
distal supinator fascia was only visualized using the interval between ECRB and EDC.
ddsf
SECTION VII
Nerve Injuries and Palsy

CHAPTER 60 Digital Nerve Repair 466
CHAPTER 61 Ulnar Nerve Group Fascicular Repair 472
CHAPTER 62 Median Nerve Epineural and Group Fascicular
Nerve Repair 476
CHAPTER 63 Tendon Transfers for Low Median Nerve
Injury 482
CHAPTER 64 Tendon Transfers for High Median Nerve
Injury 494
CHAPTER 65 Tendon Transfers for Low and High Ulnar
Nerve Injury 502
CHAPTER 66 Tendon Transfers for High and Low Radial
Nerve Injury 521
CHAPTER 67 Tendon Transfers for Combined Nerve Palsy 530
CHAPTER 68 Distal Anterior Interosseous Nerve (AIN)
Transfer to Motor Branch of Ulnar Nerve 540
465
CHAPTER 60
Digital Nerve Repair
INDICATIONS
• The major mechanisms of nerve injury include crush/compression, tension/traction,
and laceration of the digits.
• From superficial to deep, the layers of a peripheral nerve include the epineurium,
perineurium, and endoneurium. Nerve injury can occur at any or all of these layers.
• The classification of nerve injuries has been described by Seddon and Sunderland
(Table 60.1).
• Neuropraxia describes a temporary nerve conduction block. The nerve compo-
nents remain intact and patients often recover from this injury within 3 to 4 months.
• Axonotmesis describes disruption of the neuronal axon with an intact epineurium
that preserves the channel for the axons to grow into a defined and specific path.
Spontaneous recovery after injury is possible, but timing for full recovery is vari-
INDICATIONS PEARLS
able; axonal growth occurs at a rate of 1 mm per day.
• Critical factors that affect outcomes after nerve • Neurotmesis describes complete nerve internal disruption to all layers, which
repair include patient age, the time from injury
to repair, the level of the injury, and the gap causes mismatch of axons during regeneration. Patients will not recover without
required for grafting. surgery.
• In general, younger age is correlated with • Surgical planning for nerve repair and/or reconstruction requires consideration of the
superior outcomes. Patients 20 years and mechanism of injury, time since injury, condition of the nerve ends, possible nerve
younger experience faster recovery com- gaps, concomitant injuries (bone, blood vessels), and soft tissue coverage.
pared with patients aged 50 years and
older. • Primary nerve repair should be performed within 12 hours after sharp nerve transec-
• Return of sensation has been observed after tion injuries to optimize outcomes. Nevertheless, repair may be delayed to address
nerve repairs performed up to 2 years after contamination, concomitant injuries, or comorbid conditions.
injury. Acceptable recovery of motor func- • In contrast, closed/blunt nerve injuries often require a period of observation, serial
tion, however, is obtained only within 1 year examinations, and nerve conduction/electromyography studies to permit adequate
after injury, before motor end plates at the
target muscle are lost and irreversible time for recovery and documentation of the nerve condition. If recovery does not
denervation takes place. occur within 3 to 6 months, then exploration and nerve primary repair or grafting
should be considered.
• Injured sensory nerves should be reconstructed when sensory loss affects critical
areas used for contact, such as the tip of the thumb and radial side of the index
finger (contact areas during pinch), and the ulnar aspect of the small finger, palm,
and ulnar side of the forearm.
• Nerve injuries with associated loss of motor function should be reconstructed as
early as possible to prevent irreversible denervation and muscle fibrosis. Although
TABLE Progressive Degree of Injury Starting With Conduction Block,

60.1 and Going From Partial Structural Injury Axon, Endoneurium,
Perineurium, and Finally Full Transection at the Epineural Level
Seddon Sutherland Description
Neuropraxia 1 Conduction block, intact neural architecture;
3–4 months recovery
Axonotmesis 2 Injured axon with intact epineurium, perineurium,
and endoneurium, variable recovery
3 Injured axon 1 endoneurium
Neurotmesis 4 Injured axon 1 endoneurium and perineurium
5 All layers damaged, including epineurium
466
tendon transfers can augment function for late injuries, these procedures do not
completely restore joint function and mechanics; native muscle function is preferred.
• Careful examination of the condition of the wound is necessary to determine the
degree of surrounding tissue injury, contamination, and the presence and extent of
associated injuries.
• A full sensory and motor neurologic examination should be performed to identify any
deficits and suitable donor nerves if needed. The inability to produce wrinkles or loss
of sweating and perspiration may indicate nerve disruption and loss of sympathetic
function; this physical examination finding is especially important in pediatric pa-
tients who have an unreliable examination.
• To assess motor function, the Medical Research Council system is useful and well ac-
cepted. Both motor and sensory recovery are classified into six categories (Table 60.2).
Sensation should be assessed using static and moving two-point discrimination.
• A Tinel sign can be indicative of nerve injury or recovery.
• After nerve repair, progression of a Tinel sign from proximal to distal indicates recov-
ery, typically at the rate of 1 mm/day. Limited progression may indicate a blockage
or neuroma.
IMAGING
• Nerve conduction studies (NCS) are obtained to determine a nerve’s response to a
stimulus. Two electrodes are placed on the patient’s skin at a specific distance apart;
one electrode provides the stimulus and the other records the response. The ampli-
tude of the response corresponds to the number of depolarizing axons, whereas the
latency is the time between stimulus and response. A conduction velocity is calcu-
lated by dividing the distance between the electrode and the latency. The findings
of NCS can vary depending on the time and severity of the injury. Nerves that are
not completely resected (i.e., neuropraxia or axonotmesis) may show evidence of
recovery over time.
TABLE
60.2 Medical Research Council System for Assessing Motor Function
Motor Recovery
M0 No contraction
M1 Return of perceptible contraction in the proximal muscles
M2 Return of perceptible contraction in both the proximal and distal
muscles
M3 Return of perceptible contraction in both the proximal and distal
muscles of such a degree that all important muscles are suffi-
ciently powerful to act against resistance
M4 Return of function as in stage 3 with the addition that all synergic
and independent movements are possible
M5 Complete recovery
Sensory Recovery
S0 Absence of sensibility in the autonomous area
S1 Recovery of deep cutaneous pain sensibility within the autonomous
area of the nerve
S2 Return of some degree of cutaneous pain and tactile sensibility
within the autonomous area
S3 Return of some degree of superficial cutaneous pain with disap-
pearance of any previous overreaction
S4 Complete recovery
468 CHAPTER 60 Digital Nerve Repair
• After transection of a nerve, the portion of the axon that is no longer in continuity
with the anterior horn cells in the spinal cord undergoes degeneration and degrada-
tion, a process known as Wallerian degeneration. Wallerian degeneration typically
occurs within 24 to 36 hours of an injury and is not immediately detectable on NCS.
• Needle electromyography can be used to assess the condition of the injured nerve
and muscle by evaluating the insertional activity, resting activity, voluntary recruit-
ment, and motor unit recruitment. Denervation and reinnervation of the muscle can
be detected and changes can be followed over time. Denervation is indicated by the
presence of positive sharp waves, fasciculations, and fibrillation potentials in a rest-
ing state. Reinnervation is detected by increasing the number and amplitude of the
polyphasic motor unit potential and decreasing the fibrillation potential.
• Entrapment/compression nerve injury patients exhibit a decrease in conduction ve-
locity or increased latency on nerve conduction studies.
SURGICAL ANATOMY
• Peripheral nerves are made up of axons that are surrounded by endoneurium. A
group of axons form a fascicle, which is surrounded by perineurium. The epineurium
(outermost layer) surrounds groups of fascicles.
• Donor nerves:
• Posterior interosseous nerve (PIN): The terminal branch of the PIN innervates the
wrist joint and is often resected to treat chronic wrist pain. The nerve is expend-
able at this level, as branches to the extensor muscles have already come off. The
PIN contains one to two fascicles and is a good size match for digital nerve
reconstruction, measuring around 0.8 mm2 in cross-sectional diameter. Up to
2.5 cm of graft can be harvested, on average. The nerve runs on the radial aspect
of the floor of the fourth extensor compartment deep to the tendons of the exten-
sor digitorum communis (EDC) and the extensor indicis proprius (Fig. 60.1).
• Medial antebrachial cutaneous nerve (MABC): The MABC branches off of the
medial cord of the brachial plexus. There is an anterior branch and a posterior
branch; one or both branches can be harvested for reconstruction, totaling up to
28 cm of graft, depending on the length of the patient’s arm. This nerve contains
5 to 7 fascicles and can be used for group fascicular repair or cable grafting. The
cross-sectional area is 2 to 3 mm2. MABC graft can be used for multiple digital
or common digital nerve reconstructions, or reconstruction of larger caliber
nerves where cable graft can be prepared. The MABC runs with the basilic vein
in the medial forearm overlying the bicipital groove. For additional length, the
nerve branches can be traced to the axilla. If only the anterior branch is used,
then the distal end of the anterior branch can be coapted to the posterior branch
or the median nerve in an end-to-side fashion to minimize sensory loss after
harvest.
• Sural nerve: The sural nerve is the workhorse donor nerve. Depending on the
height of the patient, 30 to 50 cm can be harvested. This nerve contains 9 to 14
fascicles and has an average cross-sectional area of 2.5 to 4 mm.2 It is used for
major nerve reconstruction (median and ulnar nerve) when large gaps are present.
The sural nerve is composed of medial and lateral sural cutaneous branches. The
medial sural cutaneous nerve arises from the tibial nerve and pierces the deep
fascia of the leg between the heads of the gastrocnemius in the upper third of the
leg. It is then joined by the lateral sural cutaneous nerve branch, which originates
from the peroneal nerve. The sural nerve travels with the lesser saphenous vein
and can be found between the lateral malleolus and Achilles tendon. The nerve
innervates the posterolateral aspect of the leg and the dorsolateral foot (Fig. 60.2).
Harvest results in sensory deficit to this area.
POSITIONING
• The operation should be performed under tourniquet control to visualize the injured
nerve clearly, with the arm outstretched on the hand table.
• A nerve stimulator can be useful to identify an intact nerve in the scarred tissue.
• A microscope is used to perform a meticulous nerve repair.
Anterior view Posterior view

Common
Tibial
peroneal nerve
nerve
Medial sural Peroneal

cutaneous nerve communicating nerve
Lateral sural
cutaneous nerve
Small
saphenous vein
Sural nerve
Lateral antebrachial
cutaneous nerve
Medial
antebrachial
cutaneous nerve Lateral antebrachial
cutaneous nerve
Posterior branch
Anterior branch Posterior
interosseous
nerve
Achilles Lateral malleolus
Superficial radial tendon
nerve
FIGURE 60.2 Sural nerve anatomy.
FIGURE 60.1 Nerve anatomy.

• PIN exposure: A longitudinal incision is made just ulnar to the Lister tubercle. The Extend old scars proximally and distally to identify
extensor retinaculum and fourth extensor compartment are incised and opened. The nerve ends in soft tissue that is free of scars. Once
EDC and EIP are retracted and the base of the compartment is visualized. The ter- healthy nerve ends are identified, they can be
traced and dissected away from the scars.
minal end of the PIN is identified on the radial aspect of the fourth compartment
floor. The nerve is then transected and dissected from the surrounded tissues
proximally for the appropriate length.
• MABC exposure: A longitudinal incision is made on the anteromedial aspect of the
upper arm, above the elbow near the biceps groove. Dissect through the subcutane-
ous tissues toward the muscle fascia. The basilic vein is an excellent landmark; the
nerve will be seen traveling with the vein superiorly. The skin incision can be ex-
tended proximally and dissection taken up to the axilla if a longer length of nerve is
required.
• Sural nerve exposure: A 2-cm longitudinal incision is made midway between the
lateral malleolus and the calcaneus. The nerve lies close to the lateral margin of
the Achilles tendon and lateral to the lesser saphenous vein. The required length
of the nerve is then dissected proximally. Multiple transverse 1-cm stepladder STEP 1 PEARLS
incisions can be used instead of a longitudinal incision to give a more aesthetic Debride the nerve ends until healthy fascicles are
result (Fig. 60.3). observed at both ends.
REPAIR OF DIGITAL NERVES STEP 1 PITFALLS

Step 1: Evaluation of the Injured Nerve Atraumatic manipulation should be performed.
Microsurgical instruments should be used—no
Dissect and visualize the proximal and distal ends of the nerve, evaluate the condition
clamps should be used across the nerve.
of each end, and measure the gap (if present) between them (Fig. 60.4).
470 CHAPTER 60 Digital Nerve Repair
RF radial digital nerve ends
Lesser saphenous V
Sural N
FIGURE 60.4 Radial digital nerve laceration identified, ulnar digital nerve
intact, and nerve ends debrided and coaptated.
FIGURE 60.3 Longitudinal incision between the lateral malleolus and
Achilles tendon.
STEP 2 PEARLS Step 2: Reconstruction of the Other Tissues

If the reconstructed nerve crosses a tendon, the Osteosynthesis and tendon repair should be performed before nerve repair if other
nerve should run on top of the tendon to avoid injuries are present.
nerve compression.
Step 3: Primary Nerve Repair or Repair with Graft
• If the ends have minimal gap, then perform a tensionless primary repair if possible
STEP 3 PEARLS (Fig. 60.5). If primary neurorrhaphy is not possible, nerve graft should be used to
Using an 8-0 nylon suture to perform nerve prevent significant tension at the suture line (Figs. 60.6 and 60.7).
coaptation can serve as a test of tension; if this • Under microscope magnification, the nerve ends are coaptated using 8-0 nylon
suture caliber cannot hold the nerve ends together, suture. The nerve should be handled with care to avoid injury to the epineurium and
then there is too much tension and a graft should
scar formation. The epineurium should be aligned without outpouching fascicles to
be used.
prevent neuroma formation caused by escaping axons from the epineural sheath.
CDN IF-MF
Repaired
radial digital CDN MF-RF
nerve
FIGURE 60.5 Primary repair digital nerve with direct coaptation using FIGURE 60.6 After debridement, a 5-cm gap between the common
the operating microscope. digital nerve index finger-middle finger (CDN IF-MF) and the common
digital nerve middle finger-ring finger (CDN MF-RF).
CDN IF-MF
CDN MF-RF
FIGURE 60.7 Sural nerve grafts to the common digital nerve index finger–middle finger (CDN IF-MF)
and the common digital nerve middle finger–ring finger (CDN MF-RF).
Step 4: Wound Closure STEP 4 PITFALLS

The wound is closed with interrupted 5-0 nylon sutures. Hematoma formation may cause severe scar
formation, which leads to poor results. Thorough
POSTOPERATIVE CARE AND EXPECTED OUTCOMES hemostasis is necessary.
• The duration of the postoperative immobilization varies based on additional proce-
dures performed and other injuries.
• Typically, a period of 1 to 2 weeks permits the nerve ends to heal.
• Around 80% of patients who undergo digital nerve repair can expect to regain • Ensure smooth tendon gliding around the su-
tured nerve during the operation.
protective sensation. • Postoperative rehabilitation and care should be
See Video 60.1 planned during the operation, which some-
times alters the procedure.
EVIDENCE
Fakin RM, Calcagni M, Klein HJ, Giovanoli P. Long-term clinical outcome after epineural coaptation
of digital nerves. J Hand Surg Eur Vol. 2016;41:148–154.
The authors retrospectively evaluate the long-term clinical outcome and complication rate of digital
nerve repair. A total of 93 coapted nerves were studied. The outcomes were evaluated with two-
point discrimination (2-PD) and a Semmes-Weinstein monofilament test with a mean follow-up of
3.5 years. No correlation was observed between sensory outcome and age, smoking, mechanism
of injury, anastomosis of a digital artery, or immobilization. Instead, surgeon experience remained the
only predictor of superior outcomes, including 2-PD and cutaneous pressure threshold assessment
Poppler LH, Davidge K, Lu JCY, Armstrong J, Fox I, Mackinnon SE. Alternatives to sural nerve grafts in
the upper extremity. Hand. 2015;10:68–75.
The authors provide an excellent summary of nerve graft alternatives to sural nerve that can be found in
the upper extremity, including MABC, LABC, and superficial radial nerve. This is of importance when
patient habitus makes sural nerve harvest less desirable or patients request other sites be considered.
Issacs J. Treatment of peripheral nerve injuries current concepts. J Hand Surg Am. 2010;35A:491–497.
This article provides an excellent review of peripheral nerve injuries and discusses patient evaluation,
timing of repair, repair techniques, role of autografts and allografts, and outcomes and ways to opti-
mize results.
CHAPTER 61
Ulnar Nerve Group Fascicular Repair
INDICATIONS
• Any deficit attributable to the ulnar nerve with an associated laceration or injury
along the course of the nerve.
• High-energy injuries associated with blunt trauma and no appreciable recovery on
examination.
• Prior nerve repairs with no appreciable recovery on examination after 6 months.
Contraindications
• Closed injury with ongoing recovery and lack of soft tissue coverage.
• The nerve should be tagged during debridement and repaired at another time if the
field is severely contaminated or the zone of injury is evolving.
• See Chapter 65 for pertinent examination findings.
• In patients with prior repair, check for a Tinel sign or symptomatic neuroma
formation.
• Because of the communicating branches between the median and ulnar nerve (i.e.,
Martin-Gruber and Riche-Cannieu), patients may have preserved motor function in
the presence of an injury. Despite these connections, sharp lacerations should un-
dergo direct repair.
IMAGING
• X-rays are used to detect fractures or dislocations that may contribute to ulnar nerve
injury/palsy.
• Electromyography and nerve conduction studies are useful to detect the presence
or absence of sensory and/or motor deficits, as well as denervation/reinnervation
based on increased latencies, decreased amplitudes, and/or the presence of
fasciculations or fibrillations within the muscle upon needle insertion during this
examination.
SURGICAL ANATOMY
• See Chapter 65 for pertinent anatomy of the nerve.
• The ulnar nerve is a mixed sensory and motor nerve with distinct grouped fascicles
that are critical to identify and realign when performing repair.
• There are 15 to 25 fascicles; the sensory component is typically volar, and the motor
component is dorsal in the usual nerve topography (Fig. 61.1).
EXPOSURES
• Prior incisions/lacerations are used and extended for ulnar nerve exploration and
repair. If no incisions exist, the nerve is identified using a longitudinal incision
over the flexor carpi ulnaris (FCU). The nerve is radial and deep to the FCU
muscle and runs with the ulnar artery, but this location can vary depending on
prior injuries.
POSITIONING
• The operation is performed under tourniquet control so that the injured nerve can be
visualized clearly, with the arm outstretched on the hand table.
• A nerve stimulator can be useful to identify an intact nerve in scarred tissue.
472
(N) 4th webspace

(N) deep motor (N) flexor digitorum profundus
1st webspace (N) dorsal cutaneous
2nd webspace
1 2
3 4
3rd webspace
4th webspace
(N) superifcial sensory
Ulnar nerve (N) palmar cutaneous (N) flexor carpi ulnaris
Motor (N) ulnar aspect of little finger
Sensory
1 2 (N) motor 3 (N) motor 4 (N) dorsal
(N) palmar component cutaneous
component
(N) 4th webspace cutaneous
(N) sensory (N) sensory
component component
(N) ulnar aspect
(N) deep motor of little finger
(N) dorsal cutaneous (N) motor
(N) sensory
component
component
FIGURE 61.1 Ulnar nerve topography demonstrates small motor fascicle deep and larger sensory fascicle superficial.
REPAIR OF ULNAR NERVE IN THE FOREARM STEP 1 PEARLS

• If the ulnar nerve injury is in the proximal fore-
Step 1: Identification and Neurolysis arm, consider an anterior interosseous nerve
• Use prior incisions/lacerations and start dissecting in an area of soft normal tissue (AIN) to ulnar motor nerve transfer to restore
(Fig. 61.2). motor function (Chapter 68).
• Perform debridement and irrigation as needed; excise scar tissue if this has formed • When ulnar nerve repair is required, identify
and protect the ulnar artery, which runs radial
since the injury. to the nerve.
• Trace the nerve ends from normal tissue into the area of injury and scar. • Because increased mobilization risks devascu-
• Perform neurolysis without devascularizing the nerve (Fig. 61.3). larization of the nerve, mobilize only what is
• Debride nerve ends to healthy fascicles. necessary to perform the repair.
Step 2: Measure Gap and Determine Need for Nerve Graft

STEP 2 PEARLS
• Measure the gap between the distal and proximal nerve ends. If a tension-free repair
can be performed primarily, this is preferred. • Tension results in decreased blood flow and
increases the chances of dehiscence and must
be avoided.
• Grouped fascicular repair provides more pre-
cise nerve alignment and requires intraneural
dissection, which may lead to more trauma
and scarring of the nerve. The distal ulnar
nerve topography, however, is well defined,
which makes separating the sensory and mo-
tor fascicles rather straightforward.
• If cable graft is needed, cut the donor graft
into several tubes of the measured gap length
and use TISSEEL to glue the pieces together
for coaptation.
FIGURE 61.2 Prior incision reused for exploration.

474 CHAPTER 61 Ulnar Nerve Group Fascicular Repair
Ulnar artery
Ulnar sensory
Mixed ulnar
nerve
Nerve tube
Ulnar motor
FIGURE 61.3 Exploration of previous ulnar nerve repair.
FIGURE 61.4 The nerve tube is removed and a 3.5-cm ulnar nerve gap between mixed nerve and
sensory and motor fascicles remains (white box).
• The ulnar nerve has mixed motor and sensory components in the distal forearm.
Perform grouped fascicular repair to match respective sensory and motor fascicles
STEP 3 PEARLS (Fig. 61.4).
• Because the ulnar nerve is a mixed sensory • If a gap is present and autologous graft is necessary, harvest from the chosen donor site
and motor nerve in the forearm, the surgeon (sural nerve is the standard). Ensure that the graft is 10% to 15% longer than the gap.
must have a thorough understanding of the
nerve topography to repair the respective sen- Step 3: Nerve Coaptation
sory and motor fascicles.
• In the distal forearm, the ulnar nerve has a large • For primary repair, align the distal and proximal ends of the sensory and motor fasci-
sensory component that is more volar and a cles. Consider the fascicular location (volar/dorsal, radial/ulnar), approximate fascicu-
smaller motor component that is dorsoulnar. lar diameters, and surface/intraneural blood vessels to ensure that appropriate motor
• Histologic staining of a sliced end of the proxi- and sensory fascicles are oriented.
mal nerve stump can be used to identify motor
and sensory nerves using positive stains for • Interrupted 8-0 nylon sutures are used to coaptate the nerve endings, taking small
acetylcholine esterase and carbonic anhy- bites of perineurium for a grouped fascicular repair or epineurium in epineural repair.
drase, respectively. Nevertheless, this is time- For complete repair, 8 to 10 sutures are required.
consuming and seldom used. • When nerve graft is used, ensure that the graft bridges the appropriate fascicles
• Fibrin glue can be used to augment the during the grouped fascicular repair (i.e., motor to motor and sensory to sensory;
neurorrhaphy.
Figs. 61.5 and 61.6).

Layered skin closure is performed with a combination of absorbable and nonabsorb-
able sutures at the surgeon’s discretion.
POSTOPERATIVE CARE AND OUTCOMES

• The forearm is splinted for 2 weeks to protect the repair; finger range of motion
(ROM) may or may not be permitted at the discretion of the surgeon.
Nerve graft
Proximal ulnar nerve
FIGURE 61.5 Image demonstrates surgical site after debridement of nerve ends and removal of con-
nector. The nerve graft is sutured distally first and is aligned for proximal coaptation.
FIGURE 61.6 Sural nerve cable graft reconstruction of the motor and sensory nerve branches of the
ulnar nerve (white box).
• Nonabsorbable sutures are removed at 2 weeks.

• Better sensory (S31 and higher) and motor (M4 and higher) outcomes are achieved
when surgery is performed in younger patients, at lower levels (distal forearm), and
within a few months of injury.
• Grafted median, ulnar, and radial nerve useful motor recovery occurs in 63% to 81%
of cases, and sensory recovery occurs in 75% to 78% of patients.
• A lower percentage of patients who undergo ulnar nerve motor repair recover satis-
factory function compared with median nerve repair. One study demonstrated good
outcome in 15% of high-level and 50% of low-level ulnar nerve repairs.
EVIDENCE
Secer HI, Daneyemez M, Gonul E, Izci Y. Surgical repair of ulnar nerve lesions caused by gunshot and
shrapnel: Results in 407 lesions. J Neurosurg. 2007;107:776–783.
This retrospective review examines 462 ulnar nerve injuries resulting from gunshot wounds or shrapnel.
The patients were all male and aged 19 to 30 years. Injuries were classified as high, intermediate,
and low in relation to the distance away from the wrist. Techniques included primary repair or with
the use of sural nerve grafts for gaps ranging from less than 3 cm to 15 cm. Mean follow-up was
3 years. The authors found that the following factors resulted in better sensory and motor outcomes:
repair performed within less than 6 months, low-level repairs, and gaps of less than 3 cm.
Cho MS, Rinker BD, Weber RV, et al. Functional outcome following nerve repair in the upper extremity
using processed nerve allograft. J Hand Surg Am. 2012;37A:2340–2349.
This article provides an excellent review of peripheral nerve injuries and discusses patient evaluation,
timing of repair, repair techniques, role of autografts and allografts, and outcomes and ways to opti-
mize results.
CHAPTER 62
Median Nerve Epineural and Group Fascicular
Nerve Repair
INDICATIONS
• Any deficits attributable to the median nerve with an associated laceration or injury
along the course of the nerve, high-energy injuries associated with blunt trauma and
no appreciable median nerve recovery on examination, and prior median nerve re-
pairs with no appreciable recovery on examination after 6 months.
• Simultaneous flap coverage should be considered if there is lack of soft tissue over
the nerve.
Contraindications
• A closed injury with ongoing recovery.
• The nerve should be tagged during debridement and repaired at another time if the
field is severely contaminated.
• Carefully assess any areas for lacerations or other wounds.
• Assess median nerve sensory innervation along the radial and ulnar sides of the
thumb, index, and middle fingers; the nerve also provides sensation to the radial
side of the ring finger.
• Assess median nerve motor function via thumb palmar abduction and opposition.
• Palpate and percuss to identify an advancing Tinel sign or symptomatic neuromas.
• Because of the communicating branches between the median and ulnar nerve (i.e.,
Martin-Gruber and Riche-Cannieu), patients may have preserved motor function in
the presence of an open injury.
IMAGING
Electromyography and nerve conduction studies are useful to detect the presence or
absence of sensory and/or motor deficits, as well as denervation/reinnervation based
on increased latencies, decreased amplitudes, and/or the presence of fasciculations or
fibrillations within the muscle upon needle insertion during this examination.
SURGICAL ANATOMY
• See Chapters 63 and 64 for pertinent anatomy of the nerve.
• The median nerve is a mixed sensory and motor nerve with distinct grouped fascicles. It
is critical to identify and realign the fascicles when performing repair (Figs. 62.1 and 62.2).
• See Chapter 60 for the list of potential donor nerves for the graft.
POSITIONING
• The operation should be performed under tourniquet control to visualize the injured
nerve clearly, with the arm outstretched on the hand table.
• A nerve stimulator can be useful to identify an intact nerve in the scarred tissue.
EXPOSURES
With the median nerve, prior incisions/laceration are typically incorporated and ex-
tended for nerve exploration and repair. If no incision exists, the nerve is identified using
a longitudinal incision in the distal forearm along the flexor carpi radialis (FCR) tendon
476
CHAPTER 62 Median Nerve Epineural and Group Fascicular Nerve Repair 477
MEDIAN NERVE - Forearm and Hand

KEY:
FDS - Flexor digitorum superficialis
FDP - Flexor digitorum profundus
(N) Flexor digitorum profundus
FPL - Flexor pollicis longus (N) Radial aspect of thumb
FCR - Flexor carpi radialis (N) Anterior interosseous
(N) 1st webspace and (N) Flexor digitorum profundus
PL - Palmaris longus (N) Flexor digitorum superficialis
radial aspect of thumb
PQ - Promator quadratus (N) Flexor digitorum superficialis (N) Flexor carpi radialis
(N) 2nd webspace (N) Palmar cutaneous
- Motor - Thenar fascicle (N) Flexor policis longus (N) Palmaris longus
(N) 3rd webspace (N) Articular
- Sensory - Articular fascicle 1st webspace (N) Pronator teres
(N) Recurrent thenar (N) Pronator quadratus
2nd webspace
1
2 3 4 5 6
3rd webspace
4th webspace
(N) PQ and articular (N) Sensory component

(N) Sensory component and recurrent thenar
(N) Palmar cutaneous (N) Anterior interosseous and recurrent thenar
(N) Recurrent thenar
(N) Recurrent thenar (N) Sensory component 6
(N) PQ and articular (N) FPL 5
(N) Recurrent thenar (N) Articular (N) Recurrent thenar
3 4
1 2
(N) FDP
(N) 2nd webspace (N) 1st webspace and (N) Palmar cutaneous
(N) 1st webspace and
radial aspect of thumb radial aspect of thumb (N) 1st webspace and (N) Anterior (N) FDS
LR (N) FDS (N) FDS interosseous
(N) 3rd webspace (N) 3rd webspace (N) 2nd webspace radial aspect of thumb (N) FCR/PL
P A (N) Pronator teres
(N) 2nd webspace (N) 3rd webspace
MU
FIGURE 62.1
FIGURE 62.2 Extended carpal tunnel incision incorporates previous incision.
or using an extended carpal tunnel release incision. The nerve is typically between the
flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons, but
this location can vary depending on prior injuries.
GROUPED FASCICULAR REPAIR OF MEDIAN NERVE

IN FOREARM WITH GRAFT STEP 1 PEARLS
• Identify the median nerve in an area of soft,
Step 1: Median Nerve Identification normal-appearing tissue and trace it into scar.
• Use prior incisions/lacerations and start dissection in an area of soft normal tissue. • In the forearm, watch for the palmar cutane-
Typically, an extended carpal tunnel type incision is used (see Fig. 62.2). ous branch of the median nerve, which comes
• Perform debridement and irrigation as needed; excise any significant scar tissue that off approximately 5 to 8 cm proximal from the
wrist crease along the radial side.
has formed since the injury (Figs. 62.3 and 62.4).
478 CHAPTER 62 Median Nerve Epineural and Group Fascicular Nerve Repair
FIGURE 62.3 Extensive scar tissue overlying the median nerve and flexor tendons in the volar fore-
arm (black arrow).
• Trace the nerve ends from normal tissue into the area of injury and scar.
• Perform neurolysis without devascularizing the nerve.
• Debride nerve ends to healthy fascicles.
STEP 2 PEARLS Step 2: Measure Gap and Determine Need for Nerve Graft
A good gauge for suitable primary nerve repair is • Measure the gap between the distal and proximal nerve ends. If a tension-free repair
whether the repair can be completed using 8-0 can be performed primarily, this is preferred.
nylon with the hand and wrist in flexion. If there • The median nerve is largely sensory in the distal forearm with a small motor compo-
is too much tension with this size suture, consider
6-0 Prolene or nerve graft. nent; either epineural or group fascicular repair is acceptable (see Fig. 67.1).
• If a gap is present and autologous graft is necessary, harvest from the chosen donor
site (sural nerve is the standard). Ensure that the graft is 10% to 15% longer than
the gap.
STEP 3 PEARLS Step 3: Nerve Coaptation

The wrist can be flexed slightly during repair to • To ensure proper orientation of the motor and sensory fascicles during coaptation,
relieve tension across the repair site.
align the distal and proximal ends using fascicles of similar diameters and corre-
sponding surface/intraneural blood vessels.
• Use interrupted 8-0 nylon sutures to perform a grouped fascicular repair.
• When nerve graft is used, ensure that the graft bridges the appropriate fascicles (i.e.,
motor to motor and sensory to sensory). Cable graft is often prepared (Figs. 62.5 A–B
and 62.6).

FIGURE 62.4 After neurolysis, an area of damaged scarred median nerve was identified.
Sural nerve graft

Fibrin glue
Edges
freshened
Cable graft
FIGURE 62.5 (A–B) A 2.5-cm fascicular defect was reconstructed with sural nerve graft. ([B] from Spinner, RJ. Traumatic
brachial plexus injury. In Wolfe, SW, Pederson WC, Kozin SH, Cohen MS., eds. Green’s Operative Hand Surgery. 7th ed.
Elsevier; 2016:1146–1207.)
EPINEURAL FASCICULAR REPAIR OF MEDIAN NERVE

IN FOREARM
Step 1: Median Nerve Identification
• Use prior incisions/lacerations and start dissection in an area of soft normal tissue.
Typically, an extended carpal tunnel incision is used (Fig. 62.7).
• In fresh injuries, minimal debridement is necessary.
Step 2: Align Median Nerve and Palmar Cutaneous Branch

During coaptation, align the distal and proximal ends using fascicles of corresponding
diameters and surface/intraneural blood vessels on each side to ensure appropriate
orientation of the motor and sensory fascicles (Fig. 62.8).
Step 3: Nerve Coaptation

Interrupted 6-0 Prolene sutures are used to perform epineural repair of the median
nerve, and 8-0 sutures are used to repair the palmar cutaneous branch (Fig. 62.9).

POSTOPERATIVE CARE AND OUTCOMES

• The forearm is splinted to protect the repair for 2 weeks; finger range of motion
(ROM) may or may not be permitted at the discretion of the surgeon.
• Better sensory (S31 and higher) and motor (M4 and higher) outcomes are achieved
when surgery is performed in younger patients, at lower levels (distal forearm), and
within a few months of injury.
480 CHAPTER 62 Median Nerve Epineural and Group Fascicular Nerve Repair
FIGURE 62.6 Nerve after coaptation of cable graft to distal and proximal median nerve ends.
Incision to extend laceration
Laceration
Incision to extend laceration
FIGURE 62.7 Transverse laceration extended distal and proximally to provide exposure.
Median nerve
Median nerve
Palmar Palmar
cutaneous branch cutaneous branch
FIGURE 62.8 Nerves identified.
• Grafted median, ulnar, and radial nerve useful motor recovery occurs in 63% to 81%
of cases, and sensory recovery occurs in 75% to 78% of patients.
• A lower percentage of patients who undergo ulnar nerve motor repair recover satis-
factory function compared with median nerve repair. One study demonstrated good
outcomes in 15% of high-level and 50% of low-level ulnar nerve repairs.
• If ulnar nerve injury is in the proximal forearm, consider anterior interosseous nerve
(AIN) to ulnar motor nerve transfer to restore motor function.
See Video 62.1
Median nerve
FIGURE 62.9 (A–B) Nerves after coaptation ([B] from Birch, R. Nerve injury and repair. In Wolfe, SW,
Pederson WC, Kozin SH, Cohen MS., eds. Green’s Operative Hand Surgery. 7th ed. Elsevier;
2016:979–1022.)
EVIDENCE
Ruijs AC, Jacquet JB, Kalmijn S, Giele H, Hovius SE. Median and ulnar nerve injuries: A metanalysis of
motor and sensory recovery after modern microsurgical nerve repair. Plast Reconstr Surg.
2005;116:484–494.
This metanalysis examines 23 studies involving 623 median and ulnar nerve injuries. A satisfactory sen-
sory outcome (S3+ and higher) was noted among 42.6 % and satisfactory motor outcome (M4 and
higher) was noted among 51.6%. Lower nerve injuries, younger age, and decreased time between in-
jury and surgical intervention were associated with better outcomes. Ulnar nerve injuries were noted
to have a 71% lower chance of motor recovery than median nerve injuries.
CHAPTER 63
Tendon Transfers for Low Median Nerve Injury
INDICATIONS
• Median nerve injuries are classified as “low” injuries if they arise distal to the branch
of the anterior interosseous nerve, causing functional loss that is limited to the intrin-
sic muscles of the hand: the abductor pollicis brevis (APB), the opponens pollicis,
and the superficial head of the flexor pollicis brevis (FPB).
• Both tendon transfers and nerve transfer options exist for patients with low median
nerve injuries. Although tendon transfers lead to more predictable outcomes and
earlier recovery, nerve transfers provide better fine motor control and require less
retraining.
• Tendon transfer is indicated for patients with low median nerve injuries when motor
recovery is not expected. This typically includes three groups of patients:
• Patients who experienced injuries more than 18 to 24 months prior and can no
longer experience reinnervation given the onset of irreversible muscle fibrosis.
• Patients with segmental nerve injury, who likely have inaccurate topographic
alignment of the thenar motor fascicles. These patients can either wait to
see if nerve regeneration is successful or can have a primary opponens-
plasty to provide a more predictable result with an earlier time to recovery
of function.
• Patients who prefer not to wait for nerve regeneration.
• Several options for opponensplasty exist:
• The Camitz transfer procedure is indicated for patients who require carpal tunnel
release (CTR) for severe carpal tunnel syndrome with thenar atrophy because the
palmaris longus (PL) can be transferred through the CTR incision to augment
thumb opposition. The transfer can be performed with or without a pulley, which
is typically created through a small window created in the flexor retinaculum. The
pronation and flexion components of opposition are not reconstructed during this
procedure.
• The extensor indicis proprius (EIP) tendon may be used for opponensplasty for
patients with either high or low median nerve injuries, and it is advantageous
given the length and location of the EIP tendon. In these procedures, supplemen-
tal tendon grafts or additional pulleys to augment the line of pull are rarely neces-
sary, and there is minimal donor morbidity. The pulley for this transfer is located
at the ulnar border of the wrist.
• During a Bunnell transfer, the flexor digitorum superficialis (FDS) tendon of the
ring finger can be used to provide palmar abduction. Because the motor branch
of the FDS muscle arises from the proximal aspect of the median nerve, this
INDICATIONS PEARLS
procedure is indicated only for patients with low median nerve palsy. Additionally,
For many patients with low median nerve injuries, this technique requires the construction of a pulley along the ulnar aspect of the
thumb opposition and palmar abduction are strong
because of dual innervation by the ulnar nerve. hand, typically the flexor carpi ulnaris (FCU) tendon. Harvesting the ring finger
FDS tendon may result in weakened grip.
• In a Huber transfer, transfer of the abductor digiti minimi (ADM) is commonly used
INDICATIONS PITFALLS to restore opposition among pediatric patients with congenital absence of thenar
Difficulty with thumb opposition and palmar musculature (See Chapter 109 Pediatric Opponensplasty). This procedure can
abduction may result from other causes, including also improve appearance by increasing the bulk of the thenar eminence. Patients
sensory impairment and joint stiffness caused by can adapt to use the transferred tendon without intensive rehabilitation. For pe-
diabetic neuropathy, severe carpometacarpal (CMC)
diatric patients, EIP tendon transfer is also indicated. The ADM origin acts as the
osteoarthritis of the thumb, or rheumatoid arthritis.
“pulley” for this transfer.
482
CHAPTER 63 Tendon Transfers for Low Median Nerve Injury 483
• Successful recovery from tendon transfer procedures demands that patients can
comply with postoperative rehabilitation protocols and have supple joints with full pas-
sive range of motion (ROM), intact protective sensation, and no soft tissue scarring.
• Passive ROM should be tested at the thumb CMC, interphalangeal (IP), and meta-
carpophalangeal (MCP) joints.
• Tendon transfers to restore opposition should be avoided in the setting of a first
webspace contracture, which should be released before transfer.
• Sensation in the hand should be assessed using the Semmes-Weinstein monofila-
ment test (threshold test) and two-point discrimination (innervation-density test),
with a specific focus on the sensation along the ulnar pulp of the thumb and the
radial pulp of the index finger. Palmaris longus
• For patients who are potential candidates for a Camitz procedure, assess the pres-
ence of the PL. The Mishra test consists of passive hyperextension of the MCP joints
followed by resisted active flexion at the wrist. This test can be performed for low
median nerve palsy patients who cannot oppose their thumb (Fig. 63.1).
IMAGING
A radiograph is useful to check the existence of other skeletal disorders such as CMC FIGURE 63.1
or MCP joint arthritis. Patients with thumb CMC arthritis often present with a supination
and adduction deformity of the thumb, which may be corrected by trapeziectomy in
conjunction with tendon transfer.
SURGICAL ANATOMY
• Thumb opposition is derived from thumb flexion, palmar abduction, and pronation
at both the MCP and CMC joints. For patients with low median nerve palsy, the APB,
opponens pollicis, superficial head of the FPB, and radial two lumbricals are dener-
vated, but the deep head of the FPB and the adductor pollicis are innervated by the
ulnar nerve, and this may provide sufficient palmar abduction and opposition for
many patients (Fig. 63.2).
Adductor pollicis
Flexor pollicis brevis

(deep head)
Opponens pollicis
(superficial head)
Abductor pollicis brevis
FIGURE 63.2
484 CHAPTER 63 Tendon Transfers for Low Median Nerve Injury
Deeper transverse
fibers
Deepest vertical
fibers
Superficial
longitudinal fibers
Palmaris longus,
merging with the
palmar aponeurosis
FIGURE 63.3
• The palmar aponeurosis consists of three layers: superficial longitudinal fibers,

deeper transverse fibers, and the deepest vertical fibers in the palm. For pa-
tients undergoing a Camitz transfer procedure, only the superficial longitudinal
fibers are used to extend the length of the PL tendon for transfer (Fig. 63.3).
POSITIONING
Opponensplasty is performed under tourniquet control with the patient in the
supine position and the extremity abducted with the hand on a hand table. It can
be done under regional anesthesia, IV regional (Bier block) anesthesia, or local
anesthesia.
Palmaris Longus to Abductor Pollicis Brevis (Camitz EXPOSURES PITFALLS
Opposition Transfer) To avoid scar contracture, the incision should not

be made perpendicular to the wrist crease; use a
This transfer can be performed in conjunction with carpal tunnel release (see Chapter 55) Bruner orientation instead.
for patients with advanced median nerve compression at the wrist and weakened palmar
abduction that is functionally limiting.
EXPOSURES
• An extended carpal tunnel incision is marked: a 7-cm longitudinal straight skin inci-
sion is created over the palm along the axis of the ulnar border of the long finger.
The incision is extended proximally with Bruner extensions at the wrist crease into
the forearm (Fig. 63.4)
• A 3-cm V-shaped incision is created along the radial border of thumb at the level of
the MCP joint to expose the APB tendon (see Fig. 63.4). FIGURE 63.4
Step 1: Raise an Extended Palmaris Longus Donor Tendon • A surgical sponge can again be used to esti-
mate the length of the PL tendon needed for
• This skin incision over the palm and PL is created first. transfer that will reach the radial aspect of the
• The goal is to harvest both PL and an extension of palmar aponeurosis, with which thumb MCP joint.
PL is contiguous (see Fig. 63.3), to provide a longer donor tendon for transfer. There- • A longer extension of palmar aponeurosis can
fore wide exposure is provided by raising skin flaps radially and ulnarly to create an be harvested, and the deep extension of dis-
section will be the palmar fat pad. Great care
approximately 2-cm wide exposure of the palmar fascia. is taken during the distal dissection to protect
• The palmar aponeurosis is exposed distally to roughly where the transverse carpal the underlying superficial arch and common
ligament would be. Proximally, the palmar aponeurosis is exposed to where it digital nerves. Once the TCL is visualized,
merges with the PL insertion (Fig. 63.5). dissection can proceed more expeditiously
• Once the donor tendon and palmar aponeurosis extension is exposed, the distal pal- in the proximal direction.
• Recognize that the PL harvest is quite proximal
mar fascia is dissected sharply free from the underlying transverse carpal ligament. to the palmar cutaneous branch of the median
Dissection is continued proximally until the PL tendon is dissected free. Dissection is nerve. This nerve arises in the forearm be-
continued distally until the tendon will reach the APB insertion (Fig. 63.6). tween PL and FCR and typically pierces the
deep fascia to become a subcutaneous struc-
Step 2: Carpal Tunnel Release ture roughly 1 cm proximal to the wrist crease;
however this is variable, so the surgeon needs
A standard carpal tunnel release is performed at this stage (see Chapter 55). to be looking for this branch when harvesting
the PL tendon.
Step 3: Expose the Abductor Pollicis Brevis Recipient Tendon
• The incision along the radial border of the thumb MCP is created, and blunt dissec-
tion using tenotomy scissors is used to expose the APB tendon inserting onto the STEP 3 PEARLS
radial base of the thumb proximal phalanx. • The APB tendon is located just under the skin
• The APB tendon is identified and exposed circumferentially with a small hemostat to and attaches to the radial side of the base of
facilitate the tendon weave. the proximal phalanx of the thumb.
• The APB tendon is quite small but stout; it only
needs to be dissected circumferentially with a
Palmaris longus tendon blunt hemostat for a few millimeters to facili-
tate the transfer.
Superficial longitudinal fibers

FIGURE 63.5
Harvested tendon
FIGURE 63.6
A B
Transferred tendon
FIGURE 63.7
STEP 4 PEARLS Step 4: Create a Subcutaneous Tunnel for the Tendon Transfer
The original Camitz tendon transfer has been • Using a small hemostat, a subcutaneous tunnel is gently created along the thenar
modified to include a pulley, which is typically eminence from the MCP joint incision into the palmar incision.
made by passing the PL through a small window • A tendon passer is inserted through the subcutaneous tunnel from the incision along
created in the ulnar side of the transverse carpal the MCP joint into the palm. The PL tendon and fascial extension are gently withdrawn
ligament (Fig. 63.8).
through the tunnel into the incision along the radial aspect of the thumb (Fig. 63.7).
Slit
Incised flexor PL tendon

retinaculum
FIGURE 63.8
Sutured palmaris longus tendon to

abductor pollicis brevis tendon
A B
Abductor pollicis brevis tendon

FIGURE 63.9
Step 5: Secure the Tendon Transfer STEP 5 PEARLS

• The thumb is held in palmar abduction by an assistant. Subtle differences in postoperative thumb function
• The PL tendon is woven into the APB tendon using a sharp Pulvertaft tendon weaver depend on precisely where the PL is transferred:
and secured using 3-0 Ethibond suture. a more radial insertion adds stronger palmar
abduction, and a more dorsal insertion adds
• Additional tendon weaves are performed as permitted and secured with 3-0
greater opposition. It is difficult to split the tendon
Ethibond sutures (Fig. 63.9). to insert at both ends because this may risk
weakening the tendon.
Step 6: Closure
The tourniquet is let down, hemostasis is achieved with pressure and conservative bipo-
lar cautery, the wound is irrigated, and standard closure is done with 4-0 Nylon sutures.

The hand is placed in a thumb spica splint in an abducted position for 2 weeks after
the surgery, after which the wound is inspected, the sutures are removed, and the
thumb spica cast is applied for a total of 4 weeks of immobilization. Hand therapy is
then needed for most patients to begin active ROM.
Extensor Indicis Pollicis to Abductor Pollicis Brevis

Transfer
EXPOSURES
• Multiple small incisions are needed for tendon harvest, subcutaneous tunneling, and
securing the EIP to the APB tendon.
• A V-shaped incision is designed over the dorsal index MCP joint.
• A longitudinal incision is created along the volar ulnar border of the wrist and across
the dorsal wrist at the level of the fourth extensor compartment.
• A V-shaped incision is created along the radial border to the thumb MCP joint at the
level of the APB insertion (Fig. 63.10).
PROCEDURE
Step 1: Harvest the Extensor Indicis Pollicis Tendon
• The skin over the dorsal index MCP is opened and subcutaneous dissection taken
down until the EIP and extensor digitorum communis (EDC) to the index finger are
exposed.
• The dorsal wrist incision is made, subcutaneous dissection is taken down to the
extensor retinaculum, and the fourth dorsal extensor compartment is entered.
Incision lines for first webspace deepening Incision for FDS

opponensplasty
A B
Incision lines for EIP transfer

FIGURE 63.10
Extensor indicis proprius
A B

STEP 1 PEARLS
FIGURE 63.11
• The EIP tendon has variable anatomy; it is most
often identified as the ulnar-sided tendon, but
also has no junctura tendinae, and has the
most distal muscle belly at the dorsal wrist. • Once the EIP tendon is identified, it is divided sharply as distally as possible at the
• The extensor hood is not disrupted over the MCP joint but proximal to the extensor hood.
index finger to avoid tendon subluxation. It can • The tendon is released from the EDC of the index tendon and pulled out into the
be repaired if injured.
dorsal wrist incision (Fig. 63.11).
Step 2: Creation of Subcutaneous Tunnel

• The EIP tendon is released from the extensor retinaculum and passed into the sub-
cutaneous tissue. The tendon and muscle belly are freed from surrounding fascial
attachments for smooth excursion and adequate length.
• An additional incision is created along the ulnar aspect of the wrist (as previously
marked), and a small hemostat or short tenotomy scissors are used to create a
subcutaneous tunnel between this ulnar incision and the dorsal wrist incision.
• The EIP tendon is passed from the dorsal wrist to the ulnar wrist in a subcutaneous
plane (Fig. 63.12).
• The incision is created along the radial aspect of the thumb to expose the insertion of
FIGURE 63.12 the APB tendon, in the same fashion as the Camitz procedure mentioned previously.
A small hemostat or short tenotomy scissors are used to create a subcutaneous tunnel STEP 2 PEARLS
to the ulnar incision at the wrist, and a tendon passer is placed through this incision
Care is taken to pass the EIP tendon volar to the
to retrieve the EIP tendon.
FCU tendon within the subcutaneous space to
avoid compression along the ulnar neurovascular
Step 3: Secure the Tendon Transfer bundle.
The EIP tendon is delivered into the incision at the APB insertion, and the transfer is
secured as mentioned previously for the Camitz transfer.

Refer to “Step 6: Closure” of the Camitz transfer procedure.

Refer to “Postoperative Care and Expected Outcomes” under the Camitz transfer.
Flexor Digitorum Superficialis of Ring Finger to Abductor

Pollicis Brevis
EXPOSURES
• An extended carpal tunnel incision is designed similar to the Camitz transfer, but a
small skin bridge is left in place at the wrist to prevent contracture formation.
• A 2-cm transverse incision is created at the base of the ring finger (see Fig. 63.10).
• A 2-cm V-shaped incision is marked at the APB insertion, as for both previous trans-
fers (Fig. 63.13).
PROCEDURE
Step 1: Exposure of Flexor Digitorum Superficialis Ring
• A standard carpal tunnel release is done first through the distal marking. The carpal
tunnel incision is made only if it is difficult to retrieve the tendon through the forearm
incision. If the attachments of the FDS tendon are detached distally, this tendon can
typically be withdrawn from the distal forearm with moderate traction.
• The proximal skin incision is made, and subcutaneous dissection taken down to the
deep fascia, being careful not to injure the palmar cutaneous branch of the median
nerve (PCM).
• The deep fascia is opened ulnar to the PL tendon, which also protects the PCM.
• The FCU tendon is identified and its distal tendon is dissected free for several cen-
timeters proximal to the wrist crease.
• The FDS to ring finger tendon is identified in the muscle group deep to the FCU and
PL (Fig. 63.14).
STEP 2 PEARLS
Step 2: Flexor Digitorum Superficialis Ring Harvest
• Use the familiar trigger finger release approach
• An incision at the base of the ring finger is created and dissection taken down to the to simplify the procedure.
A1 pulley, as in a standard trigger finger procedure. • Develop a systematic method to identify the
• The digital nerves are protected with retractors and the A1 pulley is divided, expos- FDS tendon, compared with the FDP tendon,
ing the flexor tendons below. and transect it quickly to avoid wasting time in
this step.
• At this level, the FDS tendons are superficial to the flexor digitorum profundus (FDP)
tendons; however, this should be confirmed by flexing the distal interphalangeal (DIP)
only and observing the FDP in the field. The other tendon can be retracted with a right
FIGURE 63.13
Dissected and transected distally;

retracted into forearm for re-route
toward APB
FCU
A RF FDS
B
FIGURE 63.14
angle and tension will demonstrate proximal interphalangeal (PIP) flexion only, with a
flaccid DIP, thereby identifying the tendon as FDS. The tendon is divided as distally
STEP 3 PEARLS
as possible and withdrawn through the wrist incision (see Fig. 63.14).
• For optimal gliding, care should be taken to Step 3: Pulley Creation Using the Flexor Carpi Ulnaris
create a loop that will accommodate the FDS
tendon securely. The loop should be neither • The FCU tendon is split longitudinally approximately 3 cm from its insertion on the
constrictive nor too loose to negate the pulley pisiform at the wrist. The radial half is separated from the ulnar half with a retractor,
effect. and the proximal aspect of the radial half is sharply divided, creating a distally based
• The loop is created as distally as possible to tendon.
create a pulley with the most optimal vector of
• The pedicled tendon is sutured to itself distally, creating a secure loop through which
pull, which is toward the pisiform.
the FDS ring can be passed (Figs. 63.15 and 63.16).
Step 4: Create the Subcutaneous Tunnel and Transfer the Flexor

Digitorum Superficialis Tendon
This step is the same as the one for the Camitz transfer (Fig. 63.17).
Transferred FDS tendon
Partial strip
of FCU
Suture Loop FCU

B
FCU
A
FIGURE 63.15
FCU loop
FIGURE 63.16
Subcutaneous tunnel
RF FDS FCU loop

A
Transfers related
to a different
APB fascia procedure
B FCU loop RF FDS
FIGURE 63.17
Step 5: Closure

Splint the patient dorsally with the wrist flexed at about 45 degrees to take the tension
off the tendon transfer. After 4 weeks, active ROM exercises are initiated.
Abductor Digiti Minimi to Abductor Pollicis Brevis

Transfer
EXPOSURES
• A 4-cm longitudinal incision along the ulnar aspect of the hypothenar eminence is
used to identify the tendon and the muscle belly of the ADM (Fig. 63.18).
• A 2-cm V-shaped incision is marked at the APB insertion, as mentioned previously.
FCU
A B Abductor digiti Pisiform

minimi m.
FIGURE 63.18
A
B

FIGURE 63.19
PROCEDURE
Step 1: Harvest the Abductor Digiti Minimi Muscle
• The skin is incised along the hypothenar eminence, and the muscle belly is identified
underneath the palmar fat pad.
• The ADM inserts along the small finger proximal phalanx and extensor mechanism.
Dissection is carried distally until the tendinous insertion is identified and the distal
insertions are divided sharply.
• The dissection is then carried proximally toward the origin of the ADM along the
STEP 2 PEARLS pisiform to free the muscle of its surrounding fascial attachments. The neurovascular
• To allow the ADM muscle flap to run through the pedicle arises from the ulnar artery and nerve and lies along the dorsal and radial
tunnel in a comfortable position, the flap is rotated aspect of the muscle belly. Care is taken as the muscle is dissected proximally to
180 degrees on its long axis (see Fig. 63.20). avoid injury to the pedicle (see Fig. 63.18).
• Because this is a muscle transfer and muscles
are particularly susceptible to ischemia, be Step 2: Transfer of ADM to APB
sure that the subcutaneous tunnel is generous
by releasing the palmar fascia liberally to pro- • The standard V-shaped incision is made to expose the APB insertion, and a sub-
vide space for passage of the ADM muscle. cutaneous tunnel is created using short hemostats followed by a tendon passer
• If soft tissue is needed after release of scar (Fig. 63.19).
contracture over the wrist, a skin pedicle can • A tendon passer is used to gently draw the ADM muscle flap toward the radial as-
be taken in concert with the muscle to provide pect of the thumb for transfer to the APB tendon (Fig. 63.20).
a fasciocutaneous flap.
• The ADM is secured to the APB as mentioned previously for the Camitz transfer.
Abductor digiti minimi Pisiform

tendon moved to base of
proximal phalanx
A B
FIGURE 63.20
Step 3: Closure

Refer to “Postoperative Care and Expected Outcomes” under the Camitz transfer
procedure.
EVIDENCE
Hattori Y, Doi K, Sakamoto S, Kumar K, Koide S. Camitz tendon transfer using flexor retinaculum as a
pulley in advanced carpal tunnel syndrome. J Hand Surg Am. 2014; 39:2454–2459.
The authors performed a case series study of 46 hands in 43 patients who underwent modified Camitz
opponensplasty. Approximately 50% of patients regained useful recovery of APB, and patient-
reported outcomes and functional outcomes were similar among patients who did and did not
regain APB function. Among patients who regain APB function, Camitz transfer serves as an
internal splint during early recovery, and it provides palmar abduction among those who do
not regain APB function because of prolonged compression (Level IV evidence).
Schwarz RJ, Macdonald M. Assessment of results of opponensplasty. J Hand Surg Br. 2003;28:
593–596.
The authors describe patient-reported outcomes and functional outcomes among 115 patients who
underwent 156 opponensplasty procedures. Reconstruction of thumb opposition was most com-
monly performed using the FDS. The majority of patients achieved excellent or good functional
results (89%), and 93% of patients reported at least good-to-fair satisfaction. Complication rates
were low (4%) and primarily included infection and skin or digital ischemia (Level IV evidence).
Skie MC, Parent T, Mudge K, Dai Q. Kinematic analysis of six different insertion sites for FDS
opponensplasty. Hand (N Y). 2010;5(3):261–266.
The authors compared six insertion sites for opponensplasty in a cadaveric biomechanical study and
reported that the Riordan method is superior to others. This method consists of insertion of the
transferred tendon into the EPL and dorsal hood.
Iwase M, Matsuura Y, Kuniyoshi K, Suzuki T, Nagashima K, Ohtori S. Biomechanical evaluation of
opponensplasty for low median palsy: A cadaver study. J Hand Surg Glob Online. 2021;3(2):74–80.
doi:10.1016/j.jhsg.2020.11.002.
The authors performed a biomechanical study to demonstrate that using an FCU pulley during a PL op-
ponensplasty may improve the overall biomechanics of the transfers, but it still remains inferior to an
EIP opponensplasty.
CHAPTER 64
Tendon Transfers for High Median Nerve Injury
INDICATIONS
• In contrast to low median nerve injuries, the anterior interosseous nerve (AIN) is
harmed in high median nerve injuries. This causes a loss of thumb interphalangeal
(IP) joint flexion and index finger IP joint flexion. Both high and low median nerve
injuries also cause sensory deficits, but these are treated with nerve transfers.
• In general, tendon transfer procedures are indicated for patients whose deficiencies
are not able to recover with reinnervation. Patients without joint stiffness, who have
minimal scarring along the path of the tendon transfer, who experience sufficient
sensation of the hand, and who are able to comply with rehabilitation protocols for
motor reeducation are ideal candidates.
• Many options exist for reconstruction of thumb opposition (see Chapter 63), but loss of
thumb IP flexion and index finger flexion is specific to high median nerve injuries.
• Unlike patients with low median nerve injuries, suitable donors are sparse and
mainly derived from the radial nerve innervated muscles, which include the brachio-
radialis (BR), extensor indicis proprius (EIP), extensor carpi radialis longus (ECRL),
and extensor carpi ulnaris (ECU). Common transfers include:
• BR to flexor pollicis longus (FPL)
• Flexor digitorum profundus (FDP) tenodesis: side-to-side transfer of ulnar-innervated
FDP to median-innervated FDP
• ECRL to median FDP transfer (typically only the index finger)
• The ECRL to profundus transfer is an elegant procedure that gives patients indepen-
dent pincer function. The radial nerve innervated muscles are over the dorsum of the
arm and are often spared from injury, whereas the ulnar nerve is close to the median
nerve in the forearm, which makes the combined median and ulnar nerve injury a
common occurrence.
• Forearm pronation is also a median nerve function, powered by the distal pronator
quadratus (anterior interosseous nerve, AIN) and proximal pronator teres (median
nerve proper). This pronation function may be spared if the injury is distal to the el-
bow because the pronator teres nerve branches come off close to the elbow.
Contraindications
• Tendon transfers are not time sensitive. Thus contraindications include absence of
the aforementioned indications, active smoking, poorly controlled comorbidities,
and social situations that preclude compliance with postoperative therapy.
• Patients with multiple nerve injuries require more complex transfers, as described in
Chapter 67.
• Soft tissue equilibrium: The transferred tendons will only glide if they are covered by
supple, soft tissues. Transfers will not function as well if covered by skin graft or
scarred tissue.
• Joints: All joints across which the tendon transfer acts must have full passive range
of motion (ROM) before the transfer is performed.
• Strength: Although standard strength comparisons exist (Table 64.1), the actual
strength of potential donor tendons should be examined thoroughly before selec-
tion. Donors should be at least as strong as the recipient because a muscle-tendon
unit loses strength after transfer.
• Excursion: Wrist flexors and extensors have 3 cm of excursion, digital extensors
have 5 cm of excursion, and digital flexors have 7 cm of excursion. Although donor
494
CHAPTER 64 Tendon Transfers for High Median Nerve Injury 495
TABLE
64.1 Relative Strength of Tendons
Muscles Relative Strength
Brachioradialis 2
Wrist extensors 1
• Extensor carpi radialis longus/brevis
• Extensor carpi ulnaris
Digital flexors 1
• Flexor pollicis longus
• Flexor digitorum superficialis
• Flexor digitorum profundus
Digital extensors 0.5
• Extensor digitorum communis
• Extensor indicis proprius
• Extensor digiti minimi
and recipient excursion should match whenever possible, excursion can also be
augmented with other motion (e.g., finger flexion excursion can improve with wrist
extension/tenodesis effect).
IMAGING
Radiographs are useful to identify the presence of arthritic joint changes or other bony
abnormalities that may preclude full passive ROM.
SURGICAL ANATOMY
Patients with high median nerve injuries suffer denervation of the abductor pollicis
brevis (APB), the opponens pollicis, the superficial (radial) head of the flexor pollicis
brevis (FPB), the radial two lumbricals, the FPL, the index and long finger FDP, the
flexor digitorum superficialis (FDS) to all fingers, the flexor-pronator group (pronator
teres, flexor carpi radialis [FCR]), the palmaris longus (PL), and the pronator quadratus
(PQ; Fig. 64.1).
POSITIONING
• The patient is placed in a supine position with the upper extremity on a hand table.
A nonsterile tourniquet is used.
• Procedures are performed under either general or regional anesthesia.
Profundus Tenodesis: Ulnar Flexor Digitorum Profundus

Side-to-Side Transfer to Median Flexor Digitorum
Profundus to Restore Finger Flexion
EXPOSURES
This transfer is performed through a single, 4-cm longitudinal incision along the distal
forearm just proximal to the wrist crease and just radial to the PL (Fig. 64.2).

Step 1: Incision • Only the palmar cutaneous branch of the
• The skin incision is made, and sharp dissection is carried down to the PL tendon median nerve is encountered in the superficial
dissection; care is taken to protect it if
and deep fascia. identified.
• The deep fascia is sharply incised, and the median nerve is identified lying deep and • To confirm which tendons are the profundi to
ulnar to the PL. The FDS tendons are identified and retracted ulnarly with the median each finger, it is often easier to first flex the
nerve. The FCR tendon is identified and retracted radially. DIP joint and see what tendon moves proxi-
• The FDP tendons to the index, long, ring, and small finger are identified just deep to mally, and then confirm by manual traction on
the tendon.
FDS (see Fig. 64.1).
496 CHAPTER 64 Tendon Transfers for High Median Nerve Injury
Pronator teres
Flexor carpi
radialis
Palmaris
Median nerve longus
Flexor digitorum
superficialis
Carpal tunnel deep

Lateral to flexor retinaculum
lumbricals
Thenar
muscles
PL
FCR
Median nerve
BR FDS
ECRL FCU
Ulnar artery
Ulnar nerve
FDP
B Pronator quadratus
FIGURE 64.1 Patients with high median nerve injuries suffer denervation of the abductor pollicis brevis FIGURE 64.2 The profundus tenodesis transfer
(APB), the opponens pollicis, the superficial (radial) head of the flexor pollicis brevis (FPB), the radial is performed through a single, 4-cm longitudinal
two lumbricals, the flexor pollicis longus (FPL), the index and long finger flexor digitorum profundus incision along the distal forearm just proximal to
(FDP), the flexor digitorum superficialis (FDS) to all fingers, the flexor-pronator group (pronator teres, the wrist crease and just radial to the PL. PL,
flexor carpi radialis [FCR]), the palmaris longus (PL), and the pronator quadratus (PQ). Palmaris longus.
Step 2: Side-to-Side Tenodesis

• The median FDP tendons are sutured to the ulnar FDP tendons in a side-to-side
fashion using horizontal mattress 3-0 Ethibond sutures (Fig. 64.3). Typically, only the
index FDP is innervated by the median nerve, but the long finger FDP can also be
innervated by the median nerve; preoperative examination is important to determine
the patient’s functional needs.
• To set the tension, care is taken to ensure that the ring and small fingers touch the
palm during initiation of grip (Fig. 64.4).
• The transfer is reinforced with additional horizontal mattress sutures, and the pos-
ture of the fingers and tension of the transfer is examined with wrist flexion and
extension using the tenodesis effect.
Side-to-side sutured flexor digitorum profundus
FIGURE 64.3 The FDP tendon to the index finger is sutured in a side-to-side fashion using horizontal
mattress 3-0 Ethibond sutures to the common FDP tendons to the long, ring, and small fingers.
FDP, Flexor digitorum profundus.
A B
FIGURE 64.4 (A–B) To set the tension, care is taken to ensure that the ring and small fingers touch the palm
during initiation of grip before the index finger to preserve strength.
• If possible, use local anesthesia so that the surgeon can check the tension of the
repair with the patient actively flexing the fingers.

The hand is placed in a volar splint with the wrist slightly flexed and all fingers flexed
across the metacarpophalangeal (MCP) joint for 4 weeks after the operation. Active
ROM exercises are initiated at 4 weeks after the transfer.
EXTENSOR CARPI RADIALIS LONGUS TO INDEX FLEXOR

DIGITORUM PROFUNDUS TENDON TRANSFER
FIGURE 64.5 An 8-cm incision is created along Step 1: Markings
the radial aspect of the distal forearm dorsal to
the BR. BR, Brachioradialis. An 8-cm incision is created along the radial aspect of the distal forearm dorsal to the
BR (Fig. 64.5).
Brachioradialis
Step 2: Exposure
• The incision is created sharply and continued through the subcutaneous tissue to
identify the tendon and muscle belly of BR. The ECRL tendon is identified dorsal and
radial to BR and inserts at the base of the index finger metacarpal (Fig. 64.6).
• The dissection is then carried volarly to expose the FDP tendon to the index
finger. The transition from dorsal exposure of the ECRL to volar exposure of FDP
to the index finger identifies and protects two important structures: the radial
Extensor carpi radialis longus artery and radial sensory nerve. The nerve is located between the ECRL and BR,
FIGURE 64.6 The incision is created sharply and whereas the radial artery is more volar, located between the BR and FCR (gener-
continued through the subcutaneous tissue to ally it is deep to the FCR; Fig. 64.7). The radial sensory nerve is protected with
identify the tendon and muscle belly of the BR. gentle retraction while the ECRL tendon is prepared. The radial artery is retracted
The ECRL tendon is identified dorsal and radial
to the BR and inserts at the base of the index
radially, and an interval between the radial artery and the FCR tendon is devel-
finger metacarpal. BR, Brachioradialis; ECRL, oped to enter the deep forearm compartment and identify the FDP tendon to the
extensor carpi radialis longus. index finger.
Step 3: Transfer
STEP 2 PEARLS
• The ECRL tendon is transected in its entirety as distally as possible by extending the
The median nerve lies between the FDP and FDS
wrist near its insertion. It is dissected proximally to free the surrounding tendon and
tendons, and care is taken to retract the FDS
tendons and median nerve ulnarly to improve muscle belly of any additional attachments and to ensure smooth excursion and a
exposure to the FDP tendon. The FDP tendon to straight line of pull.
the index finger is then isolated and exposed.
Radial artery
STEP 2 PITFALLS
Care is taken to avoid injury to the superficial
sensory branches of the radial nerve. BR
(divided and
retracted,
used for a
different
tendon
transfer)
ECRL
Superficial branch of the radial nerve

FIGURE 64.7 The dissection is then carried volarly to expose the FDP tendon to the index finger.
The transition from dorsal exposure of the ECRL to volar exposure of FDP to the index finger in-
volves identifying and protecting two important structures: the radial artery and radial sensory nerve.
The nerve is located between the ECRL and BR, whereas the radial artery is more volar, located
between the BR and FCR (generally it is deep to the FCR). BR, Brachioradialis; ECRL, extensor
carpi radialis longus; FCR, flexor carpi radialis; FDP, flexor digitorum profundus.
Sutured extensor carpi radialis longus and 5cm FDS tendon graft
flexor digitorum profundus tendons
ECRL
A
FDP
Sutured brachioradialis and flexor B
pollicis longus tendons
FIGURE 64.8 (A) The ECRL tendon is transferred under the FDS tendon to the index finger FDP. A sharp Pulvertaft tendon
weaver is used to create the weave, and the transfer can be completed in an end-to-side or end-to-end fashion. The weave is
secured using 3-0 Ethibond suture. (B) An intercalary tendon graft can be used if needed. ECRL, Extensor carpi radialis longus;
FDP, flexor digitorum profundus; FDS, flexor digitorum profundus.
STEP 3 PEARLS
• The ECRL tendon is transferred under the FDS tendon to the index finger FDP. A
sharp Pulvertaft tendon weaver is used to create the weave, and the transfer can be • Care is taken to avoid excess tension on the
completed in an end-to-side or end-to-end fashion. The weave is secured using 3-0 transfer, which could result in a debilitating
flexion contracture at the index finger.
Ethibond suture, and an interposition tendon graft can be used as needed (Fig. 64.8). • ECRL to index FDP transfer is reserved for
patients for whom restoration of tip pinch
POSTOPERATIVE CARE AND EXPECTED OUTCOMES strength is desirable. For patients with
complex injuries, the ECRL transfer may be
The hand is placed in a dorsal blocking splint for 4 weeks postoperatively to protect the
extended to include the long, ring, and small
tendon repair. After 4 weeks, active ROM exercises are initiated. finger FDP tendons to restore grip. If the ECRL
is used to power all FDP tendons, the tension
BRACHIORADIALIS TO FLEXOR POLLICIS LONGUS of the transfer is adjusted such that the
tension is greatest along the ulnar aspect of
TRANSFER TO RESTORE THUMB INTERPHALANGEAL the hand.
JOINT FLEXION • If an intercalary tendon graft is needed, the
index FDS can be used because it is
expendable (see Fig. 64.8).
Step 1: Marking
The transfer can be performed through a single incision along the radial border of the
forearm to expose the BR for transfer to the FPL. This procedure can be performed
using the same incision as the ECRL to FDP tendon transfer if multiple transfers are
planned (see Fig. 64.5).
Step 2: Exposure STEP 2 PEARLS
• The incision is created sharply along the radial aspect of the forearm. The dissection • Care is taken to avoid injury to the radial artery
and superficial branch of the radial nerve,
is continued in the subcutaneous tissue.
which lie deep to the BR.
• The BR is identified along the radial aspect of the forearm just dorsal to the radial • The BR tendon does not cross the wrist,
artery, and its insertion along the radial styloid is identified (see Fig. 64.6). whereas the adjacent tendons do; wrist flexion
• The FCR is identified along the volar aspect of the forearm, and its tendon sheath is and extension can be helpful in confirming the
incised sharply along its radial border. The FCR tendon is retracted ulnarly and the FCR and ECRL, which will move with wrist flex-
ion and extension, and the BR, which will not.
FPL muscle belly and tendon are identified lying just deep and radial to the FCR
tendon (Fig. 64.9).
Step 3: Transfer STEP 3 PEARLS

• The BR is divided sharply at its insertion along the distal radius (see Fig. 64.9). The • The tendon transfer should be performed as
tendon and muscle belly are dissected proximally to free any surrounding attachments. proximally as possible to avoid impingement at
the carpal canal.
• The BR tendon is then transferred to the FPL in an end-to-end fashion to maximize
• If the FPL tendon is short, muscle tissues
the excursion (Fig. 64.10). should be removed from the musculotendinous
• The tendon transfer may be performed either end-to-side or end-to-end using a junction to elongate the tendon portion of the
sharp tendon weaver. An intercalary tendon graft can be used as needed. The trans- muscle.
fer is secured using horizontal mattress 3-0 Ethibond suture. • The BR should be detached as distally as pos-
sible to permit comfortable tendon-to-tendon
• The tenodesis effect of extending and flexing the wrist is used to estimate the tension,
coaptation to the FPL.
and care is taken to avoid setting the tension too tightly and creating an inadvertent
Flexor digitorum profundus
Flexor pollicis longus Median nerve
ECRL
A
FPL BR
B
Radial artery Harvested brachioradialis tendon
FIGURE 64.9 The BR is identified along the radial aspect of the forearm just dorsal to the radial artery, and its insertion along the ra-
dial styloid is also identified. The FCR is identified along the volar aspect of the forearm, and its tendon sheath is incised sharply
along its radial border. The FCR tendon is retracted ulnarly and the muscle belly and tendon of FPL are identified lying just deep and
radial to the FCR tendon. (A) Narrow exposure. (B) Wide exposure, when multiple transfers are needed. Its insertion along the radial
styloid is identified. The FCR is identified along the volar aspect of the forearm, and its tendon sheath is incised sharply along its ra-
dial border. The FCR tendon is retracted ulnarly and the muscle belly and tendon of FPL are identified lying just deep and radial to
the FCR tendon. BR, Brachioradialis; ECRL, extensor carpi radialis longus; FCR, flexor carpi radialis; FPL, flexor pollicis longus.
Sutured tendon
FPL 5 cm FDS tendon graft

ECRL
FCR BR
A B
FIGURE 64.10 (A) The BR tendon is then transferred to the FPL in an end-to-end fashion to maximize the excursion. (B) An
intercalary tendon graft is used when needed. BR, Brachioradialis; FCR, flexor carpi radialis; FDS, flexor digitorum superficialis;
FPL, flexor pollicis longus.
contracture at the thumb IP joint (Fig. 64.11). Tension should be adjusted so that the
resting posture of the thumb IP is slightly more than normal, permitting stretching with
time and therapy.
Step 4: Closure
The incision is closed with absorbable suture in a layered fashion.

The patient is placed in a thumb spica splint, keeping the thumb in slight flexion and
abduction for 4 weeks. After this period, active ROM exercises are initiated.
FIGURE 64.11 Do not tighten the transfer too much, as this will produce an IP joint contracture that
is difficult for the extensors to overcome. Use tenodesis to set the tension. IP, Interphalangeal.
EVIDENCE
Ward SR, Peace WJ, Fridén J, Lieber RL. Dorsal transfer of the brachioradialis to the flexor pollicis
longus enables simultaneous powering of key pinch and forearm pronation. J Hand Surg Am.
2006;31(6):993–997.
The authors performed a cadaveric biomechanical study, suggesting that the BR to FPL transfer can
be routed through the interosseous membrane dorsal to the radius, rather than the traditional volar
route, to produce pinch and also pronation, which is a useful adaptation in patients who also lack
pronation.
CHAPTER 65
Tendon Transfers for Low and High Ulnar Nerve
Injury
Tendon Transfers for Low and High Ulnar Nerve Injury

INDICATIONS
• Management of ulnar nerve injuries is challenging given the distance required to reach
the distal innervation targets of the ulnar nerve in the hand. Tendon transfers are indicated
for patients with motor deficits without expected muscle endplate recovery. If growing
axons are not expected to reach the endplates by 18 months after injury or muscle tar-
gets have been de-innervated for 1 year or longer, tendon transfers should be considered.
• Common etiologies include delayed or failed ulnar nerve repair and chronic com-
pression of the ulnar nerve at the wrist or elbow.
• Procedures are tailored to individual patients and directed toward improving hand
posture, alleviating clawing, strengthening key pinch, correcting small finger abduc-
tion, and improving grip by improving small and ring finger flexion at the distal inter-
phalangeal (DIP) joint (Table 65.1).
TABLE
65.1 Tendon Transfers for Ulnar Nerve Palsy
Deformity/Problem Surgical Procedure Features
Claw hand deformity FDS transfer to correct claw • Most recommended
deformity procedure
• Dynamic procedure
Claw hand deformity FDS–lasso procedure • Dynamic procedure
• Less effective than FDS transfer
Claw hand deformity MCP capsuloplasty/volar plate • Static procedure
advancement • Less effective than bony
arthrodesis
Claw hand deformity Bony MCP joint arthrodesis • Static procedure
• Effective but lose MCP joint
motion
Weak thumb Long finger FDS-to-adductor • Indicated only for patients with
adduction transfer to restore thumb severe hand paralysis
adduction
Thumb adduction with ECRB
with free tendon graft
Instability of the Partial FPL-to-EPL tenodesis • Provide increased pulp pinch
thumb IP joint stabilization strength
• Lose IP joint motion
Loss of ring and Extrinsic finger flexors—FDP • Provide full grip to the hand
little finger flexion side-to-side transfer
Instability of index Index abduction-APL transfer • Provide stability and versatility
finger using tendon graft to index finger
APL, Abductor pollicis longus; ECRB, extensor carpi radialis brevis; EPL, extensor pollicis longus; FDP, flexor
digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; IP, interphalangeal;
MCP, metacarpophalangeal.
502
CHAPTER 65 Tendon Transfers for Low and High Ulnar Nerve Injury 503
• With an ulnar nerve palsy, the hand assumes an “intrinsic minus” posture consisting of
interphalangeal (IP) joint flexion and metacarpophalangeal (MCP) joint hyperextension.
The deformity results from weakness of the intrinsic muscles in the setting of intact
extrinsic finger extensors (innervated by the radial nerve) and flexors (flexor digitorum
superficialis [FDS] innervated by the median nerve). Clawing is more pronounced in
patients with low ulnar nerve injuries in which the flexor digitorum profundus (FDP) to
the ring and small fingers remains innervated. Similarly, clawing may worsen among
some patients with high ulnar nerve injuries that experience recovery as the innervation
to the FDP of the ring and small fingers improves.
• Clawing results in difficulty with grip because the coordination of joint flexion be-
tween the MCP and IP joints is lost. Clawing may be corrected using either dynamic
techniques to establish MCP joint flexion in conjunction with proximal interphalan-
geal (PIP) joint extension or static techniques to reposition the MCP joint in flexion,
depending on the competency of the extensor mechanism (Fig. 65.1).
Normal Clawing hand
FIGURE 65.1 Clawing deformities impair the ability to grip objects.

504 CHAPTER 65 Tendon Transfers for Low and High Ulnar Nerve Injury
INDICATIONS PEARLS • In general, a dynamic transfer using the FDS if preferred whenever possible. Static
procedures are reserved for those patients for whom FDS is not available (e.g., high
• Static procedures reposition the MCP joint in
flexion to promote the extrinsic extensors to median nerve injury) or if the FDS is needed for reconstructive goals of greater prior-
extend the PIP joint, and include volar plate ity. Other than fusion of the MCP joints of the fingers, static transfers may not be able
advancement, FDS lasso around the A1 pulley, to overcome the force of MCP hyperextension and invariably these static procedures
or MCP arthrodesis. Static procedures are will stretch out over time.
conceptually simpler compared with dynamic
• Key and tip pinch are weakened in patients with ulnar nerve palsy because of de-
procedures; however, volar plate advancement
may stretch over time, with recurrence of nervation of the adductor pollicis, flexor pollicis brevis (FPB), and first dorsal interos-
clawing. MCP arthrodesis is typically reserved seous, and can be improved by transferring the extensor carpi radialis brevis (ECRB)
for patients with high median and ulnar nerve augmented with a tendon graft to the thumb adductor.
injury in which there is a lack of donor ten- • Stability of the thumb IP joint can be created by either joint arthrodesis or by a split
dons, and it is technically demanding to
flexor pollicis longus (FPL), which regain pulp pinch to the side of the index finger.
achieve fusion of all four digits. Therefore,
when possible, dynamic procedures are • Among patients with high ulnar nerve injuries, transfer of the median nerve inner-
preferred and are described here. vated FDP tendon to the long finger can augment grip strength, which is weakened
• Restoring thumb adduction power is frequently from denervation of the ring and small finger FDP.
beneficial to patients. Augmenting index finger
abduction, however, may only be selectively Contraindications
required. Frequently, patients can use the re-
maining digits to support the index finger as • Persistent joint contractures are a contraindication to tendon transfers. Patients
a post for pinch. must have full passive mobility of their fingers and thumb before surgery for transfers
to be successful.
• The extremity must be free from edema and the planned tendon routes should be
INDICATIONS PITFALLS
without significant skin and subcutaneous scarring.
Stabilization of the thumb IP joint should be tailored • Tendon transfer should not be undertaken if there is pre-operative weakness of donor
to individual patients. A heavy manual laborer may
motor muscles. Donor muscles must be British Medical Research Council (BMRC)
benefit from additional strength, but many patients
may need to flex their thumb IP joint during daily grade 4 or 5 before surgery, and loss of one strength grade is typical after transfer.
activities, such as when using a mobile phone. • Progressive neurologic disease may preclude tendon transfer because the patient
may continue to lose additional muscle function.
• Patients that may be uncooperative with the postoperative immobilization and reha-
bilitation should not undergo surgery.
• Common deficits among patients with ulnar nerve palsy include claw hand defor-
mity, weak thumb key pinch, small finger abduction deformity, and loss of ring and
small finger DIP joint flexion. Weak thumb key pinch is caused by adductor pollicis
and first dorsal interosseous muscle denervation. The small finger is held in abduc-
tion because of intrinsic muscle paralysis that is overpowered by the extensor digiti
minimi, which tends to extend and abduct the little finger because of the eccentric
tendon insertion site, innervated by the radial nerve.
• The Bouvier test examines the integrity of the extensor mechanism and is a critical guide
when selecting tendon transfer procedures to correct clawing. To perform this test, the
MCP joints are blocked in flexion, and the patient is asked to extend their fingers. If the
extensor mechanism, specifically the central slip, is intact, the patient can actively extend
the PIP and DIP joints (positive test). The test is negative if the patient is unable to extend
the digits at the PIP and DIP joints with the MCP joints held in flexion (Fig. 65.2A–C).
• Patients with a positive Bouvier test (full extension at the PIP joints with the MCP
joints flexed) are candidates for static procedures to correct MCP joint position.
Patients with a negative Bouvier test but full passive extension with the MCP joint
flexed require dynamic procedures to achieve PIP joint extension, given that the
extensor mechanism is not competent. If possible, we prefer to perform the tendon
transfer procedures regardless of the Bouvier test results.
• Patients with PIP joint stiffness are not candidates for tendon transfer because pas-
sive joint flexibility is crucial to tendon transfer success. For these patients, joint
contracture release and tenolysis should be performed first to achieve a mobile joint
before the tendon transfer procedures.
IMAGING
Radiographs should be obtained to determine the presence of arthrosis at the MCP or
PIP joints that may preclude full passive range of motion (ROM).
A B C
FIGURE 65.2 (A) One performs the Bouvier test by keeping the metacarpophalangeal (MCP) joints flexed when the patient extends
the interphalangeal (IP) joints. (B) The inability to extend the IP joints with the MCP joints flexed is a negative test; (C) Active exten-
sion signifies a positive test.
SURGICAL ANATOMY
• The ulnar nerve is the terminal branch of the medial cord. It courses subfascially
through the upper arm in the bicipital groove posteromedial to the brachial artery.
It pierces the intermuscular septum at the arcade of Struthers 8 cm proximal to
the medial epicondyle to travel posteriorly around the elbow in the cubital tunnel
(Fig. 65.3). In the forearm, the ulnar nerve gives off the motor branches to the
flexor carpi ulnaris (FCU) and to the FDP to the ring and little fingers just distal to
the elbow, after the outlet of the cubital tunnel. These two muscles are affected
in high ulnar nerve palsy patients only. The dorsal cutaneous branch arises ap-
proximately 5 cm proximal to the ulnar styloid and travels deep to the FCU to give
sensation to the dorsoulnar hand. The palmar cutaneous sensory branch diverges
from the ulnar nerve just proximal to the ulnar nerve entry into the Guyon canal.
In the Guyon canal, the ulnar nerve divides into superficial sensory and deep mo-
tor branches. The motor branch controls the hypothenar muscles, the two ulnar
Ulnar nerve
Medial intermuscular
septum
Arcade of
Struthers
Medial epicondyle
Osborne fascia
Olecranon
Motor branch to
FCU muscle Arcade of
FCU FCU
FIGURE 65.3 Relevant anatomy around the ulnar nerve at the elbow. FCU, Flexor carpi ulnaris.
Adductor
Lumbricals pollicis
DI PI
DI
Flexor digiti minimi DI
DI PI DI
Opponens digiti minimi PI
Palmaris brevis Flexor pollicis

brevis
FIGURE 65.4 Muscle innervation of the distal ulnar nerve.
lumbricals, the dorsal and palmar interossei, and the APB and gives partial in-
nervation to the FPB (Fig. 65.4).
• The FDS is innervated by the median nerve and is commonly used for dynamic
transfer to correct clawing.
POSITIONING
Tendon transfer procedures are performed under tourniquet control, and the patient is
positioned supine with the affected extremity extended on a hand table.
Flexor Digitorum Superficialis Transfer to Correct Claw

Deformity
EXPOSURES
A Bruner zigzag incision is designed on the volar middle finger over the PIP joint for
access to the FDS tendon. In addition, a midpalmar incision is made over the flexor
tendons of the long finger, just proximal to the distal transverse palmar crease. Radial-
sided midaxial incisions are designed over the ring and small fingers to access the
common radial intrinsic tendons (Fig. 65.5).
STEP 1 PEARLS
Step 1
• To correct clawing of the ring and small fingers, the FDS tendon of the middle finger,
• Using the FDS to correct clawing obviates the
need for tendon grafts, which are typically which is innervated by the median nerve, is selected for transfer. Skin incisions are
required if wrist extensors are used as tendon made to expose the volar aspect of the PIP joint of the middle finger, and the skin
donors. and subcutaneous tissue are elevated above the flexor tendon sheath along the
• To correct claw deformity of four fingers, the flaps designed using Bruner-style incisions.
FDS tendon of the ring finger can also be har- • The digital neurovascular bundles are identified using blunt dissection. While pro-
vested for transfer, in which the long finger FDS
is transferred to the index and long fingers, and tecting them, the flexor tendon sheath is identified, and the pulley system is exposed
the ring finger FDS is transferred to the ring (Fig. 65.6). The tendon sheath is entered at the A3 pulley, and the FDS tendon is
and little fingers. Alternatively, the FDS of the identified (Fig. 65.7).
long finger can be used as the sole motor, aug- • The FDS tendon of the middle finger is located at the level of the decussation under
mented with tendon grafts that provide more the FDP tendon and transected as distally as possible from its insertion on the
tendon substance to power all four fingers.
middle phalanx (Fig. 65.8).
FDP tendon
FIGURE 65.5 Incisions to correct ring and small finger claw deformities with flexor digi- FIGURE 65.6 Exposure of the flexor tendons after open-
torum superficialis (FDS) transfer. ing the A3 pulley.
Retracted
FDP tendon Transected
FDS tendon
FIGURE 65.7 Retraction of the flexor digitorum profundus (FDP) FIGURE 65.8 Transect the flexor digitorum superficialis
tendon reveals the underlying flexor digitorum superficialis (FDS) (FDS) tendon distally for harvest.
tendon.
• The harvested FDS tendon is brought out of the palmar incision (Fig. 65.9).
• The two slips of FDS are then separated proximally starting at the chiasm to provide
two separate donor tendons for transfer (Fig. 65.10).
Step 2
• Midaxial incisions along the radial aspect of the ring and small finger at the level of
the PIP joint are made and blunt dissection is used through the subcutaneous tissue
to identify the radial lateral band. Care is taken not to dissect volarly and risk injury
to the neurovascular bundle (Fig. 65.11A–B).
• A small hemostat is used from distal to proximal to create a subcutaneous tunnel,
and the donor FDS tendon slips are tunneled volar to the deep transverse metacar-
pal ligament through the lumbrical canal to reach the small and ring finger midaxial
incisions (Fig. 65.12A–C).
Proximal Splitting
FDS tendon proximal
FDS tendon
FIGURE 65.9 Deliver the transected flexor digitorum su- FIGURE 65.10 The flexor digitorum superficialis (FDS) tendon is
perficialis (FDS) tendon through the proximal incision. split to create limbs for the ring and small fingers.
Radial
lateral band
Radial
lateral band
FIGURE 65.11 Exposure of the radial lateral bands of the ring (A) and small (B) fingers.
Hemostat
on FDS slip
Split FDS
tendon slips
A B
FDS slips passed

through lumbrical
canals
FIGURE 65.12 A hemostat is used to create a tunnel from the radial lateral band to the harvested flexor digitorum su-
perficialis (FDS) tendon for both the ring (A) and small (B) fingers, and the tendon is passed (C).
• Using a sharp Pulvertaft tendon weaver, the FDS tendon is woven to the lateral band
and secured using 4-0 Ethibond suture with sufficient tension to flex the MCP joint
and extend the IP joints. The tension is set with the wrist in neutral and the MCP
joints in 70 degrees of flexion. Care must be taken not to capture the joint capsule,
lateral collateral ligaments, or the central slip with these sutures to prevent adhe-
sions and subsequent loss of motion (Fig. 65.13A–B).
• The wrist is then passively flexed and extended to assess the tension of the transfer.
With wrist flexion, the MCP joints should be extended, given the laxity of the FDS
donor tendons. With wrist extension, the tension over the tendon should flex the
MCP joints and extend the PIP joints. In practice, one should suture the tendons to
the lateral bands in maximum tension because the tension is invariably not strong
enough to achieve an intrinsic plus posture.
• If the wide-awake, local anesthetic, no tourniquet (WALANT) technique is used, the
patient is asked to flex and extend their fingers and ensure adequate tension of the
transfer. This can be done after the first suture has been placed in the Pulvertaft weave
and any needed adjustment should be made before securing the entire transfer.

The hand is placed in an intrinsic plus volar resting splint and is maintained in immobi-
lization for 4 weeks. After 4 weeks, active and passive ROM exercises are initiated.
Transferred flexor digitorum

superficialis tendon Lateral band
Deep transverse
metacarpal ligament
B
FIGURE 65.13 (A) The transferred tendon is secured to the radial lateral band with 4-0 Ethibond sutures.
(B) The flexor digitorum superficialis (FDS) tendon should be deep to the transverse metacarpal
ligament.
ECRB-to-Adductor Transfer With Free Tendon Graft

to Restore Thumb Adduction
EXPOSURES
• A longitudinal incision along the ulnar border of the thumb within the first webspace
is used to expose the adductor tendon insertion to the proximal phalanx.
• A longitudinal incision over the dorsal wrist is made to expose the ECRB, which in-
serts on the base of the long finger metacarpal.
• A dorsal zigzag incision is made between the head of the long and ring finger meta-
carpals within the third intermetacarpal space by which the tendon graft is routed to
the thumb.
• A series of transverse volar incisions in the midline of the forearm are used to harvest
the palmaris longus (PL). Alternatively, a short, longitudinal incision is created pos-
terior to the lateral malleolus to harvest the plantaris tendon if the PL is not available.
It is quite possible that the ECRB tendon is split in its midline as proximally as pos-
sible to flip over to its end to augment its reach. The distal juncture is prevented from
splitting by multiple sutures.
PROCEDURE
Step 1
The dorsal wrist incision is created, and blunt dissection is carried down through the
subcutaneous tissues. The extensor pollicis longus (EPL) tendon is identified, pro-
tected, and retracted radially to expose the second extensor compartment. The ECRB
tendon lies ulnar to the ECRL and inserts on the base of the long finger metacarpal. The
ECRB is divided as distally as possible. It is withdrawn through the extensor retinacu-
lum proximally.
Step 2
An incision is made along the ulnar border to the thumb to identify the adductor tendon
at its insertion on the proximal phalanx. Care is taken to protect the neurovascular
bundle, which lies volar to the adductor insertion.

• A free tendon graft is harvested measuring 12 cm in length, typically from the PL if • Tension on the tendon transfer is created such
available. that the thumb and the other metacarpals
• To create the appropriate vector of pull, the tendon graft is drawn through a window should be parallel to each other in a wrist neu-
tral position. The key posture for any tendon
in the intermetacarpal space between the long and ring fingers, with the long finger
transfer is the tenodesis effect of normal digit
metacarpal serving as a pulley. A dorsal incision is made between the metacarpals, posture with wrist extension and flexion.
and blunt dissection is used to create a tunnel that penetrates the interosseous • If the ECRB is not available, the transfer may
membrane. be powered using a free tendon graft woven to
• A tunnel is made using a short hemostat deep to the longitudinal fibers of the palmar alternate wrist extensors (extensor carpi ulna-
ris [ECU], extensor carpi radialis longus [ECRL],
fascia and along the path of the denervated thumb adductor muscle within the sub-
brachioradialis [BR]).
cutaneous tissue to the palm between the thumb incision and the dorsal incision to
pass the harvested tendon graft. The hemostat should be hugging the volar meta-
carpal when making the tunnel to avoid all volar vital structures. The free tendon
graft is drawn from the dorsal wrist incision subcutaneously into the intermetacarpal
tunnel and delivered to the ulnar border of the thumb. A hemostat is used to secure
both ends of the tendon graft to prevent pulling the ends into the tunnel. Preferably,
the tendon graft is sutured to the adductor insertion at the ulnar MCP joint before
pulling it through the tunnel.
• The tendon graft is woven to the adductor tendon just proximal to its insertion using
a sharp Pulvertaft tendon weaver. The weave is secured with 4-0 Ethibond suture as
the thumb is held in adduction (Fig. 65.14).
• The tendon graft is then woven to the distal cut end of the ECRB using a sharp Pul-
vertaft tendon weaver to set the tension. The thumb should lie against the index finger
with wrist flexion and in abduction with wrist extension. A minimum of two weaves are
created and secured using 4-0 Ethibond suture in a horizontal mattress fashion.

• Postoperatively, the hand is immobilized with the thumb in neutral position and the
wrist in 40 degrees of extension. At 2 weeks, the plaster is exchanged for a custom
removable splint.
• The splint is made with the wrist and thumb in neutral position. It is worn for a total
of 4 weeks, after which splint removal is permitted and active motion of the thumb
and wrist is encouraged.
Split ECRB-to-Adductor Transfer to Restore Thumb

Adduction
EXPOSURES
• A longitudinal incision along the ulnar border of the thumb within the first webspace
is used to expose the adductor tendon insertion to the proximal phalanx.
• A longitudinal incision over the dorsal wrist is made to expose the ECRB, which
inserts on the base of the long finger metacarpal.
Extensor carpi
radialis brevis
FIGURE 65.14 The extensor carpi radialis brevis (ECRB) and tendon graft are passed around the
long finger metacarpal to mimic the vector of the adductor pollicis.
• A dorsal zigzag incision is made between the head of the long and ring finger meta-
carpals within the third intermetacarpal space by which the tendon graft is routed to
the thumb.
• An additional transverse dorsal incision in the radial mid forearm is used to extract
the ECRB tendon for lengthening.
PROCEDURE
Step 1
• The dorsal wrist incision is created, and blunt dissection is carried down through the
subcutaneous tissues. The EPL tendon is identified, protected, and retracted radially
to expose the second extensor compartment. The ECRB tendon lies ulnar to ECRL
and inserts on the base of the long finger metacarpal. The ECRB is divided as dis-
tally as possible and withdrawn through the extensor retinaculum proximally.
• The proximal transverse dorsal forearm incision is made over the radial aspect at the
musculotendinous junction of the ECRB and blunt dissection is carried down to the
extensor compartment fascia.
• The fascia is incised and the ECRB is identified and isolated from the ECRL, which
is radial to the ECRB. Gentle traction with a closed hemostat or a blunt retractor
(Regnel) is used to pull the ECRB tendon out of the proximal incision.
• The ECRB tendon is split longitudinally from the musculotendinous junction distally,
leaving 2 cm of distal tendon intact.
• The split limb is then rotated 180 degrees about the intact distal tendon and sutured
side-to-side to the distal stump with 3-0 permanent braided suture (Fig. 65.15).
FIGURE 65.15 The extensor carpi radialis brevis (ECRB) tendon may be split and folded on itself to
avoid a tendon graft.
Step 2
An incision is made along the ulnar border to the thumb to identify the adductor tendon
at its insertion on the proximal phalanx. Care is taken to protect the neurovascular
bundle, which lies volar to the adductor insertion.
Step 3
• The lengthened ECRB tendon is passed subcutaneously back through the proximal STEP 3 PEARLS
incision and delivered out of a dorsal incision made between the middle and ring • Tension on the tendon transfer is created such
finger metacarpal necks. that the thumb and the other metacarpals
• To create the appropriate vector of pull, the tendon is drawn through a window in the should be parallel to each other in a wrist neu-
intermetacarpal space between the long and ring fingers, with the long finger meta- tral position.
carpal serving as a pulley. Blunt dissection between the middle and ring finger meta- • If the ECRB is not available, the transfer may
be powered using a free tendon graft woven to
carpal necks is used to create a tunnel that penetrates the interosseous membrane. alternate wrist extensors (ECU, ECRL, BR).
• A tunnel is made using a short hemostat deep to the longitudinal fibers of the palmar
fascia, flexor tendons, and neurovascular bundles. This tunnel runs along the path of the
denervated thumb adductor muscle from the thumb incision to the ring metacarpal
neck. The extended ECRB tendon is drawn from the dorsal wrist incision subcutane-
ously into the intermetacarpal tunnel and delivered to the ulnar border of the thumb
using a curved tendon passer.
• The tendon graft is then woven to the adductor tendon just proximal to its insertion
using a sharp Pulvertaft tendon weaver. The weave is secured with 4-0 Ethibond
suture as the thumb is held in adduction.
APL-to-First Dorsal Interosseous Transfer Using Tendon

Graft for Index Abduction
EXPOSURES
• Make two chevron-shaped incisions over the first dorsal compartment and over the
radial MCP joint of the index finger (Fig. 65.16).
• Additional incisions along the volar forearm or lower extremity are required to har-
vest either the PL or plantaris as a free tendon graft.
PROCEDURE
Step 1
• The skin is incised sharply over the first dorsal compartment, and blunt dissection
through the soft tissues exposes the extensor retinaculum. Care is taken to avoid
injury or excessive traction along the superficial sensory branches of the radial nerve.
• The first dorsal compartment is identified and incised sharply in a longitudinal fash-
ion. The abductor pollicis longus (APL) tendon is identified in the radial aspect of the
compartment, and its insertion on the base of the first metacarpal is visualized. A
radial slip of the APL is isolated and divided as distally as possible (Fig. 65.17).
Step 2
• A chevron incision is created along the radial aspect of the index finger at the level of
the MCP joint, and the extensor apparatus is exposed bluntly. The radial lateral band
and collateral ligament are exposed for insertion of the tendon graft (Fig. 65.18).
• A tendon graft measuring approximately 10 cm in length is harvested from either the
PL or plantaris tendons.
• The tendon graft is woven to the radial lateral band and collateral ligament (Fig. 65.19).
A subcutaneous tunnel is created between the incisions across the dorsal hand and
wrist and the graft is passed to the proximal incision. After passing through the tunnel,
Dorsal APL slip
Volar APL
and EPL
tendons
FIGURE 65.16 Incisions for the abduc-

tor pollicis longus (APL)-to-first dorsal FIGURE 65.17 Harvest of a dorsal abductor pollicis longus FIGURE 65.18 Identification of the
interosseous transfer. (APL) slip. first dorsal interosseous tendon.
Pulvertaft weave to 1st

dorsal interosseous
tendon
Tendon graft
Subcutaneous tendon
FIGURE 65.19 The tendon graft is secured distally with a Pulvertaft weave. FIGURE 65.20 The tendon graft is passed subcutaneously
and secured to the abductor pollicis longus (APL) tendon.
the tendon graft is woven to the proximal slip of the APL, and all tendon weaves are
secured with 4-0 Ethibond suture (Fig. 65.20).
• Tension is set with the index finger in slight radial abduction to permit relaxation with
time.

The patient is placed in a volar splint with the wrist extended and padded sufficiently
between the index and long finger to achieve radial abduction of the index finger. After
3 weeks, the splint is removed, and active ROM exercises are initiated.
Extrinsic Finger Flexors—FDP Side-to-Side Transfer

EXPOSURES
The flexor tendons are exposed through a longitudinal incision in the midline over the
volar distal forearm positioned ulnar to the PL. Care is taken to avoid the superficial
palmar cutaneous branch of the median nerve along the ulnar aspect of the flexor carpi
radialis (FCR) tendon.
PROCEDURE
Step 1
• The skin is incised sharply; sharp dissection is used to expose the antebrachial
fascia. The antebrachial fascia is incised, and the musculotendinous units of the
FDS and FDP are identified. The median nerve is identified between the FDS and
FDP. The FDS and the median nerve are gently retracted radially to achieve ade-
quate exposure.
• The FDP to the index, long, ring, and small fingers are each identified separately.
• While maintaining the wrist in neutral and the fingers in the normal-appearing, natu-
ral cascade, the FDP tendons from the ring and little fingers are sutured to the FDP
of the long finger in a side-to-side fashion using several horizontal mattress 2-0
STEP 2 PEARLS
Ethibond sutures (Fig. 65.21).
The index finger FDP tendon should not be
Step 2 included. This permits independent motion of the
digit.
The skin is closed using absorbable sutures, and a dorsal blocking splint is placed.
A B
FIGURE 65.21 Side-to-side transfer of the ring and small finger flexor digitorum profundus (FDP) tendons to
the middle finger tendon.

The hand is immobilized within a dorsal blocking splint for 2 weeks. At 2 weeks, active
ROM exercises are initiated within the splint for a total of 6 weeks to protect the tendon
repair.
EXPOSURES PEARLS FDS-Lasso Procedure

The A3 pulley originates from the volar plate of
the PIP joint. The joint is a useful landmark to EXPOSURES
identify the window between the A2 and A3 pulleys A Bruner zigzag incision is designed over the volar proximal finger to expose the FDS
(Fig. 65.22).
tendon between the A2 and A3 pulleys.
PROCEDURE
Step 1
The skin is incised sharply, and sharp dissection is continued over the volar aspect of
the digit within the midline to expose the flexor tendon mechanism. The flexor tendon
sheath is entered at the A3 pulley, and the FDS tendon is identified at the level of the
decussation. The tendon is then transected as distally as possible from its attachment
along the proximal phalanx (Fig. 65.23).
Step 2
The incision is carried proximally to expose the A1 pulley. The FDS tendon proximal to
the A1 pulley is identified and delivered into the wound (Fig. 65.24). The distal aspect
FDS tendon
A3 pulley FDS tendon (cut)
A1 and A2 pulleys
FIGURE 65.22 Exposure of the A3 pulley. FIGURE 65.23 The flexor digitorum superficialis (FDS) tendon is
transected distally when the flexor digitorum profundus (FDP) is
protected.
Distal (cut)
FDS tendon
A1 pulley
Proximal
FDS tendon
FIGURE 65.25 The flexor digitorum su-

FIGURE 65.24 The proximal flexor digitorum superficialis (FDS) perficialis (FDS) tendon is sutured to it-
tendon is found proximal to the A1 pulley. self after being folded over the A1 pulley.
of the FDS tendon is then sutured back to itself with 3-0 braided nonabsorbable suture, STEP 2 PEARLS
thus looping the A1 pulley (Fig. 65.25).
The finger should be held with the MCP joint in
slight flexion (around 45 degrees) when the FDS is
Step 3 secured to itself to set tension (Fig. 65.26).
The skin is closed using nylon sutures, and a dorsal blocking splint is placed.

The patient is splinted in a dorsal blocking splint. Remove the splint after 3 weeks and
initiate active ROM exercises.
Metacarpophalangeal Capsuloplasty/Volar Plate

Advancement
EXPOSURES
A 4-cm transverse incision is made over the palm at the level of the distal palmar crease
and the MCP joints (Fig. 65.27).
PROCEDURE
Step 1
• The skin is incised and blunt dissection is used to expose the flexor tendon sheath
for each planned digit. The neurovascular bundles are identified and gently retracted
(Fig. 65.28).
• The A1 pulley is identified and incised longitudinally, and the FDS and FDP tendons
are retracted laterally.
• It is difficult to fully expose the volar metacarpal without a long incision, so make the
incision as long as needed to see the volar plate.
FIGURE 65.26 Final positioning of the metacar-
pophalangeal (MCP) joint after flexor digitorum
Step 2
superficialis (FDS) lasso. • The volar plate is exposed, and a distally based U-shaped trapdoor incision is
designed on the volar plate of the MCP joint (Fig. 65.29).
• The volar plate flap is elevated by detaching the proximal end of the volar plate from
the metacarpal (Fig. 65.30).
• At the neck of the metacarpal, a Freer elevator is used to expose the bone surface
and a Mitek mini suture anchor is placed, after partial decortication of the metacar-
pal for secure healing (Fig. 65.31A–B).
• The volar plate flap is then advanced proximally and the suture anchor is used to
secure the MCP joint in 50 degrees of flexion. All finger MCP joints are secured in a
similar fashion (Fig. 65.32A–B).
Step 3
The skin is closed using nylon sutures, and a dorsal blocking splint is placed, keeping
the MCP joints flexed at around 75 degrees (Fig. 65.33).
Distally based
capsulotomy
FIGURE 65.27 Planned incision for FIGURE 65.28 Blunt dissection exposes
metacarpophalangeal (MCP) capsu- the volar metacarpophalangeal (MCP)
lodesis of index through small fingers. joint capsule. FIGURE 65.29 A distally based capsule flap is planned.
MP volar plate
A B
FIGURE 65.31 (A) A drill hole for a suture anchor is made proximal to the
metacarpophalangeal (MCP) joint capsule. (B) A suture anchor is placed in
the metacarpal.
FIGURE 65.30 The proximal metacarpophalangeal (MCP) joint vo-
lar plate is elevated off the metacarpal.
A B
FIGURE 65.32 (A) The volar plate flap is tied down to the suture anchor. (B) The proce- FIGURE 65.33 Final metacarpophalan-
dure is repeated for the remaining fingers. geal (MCP) joint positioning after capsu-
lodesis.

The hand is maintained in a dorsal blocking splint to immobilize the MCP joints in about
75 degrees of flexion for 8 weeks. Active and passive ROM exercises of the DIP and
PIP joints are permitted within the splint.
See Videos 65.1, 65.2, 65.3, 65.4, 65.5, and 65.6.
EVIDENCE
Nemoto K, Arino H, Amako M, Kato N. Abductor pollicis longus transfer to restore index abduction in
severe cases of cubital tunnel syndrome. J Hand Surg Eur Vol. 2007;32:296–301.
This study examined the functional outcomes of 18 patients who underwent APL transfer to augment
index finger abduction in the setting of advanced cubital tunnel syndrome. The authors noted sub-
stantial improvement of key pinch from 39% of the opposite side preoperatively to 81% at the final
evaluation. This procedure is a straightforward and safe option to improve key pinch strength in the
setting of ulnar nerve palsy (Level IV evidence).
Ozkan T, Ozer K, Gülgönen A. Three tendon transfer methods in reconstruction of ulnar nerve palsy.
J Hand Surg Am. 2003;28:35–43.
The authors examined the use of three tendon transfer procedures for the correction of claw hand
deformity among 44 patients: FDS four-tail procedure, ECRL four-tail procedure, and an FDS lasso.
The authors specifically examined functional and patient-reported outcomes and noted that the most
important predictors of postoperative function were the mean duration of paralysis and PIP extensor
lag. Grip strength was greater among patients who underwent FDS lasso procedures and ECRL
four-tail tendon transfer, but FDS four-tail procedure provided the greatest improvement in the
clawed hand posture. Given the ease of transfer and the avoidance of a tendon graft, the FDS
four-tail procedure is preferred for reconstruction (Level IV evidence).
Hastings H, McCollam SM. Flexor digitorum superficialis lasso tendon transfer in isolated ulnar nerve
palsy: a functional evaluation. J Hand Surg Am. 1994;19(2):275–280.
This study reviews the FDS lasso procedure to correct claw deformities for ulnar nerve palsy in 12 patients
(23 digits total). Average follow-up was 3 years after surgery and they noted correction of clawing in
19 out of 23 fingers. The small finger and those with PIP contractures were less likely to correct well.
The authors also note that even though deformity was corrected well, grip strength did not improve
after the procedure.
Rath S. Immediate postoperative active mobilization versus immobilization following tendon transfer for
claw deformity correction in the hand. J Hand Surg Am. 2008;33:232–240.
The author examines the outcomes of 32 patients who underwent FDS long finger four-tailed recon-
struction for four-digit claw deformity with early rehabilitation (initiated 2 days after surgery). They
were compared with 32 historical control patients immobilized for 3 weeks after surgery. Compared
with the immobilization group, patients who receive early mobilization protocols achieve superior
total active ROM. Correction of claw-deformity was equal between groups (Level III evidence).
Van Heest A, Hanson D, Lee J, Wentdorf F, House J. Split flexor pollicis longus tendon transfer for
stabilization of the thumb interphalangeal joint: a cadaveric and clinical study. J Hand Surg Am.
1999;24(6):1303–1310.
The authors created a cadaveric model to test the split FPL to EPL transfer and to retrospectively
review 12 thumbs that had undergone the procedure (10 patients). Average follow up was 2 years,
and all patients had other tendon transfer procedures in addition to the split FPL to EPL transfer.
Final pinch strength averaged 33N, and the Froment sign was eliminated in all patients. No thumb
required a subsequent procedure to balance the IP joint and all 10 patients were satisfied with the
new thumb position.
CHAPTER 66
Tendon Transfers for High and Low Radial Nerve
Injury
INDICATIONS
• Tendon transfers are indicated for patients with radial nerve injury who have failed to
regain sufficient motor function. Critical deficits for patients with radial nerve injury
include wrist extension, finger extension, and a combination of thumb extension and
abduction.
• High radial nerve palsy is defined as an injury above the elbow; in a low radial nerve
palsy (below the elbow), innervation to the upper arm muscles (triceps, brachiora-
dialis [BR], and extensor carpi radialis longus [ECRL]) remains intact.
• Common tendon transfers for radial nerve palsy include pronator teres (PT) to exten-
sor carpi radialis brevis (ECRB) to restore wrist extension, flexor carpi radialis (FCR)
to extensor digitorum communis (EDC) to restore finger extension, and palmaris
longus (PL) to extensor pollicis longus (EPL) to restore thumb extension. If the PL is
not present, the flexor digitorum superficialis (FDS) tendon of the long finger is used
to restore thumb and index finger extension. We do not take the ring finger FDS
tendon to preserve the power grip that is a critical function. The FDS tendon from
the long finger is strong enough to power the thumb and index finger simultaneously
for coordinated extension of these two digits during pinch.
• Restoring wrist extension helps stabilize the hand during finger flexion, which
permits a powerful grip. Stabilizing the wrist should be done first in the se-
quence of tendon transfer procedures. Once the wrist transfer tension is set,
then the finger tendon can be modulated based on the tenodesis effect of a
normal wrist arc.
• Although there are several wrist extensor tendons, the first choice as a recipient for
wrist extension is the ECRB. Because it inserts along the long finger metacarpal, it
provides effective wrist extension without ulnar or radial deviation.
• Early end-to-side transfer of the PT to ECRB for high radial nerve palsy patients can
be considered at the time of initial nerve repair to act as an internal splint and
facilitate activities of daily living while nerve recovery is anticipated.
• In a low radial nerve (or posterior interosseous nerve [PIN]) palsy, active wrist exten-
sion is maintained. In these patients, only transfers to restore finger and thumb ex-
tension are indicated.
Contraindications
• Persistent joint contracture is a contraindication to tendon transfers. Patients must
have full passive mobility of their wrist, fingers, and thumb before surgery for trans-
fers to be successful.
• The extremity must be free of edema and the planned tendon routes should be
without significant skin and subcutaneous scarring. If the path of the transfer is
scarred or is covered by skin grafts, one must excise these unyielding tissues and
cover them with a pliable skin flap.
• Tendon transfer should not be undertaken if there is preoperative weakness of do-
nor motor muscles. Donor muscles must be British Medical Research Council
(BMRC) grade 4 or 5 before surgery because loss of one strength grade is typical
after transfer.
• Progressive neurologic disease may preclude tendon transfer because the patient
may continue to lose additional muscle function.
521
522 CHAPTER 66 Tendon Transfers for High and Low Radial Nerve Injury
• Patients who may be uncooperative with the postoperative immobilization and reha-
bilitation should not undergo surgery.
• Examination of the wrist and digits should demonstrate passive range of motion
(ROM) and ensure that no contractures are present.
• The muscles affected in patients with high radial nerve palsy include the triceps, BR,
ECRL, ECRB, supinator, extensor carpi ulnaris (ECU), extensor digiti minimi (EDM),
abductor pollicis longus (APL), EPL, extensor pollicis brevis (EPB), and extensor in-
dicis proprius (EIP). Each should be tested independently to determine the level of
injury and reconstructive needs.
• The presence of the PL tendon can be confirmed by having the patient touch the
thumb and little finger with the wrist in flexion. The PL tendon is usually palpable on
the palmar aspect of the wrist, on the ulnar side of the FCR tendon.
SURGICAL ANATOMY
• The pathway and branches of the radial nerve are noted in Chapter 59.
• Patients with low radial nerve palsy present with preserved wrist extension because
of the proximal innervation of the ECRL. Low injuries proximal to the PIN will result
in wrist extension with radial deviation stemming from unbalanced action of the in-
tact ECRL because the innervations to the ECRB and ECU are lost. Injuries distal to
the PIN will have preservation of ECRB and ECU innervation and thus will present
with balanced wrist extension.
POSITIONING
• Tendon transfers are performed with the patient placed in a supine position with an
upper arm tourniquet and a regional block, or under general anesthesia.
• Surgeons comfortable with the WALANT (wide awake, local anesthesia, no tourni-
quet) technique may choose to perform the surgery using local anesthesia; a large
volume of local anesthetic may be needed to adequately infiltrate every planned
incision.
• The upper extremity is outstretched on a hand table.
EXPOSURES
EXPOSURES PEARLS
Three separate incisions are used: (1) on the radial forearm, (2) on the volar forearm,
• The EPL tendon can be exposed and delivered and (3) over the proximal dorsal wrist. A 6-cm incision along the radial aspect of the
through a small incision on the dorsal thumb midforearm provides access to the insertion of the PT, as well as the BR, ECRL, and
by identifying the Lister tubercle.
• Exposure and harvest for all planned transfers ECRB (Fig. 66.1A–B). A 4-cm longitudinal incision is made over the dorsal wrist just
may be performed before the first transfer is ulnar to the Lister tubercle to expose the third and fourth extensor compartments. A
completed. The most robust transfer (PT to 6-cm longitudinal incision is made over the volar aspect of the distal forearm beginning
ECRL) should be tensioned and secured first at the proximal wrist to expose the FCR, PL, and FDS to the long finger. A 2-cm longi-
before moving on to more delicate transfers tudinal incision is made over the dorsal aspect of the thumb metacarpophalangeal
(e.g., PL to EPL).
(MCP) joint.
FIGURE 66.1 Incision design for PT-to-ECRB, FCR-to-EDC, and PL-to-EPL transfers. ECRB, Extensor carpi radialis brevis; EDS, extensor
digitorum superficialis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; PL, palmaris longus; PT, pronator teres.
CHAPTER 66 Tendon Transfers for High and Low Radial Nerve Injury 523
PRONATOR TERES TO EXTENSOR CARPI RADIALIS BREVIS

TENDON TRANSFER TO RESTORE WRIST EXTENSION
The PT to ECRB transfer is performed first to restore wrist extension and set the tension
for later finger and thumb transfers.
• The skin is incised through a dorsoradial forearm incision. The BR muscle is identi- The radial sensory nerve and radial artery lie just
fied just radial to the ECRL and retracted ulnarly to expose the insertion of the PT beneath the BR muscle and should be identified
and protected.
underneath the BR along the midportion of the radius. Care is taken to identify and
protect the sensory branch of the radial nerve and the radial artery. The PT lies deep
to the BR and inserts on the dorsal and radial aspect of the radius just distal to the STEP 2 PEARLS
midpoint, between the BR and FCR (Figs. 66.2 and 66.3).
• The wrist is held in 45 degrees of extension by
• Detach the PT insertion on the radius with a 4 cm extension of periosteum along the the assistant as the transfer is created. This
radius to ensure adequate length for the transfer. The muscle is then dissected proxi- position should be maintained without support
mally to improve excursion, trajectory, and length by releasing its fascial attachments once the transfer is complete. The extension of
(Fig. 66.4). the wrist is overcorrected at this stage, antici-
pating laxity and stretch over time.
Step 2 • If multiple transfers are being performed si-
multaneously (FCU-to-EDC and PL-to-EPL), the
• The ECRB musculotendinous junction is identified by dissecting superficially over PT-to-ECRB transfer should sutured first to set
the BR and ECRL. The ECRB tendon is commonly used as the recipient to achieve the tension with the wrist at neutral 0 degrees
wrist extension because it inserts into the long finger metacarpal base and provides so that finger tension can be set using the te-
centralized extension. The PT tendon is passed superficial to the BR and ECRL and nodesis effect to help establish tension of the
finger and thumb transfers.
underneath the ECRB.
PT tendon
BR tendon
Radial artery
FIGURE 66.2 Exposure of the PT donor tendon and adjacent structures. BR, Brachioradialis;
PT, pronator teres.
PT tendon
FIGURE 66.3 Exposure of the PT tendon. PT, Pronator teres.

PT tendon harvested
with periosteum
FIGURE 66.4 PT tendon harvested with periosteum. PT, Pronator teres.
PT tendon
ECRB tendon
FIGURE 66.5 PT tendon secured to the ECRB tendon. ECRB, Extensor carpi radialis brevis;
PT, pronator teres.
• If radial nerve recovery is not expected, the ECRB tendon is divided sharply at its
musculotendinous junction, and the transfer is performed using a tendon weaver and
2-0 Ethibond suture in a Pulvertaft weave. Transecting the ECRB is preferred if radial
nerve recovery is not expected because it provides a straighter line of pull. If radial
nerve recovery is anticipated, the transfer is performed end-to-side, and the ECRB is
not divided. The PT tendon is woven into the ECRB just distal to the musculotendi-
nous junction (Fig. 66.5).
• Tension is set with the wrist in neutral extension so that the patient can flex the wrist
more easily to gain additional extension of the fingers through the tenodesis effect.
A tendon weaver is used to sharply incise the ECRB, and the PT is woven and se-
cured with three passes. Each pass is performed sequentially and secured using 2-0
STEP 1 PEARLS Ethibond suture. When the transfer is complete, the wrist should be maintained in a
To restore finger extension, either the FCR or straight neutral posture (Fig. 66.6A–B).
the flexor carpi ulnaris (FCU) can be selected for
transfer. The FCR is preferred for transfer because
the FCU is a stronger wrist flexor and provides FLEXOR CARPI RADIALIS TO EXTENSOR DIGITORUM
ulnar deviation. In addition, the FCR tendon is COMMUNIS TRANSFER TO RESTORE FINGER EXTENSION
slightly longer, which can provide greater length
for transfer and has fewer attachments, making Step 1
the dissection and transfer easier. Transfer of FCU • Using a volar incision, we identify the FCR tendon lying just ulnar to the radial artery
may cause loss of wrist motion and grip strength in the wrist. Care is taken to identify the median nerve and palmar cutaneous branch
compared with FCR transfer.
of the median nerve to avoid injury to these structures during harvest.
Extensor carpi
Brachioradialis radialis longus
and brevis
Insertion of
pronator teres
A B
FIGURE 66.6 (A–B) PT tendon is routed over the BR to the ECRB. BR, Brachioradialis;
ECRB, extensor carpi radialis brevis; PT, pronator teres.
• The tendon is dissected circumferentially and incised as distally as possible by flex-

ing the wrist maximally to provide as much tendon length as possible for transfer.
The tendon is then dissected proximally to the musculotendinous junction and
muscle belly to release the surrounding fascial attachments to the proximal forearm
to enhance excursion and direction of pull (Fig. 66.7A–B).
Step 2
• An 8-cm incision is created along the dorsal distal portion of the forearm. The skin
STEP 2 PEARLS
is incised, and the subcutaneous tissue is dissected down to the extensor tendons
of the EDC lying in the fourth extensor compartment. The tendons are mobilized just • The tension of the transfer is a critical compo-
proximal to the extensor retinaculum (Fig. 66.8). nent of the reconstruction. The sutured tendon
should not be so tight that it prevents a full
• A short hemostat is used to create a subcutaneous tunnel along the distal radial grip and not so loose that it inhibits full finger
aspect of the forearm, and the mobilized FCR tendon is passed through this tunnel extension. Full grip should be obtained with
superficial to BR and the radial artery. Care is taken to ensure that the FCR tendon the wrist in an extended position, and full
glides in a straight path to the dorsal forearm incision. finger extension should be achieved with the
• The wrist is maintained in neutral extension with the MCP joints in extension as the wrist in a flexed position. Tension may be esti-
mated by positioning the wrist in extension and
transfer is created. flexion to examine the finger position with
• The FCR tendon is woven to each finger extensor using a sharp tendon weaver, tak- tenodesis and with passive manipulation of
ing care to keep the fingers in the natural digital cascade. The transfer is performed the fingers into flexion once the transfer is
end-to-end to provide maximal excursion. With the wrist in neutral and the FCR complete. (Fig. 66.9).
under maximal tension, each EDC tendon is woven to the FCR to maintain the MP • The EDC tendons may also be sutured to-
gether at their natural cascade position before
joints in extension. The greatest tension is set with the index finger to mimic the the FCR tendon weave to facilitate transfer,
cascade and ensure adequate tendon length to reach the EDC of the ulnar digits. A which may be more expedient and is our
2-0 Ethibond is used to secure each tendon-weave, and horizontal mattress sutures preferred option.
are used to supplement and secure the repair. A more expedient transfer is to suture • Typically, the EDM tendon is not included be-
the EDC tendons in a side-to-side fashion first, then the FCR is weaved into this cause it may cause excessive small finger
abduction.
tendon bulk. In most cases the resting tension of the EDC is rather anatomic and the
PL tendon
FCR tendon
Flexor carpi
radialis
B
FIGURE 66.7 (A) The PL and FCR tendons are harvested via a single incision. (B) Anatomy of the
FCR and EPL and EDC tendons. EDC, Extensor digitorum communis; EPL, extensor pollicis longus;
FCR, flexor carpi radialis; PL, palmaris longus.
EDC tendons Extensor retinaculum
FIGURE 66.8 Exposure of the EDC tendons for transfer. EDC, Extensor digitorum communis.
side-to-side sutures will establish the natural cascade. Nevertheless, imperfect ten-
sion can be adjusted by tightening each EDC tendon to the FCR.
PALMARIS LONGUS TO EXTENSOR POLLICIS LONGUS

TRANSFER TO RESTORE THUMB EXTENSION AT THE
INTERPHALANGEAL JOINT
Step 1
Within the previously created volar forearm incision, the PL tendon, if present, is identified
lying ulnar to the FCR. Care is taken to identify the median nerve and palmar cutaneous
FCR-to-EDC
PT-to-ECRB
PL-to-EPL
FIGURE 66.9 Final tension of three simultaneous transfers for high radial nerve palsy.
branch of the median nerve to avoid injury to these structures. The tendon is divided
sharply as distally as possible, and the proximal tendon and muscle belly are released
from their surrounding fascial attachments.
Step 2
• Within the dorsal wrist incision, the EPL is identified. The Lister tubercle is a useful
landmark because the EPL tendon within the third extensor compartment will lie just
ulnar to this. The tendon is identified and traced proximally to the musculotendinous
junction. The EPL tendon is sharply divided at the musculotendinous junction.
• The EPL tendon is identified distal to the extensor retinaculum within the dorsal wrist
incision and is retrieved distally to extract it from the third dorsal compartment.
Step 3
STEP 3 PEARLS
A tendon passer or hemostat is used to gently create a subcutaneous tunnel to route
the EPL toward the PL over the radial styloid. The EPL tendon is then passed through The first extensor compartment may be used as
this tunnel from the incision at the thumb to reach the PL. The tendon transfer is then a pulley to reroute the course of the transferred
EPL tendon. Instead of creating a subcutaneous
performed using a sharp tendon weaver and secured with 2-0 Ethibond suture. The tunnel, the EPL tendon is passed using a tendon
tension is set, with the initial weave resulting in thumb extension and radial abduction. passer through the first compartment tendons
Multiple passes are performed with the tendon weaver and supplemental horizontal from the incision across the dorsal aspect of the
mattress sutures are used to secure the transfer (Fig. 66.10A–B). thumb to lie in the volar forearm, and the transfer
is completed using a sharp tendon weaver and
2-0 Ethibond sutures as described previously. This
FLEXOR DIGITORUM SUPERFICIALIS (III) TO EXTENSOR option may provide more abduction of the thumb
POLLICIS LONGUS TRANSFER TO RESTORE THUMB because the EPL is a natural thumb adductor.
EXTENSION AT THE INTERPHALANGEAL JOINT
Step 1
STEP 1 PEARLS
• If the PL tendon is absent, the FDS of the long finger can be used to restore thumb
and index finger extension. The FDS tendon of the long finger is identified in the If the PL is not present, the FDS to the long finger is
used to provide extension to the thumb and index
volar wrist incision superficially and ulnarly in the wrist. Care is taken to identify
finger by transfer to the EPL and EIP, and the FCR is
the median nerve to avoid injury. The tendon is taken as distally as possible within transferred to the EDC of the long, ring, and small
the wrist incision by flexing the long finger to obtain adequate length for transfer. It fingers. This will create independent extension of
is unnecessary to harvest the whole length of the FDS tendon (Fig. 66.11). the thumb and index fingers.
• The FDS tendon is rerouted radially and dorsally through a radial subcutaneous tun-
nel to weave into the detached EPL and EIP tendons.
STEP 1 PITFALLS
• With the wrist in neutral position, natural cascade of the thumb and index finger
should be the goal. Use of the FDS tendon may result in a swan-neck
deformity in the long finger, only when the FDS
POSTOPERATIVE CARE AND EXPECTED OUTCOMES tendon is detached from its insertion at the base
of the middle phalanx. For radial nerve tendon
The patient is placed in a forearm and hand splint for 3 weeks postoperatively before ini- transfer, the FDS is harvested from the wrist, which
tiating range-of-motion (ROM) exercises. The wrist should be immobilized at 45 degrees leaves a substantial amount of tendon distally
of extension, and the thumb should be in full extension and abduction. The finger MCP that has inherent various attachments to prevent
hyperextension of the proximal interphalangeal
joints should also stay in extension.
(PIP) joint.
FCR-EDC transfer
A PL- EPL transfer
Extensor
retinaculum
Palmaris Extensor
longus pollicis
longus
B
FIGURE 66.10 (A) FCR-to-EDC transfer is secured proximal to the PL-to-EPL transfer. (B) The EPL
tendon is moved volarly to connect to the PL tendon. EDC, Extensor digitorum communis;
EPL, extensor pollicis longus; FCR, flexor carpi radialis; PL, palmaris longus.
Long finger FDS tendon
FCR tendon
FIGURE 66.11 If needed, the long finger FDS may be used as a donor motor muscle. FDS, Flexor
digitorum superficialis.
EVIDENCE
Agarwal P, Kukrele R, Sharma D. Outcome of tendon transfer for radial nerve palsy using flexor carpi
radialis combination (Brands transfer). J Clin Orthop Trauma. 2020;11:630–636.
This retrospective study reviewed the outcomes of 58 patients with high radial nerve palsies who un-
derwent all PT-to-ECRB, FCR-to-EDC, and PL-to-EPL transfers. Forty-seven patients were male and
11 were female. Average age was 35 years and mean follow-up was 10 years. Fifty-five patients were
rated to have excellent or good results by the Bincaz scale and 95% returned to work. One patient
developed radial wrist deviation and two had wrist flexion limitations (Level IV evidence).
Al-Qattan MM. Tendon transfer for radial nerve palsy: a single tendon to restore finger extension as
well as thumb extension/radial abduction. J Hand Surg Eur Vol. 2012;37:855–862.
This single surgeon performed PT-to-ECRB and either FCR or FCU-to-Combined Finger and Thumb
Extensor transfers in 15 consecutive patients for radial nerve palsy. In his technique, the EPL, APL,
EDC, EIP, and EDM tendons are all transferred together to the FCR. In one case, the FCR was un-
available and thus the FCU was used. Follow-up averaged 30 months (minimum 6 months) and
results were rated as excellent in 12 and good in 3 using the Bincaz scale. Patient-rated satisfaction
was similar (12 very satisfied, 3 satisfied). Wrist ROM was noted to be better with the fingers flexed
Bertelli JA. Nerve versus tendon transfer for radial nerve paralysis reconstruction. J Hand Surgery Am.
2020;45:418–426.
The authors compared 14 patients with high radial nerve palsies who underwent nerve transfers
(anterior interosseous nerve [AIN] to nerve to ECRB, nerve to FCR to PIN) with 13 patients who
underwent triple tendon transfers (PT-to-ECRB, FCU-to-EDC, and PL-to-EPL). All patients who
received tendon transfers had radial nerve palsy for a longer duration. Patients with nerve transfers
had greater wrist ROM (average flexion-extension 66 to 67 degrees vs. 37 to 35 degrees). Five
tendon transfer patients were noted to have radial wrist deviation. Both groups showed poor
recovery of thumb MCP extension (Level IV evidence).
Dabas V, Suri T, Surapuraju PK, Sural S, Dhal A. Functional restoration after early tendon transfer in
high radial nerve paralysis. J Hand Surg Eur. 2011;36:135–140.
The authors describe the use of early transfer of PT to ECRB among 15 patients with high radial nerve
paralysis, with 6-month follow-up of 10 patients. At follow-up, improvements in power grip, tip pinch,
key pinch, and palmar pinch were observed compared with preoperative measurements, suggesting
that early PT to ECRB end-to-side tendon transfer can restore efficient grip posture without
prolonged external splinting (Level IV evidence).
Ochi K, Horiuchi Y, Matsumura T, Morita K, Kawano Y, Horiuchi K. A modification of the palmaris lon-
gus-to-extensor pollicis longus transfer for radial nerve palsy. J Hand Surg Am. 2012;37:2357–2361.
This study describes a modification to the PL to EPL transfer used to restore thumb extension at the
interphalangeal (IP) joint. In this technique, the palmar aponeurosis is used to augment the PL, and
the EPL is left in situ as the transfer is performed end-to-side at the level of the thumb metacarpal for
patients in whom radial nerve function may be expected to recover, as an augmentation to elongate
the PL tendon and preserve the EPL tendon. The outcomes reveal similar ROM and strength
compared with the contralateral hand (Level IV evidence).
Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and
posterior interosseous nerve paralysis. J Hand Surg Br. 2006;31:502–506.
This study examines the long-term outcomes (mean follow-up of 9.5 years) of 18 cases of tendon
transfer for isolated radial nerve palsy across multiple tendon transfer combinations. The authors
conclude that the use of FCU to restore EDC, EIP, and EDM results in loss of grip strength and radial
deviation of the wrist compared with the use of the FCR and advocates for tenodesis of the abductor
pollicis longus to the BR to restore thumb abduction (Level IV evidence).
Woodside JC, Bindra RR. Rerouting extensor pollicis longus tendon Transfer. J Hand Surg Am.
2015;40:822–825.
The authors describe an alternate technique for tendon transfer to restore thumb extension at the IP
joint that prevents tendon bowstringing and enhances radial abduction. In this technique, the EPL
tendon is withdrawn and rerouted through the first dorsal compartment, and then it is transferred to
the PL or FDS proximal to the retinaculum (Level V evidence).
CHAPTER 67
Tendon Transfers for Combined Nerve Palsy
INDICATIONS
• Tendon transfers may be indicated to restore specific functions in patients with com-
bined nerve injuries and resultant motor function loss with no expected recovery.
• Combined upper extremity nerve deficits typically result from severe trauma to the
arm or after spinal cord injuries. Patients typically have profound disability, signifi-
cant scarring, and limited remaining muscle tendon units.
• Another indication is high nerve lacerations that do not recover before the deteriora-
tion of muscle motor endplates (at around 18 months) and are not candidates for
nerve transfer.
• Deficits will depend on which nerves have been damaged. Common injury combinations
include low median-ulnar, high median-ulnar, high ulnar-radial, and high median-radial
(Table 67.1). Low median-ulnar palsy is a common combined injury from lacerations of
the distal volar wrist (Figs. 67.1 and 67.2).
• Depending on the patient’s level of function, tendon transfers may facilitate wrist,
finger, or thumb flexion and extension; thumb opposition and pinch; or prevention of
finger clawing.
• Surgical reconstruction must be individualized to each patient to manage specific
functional goals and may not fit a prescribed set of tendon transfers.
• Before surgery, the tissues must be in equilibrium, with all wounds and fractures
healed. Any edema should be resolved and all joints must have full passive range of
motion (ROM).
TABLE
67.1 Deficits and Goals in Combined Nerve Injuries
Injury Deficits Reconstruction Goals Available MTUs
Low median-ulnar Hand intrinsics (thenar, hypothenar, Key pinch BR, wrist and finger
interossei/lumbricals) Thumb opposition extensors
Prevention of finger clawing PT, PL, FCR, FCU, FDS, FDP,
Coordinated interphalangeal flexion FPL
High median-ulnar Hand intrinsics All of above plus: BR, wrist and finger extensors
All FDS and FDP Simple finger flexion
FCR, FCU, PL, PT
High median-radial BR, ECRL, ECRB, ECU, FCR Wrist stability FCU (typically after wrist
PL, PT, FDS, FPL Thumb opposition arthrodesis)
Radial FDP Grip Ulnar FDP
Thenar muscles except adductor Thumb and finger extension Hypothenar muscles
pollicis and deep FPB
Radial lumbricals
High ulnar-radial Hypothenar Wrist extension PT, PL, FCR, FDS
Interossei and ulnar lumbricals Finger and thumb extension Radial FDP
Finger and wrist extensors Key pinch
FCU, ulnar FDP Ring and small finger flexion
BR, Brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ul-
naris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis longus; PL, palmaris longus; PT, pronator teres.
Adapted from Makarewich CA and Hutchinson DT. Tendon transfers for combined peripheral nerve injuries. Hand Clin. 2016;32:377–387.
530
Finger clawing
Thenar atrophy
FIGURE 67.1 An injured left hand with a combined low median-ulnar, low nerve palsy. Note the finger clawing and thenar wasting but intact
extrinsic finger flexors.
FIGURE 67.2 The injured left hand has no ability to oppose the thumb. The right hand is normal.
• Donor muscle tendon units must be of grade 4/5 strength or greater. Loss of one
strength grade after transfer is typical.
• Joint contractures unresponsive to occupational therapy may need to be released
simultaneously or in a prior procedure. Transfers involving the adductor pollicis may
benefit from a first webspace deepening or Z-plasty.
Contraindications
• Severe tissue scarring, which may limit the excursion of transferred tendons, may
restrict reconstructive options.
• Finger and wrist joint contractures should be released before tendon transfers.
• Loss of sensation is common in combined nerve injuries. If return of protective sen-
sation is not anticipated or procedures to restore sensation are not possible, tendon
transfers are not indicated.
532 CHAPTER 67 Tendon Transfers for Combined Nerve Palsy
• Patient cooperation is critical for tendon transfer success. Any patient who cannot
comply with the postoperative rehabilitation course should not undergo tendon
transfer.
• Patient expectations must be discussed pre-operatively. For these severe injuries,
no tendon transfer will re-create a normal hand.
• The goal of the physical examination is to determine the patient’s current abilities
and functional deficits and evaluate remaining active muscle tendon units (MTUs)
available for transfer.
• Examination should take place over several visits to adequately observe active mo-
tion and ensure that any spontaneous recovery and adaptive functional recovery has
plateaued.
• Wrist and finger joints must be evaluated to ensure full passive motion.
• The available muscles with active function will depend on the individual level and
combination of injuries and may not follow a predictable pattern.
• Strength grading based on the British Medical Research Council (BMRC) must be
documented pre-operatively. MTUs that do not achieve grade 3 strength are not
candidates for transfer.
• If the median nerve is spared, the presence of the palmaris longus (PL) tendon can
be confirmed by having the patient touch the thumb and little finger with the wrist in
flexion. The PL tendon is usually palpable on the palmar aspect of the wrist, on the
ulnar side of the flexor carpi radialis (FCR) tendon.
IMAGING
• If the patient sustained fractures during the injury, obtain radiographs before tendon
transfer to ensure fracture union.
• Magnetic resonance imaging (MRI) is not needed to ensure tendon continuity; these
should be ensured with a thorough physical examination.
SURGICAL ANATOMY
The pathways and branches of the median, radial, and ulnar nerves have been illus-
trated previously (see Chapters 63–66Chapter 63Chapter 64Chapter 65Chapter 66).
POSITIONING
• Tendon transfers are performed with the patient placed in supine position with an
upper arm tourniquet and a regional block or under general anesthesia.
• Surgeons comfortable with the wide awake local anesthesia no tourniquet (WALANT)
technique may choose to perform the surgery using local anesthesia; a large volume
of local anesthetic may be needed to adequately infiltrate the hand and forearm.
• The upper extremity is outstretched on a hand table.
INDICATIONS PEARLS Low Median-Ulnar Palsy

• If the FDS has been lacerated, then the bra- INDICATIONS
chioradialis (BR) or extensor carpi radialis lon-
gus (ECRL) may be transferred to the radial • This injury combination is frequently the result of a volar laceration across the distal
lateral bands with a four-tail tendon or fascia wrist.
lata graft. The authors prioritize FDS, then BR, • Careful attention during the physical examination should ensure that all of the
and finally ECRL for donor MTUs to prevent remaining MTUs are clinically functional, because any penetrating injury to the
clawing so the patient does not lose radial
median and ulnar nerves at the wrist may also lacerate the extrinsic finger and
wrist extension when the ECRB is transferred
for thumb adduction. wrist flexors.
• An FDS lasso procedure may also be used to • Reconstructive goals (with our preferred reconstruction techniques):
correct clawing (Fig. 67.3). • Key pinch (extensor carpi radialis brevis [ECRB] to adductor transfer; see
Chapter 65)
• Thumb opposition (extensor indicis proprius [EIP] to abductor pollicis brevis
[APB] opponensplasty; see Chapter 63)
• Treatment of finger clawing and coordinated interphalangeal joint flexion (flexor
digitorum superficialis [FDS] transfer to correct claw deformity; see Chapter 65)
A B C
FIGURE 67.3 Patient from Fig. 67.1 and 67.2 after treatment with EIP-to-APB opponensplasty, first webspace
deepening, and FDS lasso to the ring and small fingers. The EIP tendon is harvested (A), passed around the ulna
(B), and tensioned to the APB (C). APB, Abductor pollicis brevis; EIP, extensor indicis proprius; FDS, flexor digitorum
superficialis.
High Median-Ulnar Palsy

INDICATIONS
• If both the median and ulnar nerves are not functional, the loss of extrinsic finger and
wrist flexors creates a much greater disability than a low injury.
• In this palsy, the hand may also be completely insensate, which will limit the utility
of tendon transfers.
• Reconstructive goals (with our preferred reconstruction techniques):
• Key pinch (ECRB to adductor transfer; see Chapter 65)
• Thumb opposition (EIP to APB opponensplasty; see Chapter 63)
• Finger flexion (ECRL to flexor digitorum profundus [FDP])
• Thumb flexion (BR to flexor pollicis longus [FPL]; see Chapter 64)
• Treatment of finger clawing and coordinated interphalangeal joint flexion (meta-
carpophalangeal [MCP] capsuloplasty; see Chapter 65)
ECRL to FDP Transfer EXPOSURES PEARLS

The incision facilitates access to multiple wrist
EXPOSURES extensor donor MTUs (ECRL, ECRB, BR), and
• A longitudinal incision along the dorsoradial aspect of the distal forearm is used to numerous transfers may be performed in the same
operation.
expose the ECRL tendon (Fig. 67.4A).
• Blunt dissection reveals the extensor retinaculum and radial wrist extensor tendons.
• A second longitudinal incision is made along the distal third of the volar forearm (see EXPOSURES PITFALLS
Fig. 67.4B). Dissection through the subcutaneous tissue and opening of the volar Care must be taken to identify and protect branches
forearm fascia permits access to the finger flexor tendons. of the dorsal sensory branch of the radial nerve.
PROCEDURE
Step 1
• The ECRL tendon is identified ulnar to the BR tendon and radial to the ECRB tendon
in the second dorsal compartment.
• The ECRL is transected sharply proximal to the extensor retinaculum.
• We prefer to pass the tendon under the radial soft tissue, under the radial sensory
nerve, to reach the FDP tendons because of the good gliding surfaces here.
A B
FIGURE 67.4 Longitudinal incisions both dorsally (A) and volarly (B) permit access to the donor
ECRL and recipient FDP tendons. ECRL, Extensor carpi radialis longus; FDP, flexor digitorum
profundus.
STEP 2 PEARLS • If the tendon length is a consideration because the FDP tendons were lacerated
distally, a window is created in the radial aspect of the interosseous membrane at
• Set the appropriate cascade by suturing the
FDP tendons together before attaching them the level of the midforearm to give additional length because of the direct path of the
to the ECRL. The resting tension of the fingers donor tendon. Nevertheless, the window must be generous so that the ECRL tendon
should assume the natural cascade, and is not trapped across the interosseous membrane.
suturing them together first will expedite • The ECRL is passed through the interosseous membrane to the volar aspect of the
the reconstruction in lieu of setting tension wrist (Fig. 67.5).
to the individual finger.
• If the ECRL is not long enough to reach the
FDP tendon stumps, a nearby (and Step 2
nonfunctional) FDS tendon may be used • The ECRL tendon is retrieved in the volar wound through the interosseous membrane.
as an interpositional graft (Fig. 67.8A–B). • The four FDP tendons are identified by gentle traction and sutured side-to-side, tak-
ing care to ensure even flexion and a normal cascade to the fingers.
• A Pulvertaft weave is used to attach the four combined FDP tendons to the ECRL.
STEP 2 PITFALLS
• Tension should be set so that the fingers are flexed when the wrist is in 45 degrees
We do not advocate for wrist arthrodesis despite a of extension (Figs. 67.6 and 67.7).
lack of active wrist flexors. The patient may still use
active wrist extension to help with finger flexion POSTOPERATIVE CARE AND EXPECTED OUTCOMES
and grip via tenodesis.
The patient is placed in a forearm and hand splint for 3 weeks postoperatively before
initiating ROM exercises. The wrist should be immobilized in neutral and the fingers and
POSTOPERATIVE PITFALLS thumb should be flexed gently (around 70 degrees at the finger MP joints).
Careful application of the bandage is essential to
prevent excess constriction and swelling.
ECRL
FDP FPL BR
FIGURE 67.5 Tendon harvest for ECRL to FDP and BR to FPL transfers. BR, Brachioradialis; ECRL,
extensor carpi radialis longus; FDP, flexor digitorum profundus; FPL, flexor pollicis longus.
BR-to-FPL with FDS

tendon graft
FIGURE 67.6 Tension of BR-to-FPL transfer. BR,

Brachioradialis; FPL, flexor pollicis longus.
A
ECRL with FDS

tendon graft
FDP
B
FIGURE 67.8 BR-to-FPL transfer to restore thumb flexion (A) and ECRL-to-FDP transfer to restore finger
flexion (B). In this case, FDS was used as intercalary tendon graft for both transfers. BR, Brachioradialis;
ECRL, extensor carpi radialis longus; FDP, flexor digitorum profundus; FPL, flexor pollicis longus.
High Median-Radial Palsy

INDICATIONS
• Flexor carpi ulnaris (FCU) is the only remaining wrist MTU with high combined me- FIGURE 67.7 Tension to achieve the proper cas-
dian and radial nerve palsies. A wrist arthrodesis (see Chapter 53) is often performed cade after ECRL-to-FDP transfer. ECRL, Exten-
sor carpi radialis longus; FDP, flexor digitorum
simultaneously, so the FCU may be used to power digital extension.
profundus.
• The ulnar FDP tendons, intrinsic muscles, and hypothenar muscles remain functional.
• Thumb opposition (Abductor digiti minimi to APB [Huber] opponensplasty; see INDICATIONS PEARLS
Chapter 109) A first webspace deepening or Z-plasty may be
• Grip (Side-to-side FDP transfer; see Chapter 65) performed at the same time as tendon transfers
• Thumb and finger extension (FCU to extensor digitorum communis [EDC] and (Fig. 67.9).
extensor pollicis longus [EPL] transfer)
EXPOSURES PEARLS
FCU to EDC and EPL Transfer • The volar incision is used to access the FDP
tendons for simultaneous side-to-side FDP
EXPOSURES transfer.
• A longitudinal incision along the central volar aspect of the distal forearm is used to • The dorsal incision is designed to facilitate
wrist arthrodesis. The EDC and EPL tendons
expose the FCU tendon.
can be found in the proximal extent of the
• Blunt dissection reveals through the subcutaneous tissue, and opening of the volar incision.
forearm fascia permits access to the FCU muscle and tendon.
• A second longitudinal incision is made along the central wrist and distal third of the
EXPOSURES PITFALLS
dorsal forearm. Dissection is carried down to the extensor retinaculum.
The ulnar nerve must be carefully protected when
harvesting the FCU tendon.
PROCEDURE
• The FCU tendon is identified ulnar to the finger flexor tendons in the volar forearm. The FCU has an extensive origin with a prolonged
• Sharply transect the FCU tendon proximal to the pisiform near the wrist. attachment to the ulna. The distal muscle fibers
should be released from the ulna to facilitate a
• The tendon is freed of its muscle attachments. Blunt dissection helps to separate
direct path around the forearm.
the tendon from the ulnar artery and nerve.
FIGURE 67.9 Webspace deepening Z-plasty during tendon transfers for high median-ulnar nerve.
STEP 1 PITFALLS
• A hemostat is used to create a subcutaneous tunnel around the ulna in the distal
The ulnar artery and nerve travel immediately deep one-half to one-third of the forearm.
to the FCU and must be carefully separated from • The FCU is passed around the ulna to the dorsal aspect of the wrist.
the muscle.
Step 2
STEP 2 PEARLS • The FCU tendon is retrieved in the ulnar side of the dorsal wound.
Set the appropriate cascade by suturing the EDC • The EPL and EDC tendons are identified proximal to the extensor retinaculum in
tendons together before attaching them to FCU. their locations in the third and fourth dorsal compartments, respectively.
• The EDC tendons are sutured side-to-side with the fingers in a normal cascade.
• A Pulvertaft weave is used to attach the four combined EDC tendons to the FCU.
• The EPL is then also sutured to the FCU with a Pulvertaft weave.
• Tension should be set so that the fingers are extended when the wrist is in its fixed
neutral position after arthrodesis.
• If there is any way to restore wrist extension via any proximal tendon/muscle recon-
struction or nerve transfer procedure, then wrist fusion should not be done, because
patients with limited hand function employ the tenodesis capability to modulate
wrist extension (and corresponding finger flexion) using the intact muscle units and
rely on gravity for wrist flexion. The tenodesis ability helps with finger extension and
flexion.
INDICATIONS PEARLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Using the FCR and PL to restore finger and thumb The patient is placed in a forearm and hand splint with the thumb and finger MP
extension leaves the wrist without an active flexor joints extended for 3 weeks postoperatively before initiating ROM exercises. The
(because the FCU is nonfunctional in an ulnar nerve
wrist is immobilized in neutral for 6 weeks to enable consolidation of the concomi-
palsy). An alternative is to use the middle and ring
finger FDS tendons transferred to the EPL/EIP tant arthrodesis.
and the EDC, respectively. Cortically reintegrating
finger flexors as a finger extensor requires more High Ulnar-Radial Palsy
rehabilitation than converting wrist flexors to finger
extensors, so the authors prefer the traditional INDICATIONS
PL-to-EPL and FCR-to-EDC. The strong finger
flexors help stabilize the wrist in the absence of a • Patients with injuries to both the radial and ulnar nerves are candidates for tendon
dedicated wrist flexor. transfers when no additional neurologic recovery is expected.
• This type of injury is uncommon because the ulnar and radial nerves are at opposite
sides of the arm.
• Preserved median nerve sensation is beneficial for optimal function in these patients.
• Any planned donor tendon should be examined to ensure at least grade 4/5
strength.
• Wrist extension (pronator teres [PT] to ECRB; see Chapter 66)
• Thumb extension (PL to EPL; see Chapter 66)
• Finger extension (FCR to EDC; see Chapter 66)
• Key pinch (Split FDS to adductor and ring and small A2 pulleys)
• Ring and small finger clawing (Split FDS to adductor and ring and small A2 pulleys)
• Ring and small finger flexion (Side-to-side FDP transfer; see Chapter 65)
• This procedure is done after restoring extension of the digits. The lasso procedure to
the ring and small fingers will accentuate the FCR tendon transfer to the fingers by
augmented extension of the interphalangeal (IP) joints to correct the claw deformity.
• The lasso procedure serves to flex the MCP joints in a static fashion, rather than
employing a dynamic construct to the lateral bands, which would be unable to set
sufficient tension to achieve two functions of IP joint extension through the lateral
bands and thumb adduction with the split tendon attaching to the adductor pollicis.
Split FDS to Adductor and Ring and Small A2 Pulleys

• A Bruner zigzag incision is designed on the volar middle finger over the proximal interpha- If transfers for wrist and finger extension are
langeal (PIP) joint for access to the FDS tendon. A second incision in the palm proximal to being performed in the same setting, volar and
the A1 pulley in line with the middle finger is used for retrieval of the donor tendon. dorsal longitudinal distal forearm incisions will also
be made for donor tendon harvest and recipient
• In addition, incisions over the volar ring and small fingers, just proximal to the distal tendon access, respectively.
transverse palmar creases, are used to expose the A2 pulleys. Blunt dissection is
used to protect the digital nerves as the pulleys are exposed.
• A chevron or longitudinal incision is made over the ulnar aspect of the thumb MP
joint and blunt dissection through the subcutaneous tissue reveals the adductor
tendon insertion (Fig. 67.10).

Continue the natural split in FDS at Camper’s
Step 1 chiasm for the first division of the FDS donor
• The middle finger incision is opened and blunt dissection is carried to the flexor tendon. The donor tails will not be equal in size and
the largest one will be used to power key pinch.
tendon pulleys; the digital arteries and nerves are preserved.
FIGURE 67.10 Incisions for split FDS to adductor and A2 pulleys. FDS, Flexor digitorum superficialis.
(Fig. 26.14 from Neligan PC, Buck DW. Core Procedures in Plastic Surgery. 2nd ed. Elsevier; 2020:
e18-e38.)
STEP 1 PITFALLS • The A3 pulley is incised longitudinally to access the flexor tendons. Gentle retraction
of the FDP tendon reveals the FDS insertion on the middle phalanx.
When splitting the tendon, take care not to transect
the tendon and lose length. • Both slips of FDS are transected sharply and the tendon is delivered into the proxi-
mal middle finger incision with blunt traction.
• The harvested tendon is split longitudinally in line with its fibers. The ulnar half of the
STEP 2 PEARLS
split tendon is divided once more in line with its fibers to create three tails.
Tension for the FDS-to-adductor transfer should be
set so that the thumb may be abducted easily when Step 2
the wrist is flexed in the tenodesis movements.
• A hemostat is passed bluntly from the thumb incision at the adductor insertion to the
proximal middle finger incision, superficial to the adductor pollicis muscle, and deep
to the neurovascular bundles and flexor tendons.
• The radial limb of the FDS donor is passed through this tunnel and delivered to the
ulnar thumb wound.
• A nonabsorbable suture (such as 3-0 Ethibond) is used to fix the donor tendon to
the adductor insertion.

If the tails of the FDS are not long enough to loop • The ulnar two slips of the middle finger FDS are passed subcutaneously and deliv-
around the A2 pulleys, one may secure the graft to ered to the ring and small finger incisions, after the flexor tendon pulleys have been
the pulley in an onlay fashion. Care must be taken exposed (Fig. 67.11).
not to accidentally suture the underlying flexor
tendons.
FIGURE 67.11 Diagram for split FDS to adductor and A2 pulleys. FDS, Flexor digitorum superficialis.
• Each is passed around the A2 pulley of the recipient finger and sutured to itself using
3-0 Ethibond. (See the FDS lasso procedure in Chapter 65).
• The MP joints of the ring and small fingers should rest in around 35 degrees of flex-
ion after the FDS transfer is secure.

• The hand is splinted with the wrist in slight extension, the thumb extended, and the
fingers extended around 35 degrees (if transfers to regain extension are performed
simultaneously).
• Active motion exercises are started 2 weeks postoperatively, but the splint is main-
tained for a total of 6 weeks for protection of the tendon transfers when not doing
therapy exercises.
See Videos 67.1 and Video 67.2
EVIDENCE
Ejeskär A, Dahlgren A, Fridén J. Clinical and radiographic evaluation of surgical reconstruction of finger
flexion in tetraplegia. J Hand Surg. 2005;30(4):842–849.
The authors performed ECRL-to-profundus tendon transfers for finger flexion in a total of 62 arms in
47 patients over a 15-year period (1984–1999). The procedure was performed in conjunction with
other transfers, most commonly BR-to-FPL for thumb flexion and FDS lasso to correct clawing. The
measured tendon elongation with radiographic metal markers placed at the time of surgery and cor-
related it with finger flexion and grip strength. Three arms underwent a secondary procedure to
enhance finger flexion. In their cohort the tendon transfer junction elongated an average of 9 mm
during the rehab period but grasp was still adequate and fingertip-to-palm distance averaged 8 mm.
Sabapathy SR, Gowda DKL, Ranade AB, Venkatramani H, Sebastin SJ. Functional outcome of exten-
sor carpi radialis longus transfer for finger flexion in posttraumatic flexor muscle loss. J Hand Surg.
2005;30(2):267–272.
In this retrospective review, the authors’ experience with 14 patients (16 arms) who underwent tendon
transfers to restore both finger and thumb flexion at the same time as transfers to improve extension
(grip and release) was compared with the registry data of 15 patients (18 arms) who underwent tradi-
tional staged procedures. The simultaneous operation included a split FPL–EPL tenodesis, thumb
carpometacarpal (CMC) arthrodesis, free tendon intrinsic tenodesis, BR–FPL transfer for thumb
flexion, ECRL-to-profundus transfer for finger flexion, and EPL tenodesis and extensor carpi ulnaris
(ECU) tenodesis for wrist stabilization. Postoperative grip strength averaged 6.53 kg, which was
higher than the comparative group. One patient needed tenolysis and one patient needed the
tenodesis revised. Twelve of 16 hands could make a full fist. All but one patient were satisfied
with the procedure.
Al-Qattan MM. Tendon transfer for radial nerve palsy: A single tendon to restore finger extension as
well as thumb extension/radial abduction. J Hand Surg Am. 2012;37(9):855–862.
The author prospectively followed 15 consecutive patients treated with a single FCU or FCR tendon
transfer to both EDC and EPL, along with PT-to-ECRB for wrist extension. Mean follow-up was
30 months. Active wrist extension was noted in all patients. MP joint extension lags were less than
10 degrees in all patients and all patients were able to extend the thumb IP joint. The author noted
limitations in thumb flexion and opposition after the transfer with no patient being able to touch the
thumb to the distal palmar crease of the small finger. The overall results were rated as excellent in
12 patients and good in 3.
CHAPTER 68
Distal Anterior Interosseous Nerve Transfer
to Motor Branch of Ulnar Nerve
INDICATIONS
• An anterior interosseous nerve (AIN) transfer to the motor branch of the ulnar nerve
is used to restore ulnar intrinsic hand function.
• It is performed for both chronic ulnar nerve compression and acute high ulnar nerve injury.
• For chronic nerve compression, AIN transfer is performed when patients have evi-
dence of acute muscle denervation on electrodiagnostic studies, which indicates
that muscle can be reinnervated. If a patient has no evidence of acute denervation,
the transferred median axons will not have distal muscle targets to reinnervate.
• For high acute ulnar nerve trauma, the AIN to deep motor transfer is indicated if
normal reinnervation will not take place within 12 to 18 months of the injury. For in-
stance, if the injury causes a significant nerve gap and requires grafting, this will
delay normal reinnervation and the AIN to deep motor transfer is indicated. The
coaptation is performed 10 cm proximal to the wrist crease. Therefore lacerations
distal to this level cannot be treated effectively with this procedure.
• AIN transfer to the motor branch of the ulnar nerve may be performed in an end-to-
end or end-to-side manner. End-to-end coaptation is indicated for injuries proximal to
the elbow, in which reinnervation will not reach the intrinsic musculature of the hand
before the loss of motor end plates. End-to-side coaptation may also be considered
for patients with more proximal injuries, when the goal is to preserve motor endplates
until normal reinnervation can occur. This method is also useful when compression
causes intrinsic muscle denervation, as indicated by electrodiagnostic testing and
weakness on physical examination, although the ulnar nerve remains in continuity.
• Nerve transfer procedures are ideally performed in a timely manner so that reinner-
vation of the target muscles can occur within 12 to 18 months after the time of injury.
After 18 months, loss of motor end plates at the distal targets occurs, and tendon
transfer procedures provide more predictable outcomes.
• The function of the AIN is confirmed by testing the strength of the flexor pollicis
longus (FPL; flexion of the thumb at the interphalangeal joint) and the independent
strength of flexor digitorum profundus (FDP) to the index and middle finger (flexion
of the distal interphalangeal joint). Strength of the pronator quadratus is tested by
examining the patient’s ability to pronate the forearm with the elbow in flexion.
• Passive range of motion (ROM) of the hand is examined to ensure that all joints are
supple and without contracture.
IMAGING
• Electromyography (EMG) is often obtained to determine whether the intrinsic mus-
cles are actively denervating and can potentially be reinnervated or to determine
whether the ulnar nerve can regenerate after an acute closed injury.
• Active denervation is required for this procedure to be effective because empty
motor-endplates are necessary for reinnervation. This is indicated by increased in-
sertional activity, positive sharp waves, and fibrillations.
• The EMG can be helpful for identifying chronic reinnervation, which is indicated by
polyphasic motor units of longer duration and/or increased amplitude.
• For closed ulnar nerve injuries, an EMG is obtained at 3 months, at which point the
presence of motor units indicates that the ulnar nerve will regenerate and observation
540
CHAPTER 68 Distal Anterior Interosseous Nerve Transfer to Motor Branch of Ulnar Nerve 541
can be continued. If there are no motor units at 3 months, then an end-to-end AIN to
deep motor transfer can be performed to reinnervate the ulnar intrinsic muscles. The
exception is gunshot injuries, for which we recommend waiting 6 months for electro-
diagnostic results to predict recovery.
SURGICAL ANATOMY
• Within the forearm, the ulnar nerve lies between the two heads of the flexor carpi ulnaris
(FCU) and innervates the FCU and FDP to the ring and small fingers. The ulnar nerve and
artery run together along the volar ulnar aspect of the forearm. The ulnar artery lies radial
to the ulnar nerve, and the neurovascular bundle is located deep to the tendon of the FCU.
• The dorsal sensory branch of the ulnar nerve arises 5 cm proximal to the pisiform to
supply cutaneous sensation to the dorsoulnar aspect of the hand.
• At the wrist, the ulnar nerve and artery lie superficial to the flexor retinaculum (trans-
verse carpal ligament) within Guyon canal. The ulnar nerve divides at the hook of the
hamate into the superficial branch, which contributes sensation to the ring and small
fingers, and the deep motor branch, which courses under the hypothenar muscles
to innervate the intrinsic muscles of the hand (interosseous muscles, third and fourth
lumbricals), adductor pollicis, and the deep head of the flexor pollicis brevis.
• The ulnar nerve at the forearm has predictable topography with respect to the orien-
tation of the fascicles. At the mid and proximal forearm, the motor fascicle group is
flanked by two sensory fascicular groups (sensory-motor-sensory). The sensory fas-
cicles that innervate the small finger and ulnar aspect of the ring finger lie along the
radial aspect of the motor fascicular group. The sensory fascicles that contribute to
the dorsal sensory branch of the ulnar nerve lie ulnar to the motor fascicular group.
• The anterior interosseous nerve arises from the median nerve approximately 4 cm
distal to the elbow. It lies along the volar aspect of FDP and the interosseous mem-
brane after passing through the two heads of the pronator teres. AIN function is
primarily motor, and it innervates the FPL and the FDP to the index and long finger,
Its terminal motor branch supplies the pronator quadratus.
POSITIONING
• AIN transfer is performed with the patient in the supine position and the upper ex-
tremity outstretched along a hand table with a tourniquet placed above the elbow.
• The surgery can be performed under general or regional anesthesia. The motor
nerve is identified by topography and not stimulation. Therefore paralysis and re-
gional anesthesia are acceptable.
PROCEDURE
Step 1: Markings
STEP 1 PEARLS
A 10-cm curvilinear incision is created along the ulnar aspect of the forearm and is ex-
• Wide exposure is permitted to ensure a techni-
tended into the palm over the Guyon canal toward the pisiform (Fig. 68.1). This incision
cally perfect transfer with no tension.
exposes the ulnar nerve in the palm, forearm, and the AIN. Make a long exposure so that • The Guyon canal is always decompressed
the motor nerve can be identified distally as it dives under the hypothenar muscles, and when performing the AIN to deep motor trans-
then trace as far proximally as needed to coapt to the AIN without tension. fer so that compression does not impede axon
growth into the denervated intrinsic muscles.
Step 2: Exposing the Ulnar Motor Nerve at the Wrist
• The Guyon canal is decompressed first, in the standard fashion. An incision is cre-
ated sharply through the skin across the palm and distal forearm. Tenotomy scissors STEP 2 PEARLS
are used to gently spread the subcutaneous tissues, which are retracted using small,
• The deep motor branch travels ulnar to the
blunt, self-retaining retractors. The entirety of the Guyon canal is decompressed, hook of hamate, which can be palpated and
including the tight distal antebrachial fascia. used as a landmark (Fig. 68.3).
• Fibers of the palmaris brevis overlying the ulnar neurovascular bundle are divided • Care is taken to avoid injury to the palmar
with bipolar cautery. cutaneous branch of the ulnar nerve, which
• The deep motor branch is then decompressed, also in the standard fashion. The arises ulnar to the nerve at the level of the
wrist crease.
ulnar neurovascular bundle is retracted ulnarly, exposing the tendinous leading edge
of the hypothenar muscles. This fascia is carefully divided, exposing the deep motor
branch diving deep, away from the neurovascular bundle (Fig. 68.2).
542 CHAPTER 68 Distal Anterior Interosseous Nerve Transfer to Motor Branch of Ulnar Nerve
FIGURE 68.1 Typically, the anterior interosseous nerve

(AIN) to deep motor branch (DMB) transfer is performed Ulnar nerve
with wide exposure, releasing the Guyon canal and the FIGURE 68.2 The Guyon canal is completely decom-
deep motor branch itself, aiding in decompression and pressed first, including the deep motor branch. This is
identification of the deep motor branch. The dissection is best done by retracting the ulnar neurovascular bundle
carried proximally with either a straight or curved incision. ulnarly, exposing the tendinous leading edge of the hy-
pothenar muscles, which is divided, exposing the deep
motor branch below.
Dorsal ulnar
cutaneous sensory
Palmar cutaneous
sensory Superficial branch
Deep palmar motor

branch
Branch to the
Hypothenar motor palmaris brevis
Digital sensory
Pisiform 3
bone
2 4
Hook
1 of the
hamate
FIGURE 68.3 Anatomy of the ulnar nerve at the wrist. From Preston DC. Ulnar neuropathy at the
wrist. In: Preston DC, Shapiro B, eds. Electromyography and Neuromuscular Disorders. 3rd ed.
Saunders/Elsevier; 2012:402–416.
STEP 3 PEARLS Step 3: Exposing the AIN and Proximal Ulnar Nerve in the Forearm
The AIN branches underneath the pronator • The ulnar nerve is dissected proximally to release the tight antebrachial fascia, and
quadratus. The branches can either be trimmed then the nerve is followed proximally under the FCU muscle. The dorsal cutaneous
after the nerve is manipulated, or each of the ulnar nerve is identified 5 cm proximal to the wrist crease; this is helpful to confirm
branches (there are up to three) can be individually that the ulnar motor nerve is correctly identified in the forearm. The coaptation is
coapted with the ulnar nerve.
performed 10 cm proximal to the wrist crease, so the ulnar nerve is dissected
proximally until this exposure is well visualized.
AIA AIN, divided distally under

the PQ, and rotated over to
the proximal deep motor
branch
AIN & AIA Pronator quadratus

Pronator divided to expose
quadratus the AIN
FIGURE 68.4 The forearm flexors are retracted radially, ex- FIGURE 68.5 The anterior interosseous nerve is traced distally into the
posing the pronator quadratus (PQ). The anterior interosse- muscle belly, and the overlying muscle fibers are carefully divided us-
ous nerve (AIN) and anterior interosseous artery (AIA) are ing bipolar cautery, which enables additional gain in length of the do-
seen traveling deep to the leading edge of the PQ. nor nerve to be transferred. The deep motor branch is traced from its
known location distally toward the coaptation site, where it is
neurolyzed for several centimeters to enable a perfect coaptation.
• The AIN lies deep in the forearm along the midline and runs with the anterior interos-
seous artery. The forearm flexors are retracted radially, taking care to protect the
median nerve, and the pronator quadratus is identified because its muscle fibers run
transversely over the radius and ulna. The proximal edge of the muscle is identified,
and the anterior interosseous neurovascular bundle is dissected entering into the
central aspect of the muscle belly (Fig. 68.4).
• The anterior interosseous nerve is traced distally into the muscle belly, and the over-
lying muscle fibers are carefully divided using bipolar cautery, which permits addi-
tional gain in length of the donor nerve (Fig. 68.5). The AIN is divided as distally as
possible before it begins to branch at the midportion of the pronator quadratus.
• The AIN is then transposed under the flexor tendons to the anticipated site of transfer—
the motor branch of the ulnar nerve—to ensure that the coaptation can be performed
without tension (see Fig. 68.5). The nerve should lie comfortably at the anticipated site
and remain lax throughout all positions of wrist motion.
STEP 4 PEARLS
Step 4: Identifying the Deep Motor Branch Proximally An operating room microscope is used to perform
internal neurolysis.
• The deep motor branch is identified distally in the wrist, where it dives beneath the
released tendinous leading edge of the hypothenar muscles (see Fig. 68.3). This
guarantees the proper fascicle is identified. STEP 5 PEARLS
• The deep motor branch fascicle is followed proximally with visual inspection or seg-
• For an end-to-end coaptation, the AIN is al-
mental internal neurolysis until its location in the forearm is precisely identified. ways divided first and rotated into position. The
• Once this plane is identified, the fascicular groups are gently dissected free for 5 cm, ulnar motor branch is divided as proximally as
and the motor branch is looped loosely with a vessel loop to preserve orientation necessary to enable a tension-free coaptation.
(see Fig. 68.5). • It is critical to gain adequate length of both the
recipient nerve and the donor nerve to ensure
that the nerves can be coapted primarily with-
Step 5: Perform the Coaptation out tension. A nerve graft should not be used
• The AIN is passed underneath the flexor tendons to avoid compression of the nerve because the number of axons will decrease in
(see Fig. 68.5). each coaptation site. The donor nerve is tran-
• The AIN is coapted to the motor fascicular group of the ulnar nerve under the micro- sected as distally as possible, and the recipient
is transected as proximally as possible if an
scope using interrupted 9-0 nylon sutures in an epineural fashion, ensuring that the
end-to-end transfer technique is chosen.
coaptation is tension-free in all wrist positions (Fig. 68.6).
544 CHAPTER 68 Distal Anterior Interosseous Nerve Transfer to Motor Branch of Ulnar Nerve
AIN
Sensory
Motor
Dorsal sensory branch
FIGURE 68.6 Nerve anatomy.
Step 6: Closure
• The skin is closed in layers using absorbable sutures along the forearm incision and
with simple nylon sutures within the palm.
• Drains are not routinely used.

• The wrist and hand are immobilized in a volar-based splint, keeping the wrist in
neutral and the hand in the intrinsic-plus position for 2 weeks.
• After 2 weeks, active range of motion exercises are initiated.
• Strenuous activity and contact sports are avoided for 3 months after surgery.
See Video 68.1
EVIDENCE
Davidge KM, Yee A, Moore AM, Mackinnon SE. The supercharge end-to-side anterior interosseous-to-
ulnar motor nerve transfer for restoring intrinsic function: Clinical experience. Plast Reconstr Surg.
2015;136(3):344–352.
The authors report the clinical outcomes of 55 patients with in-continuity lesions of the ulnar nerve who
underwent end-to-side transfer of the AIN to the ulnar motor nerve with an average follow-up of
8 months. Patients undergoing end-to-side transfer demonstrated significant improvement in key
pinch and grip strength, as well as patient-reported hand disability, compared with preoperative
values. Although the degree to which the regain in function was directly attributable to the nerve
transfer is not quantifiable, this technique provides an important treatment option for patients with in-
continuity proximal ulnar nerve lesions for whom timely recovery to reach distal targets remains un-
certain.
Flores LP. Comparative study of nerve grafting versus distal nerve transfer for treatment of proximal
injuries of the ulnar nerve. J Reconstr Microsurg. 2015;31(9):647–653.
This study describes the differences in outcomes among patients who underwent nerve grafting
(20 patients) and distal sensory and motor nerve transfer (15 patients) for patients with proximal
ulnar nerve injuries. Functional recovery of grip strength (M3 or M4) was observed in 80% of patients
who underwent nerve transfer, compared with only 22% of patients who underwent nerve grafting.
Although sensory outcomes were equivalent, patient-reported hand disability was greater among
patients who underwent nerve grafting compared with nerve transfers.
Haase SC, Chung KC. Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for
high ulnar nerve injuries. Ann Plast Surg. 2002;49(3):285–290.
The authors examine early outcomes among one of the first descriptions of using the AIN nerve
transfer technique to restore intrinsic muscle denervation for high ulnar nerve injuries. The authors
describe an end-to-side technique and decompression of the deep motor branch in the distal palm,
and one patient required nerve grafting to achieve the transfer without tension. Functional improve-
ment in hand strength and dexterity was noted at 6 months, with evidence of reinnervation at
12 months with electromyography.
Farber SJ, Glaus SW, Moore AM, Hunter DA, Mackinnon SE, Johnson PJ. Supercharge nerve transfer
to enhance motor recovery: A laboratory study. J Hand Surg Am. 2013;38(3):466–477.
The authors provide basic science evidence using a rodent model that supports the idea that AIN
axons can enter the ulnar deep motor nerve when coapted in an end-to-side model.
Baltzer H, Woo A, Oh C, Moran SL. Comparison of ulnar intrinsic function following supercharge
end-to-side anterior interosseous-to-ulnar motor nerve transfer: a matched cohort study of
proximal ulnar nerve injury patients. Plast Reconstr Surg. 2016;138(6):1264–1272.
The authors performed a retrospective matched-cohort study in patients with high ulnar nerve injuries,
comparing 13 patients that underwent an end-to-side AIN to deep motor transfer and conventional
treatment, and 13 who received conventional treatment only. Eleven of 13 (84%) patients who had
the transfer regained ulnar intrinsic function at an average of 13.5 months follow-up, whereas only
5 of 13 (38%) patients without the transfer regained ulnar intrinsic function at an average of
39 months follow-up, providing evidence that the AIN to deep motor transfer works in an end-
to-side manner.
Dengler J, Dolen U, Patterson JMM, et al. Supercharge end-to-side anterior interosseous-to-ulnar
motor nerve transfer restores intrinsic function in cubital tunnel syndrome. Plast Reconstr Surg.
2020;146(4):808–818.
The authors present a retrospective series of 42 patients who underwent end-to-side transfers in purely
compressive ulnar neuropathy of varying severity, and found that only age was predictive
of failure, not clinical or electrodiagnostic severity of compound motor actional potentials.
ddsf
SECTION VIII
Tetraplegic Conditions
CHAPTER 69 Tendon and Nerve Transfers for Spinal
Cord Injury Patients 547
CHAPTER 70 Restoration of Elbow Extension: Deltoid to Triceps
Transfer and Biceps to Triceps Transfer 555
CHAPTER 71 Restoration of Wrist Extension: Brachioradialis to
Extensor Carpi Radialis Tendon Transfer 562
CHAPTER 72 Brachioradialis/Pronator Teres to Flexor Pollicis
Longus Tendon Transfer 566
CHAPTER 73 Restoration of Passive Key Pinch 572
CHAPTER 74 Restoration of Active Pinch and Grasp:
Extensor Carpi Radialis Longus Transfer to
Flexor Digitorum Profundus 582
CHAPTER 75 Intrinsic Tendon Reconstruction 587
CHAPTER 76 Nerve Transfers for Spinal Cord Injuries 597
546
CHAPTER 69
Tendon and Nerve Transfers for Spinal Cord
Injury Patients
This chapter gives an overview of the indications, clinical exam, and principles for the
surgical treatment of spinal cord patients who desire reconstruction of the upper ex-
tremity. The corresponding procedure details are found in Chapters 70 to 76.
INDICATIONS
• The most common causes of spinal cord injury (SCI) are motor vehicle collisions,
sports injuries, and falls. SCI patients are typically between 20 and 50 years of age.
• SCI affects the upper motor neurons and causes either complete or incomplete loss
of function below the point of injury. As a result, patients may have a range of
physical and functional deficits. In patients with bilateral upper limb involvement, the
sensory and motor deficits often differ on each side.
• Many SCI patients seek restoration of upper extremity function to regain control
over activities of daily living, such as self-grooming, eating, and self-catheterization.
Restoration of grip facilitates the patient’s ability to use utensils, write, or push a
wheelchair.
• Caring for SCI patients requires collaboration among family or caregivers, hand sur-
geons, rehabilitation medicine physicians, occupational therapists, physiatrists,
nurses, and social workers.
• A good surgical candidate is one who is motivated, with realistic expectations for post-
operative outcomes. It is essential that the hand surgeon understands which functions
the patient wants to regain and discusses the goals of surgery in detail with the patient.
• The patient must be emotionally and psychologically stable, with excellent social sup-
port, because they will be more dependent on caregivers immediately after surgery.
• The patient should also recognize that a 4-week period of immobilization is typically
necessary postoperatively, followed by an extensive occupational therapy regimen
to learn how to activate and use the tendon transfers.
• Surgery is typically performed at least 12 months after the injury so that the patient
can accept the injury and maximize gains from therapy. In rare circumstances, some
surgeons may perform reconstruction as early as 6 months after injury if motor im-
provement has plateaued, there is no concern for ascending myelopathy (neurologic
deterioration above the initial injured site in tetraplegic patients), and patients have
fulfilled the aforementioned requirements.
• Reconstruction should be tailored based on the needs of the patient and the avail-
able donor muscles. The specific indications for certain tendon and nerve transfers
are explained further in the following sections.
Contraindications
• Bedridden patients with pressure sores or recurrent urinary tract infections.
• Severe cardiac or pulmonary medical comorbidities that prohibit general anesthesia.
• Bilateral poor proprioception (2 point-discrimination .12 mm) in the thumb and in-
dex fingers. This is a relative contraindication to key pinch reconstruction because
performance of bimanual activities will be limited if patients must rely on their eyes
for confirmation of function at all times.
• Poorly controlled spasticity is a relative contraindication to surgery. In some cases,
a spastic muscle can be transferred to improve grasp and grip, but these transfers
can be unreliable.
• Psychological impairment or unrealistic expectations.
547
548 CHAPTER 69 Tendon and Nerve Transfers for Spinal Cord Injury Patients
ANATOMY AND SEGMENTAL INNERVATION

• Tetraplegia can affect high cervical nerves (C1-C4) or low cervical nerves (C5-C8);
the higher the level, the greater the severity of the functional deficits.
• The Medical Research Council (MRC) System (Table 69.1) is used to grade the
patient’s muscle strength on a scale from 0 to 5.
• The International Classification for Surgery of the Hand in Tetraplegia (ICSHT; Table 69.2)
is used to develop treatment plans for individual patients. This system groups tetraplegic
patients based on the number of functional muscles (grade 4 or 5 on the MRC scale)
available below the elbow. The expected function for patients in each group is also listed.
• Fig. 69.1 depicts the segmental innervation of all upper extremity muscles.
• Common donor muscles for reconstruction of the upper extremity include:
• Brachioradialis (BR)
• Extensor carpi radialis longus (ECRL)
• Pronator teres (PT)
• Biceps
• Deltoid
• Recipient muscles that are restored during reconstruction include:
• Triceps
• Extensor carpi radialis brevis (ECRB)
• Extensor pollicis longus (EPL)
TABLE
69.1 Muscle Research Council Grading System
Medical Research Council System Function
Grade 5 Muscle moves normally against full resistance
Grade 4 Muscle strength reduced, moves against some
resistance
Grade 3 Muscle strength can only move against gravity
Grade 2 Muscle can only move if gravity resistance is
removed
Grade 1 Muscle has trace flicker of movement
Grade 0 No movement is observed
TABLE
69.2 The International Classification for Surgery of the Hand in Tetraplegia
Group Motor Characteristics Function
0 No muscle below elbow for transfer Elbow flexion, forearm supination
1 BR Elbow flexion, forearm supination
2 ECRL Wrist extension (weak)
3 ECRB Wrist extension (strong)
4 PT Wrist extension, forearm pronation
5 FCR Wrist flexion
6 Finger extensors Extrinsic finger extension
7 Thumb extensors Extrinsic thumb extension
8 Partial finger flexors Extrinsic finger flexion (weak)
9 Lacks only intrinsics Extrinsic finger flexion
BR, Brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; FCR, flexor
carpi radialis; PT, pronator teres.
CHAPTER 69 Tendon and Nerve Transfers for Spinal Cord Injury Patients 549
Cervical Thoracic
5 6 7 8 1
Biceps
Brachialis
Brachioradialis
Supinator
Extensor carpi radialis longus
Extensor carpi radialis brevis
Pronator teres
Triceps

Extensor digiti quinti
Extensor indicis proprius
Pronator quadratus
Flexor digitorum profundus
Flexor pollicis longus
Lumbricals
Flexor digitorum sublimis
Thenar muscle
Adductor pollicis
Interossei
Hypothenar m.
FIGURE 69.1 Segmental innervation of the upper extremity muscles. The black stars indicate donor muscles,
the red stars indicate recipient muscles.
• Flexor digitorum profundus (FDP)

• Flexor pollicis longus (FPL)
• Thenar muscle (Abductor pollicis brevis)
• Interossei muscles
Surgical Treatments Based on Groups

• Table 69.3 displays the preferred procedures based on ICSHT groups. It outlines
how to tailor the surgery to the patient’s specific needs.
• Intrinsic reconstruction is a separate consideration because any tetraplegic patient
with an absence of intrinsic function may benefit from this procedure, regardless of
ICSHT group.
• A thorough history is obtained to identify any preexisting medical conditions and to note
the date of injury, method of injury, spinal cord injury level, and other associated injuries.
A list of prior nonoperative (i.e., Botox) and operative procedures is also needed.
• The upper extremity is evaluated for any preexisting spasticity or contractures,
which are typically treated with antispasmodic medications (e.g., Baclofen) and oc-
cupational therapy.
TABLE International Classification for Surgery of the Hand in Tetraplegia. Depicts

69.3 available donor muscle for transfer and exisitng hiearchy of hand function
Group Motor Characteristics Procedures
0 No muscle below elbow for Splints and orthoses for function of wrist/hand
transfer Biceps or deltoid to triceps
1 BR BR to ECRB
FPL tenodesis
Split FPL to EPL
1/ Thumb CMC arthrodesis
2 ECRL BR to FPL
Split FPL to EPL
1/ EPL tenodesis
3 ECRB BR to FPL
ECRL to FDP
Split FPL to EPL
EPL tenodesis
4 PT BR to FPL
ECRL to FDP
PT to EPL
EDC tenodesis
Split FPL to EPL
1/ Thumb opponensplasty
1/ Intrinsic tenodesis
5 FCR BR to FPL
ECRL to FDP
PT to EPL
EDC tenodesis
Split FPL to EPL
1/ Intrinsic tenodesis
6 Finger extensors BR to FPL
ECRL to FDP
PT to EPL
7 Thumb extensors BR to FPL
ECRL to FDP
Split FPL to EPL
8 Partial finger flexors ECRL to FPL
Split FPL to EPL
9 Lacks only intrinsics 
BR, Brachioradialis; CMC, carpometacarpal; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi
radialis longus; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FDP, flexor digitorum profundus;
FPL, flexor pollicis longus; PT, pronator teres.
• The passive and active range of motion (ROM) of all joints including the shoulder,
elbow, wrist, fingers, and thumb is assessed “top-to-bottom,” in the following order:
• Shoulder stability and abduction (deltoid function)
• Elbow flexion (biceps/brachialis) and extension (triceps)
• Wrist flexion (flexor carpi radialis [FCR]/flexor carpi ulnaris [FCU]) and extension
(ERCB/ECRL/extensor carpi ulnaris [ECU])
• Finger flexion (flexor digitorum superficialis [FDS]/flexor digitorum profundus CLINICAL EXAMINATION PEARLS
[FDP]) and extension (extensor digitorum communis [EDC]/intrinsics)
• Donated muscles decrease in strength by
• Thumb interphalangeal (IP) flexion (FPL), extension (EPL), and opposition (APB)
1 grade. Therefore donor muscles of at least
• Tenodesis describes the position of the fingers with respect to wrist position; when level 4 strength are preferred, but level
the wrist is passively flexed, the fingers should extend, and when the wrist is pas- 3 muscles can be transferred when few
sively extended, the fingers should flex. donors are available.
• The following examination maneuvers are used to test and grade muscles according • If the patient has 5 out of 5 wrist extension,
ERCL and ECRB should be intact; another indi-
to Table 69.1. Muscles with a strength of 4 or 5 are suitable donors and should be
cation of this can be the “bean” sign seen on
noted. the dorsal radial forearm as a line between the
• Deltoid: Have the patient sit with arms at sides. The anterior, middle, and poste- ERCL and ECRB when both muscles are strong
rior deltoid heads are assessed when the patient raises the arm forward, lateral, and contract.
and posterior toward the shoulder. • Intact sensation allows a patient to use the
hands without keeping them in view.
• Biceps: Have the patient flex the elbow against resistance, with the forearm in a
• Two-point discrimination (2PD) of 10 mm or
supinated position. less at the volar thumb and index finger are
• BR: The patient flexes the elbow against resistance, with the forearm in mid to full necessary for the most effective use of the
pronation. pinch reconstruction.
• ECRB and ERCL: Have the patient actively extend the wrist; if both ERCL and
ECRB are intact, wrist extension will be central because the ERCB inserts on the
third metacarpal. If only the ECRL is intact, the wrist will radially deviate with
extension because the ERCL inserts on the second metacarpal.
• PT: Have the patient sit with elbow flexed, passively rotate the forearm into supi-
nation, and ask the patient to pronate against resistance.
• Assess proprioception by using a two-point discriminator with points set to different
distances (6 mm, 8 mm, 10 mm, etc.). Alternatively, a paper clip can be opened to
the different widths and used if a discriminator is not available.
IMAGING/STUDIES
• Plain radiographs should be obtained to identify any heterotopic ossification or other
osseous abnormalities, including fractures.
• Preoperative electromyography and nerve conduction studies can provide greater
detail regarding the level of injury and degree of denervation, which is critical for
surgical planning.
OVERVIEW OF SURGICAL OPTIONS FOR THE TETRAPLEGIC

PATIENT
Tendon Transfers
Tendon transfers are the preferred treatment when sufficient donor muscles are avail-
able. This option requires significant rehabilitative commitment to “relearn” how to use
the transfers. This technique allows patients to most rapidly regain movement and
strength in key functions needed for daily activity and independence. Examples include
BR to ECRB for wrist extension or BR to FPL for thumb flexion and key pinch.
Tenodesis
Tenodesis is used in tetraplegic patients when minimal donor muscles are available. It
describes the ability to achieve movement at one joint based on the position of a
nearby joint. Specifically, tetraplegic patients can take advantage of the synergy be-
tween wrist extension with finger/thumb flexion and wrist flexion with flexion/thumb
extension. Specific examples include EPL, APL, or FPL tenodesis.
Arthrodesis
Arthrodesis describes the fusion of a joint for stability. This is commonly performed at
the thumb carpometacarpal (CMC) joint when instability is present.
Nerve Transfers
Nerve transfers are an emerging treatment modality in tetraplegia and describe the
technique of transferring an expendable nerve to repower an essential muscle function.
The transfer often requires several months before the muscle contraction is detected.
Nerve transfers can be combined with tendon transfers. Supinator motor branch to
posterior interosseus nerve (SPIN) is a commonly performed transfer.
PRINCIPLES OF SURGICAL TREATMENT

The hierarchy of functional restoration proceeds from proximal to distal: (1) elbow ex-
tension, (2) wrist extension, (3) key pinch, (4) grasp, (5) release, and (6) intrinsic function.
Patients must first be able to extend the elbow to get the wrist and hand away from the
body and in a position of function. Wrist extension allows the patient to take advantage
of the tenodesis effect before key pinch and grasp reconstruction are performed.
Restoration of Elbow Extension – Chapter 70

• Elbow extension is critical for patients with tetraplegia because it facilitates perform-
ing overhead and manual activities. Restoring this function is a treatment priority and
sets the stage for subsequent transfers of the upper extremity.
• The deltoid or biceps can be transferred to the triceps for restoration of elbow extension.
• When the deltoid muscle is chosen, only the posterior half is transferred with
maintenance of shoulder abduction via anterior deltoid function; however, a ten-
don graft is necessary to reach the triceps for reconstruction. The deltoid to tri-
ceps transfer is synergistic because it helps the patient move the extremity away
from the body to perform various tasks.
• Biceps muscle transfer results in partial loss of forearm supination and elbow
flexion. To use the biceps, the surgeon must confirm that the supinator and bra-
chialis are intact on examination to ensure that the patient will be able to supinate
the forearm and flex the elbow after biceps transfer. Biceps transfer does not
require tendon graft; however, because the biceps is responsible for elbow flexion
and triceps is responsible for elbow extension, this transfer of antagonist muscles
requires longer rehabilitation to learn this transfer.
• The biceps to triceps transfer results in greater antigravity strength (higher on the MRC
scale) than the deltoid to triceps transfer. This means the patient is able to perform the
muscle function and hold up the extremity against gravity and/or some resistance.
• Both transfers are suitable options, depending on the surgeon’s experience and
preference.
Restoration of Wrist Extension – Chapter 71

• After restoration of elbow extension, wrist extension is next on the reconstructive
ladder for tetraplegic patients. The ability to extend the wrist facilitates passive fin-
ger and thumb flexion via the tenodesis effect; this sets the patient up for thumb-
index lateral pinch and grasp.
• Wrist extension is often combined with other thumb stabilization procedures, includ-
ing CMC arthrodesis and FPL tenodesis.
• In Class 1 patients, the brachioradialis can be transferred to one of the wrist exten-
sors to restore wrist extension. Because the extensor carpi radialis brevis inserts
onto the third metacarpal and is a more central wrist extensor, it is often chosen as
the recipient.
Restoration of Key Pinch – Chapters 72 and 73

• After wrist extension is restored, the fingers and thumb can be passively placed in a
position to enhance key pinch.
• In patients with a paucity of donors, passive key pinch is restored using FPL teno-
desis to the volar radius.
• Patients must have adequate wrist extension to take advantage of the tenodesis
effect, which enables thumb flexion with wrist extension.
• As the wrist extends, the thumb can press against the radial side of the index
finger.
• In patients who have available donor muscles, BR to FPL transfer is performed for
active pinch.
• Candidates for this procedure fall into ICSHT Class 2 or higher, with good wrist
extension and expendable BR.
• FPL activation with tendon transfer may result in exuberant IP flexion (Froment’s RESTORATION OF KEY PINCH PEARLS
sign) and unpredictable position of the thumb pulp with the lateral portion of the
• Active key pinch is necessary for manipulating
index finger. One or more adjunctive procedures can be added, including: small objects, including pens for writing and
• Thumb CMC arthrodesis if laxity is noted at this joint. utensils for feeding.
• Split FPL to EPL transfer to create extension and flexion forces across the • Assess the patient’s 2PD at the thumb and in-
interphalangeal joint; this can obviate the need for arthrodesis at this joint. dex fingertips. It should be less than 10 mm,
• EPL tenodesis can be used to synergize thumb extension with wrist flexion. to avoid being a “visual pinch,” which requires
the patient to rely on visual cues rather than
• PT (if available) to EPL transfer to restore active thumb extension and balance on proprioception when performing tasks.
the thumb in space for key pinch.
Restoration of Grasp and Release – Chapter 74

• In addition to thumb function, it is important that patients can flex and extend the
fingers to grasp and release objects.
• Patients who can benefit from these procedures are typically in ICSHT groups 3, 4,
or 5. They have supple, stable joints; active wrist extension function; and normal
passive wrist ROM.
• EDC tenodesis is an option for patients who require passive digit extension at the
MCP.
• Tenodesis of the common extensors to dorsal distal radius or sutured to the ex-
tensor retinaculum produces finger extension during wrist flexion.
• This must be carefully tensioned to avoid excessive finger clawing; if clawing
presents after tenodesis, intrinsic reconstruction can be performed to avoid early
digit roll-up (see Chapter 75).
• ECRL to FDP is performed to restore active finger flexion and facilitate grip.
• Assess both ECRL and ECRB to ensure that ECRL is expendable (ICSHT group
3 or more).
• The ECRL is more commonly used because maintaining ERCB leaves the patient
with central wrist extension rather than wrist extension and radial deviation that
would result if the ERCL were left in place and ERCB transferred.
• A thumb opponensplasty can also be performed for better thumb stability and key
pinch.
• It is preferable to use the EIP for transfer in this procedure given the strength and
length of the tendon. In cases without EIP, the PL can be transferred.
Restoration of Intrinsic Function – Chapter 75

• Restoration of intrinsic function in the tetraplegic hand corrects the following deficits:
• When the long flexors initiate finger flexion at the DIP, early finger roll-up occurs
in the absence of the intrinsic function, whereby the fingertips are flexed to the
base of the digit rather than the palm. This early finger roll-up makes it difficult to
grasp large objects.
• Additionally, tetraplegic patients without intrinsic muscle function can have claw-
ing, which manifests as MCP hyperextension. When this occurs with the index
finger, the thumb cannot meet the radial aspect of the digit for effective key pinch.
• Intrinsic stabilization can be accomplished via the House tenodesis procedure,
whereby a free tendon graft sutured to the extensor mechanism at the metacarpal head
proximally is passed volar to the intermetacarpal ligament and sutured to the lateral
band of the digit. This exerts a flexion force along the MCPJ and extension at the IPJs.
• Zancolli lasso procedure can also be performed for intrinsic stabilization. This re-
quires an incision over the A1 pulley of the digit. The FDS tendon is identified distal
to the A1 pulley and sutured proximally to itself to create a flexion force at the MCPJ.
See Video 69.1
EVIDENCE
Curtain CM, Gater DR, Chung KC. Upper extremity reconstruction in the tetraplegic population, a na-
tional epidemiologic study. J Hand Surg Am. 2006;30:94–99.
The manuscript examined the use of upper extremity reconstruction among tetraplegic patients. Using
International Classification of Diseases (ICD)-9 codes to establish the diagnosis, they found a paucity
of upper extremity reconstruction procedure codes among these patients. Despite the large
benefit to tetraplegic patients, upper extremity reconstruction procedures were widely underutilized
at the time of publication.
Gohitz A, Fridan J. Management of spinal cord injury-induced upper extremity spasticity. Hand Clin.
2018;34:555–565.
Bednar M. Tendon transfers for tetraplegia. Hand Clin. 2016;32:389-396.
Hamlin C. Upper extremity reconstruction in the tetraplegic patient. Tech Hand Up Extrem Surg.
2001;5:91–104.
These manuscripts describe the classification, general principles, indications, benefits, technical
aspects, and outcomes of elbow, wrist, and hand reconstruction in tetraplegic patients.
Friden J, Reinholdt C, Turcsanyii C, Gohritz A. A single stage reconstruction of the hand flexion,
extension, and intrinsic function in tetraplegia: The alphabet procedure. Tech Hand Up Extrem Surg.
2011;15:230–235.
This manuscript summarizes a combined approach to restoration of hand flexors, extensors, and intrin-
sic reconstruction rather than the traditional extensor and flexor phases that were previously used to
treat tetraplegic patients. With this procedure, patients have one recovery period and were reliably
able to achieve pinch, grip, grasp, and release with excellent satisfaction.
CHAPTER 70
Restoration of Elbow Extension: Deltoid to Triceps
Transfer and Biceps to Triceps Transfer
INDICATIONS
• Restoration of elbow extension is critical for patients with tetraplegia. It enables
patients to perform various overhead and manual activities and sets the stage for
subsequent reconstruction of the upper extremity.
• Patients should have a supple elbow joint on examination before transfer.
• Patients are typically 12 months out from the initial injury and should have a stable
motor examination.
• Patients should have realistic expectations, be highly motivated to perform postop-
erative therapy, and have a stable support system.
Contraindications
Relative contraindications include severe elbow flexion contracture (.30 degrees),
uncontrolled spasticity, chronic pain, and psychological instability.
• There is a specific segmental innervation (C5 to T1) of muscles of the elbow, fore-
arm, and hand (Fig. 70.1).
• An organized examination is performed to document the patient’s muscle function
and strength performing elbow flexion, elbow extension, wrist flexion, wrist exten-
sion, finger flexion, finger extension, thumb extension/abduction, thumb flexion/
opposition, and intrinsic hand function.
• The patient’s muscles are graded according to the Medical Research Council (MRC)
system (see chapter 69, Table 69.1). Muscle strength decreases by 1 grade during
transfer. Therefore only muscles of grade 4 or greater are available for transfer.
• The tetraplegic patient’s hand function and available donor muscles are organized
using the International Classification of Surgery of the Hand in Tetraplegia (see
chapter 69, Table 69.2).
• Passive range of motion (ROM) is tested at the shoulder, elbow, wrist, and fingers to
identify any joint or muscle contracture.
• A list is constructed of the patient’s functional abilities, priorities for improvement,
and available muscles for transfer.
• Either the deltoid or the biceps can be transferred for restoration of elbow extension.
555
556 CHAPTER 70 Restoration of Elbow Extension: Deltoid to Triceps Transfer and Biceps to Triceps Transfer
• Biceps to triceps transfer results in 47% loss of elbow flexion; however, patients
report maintained elbow flexion and supination against gravity and no significant
functional consequences (Kozin).
• Biceps to triceps transfer is stronger and results in antigravity muscle strength (.3)
more often compared with deltoid to triceps transfer (Kozin).
• Before a deltoid transfer, examine the anterior, middle, and posterior heads. Have
the patient sit with arms at sides. Test the anterior, middle, and posterior deltoid by
having the patient raise their arms forward, lateral, and posterior against gravity and
resistance. The muscle is palpated for bulk and strength.
• If strong enough, the posterior half of the deltoid is harvested for transfer. The patient
maintains the ability to abduct the shoulder via the anterior head.
• Because the biceps muscle transfer results in partial loss of forearm supination and
elbow flexion, the strength of the brachialis as an elbow flexor must be verified.
Have the patient sit with arms at side and forearms supinated to relax the biceps.
The brachialis can be visualized along the lateral arm from the deltoid insertion to
the lateral epicondyle. The patient is asked to flex the elbow, and the brachialis can
be palpated posterior and lateral to the biceps. The brachialis can occasionally
have dual innervation from the musculocutaneous and radial nerves. Therefore
one cannot assume that the brachialis is functional if the biceps is functional. The
brachialis should be palpated as the patient attempts elbow flexion with the fore-
arm in pronation.
IMAGING
Anteroposterior (AP) and lateral plain x-rays should be performed to rule out arthritic
and heterotopic ossification that can restrict motion.
Deltoid to Triceps Transfer

SURGICAL ANATOMY
• The deltoid muscle has three distinct groups of fibers. These are grouped into the
anterior, lateral, and posterior divisions. The deltoid is responsible for shoulder ab-
duction and external rotation.
• The groups arise from the clavicle, acromion, and posterior border of the scapular
spine, respectively, and insert on the deltoid tuberosity of the humerus.
• The vascular supply comes from the posterior circumflex artery and is innervated by
the axillary nerve.
• This transfer involves the posterior third and half of the lateral fiber groups.
• The axillary nerve courses about 5 cm distal to the acromion on the deep surface of
the deltoid and must be protected because the posterior half of the middle deltoid
is dissected with the posterior deltoid and released from its insertion.
• The deltoid to triceps transfer is synergistic. Nevertheless, a tendon graft is necessary
to reach the triceps. This transfer requires two suture lines that are susceptible to
stretch and rupture. Stretch results in loss of strength, antigravity function, and excur-
sion. Some investigators recommend that a deltoid to triceps transfer is not performed
in patients with weak or absent pectoralis function because it could compromise
shoulder stability, though this has not been proven.
POSITIONING
• The procedure is performed with the patient in a lateral decubitus position or supine
with the roll under the shoulder.
• The site for the fascia lata harvest is prepped and draped.
EXPOSURES
Deltoid
• A lazy S incision is made from the tip of the posterior corner of the acromion to the
deltoid insertion of the humerus. Dissection is along the posterior border of the del-
toid, leading into its insertion onto the deltoid tubercle (see Fig. 70.1).
CHAPTER 70 Restoration of Elbow Extension: Deltoid to Triceps Transfer and Biceps to Triceps Transfer 557
• A separate incision is made posteriorly over the distal third of the humerus to expose STEP 1 PEARLS
the triceps tendon.
• Preserve as much tendinous insertion as pos-
sible to facilitate the interposition of the tendon
PROCEDURE or fascial graft.
• Find the confluence of the posterior deltoid
Step 1: Deltoid Harvest and triceps and use finger dissection posteri-
orly to bluntly separate the deltoid and triceps
• After the skin incision, elevate skin flaps posteriorly and anteriorly.
down to the humerus.
• Dissect down to the deltoid fascia and expose the posterior edge of the deltoid from • During proximal deltoid dissection, you may see
proximal to distal. Find an edge of the deltoid muscle and finger sweep underneath branches of the axillary nerve and posterior
the muscle to create a plane for division; this also enables one to distinguish the circumflex artery if dissection is too proximal.
anterior and posterior halves of the muscle.
• Identify the posterior muscle insertion and use an osteotome or Freer to elevate the
STEP 1 PITFALLS
periosteum/tendinous insertion off the humerus. Ensure that there is enough perios-
teum and fascia together with the deltoid to hold the sutures securely. • Protect the axillary nerve branches to preserve
• Place a stay suture on the fibrous tendon and use as a handle. Dissect the muscle the innervation to the muscle fibers as they
are rotated posteriorly.
proximally to ensure adequate excursion of muscle (around 3 cm). • Avoid injury to the posterior circumflex artery
and axillary nerve as they exit the quadrangu-
Step 2: Identification and Preparation of Triceps lar space when dissecting deep to the deltoid.
Make a lazy S or longitudinal incision distally over the humerus/lateral elbow. Dissect
sharply to the triceps fascia. Use Mayo or Metzenbaum scissors to create a subcutane-
ous tunnel from the deltoid harvest incision toward the triceps.
Step 3: Fascia Lata Harvest

• Make three evenly spaced transverse incisions over the iliotibial band or one longi-
tudinal incision over the lateral thigh (Fig.70.2A).
• Identify the fascia lata and harvest a 2- to 2.5-cm-wide strip (see Fig. 70.2B).
Deltoid
• The graft should be of sufficient length to reach from the deltoid to the triceps
(Fig.70.3A–B).
Step 4: Tendon Graft Weave

• Proximally, inset the fascia lata with multiple weaves to the posterior deltoid tendon
using 0 nonabsorbable mattress sutures (Fig. 70.4). Alternatively, the fascia lata graft
can be tubularized and wrapped around the deltoid tendon and secured with sutures.
• Distally, weave the fascia lata graft into the triceps tendon and secure it using 2-0
nonabsorbable suture. Set tension with the shoulder abducted 30 degrees and elbow
Triceps
fully extended (Fig. 70.5).
B B
FIGURE 70.2 A–B FIGURE 70.3 A–B

STEP 2 PEARLS
• Ensure that the tunnel is made in a straight
line from the triceps to the prepared deltoid.
• Place the triceps incision away from bony
prominences to avoid wound healing compli-
cations at areas of pressure.
STEP 3 PITFALLS
Avoid raising large subcutaneous flaps. Only
elevate what is needed to harvest the graft.
Creating a large dead space can lead to a seroma.
FIGURE 70.4
STEP 4 PEARLS
Many different graft sources have been described,
including the second to fourth toe extensors and
tibias anterior.
FIGURE 70.5
Step 5
• Achieve hemostasis and close the incisions in layers.
• Fabricate a long arm splint and keep the elbow at about 10 degrees of flexion.

• The patient is kept immobilized for 4 to 6 weeks and should avoid shoulder adduc-
tion and elbow flexion.
• After 6 weeks, the patient is placed in an elbow hinged brace and elbow flexion is
increased at 5 to 10 degrees per week over 3 months. Full extension splinting at
night is recommended.
• After 12 weeks, strengthening of the transfer can begin.
• Deltoid to triceps transfer outcomes are variable, depending on the graft material
and the method of suture fixation.
Biceps to Triceps Transfer

SURGICAL ANATOMY
• The biceps short and long heads originate from the coracoid process and supra-
glenoid tubercle, respectively; their insertion is the radial tuberosity. The vascular
supply comes from the brachial artery, and it is innervated by the musculocutane-
ous nerve.
• The biceps are responsible for elbow flexion and forearm supination.
• The boundaries of antecubital fossa include the pronator teres (PT) medially and the
brachioradialis (BR) laterally. The biceps aponeurosis inserts centrally. The median
nerve and brachial artery are medial to the biceps aponeurosis.
• The lateral antebrachial cutaneous nerve, which is the terminal branch of the mus-
culocutaneous nerve, runs superficial to the brachialis and is identified along the
medial surface of the brachioradialis and lateral to the biceps.
POSITIONING
The procedure is performed with the patient supine, a roll under the operative shoulder
blade, and the limb draped free with a sterile tourniquet high on the arm.
EXPOSURES
Biceps
• A lazy S incision is made over the antecubital fossa, extending proximally over the
biceps muscle belly and distally over the insertion on the radial tuberosity.
• A second posteromedial (extended cubital tunnel) incision is made over the distal
third of the triceps tendon, lateral to the olecranon, to avoid subsequent olecranon
pressure ulceration.
PROCEDURE
Step 1: Biceps Harvest
STEP 1 PEARLS
• After making the biceps harvest incision, dissect through the subcutaneous tissue.
• Carefully divide the lacertus fibrosis layer by
Identify and protect the cephalic and basilic veins, which will be lateral and medial,
layer because the median nerve and brachial
respectively. Centrally, identify and divide the lacertus fibrosis of the biceps as dis- artery lie deep and are at risk of injury.
tally as possible (this gives a second point of tendon fixation). • Watch for the recurrent radial vessels during
• Flex the elbow and supinate the forearm to improve identification of the biceps ten- the dissection to identify the biceps tendon.
don. Palpate the tendon and trace it down onto its insertion of the radial tuberosity. • Use a large stay suture or penrose around the
biceps tendon for gentle traction.
Transect the tendon as close to the insertion as possible.
• The tourniquet may need to be repositioned
• Use a penrose around the biceps tendon as a handle to lift the muscle belly. Dissect the during the proximal dissection of the biceps.
muscle proximally to the point where the musculocutaneous nerve (lateral to the biceps
tendon) can be seen running between the biceps and brachialis. Ensure sufficient proxi-
mal dissection to provide excursion and reach of the tendon to the olecranon (Fig. 70.6).
STEP 1 PITFALLS
Step 2 Identify the musculocutaneous nerve running on
• Transfer the biceps tendon medially via a posteromedial incision or an extended the anterior surface of the brachialis and protect it.
cubital tunnel incision. Release the ligament of Struthers and remove the medial
intermuscular septum.
• Dissect sharply down to the triceps muscle and make a longitudinal incision to split STEP 2 PEARLS
it at its insertion but leave the tendon attached to bone. This incision provides bony
• The medial intermuscular septum may need to
be partially resected. Care is taken to protect
the neighboring ulnar nerve.
• Create a medial tunnel to avoid radial nerve
compression laterally.
• The biceps tendon is passed under the ulnar
nerve in the event of regeneration.
Bicipital
Brachialis aponeurosis
Biceps
Brachioradialis tendon
Anterior view
FIGURE 70.6
Humerus
Medial
epicondyle
Anterior bundle Radius
Posterior Ulna
bundle
Transverse
ligament
FIGURE 70.7
exposure of the olecranon. There is no need to detach the triceps tendon from the
muscle because the line of pull for the tendon transfer is relatively straight. Keeping
the triceps in continuity may decrease the tension over the transfer.
STEP 3 PEARLS • Create a large subcutaneous tunnel, medially connecting this medial dissection to
• Some authors advocate for setting tension in the proximal dissection of the biceps. Pass the biceps tendon over the median nerve
full extension, which provides a maximum and under the ulnar nerve.
30 degrees of flexion, as there may be some
stretch of the tendon transfer and muscle Step 3: Biceps to Triceps Tendon Weave
components after surgery.
• The bicep tendon is “docked” into a bone tun- • The biceps tendon is woven 2 to 3 times into the triceps tendon using mattress
nel on the olecranon as reinforcement for the sutures.
tendon weave. • At the tip of the previously exposed olecranon, drill a unicortical hole toward the
• A Keith needle can be used as an alternative posterior cortex using a 6-mm small drill bit. Enlarge the hole gradually to accom-
to a suture passer. The suture associated with
the tendon ends can be placed on Keith modate the biceps tendon (Fig. 70.7).
needles and individually passed through the • Drill two small holes through the opposite cortex of the olecranon toward the previ-
olecranon holes. ously drilled unicortical hole.
• A braided nonabsorbable suture (e.g., #2) is passed through the biceps tendon tail
and tied. Pass a suture passer through each smaller hole into the larger hole to re-
STEP 3 PITFALLS
trieve the suture tails and pull the biceps tendon into the bone. The retrieved sutures
Move the arm from extension to flexion when are tied over the olecranon with the elbow maximally extended.
drilling the bony tunnel to ensure that you do not
• Place additional mattress sutures between the triceps and biceps tendon.
enter the joint.
• Set tension to permit 60 degrees of flexion passively.
Step 4
• Hemostasis is achieved and the incision is approximated in layers.
• The patient is placed in a long-arm cast with 30 degrees of elbow flexion and the
wrist left free.

• A long-arm cast is maintained for 4 to 6 weeks.
• Then the patient can transition to an elbow hinged brace, increasing 10 to 15 degrees
per week until full ROM is achieved.
• Strengthening begins at 8 weeks.
• Because the biceps and triceps are antagonistic muscles, additional rehabilitation
time is required to learn biceps activation for elbow extension.
• Patients report improved performance and satisfaction with activities of daily living
after restoration of elbow extension.
• Delayed wound healing and wound infections, injury to nearby neurovascular struc-
tures, and insufficient tensioning of the transfer can occur.
• Over time, tendon rupture or stretch/elongation of the tendon transfer can occur.
• Compartment syndrome is a rare complication. Because patients can have little to
no sensibility, they may not express pain or discomfort; judicious splint placement is
paramount.
See Video 70.1
EVIDENCE
Revol M, Briand E. Servante J. Biceps-to-triceps transfer in tetraplegia. The medial route. J Hand Surg
Br. 1999;24:235–237.
This is a retrospective cohort study of 8 patients (13 elbows) that underwent transfer to the medial
route with follow-up up to 18 months. Patients experienced no major nerve complications, although
flexion power was decreased by a mean of 47% related to the use of the biceps. Patients were satis-
fied with their increased elbow extension despite weakness. The authors advocate the medial route
for the biceps tendon to avoid possible radial nerve injury.
Allieu Y, Coulet B, Chammas M. Functional surgery of the upper limb in high-level tetraplegia. Tech
Hand Up Extrem Surg. 2000;4:50–63.
Revol M, Cormerais A, Laffont I, Pedelucq, Dizien O, Servant J. Tendon transfers as applied to
tetraplegia. Hand Clin. 2002;18:423–439.
The previous two review articles provide an overview of surgery for tetraplegic patients with technical
descriptions of the deltoid to triceps and biceps to triceps transfer.
Mulcahey M, Lutz C, Kozin S, Betz R. Prospective evaluation of biceps to triceps and deltoid to triceps
for elbow extension in tetraplegia. J Hand Surg Am. 2003;28:964–971.
This is a prospective randomized trial comparing deltoid to triceps and biceps to triceps transfer. Eight
arms had biceps transfer and 8 arms had deltoid transfer. At 24 months, 7 of 8 biceps transfers had
antigravity effect versus 1 of 8 in the deltoid group. Loss of flexion torque occurred in 32% in the
deltoid group versus 47% in the biceps group. Both groups reported improved activities of daily
living, modified University of Minnesota tendon transfer function improvement questionnaires, and
Canadian occupational performance measures. Biceps transfer offers increased extension strength
with alternative loss of flexion strength, but both transfers clinically improve patients (Level II
evidence).
Kozin S, D’Addesi L, Chafetz R, Ashworth S, Mulcahey M. Biceps-to-triceps transfer for elbow
extension in persons with tetraplegia. J Hand Surg Am. 2010;35:968–975.
This is a retrospective cohort study of 45 patients (77 arms) who underwent biceps to triceps transfer.
A total of 40 patients (68 arms) were available for follow-up. The average age at surgery was
17.3 years (range, 6.4–21.7 y). Forty-two arms were able to extend completely against gravity
(manual muscle testing [MMT] 3 out of 5 or greater). Nine arms had a mild extension lag against
gravity (MMT of 3 out of 5). Seventy-five percent (51 of 68) of arms were able to function overhead.
Seventeen arms had MMT scores less than 3 out of 5 (Level IV evidence).
CHAPTER 71
Restoration of Wrist Extension: Brachioradialis
to Extensor Carpi Radialis Tendon Transfer
INDICATIONS
• After restoration of elbow extension, wrist extension is next on the reconstructive
ladder for tetraplegic patients. This procedure is suitable for International Classifica-
tion of Surgery of the Hand in Tetraplegia Group 1 patients who have available
brachioradialis (BR) but lack wrist extension.
• The ability to extend the wrist facilitates passive finger and thumb flexion via the
tenodesis effect; this puts the thumb and index finger in an optimal position for lateral
pinch and the remaining fingers in position to grasp.
• Additionally, wrist extension assists patients with significant flexion contracture in
performing hygiene at the crease.
• Wrist extension is often combined with other thumb stabilization procedures, includ-
ing carpometacarpal (CMC) arthrodesis and flexor pollicus longus (FPL) rerouting.
• An organized examination of the entire upper extremity is performed. See Chapter 69:
Tendon and Nerve Transfer for Spinal Cord Injury for details.
• To assess BR strength, the patient places their forearm in a neutral position between
pronation and supination. The patient flexes their elbow against resistance while the
muscle belly is palpated. A tight muscle belly of Medical Research Council (MRC)
Grade 4 or higher is suitable for transfer.
IMAGING
• Electromyography can be performed if the examination is unclear or if there is
concern for spasticity. It is not absolutely necessary with a confident clinical
examination.
SURGICAL ANATOMY
• The BR originates from the lateral supracondylar ridge of the humerus and inserts
onto the radial styloid. Its vascular supply is from the radial artery, and it is inner-
vated on its deep surface by the radial nerve above the elbow (Fig. 71.1).
• The radial nerve runs along the deep surface of the BR above the elbow and then
divides into the deep radial nerve and superficial sensory branch of the radial nerve
(SBRN).
• The SBRN runs along the deep surface of the BR until approximately 7 cm proximal
to the wrist, where it pierces the BR fascia and is more superficial in the forearm. It
provides sensation to the dorsoradial portion of the hand and to the thumb.
• The extensor carpi radialis longus (ECRL) originates from the lateral supracondylar
ridge of the humerus and inserts on the base of the index finger metacarpal. The
extensor carpi radialis brevis (ECRB) originates from the lateral epicondyle and in-
serts on the base of the long finger metacarpal. The ECRL is innervated by the radial
nerve proximal to its division (above the elbow) and the ECRB is innervated by the
posterior interosseous nerve.
POSITIONING
• The procedure is performed with the arm extended and pronated.
• A sterile tourniquet is placed on the upper arm.
562
CHAPTER 71 Restoration of Wrist Extension: Brachioradialis to Extensor Carpi Radialis Tendon Transfer 563
Brachioradialis
Extensor carpi
radialis longus
Pronator teres
Extensor carpi
radialis brevis
FIGURE 71.1 Surgical anatomy.
EXPOSURES PEARLS
EXPOSURES • Ensure that there is large enough exposure to
adequately see and mobilize the BR muscle.
• A 5-cm longitudinal incision is made over the radial aspect of the forearm between
• The incision can be placed more dorsally,
the proximal and middle thirds (Fig. 71.2). depending on the additional procedures that
• The BR tendon runs along the dorsoradial aspect of the forearm, with the ECRL and are being performed.
ECRB tendons running dorsal and parallel (Fig. 71.3).

Take care to preserve the SBRN; it is deep to BR
Step 1 until approximately 7 cm from the wrist crease,
Dissect through the subcutaneous tissue down to the BR fascia and perform a wide where it becomes more superficial. Avoid injury
because this can lead to painful neuromas.
dissection over the muscle belly. Identify and protect the SBRN and radial artery. Incise
the fascia and paratenon to expose the muscle belly.
STEP 1 PITFALLS
Step 2 The radial artery is ulnar to the BR at the wrist
• Place a marking suture over the distal BR muscle and another suture 5 cm over the and deep, going proximally; carefully identify and
proximal muscle before transecting the distal tendon. This helps to determine the protect it.
resting tension of the muscle after tendon transfer.
• Transect the BR at the tendinous insertion as distally as possible underneath the first STEP 2 PEARLS
compartment muscles (abductor pollicis longus [APL]/ extensor pollicis brevis [EPB]) • Confirm that the BR is the only muscle inserting
and dissect the tendon off the radial styloid sharply with a 15-blade. onto the radial styloid.
• Elevate the BR on its deep surface going from distal to proximal to detach the • The BR muscle must be completely detached
muscle completely from the radius, which ensures at least 3 cm of movement. Ligate from the radius to achieve an excursion of
3 cm or more.
any transverse radial artery perforators during the deep dissection.
564 CHAPTER 71 Restoration of Wrist Extension: Brachioradialis to Extensor Carpi Radialis Tendon Transfer
ECRB ECRL
BR
FIGURE 71.2 Incision design. BR, Brachioradialis; ECRB, extensor carpi radialis brevis;
FIGURE 71.3 Brachioradialis (BR) tendon.
ECRL, extensor carpi radialis longus.
ECRB ECRL BR
ECRB
ECRL
BR
FIGURE 71.4 BR, Brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis
longus.

With more proximal dissection, the innervating • From the incision, use retractors and dissect toward the dorsal wrist to identify the
radial nerve branches must be preserved. As you ECRB tendon as it inserts onto the long finger metacarpal. The ECRL will also be
get closer to the elbow, avoid injury to the radial seen inserting onto the index finger metacarpal.
recurrent vessels.
• Trace the ECRB tendon to the musculotendinous junction proximally and transect it.
• Pass the brachioradialis tendon into the dorsal compartment, over the ECRL, and
STEP 3 PEARLS perform an end-to-end Pulvertaft weave between the BR and ECRB with multiple
• The first suture sets the tension and should 2-0 nonabsorbable sutures (Fig. 71.4).
be done with the brachioradialis at its normal • Tension should be set with the elbow in 90 degrees of flexion and the wrist neutral.
resting length (which can be determined and The previously placed 2 sutures can guide the resting tension of the BR muscle.
marked in situ before transfer).
• After tension is set, ensure that 30 degrees of
passive flexion of the wrist remains intact.
Step 4
• Hemostasis is achieved and the incision is closed in layers.
• The patient is placed in a long-arm cast with 90 degrees of elbow flexion and wrist
in neutral to slight extension.

• The cast is removed at 4 weeks. After 4 weeks, the patient is placed in a removable
splint and starts protected range of motion. Exercises are initiated out of the orthosis
and the patient returns to the splint when not exercising.
• During the 6 to 12 weeks after surgery, the patient can wean the orthosis and begin
strength training without resistance. After 12 weeks, the patient can wean the orthosis.
See Video 71.1
CHAPTER 71 Restoration of Wrist Extension: Brachioradialis to Extensor Carpi Radialis Tendon Transfer 565
EVIDENCE
Freehafer A, Mast W. Transfer of the brachioradialis to improve extension in the high spinal-cord injury.
J Bone Joint Surg Am. 1967;49:648–652.
This is a retrospective review of six patients who underwent BR to ECRB/ECRL transfer. Preoperatively,
patients had no wrist extension; postoperatively, four patients obtained effective grasp and two
patients had improved posture only but no active extension. The authors propose the preoperative
BR muscle strength was insufficient and emphasize how critical the preoperative clinical assessment
of BR is.
Johnson D, Gellman H, Waters R, Tognella M. Brachioradialis transfer for wrist extension in tetraplegic
patients who have fifth-cervical-level neurological function. J Bone Joint Surg Am. 1996;78:1063–1067.
This is a retrospective review of nine patients with traumatic tetraplegia who had the BR transferred to
the ECRL and ECRB tendons to restore wrist extension. The average time from injury to the opera-
tion was 6 years and mean follow-up was 10 years (range 2–15 years). No patient had active exten-
sion of the wrist against gravity preoperatively. Postoperatively, wrist extension strength was good in
six patients and fair in three. Hand function improved markedly in seven patients and no patient had
a loss of function.
Murray W, Bryden A, Kilgore K, Keith M. The influence of elbow position on the range of motion of the
wrist following transfer of the brachioradialis to the extensor carpi radialis brevis tendon. J Bone
Joint Surg Am. 2002;84-A:2203–2210.
This is a biomechanical study of eight wrists (six patients) after BR transfer in an attempt to understand
and optimize intraoperative tensioning of BR to ERCB transfer and elbow position. Wrist range of
motion was assessed with the elbow at 0 and 120 degrees of flexion. During the procedure, patients
were tensioned with the use of electrical stimulation and evaluating the wrist movement in different
elbow positions. Maximum wrist extension was significantly correlated with passive flexion in all sub-
jects (r = 0.95 and p < .001 when the elbow was extended and r = 0.82 and p < .03 when the elbow
was flexed). The biomechanical model suggested that tensioning the tendon transfer so that the
fibers of the BR do not become excessively short when the elbow is flexed may improve outcomes.
The authors conclude increased tensioning intraoperatively may improve wrist extension; however,
the trade-off of overtensioning and decreasing the ability of the hand to flex and the fingers to open
needs to be considered.
Revol M, Cormerais A, Laffont I, Pedelucq, Dizien O, Servant J. Tendon transfers as applied to tetraplegia.
Hand Clin. 2002;18:423–439.
This review article provides an overview of surgery for tetraplegic patients with an excellent technical
description of the brachioradialis to extensor carpi radialis brevis transfer and postoperative manage-
ment recommendations. The senior author performed 59 transfers using BR at the time of publica-
tion with excellent results.
CHAPTER 72
Restoration of Active Key Pinch: Brachioradialis
and Pronator Teres to Flexor Pollicis Longus
Transfer
INDICATIONS
• Restoration of a strong, stable pinch between the pad of the thumb and the radio-
lateral aspect of the index finger is critical for spinal cord injury (SCI) patients. This
facilitates manipulation of small objects, including pens and utensils for writing and
feeding, respectively.
• Active key pinch can be restored in International Tetraplegia Classification (ITC) group
2 and higher patients who have intact wrist extension and expendable brachioradia-
lis (BR) or pronator teres (PT) available for transfer to the flexor pollicis longus (FPL).
• FPL activation with tendon transfer may result in exuberant IP flexion (Froment sign)
and unpredictable position of the thumb pulp with lateral portion of the index finger.
In this situation, a split FPL to extensor pollicis longus (EPL) may be performed to
minimize excessive thumb interphalangeal (IP) flexion. In addition to the BR to FPL
transfer, thumb carpometacarpal (CMC) arthrodesis or metacarpophalangeal (MCP)
capsulodesis may also be performed if laxity is noted at the respective joints.
• An organized examination of the entire upper extremity is performed, with focus on
the BR and PT as donor muscles. Muscles must be at least Medical Research Coun-
cil (MRC) grade 4 for transfer because often one grade of muscle strength is lost in
transfer. See Chapter 69 for details.
• Assess the patient’s ability to perform lateral pinch with wrist in flexion, neutral, and
extension to assess motion with tenodesis. The thumb must lie in a position so that
it can oppose to the radial surface of the index finger to establish key pinch. If it does
not, other procedures may be necessary to place the thumb or index finger in a more
favorable position.
• Assess the patient’s two-point discrimination (2PD) at the thumb and index finger-
tips; 2PD must be less than 10 mm to avoid a “visual pinch.”
IMAGING
If a joint is immobile, obtain plain radiographs to evaluate for arthrosis.
SURGICAL ANATOMY
• The BR originates from the lateral supracondylar ridge of the humerus and inserts
onto the radial styloid. It is innervated on its deep surface directly by the radial nerve
above the elbow.
• The PT originates from the medial epicondyle and coronoid process of the ulna and
inserts on the volar radial aspect of the midradial shaft.
• The FPL is found deep in the volar forearm compartment and originates from the
radius; it inserts on the base of the distal phalanx of the thumb.
• The radial artery is interposed between the BR and flexor carpi radialis (FCR).
• The superficial radial nerve lies deep to the BR muscle proximally; at 7 cm proximal
to the wrist crease, it pierces the fascia to lie in a more superficial plane.
POSITIONING
The patient is placed supine with the arm supinated and extended on a hand table.
566
CHAPTER 72 Restoration of Active Key Pinch: Brachioradialis and Pronator Teres to Flexor Pollicis Longus Transfer 567

• A 6-cm incision in the distal-middle third of the forearm can be used to expose the With a single large incision, care must be taken to
FPL, BR, and PT (Fig. 72.1). not transect the radial artery.
• Alternatively, an 8- to 10-cm lazy-S incision can be made over the distal two-thirds
of the forearm. This incision is utilitarian and permits access to the BR, FPL, PT,
EXPOSURES PITFALLS
extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), and FCR
(Fig. 72.2). If using two incisions, be sure to leave an adequate
skin bridge separating the incisions to prevent
• Subcutaneous flaps are elevated sharply with a no. 15 blade.
ischemia and skin loss.
• Care is taken to identify and protect the radial artery and superficial branch of the
radial nerve.
Brachioradialis Transfer to Flexor Pollicis Longus

STEP 1 PEARLS
PROCEDURE
Extensive mobilization of the BR is required to
Step 1: Brachioradialis Harvest produce 3 to 4 cm of excursion. The muscle at
baseline has much less excursion than a digital
• After elevation of subcutaneous flaps, the BR tendon is identified. It is distin- flexor muscle.
guished from the ECRL and ECRB and traced distally as it inserts onto the radial
styloid (Fig. 72.3).
STEP 1 PITFALLS
• Sharply transect the BR tendon as it inserts distally onto the radial styloid just un-
derneath the first dorsal extensor compartment muscles. Carefully identify and protect the superficial radial
• Elevate the BR on its deep surface from distal to proximal; ensure 3 cm of excursion nerve and radial artery during the dissection.
The radial recurrent vessels typically indicate the
(Fig. 72.4). proximal extent of the dissection.
FIGURE 72.1 The BR and FPL can be assessed using a distal forearm
dorsoradial incision. BR, Brachioradialis; FPL, flexor pollicis longus. FIGURE 72.2 Lazy S incision over the volar and dorsoradial forearm.
Brachioradialis
Brachioradialis
FIGURE 72.3 The BR (black arrow) is identified and distinguished from

the ERCL by its insertion onto the radial styloid. BR, Brachioradialis; FIGURE 72.4 The brachioradialis is transected as distally as possible.
ERCL, extensor radialis carpi longus. The dissection proceeds proximally to achieve adequate excursion.
568 CHAPTER 72 Restoration of Active Key Pinch: Brachioradialis and Pronator Teres to Flexor Pollicis Longus Transfer
STEP 2 PEARLS
Step 2: FPL Isolation and Tendon Weave
• In the volar forearm, incise the sheath of the FCR and retract it ulnarly to identify the
• Pull on the FPL tendon to confirm thumb IP
flexion if necessary. FPL deep and radially along the deep volar compartment. Incise the FPL tendon sheath
• Both end-to-side and end-to-end tendon and transect the FPL tendon just proximal to the pronator quadratus (Fig. 72.5A–B).
transfers have been described for the FPL. An • Tunnel the BR toward the FPL tendon deep to the radial artery and venae comitantes
end-to-end repair provides a direct line of pull. (Fig. 72.6).
• If the FPL muscle has some weak residual • The BR is woven into the FPL tendon using 2-0 braided nonabsorbable suture, be-
function, an end-to-side repair is preferred to
augment the pinch. ginning the first weave at the musculotendinous junction (see Fig. 72.6).
• With 20 degrees of wrist extension, the thumb • Tension is set such that the thumb and index finger come together in lateral pinch
should come into a key pinch position. with the wrist in neutral and elbow at 45 degrees of flexion. Perform two to three
additional weaves for strength.
STEP 2 PITFALLS
Step 3: Closure
• Ulnar to the FPL are the flexor superficialis
• The incision is closed in layers with absorbable sutures.
tendons and median nerve. Identify the median
nerve before division of any tendons. • The patient is placed in a thumb spica splint with the wrist and thumb in neutral.
• Setting tension with the elbow in full
extension will lead to a loose tendon transfer Pronator Teres Transfer to Flexor Pollicis Longus
postoperatively.
PROCEDURE
STEP 1 PEARLS Step 1: Pronator Teres Harvest
Maintaining a strip of periosteum is key to permit • Through a dorsoradial incision over the middle third of the forearm, the muscles of
the PT to reach the FPL tendon and to create a the ERCL and BR are identified. These are mobilized and retracted.
strong transfer repair.
Brachioradialis
FPL
A
Brachioradialis
Flexor
pollicis longus
FIGURE 72.5 In the volar compartment, identify and tug on the FPL tendon to confirm function.
The BR has been transposed to the volar forearm compartment. BR, Brachioradialis; FPL, flexor
pollicis longus.
FPL and BR weave
Radius
Abductor pollicis Brachioradialis transfer

secured to radius to flexor pollicis longus
FIGURE 72.6 An end-to-end weave of FPL and BR (white arrow) creating a straight line of pull.
BR, Brachioradialis; FPL, flexor pollicis longus.
ECRB
ECRL
PT BR
FIGURE 72.7 Incise the periosteum distal to the insertion of PT. ECRB, extensor carpi radialis brevis.
ECRL, extensor carpi radialis longus; PT, pronator teres; BR, brachioradialis.
Pronator teres
FIGURE 72.8 The pronator teres is identified at its insertion over the middle radius at the tendon
condenses into the periosteum.
• The PT insertion along the midportion of the radius is identified.

STEP 1 PITFALLS
• Incise the periosteum 2 to 3 cm distal to the insertion of PT and elevate the
attached periosteum with the PT tendon using a no. 15 blade going from distal to The superficial radial nerve is identified beneath
the BR and is retracted toward the BR.
proximal (Figs. 72.7–72.9). Mobilize for approximately 3 cm of excursion.
570 CHAPTER 72 Restoration of Active Key Pinch: Brachioradialis and Pronator Teres to Flexor Pollicis Longus Transfer
BR PT PQ
FCR FPL
FIGURE 72.9 Elevate the periosteum with PT tendon. BR, brachioradialis; PT, pronator teres;
FCR, flexor carpi radialis; FPL, flexor pollicis longus; PQ, pronator quadratus.
STEP 2 PEARLS
Step 2: Isolation of Flexor Pollicis Longus and Tendon Weave
• Identification of FPL in the deep volar compartment is performed, as for BR transfer.
If the PT cannot reach the FPL tendon, an
interposing tendon graft may be necessary. • Tunnel PT under BR into the volar wound for direct end-to-end transfer.
• The PT and attached periosteum are woven to the distal FPL tendon and secured to
2-0 braided nonabsorbable suture.
• Tension is set with the thumb in flexion.
Step 3: Closure
• The incisions are closed in layers with interrupted and running absorbable monofila-
ment suture.
• The patient is placed in a short-arm thumb spica splint.

• Patients are immobilized in a volar splint with wrist in neutral for 6 weeks, followed
by occupational therapy and rehabilitation thereafter. Resistance and strengthening
start after 8 weeks.
• A 2 kg lateral pinch is typically achieved with this transfer, providing the patient with
sufficient and sustainable strength for activities of daily living.
• The elbow is not immobilized postoperatively. The tendon repair is strong enough to
withstand any forces caused by elbow movement.
See Video 64.2
EVIDENCE
Frieden J, Shillito M, Chehab E, Finneran JJ, Ward SR, Lieber RL. Mechanical feasibility of immediate
mobilization of the brachioradialis muscle after tendon transfer. J Hand Surg Am. 2010;35:1473–1478.
This biomechanical study tested the necessity of elbow immobilization after BR-to-FPL transfer to key
pinch. They performed eight end-to-side BR-FPL transfers in fresh frozen cadavers using 3-0 braided
polyester suture. A 5-cm-long repair region was created. Tension was measured across the BR-
to-FPL repair at various elbow and wrist angles. The repairs were tested to failure, which was
203 give or take 19 N. This is over 10 times the load that would be expected to occur at the repair
site with elbow and wrist motion. The authors conclude that immediate mobilization of the elbow is
unlikely to result in tendon transfer failure and suggest immobilization overall may be unnecessary
after multiple tendon transfers in the forearm. This study does not account for the effects of living
tissue or true active motion (Level V evidence).
Mohindra M, Sangwan S, Kundu ZS, Gogna P, Tiwari A, Thora A. Surgical rehabilitation of a tetraplegic
hand: Comparison of various methods of reconstructing an absent pinch and hook. Hand (N Y).
2014;9:179–186.
This is a retrospective cohort study of 29 surgeries performed in 18 patients with spinal cord injuries
distal to C6 with at least grade 3 elbow extension with minimal hand function. Fourteen patients had
procedures to reestablish key pinch. Of these patients, 11 limbs were reconstructed with BR to FPL
transfer and 11 patients were reconstructed using PT-to-FPL transfer. Mean follow-up was 32
months and functional outcome was assessed using the modified Lamb and Chan score. For key
pinch, BR and PT to FPL transfers were found to be equally effective.
Waters R, Moore KR, Graboff S, Paris K. Brachioradialis to flexor pollicis longus tendon transfer for
active lateral pinch in the tetraplegic. J Hand Surg Am. 1985;10:385–391.
This is a retrospective review of 17 hands in 15 patients with posttraumatic spinal cord patients who
had BR to FPL transfer for active pinch. In addition, IP joint fixation was performed in 16 thumbs and
tenodesis of the EPL and EBP tendons to the metacarpal was performed in 11 patients. Mean age
was 32 years and mean postoperative follow-up was 2.3 years. Functional improvement was noted in
15 hands and 80% of the patients could name at least four activities of daily living that were now
possible or made more efficient as a result of surgery. With the elbow flexed to 90 degrees, the
average lateral pinch was 3.9 pounds with the wrist extended to 30 degrees, 4 pounds with the
wrist in the neutral position, and 2.3 pounds with the wrist flexed 30 degrees. There was a direct
correlation between pinch strength and the amount of residual triceps and wrist extensor strength
(Level III evidence).
House JH, Gwahmey FW, Lundsgaard DK. Restoration of strong grasp and lateral pinch in tetraplegia
due to cervical cord injury. J Hand Surg Am. 1976;1:152–159.
This article describes the classic technique for lateral pinch restoration.
House JH, Shannon MA. Restoration of strong grasp and lateral pinch in tetraplegia: A comparison of
two methods of thumb control in each patient. J Hand Surg Am. 1985;10:21–29.
This article compares two methods of thumb reconstruction techniques for six tetraplegic patients.
Each patient serves as their own control. One patient group underwent ECRL to FDP (2–5); PT to
FPL; BR to APB opponensplasty; EDC, EPL, APL tenodesis; and free graft intrinsic reconstruction.
The other group had ECRL to FDP (2–5); PT to FPL; FDS lasso 2 to 5; thumb CMC arthrodesis; BR
to EDC; and EPL. The average follow-up was 50 months and all patients reported improved ability to
complete activities of daily living. The side with opponensplasty had stronger pinch compared with
those who underwent CMC arthrodesis, who had stronger grasp. Patients tended to use each hand
for specific tasks and the authors advocate using differential reconstructive techniques for each hand
to allow specialization.
CHAPTER 73
Restoration of Passive Key Pinch
INDICATIONS
• In group 1 patients, the brachioradialis (BR) is available for tendon transfer to provide
wrist extension.
• After restoration of wrist extension, tenodesis can create passive lateral key pinch,
leading to significant improvement in a patient’s independence and ability to ma-
nipulate objects.
• In addition to thumb interphalangeal (IP) flexion, restoration of key pinch may require
adjunctive procedures, including thumb carpometacarpal (CMC) joint fusion (see
Chapter 45), thumb metacarpophalangeal (MCP) capsulodesis, extensor pollicis
longus (EPL) tenodesis, split flexor pollicis longus (FPL) to EPL transfer for IP stabi-
lization, and index finger lasso for flexion tenodesis, to optimize key pinch.
• Moberg described the original technique for restoration of passive key pinch. First, BR
to extensor carpi radialis brevis (ECRB) tendon transfer for wrist extension is per-
formed, followed by FPL tenodesis and thumb IP arthrodesis. In patients with a mobile
thumb, MCP, EPL, and extensor pollicis brevis (EPB) tenodesis are also performed.
• Alternatively, the following procedures can be performed for passive key pinch to
maximize stability and increase strength:
• FPL tenodesis to the volar radius to provide passive key pinch during wrist extension.
• Split FPL-to-extensor pollicis longus (EPL) transfer to stabilize the thumb inter-
phalangeal (IP) joint during flexion to avoid the flexed IP joint posture that is not
functional.
• EPL and abductor pollicis longus (APL) tenodesis to the dorsal and lateral radius,
respectively, to allow the thumb to abduct and extend during wrist flexion for the
release phase of key pinch.
• Flexor digitorum superficialis (FDS) lasso procedure if the index finger metacar-
pophalangeal (MCP) joint flexion is deemed inadequate for key pinch.
• Setting tension in the procedures optimizes result. The surgeon must pay attention
to the posture of thumb and digits with the wrist in neutral, flexion, and extension at
the time of surgery.
• Patients capitalize on the tenodesis effect and use wrist extension to increase the
passive tenodesis force on the finger flexors that promotes strong finger flexion.
• A comprehensive examination of the entire upper extremity is performed. See
Chapter 69 for details.
• The thumb is examined for resting position and stability. Passive flexion and exten-
sion of the thumb is tested at the IP, MCP, and CMC joint.
• The position and stability of the index finger are examined. The goal is to determine
whether the index finger can serve as a good opposing surface for key pinch.
SURGICAL ANATOMY
• The relevant anatomy is illustrated (Fig. 73.1).
• The FPL, which originates from the volar radius, travels through the carpal tunnel,
enters the thumb tendon sheath, and inserts on the base of the distal phalanx.
• The APL radially abducts the thumb and originates from the posterior radius, travels
through the first dorsal compartment, and inserts on the base of the thumb metacarpal.
• The EPL originates from the middle one-third of the dorsal ulna, travels through the
third dorsal compartment ulnar to the Lister tubercle, and inserts on the dorsal surface
at the base of the distal phalanx.
572
Extensor
pollicis longus
Extensor
pollicis brevis
Extensor carpi
Radial artery radialis brevis
Abductor Extensor carpi
pollicis longus radialis longus
Brachioradialis
FIGURE 73.1 Surgical anatomy.
POSITIONING
• The patient is placed in the supine position and the affected arm is extended on the
hand table.
• A tourniquet is applied to the upper arm.
Split FPL-to-EPL Tendon Transfer

EXPOSURES
• A midaxial incision on the radial aspect of the thumb is made from the MCP joint to
the IP joint (Fig. 73.2).
• The radial neurovascular bundle is protected and retracted volarly exposing the
flexor tendon sheath.
FPL
FIGURE 73.2 Via a radial midaxial incision, the FPL tendon (black arrow) is identified and the A2 pulley
is released. The neurovascular bundle is identified and elevated with the volar skin flap. FPL, Flexor
pollicis longus.
574 CHAPTER 73 Restoration of Passive Key Pinch
Ulnar ½ FPL
Radial ½ FPL
FIGURE 73.3 Radial half of FPL held in forceps is transected and dissected proximally for length.
The ulnar half of FPL remains in situ. Note the oblique pulley is left intact. FPL, Flexor pollicis longus.
Split FPL tendon
EPL
Radial half FPL
FIGURE 73.4 The radial half of FPL (black arrow) is weaved into EPL tendon (white arrow) and held to the appropriate
tendon. FPL, Flexor pollicis longus.
STEP 1 PEARLS
Step 1: Release of the Radial Half of Flexor Pollicis Longus
• The IP joint can be flexed to provide access to • Dissect toward the volar surface of the thumb and identify the FPL insertion onto the
the distal FPL tendon.
• Identify and protect the thumb radial neurovas- distal phalanx. Identify and release the A2 pulley (Fig. 73.3).
cular bundle (NVB), keeping them with the • The FPL sheath is incised longitudinally, and the radial half of the FPL tendon is
volar skin flap. detached at its insertion on the distal phalanx and dissected proximally for adequate
• Preserve the thumb oblique pulley to prevent length to reach the EPL dorsally at the IP joint (Fig. 73.4).
bowstringing of remaining tendon.
• If enough FPL length is not achieved, the Step 2: Transfer to the Extensor Pollicis Longus
tendon can be split to a more proximal level
and brought out between the interval of the • From the midaxial incision, dissect dorsally toward the EPL or make a separate
A2 and oblique pulleys. dorsal incision on the dorsum of the IP joint to expose the extensor hood.
• Make a longitudinal slit in the radial side of the EPL tendon.
• Tunnel the harvested FPL tendon slip subcutaneously to the dorsal side of the
thumb and perform a tendon weave of the split FPL-to-EPL twice over, using 3-0
braided nonabsorbable suture (Fig. 73.5).
• Aim for neutral IP position when setting tension.
Split FPL
sutured to EPL
FIGURE 73.5 Pulvertaft weave (arrow) of split FPL-to-EPL with nonabsorbable suture. EPL, Extensor pollicis longus; FPL,
flexor pollicis longus.
STEP 2 PEARLS
• FPL-to-EPL transfer is performed before FPL
Flexor Pollicis Longus Tenodesis to Volar Distal Radius tenodesis or functional transfers such as BR to
FPL. The FPL-to-EPL sets the tension for the IP
EXPOSURES joint and aids in setting tension for proximal
transfers that will affect the MCP joint in addi-
A 6-cm longitudinal incision is made on the volar aspect of the distal forearm over the tion to the IP joint.
flexor carpi radialis (FCR) tendon. • Exposure of the FPL tendon in the distal forearm
is necessary for simultaneous procedures, such
Step 1: Flexor Pollicis Longus Harvest as FPL tenodesis or BR-to-FPL tendon transfer.
Exposing the FPL tendon in the distal forearm
• The fascia under the FCR tendon is incised and the FPL tendon is identified in the
aids in setting tension for the split FPL tendon
forearm, deep and radial. transfer at the IP joint. The surgeon can place
• The FPL tendon is divided at the proximal edge of the pronator quadratus (PQ). traction to the proximal FPL tendon and watch
IP motion to ensure that there is enough tension
Step 2: Flexor Pollicis Longus Tension Set on the transfer to keep the thumb IP joint neu-
tral during FPL activation and key pinch.
• The FPL is secured to the volar cortex of the radius with a mini bone suture anchor
(Mitek Mini anchor) at the distal edge of the PQ. If an anchor is not available, the
STEP 2 PEARLS
tendon can be secured to the bone using drill holes with the sutures tied over the
opposite cortex. • Wrist extension enables the thumb pulp to
• Tension is set with the wrist in neutral. press the radial side of the index finger.
• Wrist flexion enables the thumb to fall away
and open the hand.
Flexor Pollicis Longus Tenodesis to the Dorsal Distal Radius • Tenodesis of the FPL produces a weak pinch,
motored by active wrist extension.
(Alternative to “Moberg-Brand” Flexor Pollicis Longus
Tenodesis)
STEP 2 PITFALLS
EXPOSURES • Avoid A1 pulley release because A2 is released

for split FPL-to-EPL transfer. Release of all
• A longitudinal incision is made on the volar aspect of the distal forearm over the FCR pulleys may result in slight bowstringing of the
tendon (Fig. 73.6A). tendon near the MCP joint, which can increase
• An incision over the hypothenar eminence is required to expose the hook of hamate flexion force.
(see Fig. 73.6A).
• A third radial midaxial incision along the thumb exposes the MCP and IP (see
Fig. 73.6A).
FPL tendon passed around FDS as a pulley
FPL tenodesed to volar radius
Thumb positioned for lateral pinch
FIGURE 73.6 (A) For FPL tenodesis, three incisions are required at the following locations: the base
of thumb, the hypothenar eminence, and the volar forearm. The FPL was ident ified in the forearm
and transected at the musculoskeletal junction. It was retrieved at the base of the thumb, then
rerouted around the FDS (black arrow) to create the appropriate line of pull. (B) The FPL has been
rerouted around FDS in the ulnar palm, and then transferred to the volar forearm for FPL tenodesis
to the radius. (C) Tension set with wrist in neutral and the thumb is in position for lateral pinch
against the proximal phalanx of the index finger. FDS, Flexor digitorum superficialis; FPL, flexor
pollicis longus. (From Figure 73.6A–B from Neligan, PC, ed. Plastic Surgery. 4th ed. Elsevier; 2017.)

Preserve the A1 pulley because A2 is released for • Make a radial midaxial incision along the thumb and expose the flexor sheath of the
split FPL-to-EPL. thumb IP and MCP joints.
• Identify the FPL just proximal to the A1 pulley (see Fig. 73.6C).
STEP 2 PEARLS
Step 2
Stay on the radial side of FCR to avoid injury to the Make a volar radial forearm incision. Identify the interval between the FCR and PL.
median nerve.
Open the FCR sheath and sweep the muscle ulnarly. The FPL is identified deep and
radial. The muscle tendon junction of the FPL is divided as proximal as possible and
the tendon is retrieved in the thumb incision.

• Make an incision at the hypothenar region of the palm to expose the hook of hamate Redirection of the FPL around the ulnar-sided
and the Guyon canal (see Fig. 73.6A). flexors creates a more favorable FPL flexor moment.
• Dissection is carried down to the hypothenar fat pad. The ulnar nerve and artery are
identified and retracted. The flexor tendons of the small and ring fingers are identi-
fied, and a tendon passer is passed dorsal to the tendons toward the thumb incision
where the distal FPL tendon is retrieved (see Fig. 73.6A).
Step 4
• A tendon passer is placed from the volar forearm into the hypothenar incision and
used to retrieve the FPL tendon in the volar incision (see Fig. 73.6B).
• A 4-mm drill hole is made in the radius from volar to dorsal. An incision is made
dorsally where the drill exits. A suture passer (with 3-0 monofilament) is passed
through the hole to retrieve the FPL, and pulled from volar to dorsal. Tension is set
such that the thumb pulp touches the distal radial side of the index finger with the
wrist neutral (see Fig. 73.6B).
• Check tenodesis, thumb flexion with wrist extension, and thumb extension with wrist
flexion. A vascular clip or bone anchor can be used to hold the tendon in place (see
Fig. 73.6C).
Step 5
Perform a layered closure of all incisions.
Extensor Pollicis Longus and Abductor Pollicis Longus

Tenodesis to Dorsal/Lateral Radius
EXPOSURES
A 6-cm longitudinal incision is made on the dorsoradial aspect of the wrist, extend-
ing proximally from the radial styloid, and is used to expose both the APL and EPL
tendons.
Step 1: APL and EPL Isolation

• The APL tendon is identified proximal to the extensor retinaculum as it enters the
first extensor compartment as the most radial structure, and it is divided at the level
of the musculotendinous junction (Fig. 73.7A).
• The EPL tendon is identified on the dorsoradial incision, ulnar to the Lister tubercle
as it enters the third extensor compartment.
Step 2: APL Tenodesis

• The APL tendon is retrieved distally from the first extensor compartment. The
proximal end of the APL tendon is fixed to the dorsolateral side of the radius with a
bone suture anchor (see Fig. 73.7B–C).
• Tension is set so that full thumb abduction is achieved when the wrist is in maximal
flexion.
Step 3: EPL Tenodesis

• The EPL tendon is divided proximal to its entrance into the third extensor compart- STEP 3 PEARLS
ment (Fig. 73.8A). Alternatively, the EPL tendon can be divided and
• The distal end of the EPL tendon is looped around the Lister tubercle radially. rerouted through the first dorsal compartment. This
makes the EPL more of a thumb abductor, which
• The tendon end is sutured to the extensor retinaculum or the bone (see Fig. 73.8B).
can make it easier to open the hand to grasp.
• The thumb position is set tightly enough to permit full thumb opening with pas-
sive wrist flexion and full passive thumb flexion with passive wrist extension
(Fig. 73.9A–B).
Stitches from
Mitek Mini anchor
Radius
Abductor pollicis
Abductor longus secured
pollicis to radius using
longus Mitek Mini anchor
B C
FIGURE 73.7 (A) The APL tendon is isolated (black arrow) and passive motion demonstrates abduction (white arrow).
(B) A drill hole and suture anchor are placed in the distal radius (yellow arrow); the APL tendon is positioned for tenodesis
(black arrow). (C) The APL is tenodesed to the distal radius. APL, Abductor pollicis longus.
A B
FIGURE 73.8 (A) EPL is identified and transected. (B) EPL is retrieved with mosquito, looped around the Lister tubercle, and anchored to the extensor
retinaculum. EPL, Extensor pollicis longus.
A B
FIGURE 73.9 (A–B) Wrist flexion produces passive thumb extension and abduction and extension produces adduction and key pinch.
Flexor Digitorum Superficialis Lasso Procedure for

the Index Finger
EXPOSURES
A 3-cm longitudinal Bruner incision is made over the palmar aspect of the index finger
MCP joint (Fig. 73.10).
STEP 1 PEARLS
Step 1: Pulley Exposure
• The A1 and A2 pulleys are clearly identified in the midline. The Zancolli lasso procedure helps initiate MCP
flexion as the first stage of digital grasp, followed
• Use the forceps to grasp on the A1 pulley and pull it proximally to simulate MCP joint by proximal interphalangeal (PIP) and finally distal
flexion. If grasping the A1 pulley alone does not cause MCP flexion, the proximal part of interphalangeal (DIP) flexion for patients with claw
A2 should be included. This will place the flexion force more distal to ensure MCP flexion. finger deformity. The procedure changes the FDS
• A transverse incision is made distal to the pulley. Flex the finger and identify the from a PIP flexor to an MCP flexor. This procedure
radial and ulnar slips of the FDS tendon. will facilitate the thumb pulp to abut the radial side
of index middle phalanx during key pinch.
Step 2
• Place a suture in the FDS tendon to minimize retraction and divide both slips of the STEP 2 PEARLS
FDS tendon over the proximal end of the A2 pulley (Fig. 73.11). Release the tendon
If inclusion of part of the A2 pulley is necessary
slips from the surrounding attachments.
for MCP flexion, a separate incision near the FDS
• The FDS tendons are flipped over the distal edge of A1 pulley, to secure it to itself, insertion will facilitate distal harvest. This way,
over to the proximal FDS tendon with 3-0 or 4-0 nonabsorbable braided mattress enough tendon length is present to loop over the
sutures (Fig. 73.12). This lasso concept uses the A1 pulley that wraps around the pulley.
MCP to flex this joint.
• Tension is set with the wrist in neutral and the index MCP flexed at 50 to 60 degrees. STEP 2 PITFALLS
POSTOPERATIVE CARE AND EXPECTED OUTCOMES When the tension of the FDS over the pulley is
checked with the wrist extended, the MCP joints
• Patients are placed in a volar thumb spica splint at the time of the operation. should flex. As the wrist is passively flexed, the
• Sutures are removed and the patient is transitioned to an orthoplast splint at MCP joint should extend fully but not hyperextend.
2 weeks postoperatively. The orthosis facilitates key pinch by flexing the index finger
and stabilizing the MCP joint of the thumb.
FIGURE 73.10 Bruner incision over index finger A1 pulley.

Opened
A2
Cut
FDS
A1
FIGURE 73.11 The FDS radial and ulnar slips are transected (black arrow); the Al pulley remains in-
tact (white arrow). FDS, Flexor digitorum superficialis. (From Wolfe S, Pederson W, Kozin SH, Cohen
M, eds. Green’s Operative Hand Surgery. 7th ed. Elsevier; 2017:1122–1145.)
FDP
A1
FIGURE 73.12 The FDS is looped over the A1 pulley and secured with multiple sutures. FDS, Flexor digi-
torum superficialis. (From Wolfe S, Pederson W, Kozin SH, Cohen M, eds. Green’s Operative Hand Sur-
gery. 7th ed. Elsevier; 2017: 1122–1145.)
• At 4 weeks, mobilization of the tendon transfers is started.

• With therapy, patients can gain excellent improvement in pinch function.
• In general, 2 kg of key pinch strength is considered ideal for many daily tasks.
• A total passive pinch reconstruction will have limited strength, usually 1 kg or less.
See Video 65.3
EVIDENCE
Revol M, Cormerais A, Laffont I, Pedelucq, Dizien O, Servant J. Tendon transfers as applied to
tetraplegia. Hand Clin. 2002;18:423–439.
The aforementioned two review articles provide an overview of surgery for tetraplegic patients with
technical descriptions of procedures performed to restore passive key pinch.
Freehafer AA, Kelly CM, Peckham H. Tendon transfer for the restoration of upper limb function after
cervical spinal cord injury. J Hand Surg. 1984;9A:887–893.
This classic article describes the senior author’s 22 years of experience performing a number of
procedures for tetraplegic patients, including passive tenodesis for patients with high-level cervical
spine injuries, and provides the reader with an excellent overview of the various types of surgeries
used for reconstruction of the tetraplegic limb.
CHAPTER 74
Restoration of Active Pinch and Grasp: Extensor
Carpi Radialis Longus Transfer to Flexor Digitorum
Profundus
INDICATIONS
• Performed in patients with intact wrist extension supported by the extensor carpi
radialis brevis (ECRB) who require transfer for active finger flexion.
• Patients must be at least class 3 on the International Classification for Surgery of the
Hand in Tetraplegia scale (see Table 69.2), with an expendable extensor carpi radia-
lis longus (ECRL) that can be transferred without compromising wrist extension.
• This transfer enables active grasp and can be tailored to achieve normal (fingers with
increased degree of interphalangeal [IP] flexion in the index to small finger direction)
or “reverse” cascade (fingers with decreased degree of IP flexion in the index to
small finger direction).
• This transfer is synergistic, using a wrist extensor to achieve finger flexion.
• This procedure can also be used in patients with combined median/ulnar nerve injury
(See Chapter 67 Tendon Transfers for Combined Nerve Palsy).
• An organized examination of the entire upper extremity is performed. See Chapter 69
Tendon and Nerve Transfers for Spinal Cord Injury Patients for details.
• Patients who are candidates for extensor carpi radialis longus (ECRL) transfer have
functional elbow and wrist extension and desire better pinch and grasp function.
• It is important to ensure adequate ERCB function to maintain wrist extension after
ECRL transfer.
IMAGING
Standard radiographs of the elbow, wrist, and hand are helpful if the patient has clinical
findings of joint stiffness or contracture or to evaluate for arthritis. Patients with signifi-
cant arthrosis and lack of passive range of motion (ROM) are not candidates for tendon
transfer.
SURGICAL ANATOMY
• The ECRL originates from the lateral supracondylar ridge of the humerus and inserts
onto the dorsal base of the index finger metacarpal. It is innervated by the radial
nerve above the elbow and receives blood supply from the radial artery. This muscle
is responsible for wrist extension and radial deviation.
• The flexor digitorum profundus (FDP) originates from the proximal ulna and interos-
seus membrane and inserts at the volar distal phalanx of index, middle, ring, and
small fingers. It is found in the deep volar forearm compartment and its blood supply
comes from the anterior interosseus artery. It has dual innervation; the index and
middle fingers are innervated by the median nerve and the ring and small fingers are
innervated by the ulnar nerve. The index finger tendon often has a separate muscle
belly.
• The median nerve enters the forearm between the superficial (humeral) and deep
(ulnar) heads of the pronator teres (PT) muscle. After emerging from the PT, the me-
dian nerve passes deep to the arch created by the two heads of the flexor digitorum
superficialis (FDS). The nerve continues distally in the forearm between the FDS and
582
CHAPTER 74 Restoration of Active Pinch and Grasp: Extensor Carpi Radialis Longus Transfer to Flexor Digitorum Profundus 583
FIGURE 74.1 Dorsal radial incision to expose extensor carpi radialis longus FIGURE 74.2 Volar forearm incision (red oval) used to assess flexor
(ECRL). digitorum profundus (FDP) in the deep volar compartment. Note the
zigzag extension across the wrist crease used to harvest the palmaris
longus with palmar fascia for an additional transfer.
FDP and becomes superficial approximately 5 cm proximal to the wrist, emerging

between the flexor carpi radialis (FCR) and palmaris longus (PL) tendons.

The patient is placed supine with the arm extended on a hand table. In many cases this procedure is combined with
other transfers, including BR-to-flexor pollicis
EXPOSURES longus (FPL) and FPL-to-extensor pollicis longus
(EPL) tenodesis to maximize thumb function.
• A longitudinal dorsal radial incision is used to expose the ECRL (Fig. 74.1). • A single utilitarian incision can often be used
• A longitudinal volar incision is used to expose the FDP (Fig. 74.2). to provide access to the ECRL, FDP, BR, and
FPL.
PROCEDURE
Step 1: Mobilization of the Extensor Carpi Radialis Longus
• After making the dorsal longitudinal incision, dissect down to the muscle fascia. The STEP 1 PEARLS
ECRL tendon is identified and detached from its insertion onto the base of the index The excursion of wrist extensors is 33 mm compared
finger metacarpal (Fig. 74.3A–B). with that of the primary finger flexors, which is
70 mm. Adequate mobilization is necessary to
• The ECRL is delivered proximal to the extensor retinaculum and dissected for suf-
maximize muscle excursion and achieve an optimal
ficient length. The ECRB is seen just ulnar to the ECRL as it inserts onto the base of result.
STEP 1 PITFALLS
Identify the ECRB tendon distally to ensure that
BR the correct tendon is being transected. The ECRB
inserts on the long finger metacarpal. Transection
of the wrong tendon will sacrifice the patient’s
ability to extend the wrist.
ECRL
Brachioradialis
Incision
B Extensor carpi radialis brevis

FIGURE 74.3 (A–B) Via the dorsoradial incision, the extensor carpi radialis longus (ECRL) is identified
dorsal to the brachioradialis (BR), inserting onto the base of the index finger metacarpal.
584 CHAPTER 74 Restoration of Active Pinch and Grasp: Extensor Carpi Radialis Longus Transfer to Flexor Digitorum Profundus
PL
FDP

Median nerve
Flexor digitorum profundus Flexor digitorum superficialis

(transected)
B
FIGURE 74.4 (A–B) Via a volar forearm incision, the flexor digitorum profundus (FDP) tendons are identified deep
to the flexor digitorum superficialis (FDS) tendons and median nerve. Note the FDP tendons are sutured together
before extensor carpi radialis longus (ECRL) transfer.
the long finger metacarpal. The BR is just radial and can be seen inserting onto the
radial styloid.
• Ensure enough proximal dissection to permit rotation for a straight line of pull to the
finger flexors.
STEP 2 PEARLS
• Identify and protect the median nerve, which Step 2: Identification of the Flexor Digitorum Profundus Tendons
is found between the FDS and FDP, before • Through a radial volar wrist incision, the FDS tendons are identified in the intermedi-
cutting any tendon. ate compartment and retracted ulnarly.
• The FDP tendons can be transferred individually • The flexor profundus tendons of the index, middle, ring, and little finger are identi-
or together as one unit.
• Ensure that the FDP to the index finger (sepa- fied. Transect the FDP tendons at the musculotendinous junction and suture them
rate muscle belly) is included with the FDP to together (Fig. 74.4A–B).
the middle, ring, and small fingers.
Step 3: Transfer of the ECRL
Tunnel the ECRL muscle subcutaneously into the volar forearm underneath the super-
STEP 3 PEARLS
ficial radial nerve and radial artery (Fig. 74.5A–B).
The subcutaneous tunnel should be directed to
provide the ECRL with a straight line of pull. Step 4: Tendon Repair
• Perform several Pulvertaft weaves of the ECRL and FDP tendon mass with 2-0 non-
STEP 4 PEARLS absorbable sutures (Fig. 74.6). This can be done in an end-to-side or end-to-end
fashion. A normal or reverse cascade can be performed.
• The tension is set loosely enough to permit easy
release of the fingers during passive wrist flexion. • Final tension should be set so that the index and thumb come together in a lateral
• With end-to-side transfer, some surgeons be- pinch with the wrist in approximately 20 degrees of extension and the elbow at
lieve the risk for tendon rupture is decreased, 90 degrees (Fig. 74.7).
compared with an end-to-end repair. For the
ECRL to FDP transfer, we prefer end-to-end Step 5: Closure
transfer to gain the maximum excursion.
• A reverse or normal cascade can be performed. • A layered closure is performed with absorbable suture.
With the reverse cascade, some surgeons be- • The patient is placed in a dorsal wrist splint with the wrist at 30 degrees of flexion to
lieve this maximizes the use of the radial digits take tension off the tendon repair.
with the thumb and therefore it is desirable if
the index finger has the most tension and POSTOPERATIVE CARE AND EXPECTED OUTCOMES
progress to the least tension going ulnarly.
• After 1 week, the patient is transitioned to a thermoplastic splint for 4 weeks.
CHAPTER 74 Restoration of Active Pinch and Grasp: Extensor Carpi Radialis Longus Transfer to Flexor Digitorum Profundus 585
ECRL FDP
Extensor carpi radialis longus Radial Radial

nerve artery
Flexor digitorum profundus Median Flexor digitorum superficialis

nerve
B
FIGURE 74.5 (A–B) The extensor carpi radialis longus (ECRL) has been tunneled toward the volar forearm
compartment in preparation for tendon transfer to the flexor digitorum profundis (FDP).
FIGURE 74.6 Multiple Pulvertaft weaves performed between the exten-

sor carpi radialis longus (ECRL) and flexor digitorum profundus (FDP)
tendons.
FIGURE 74.7 Tension is set so that in wrist extension, the fingers

flex at the metacarpophalangeal (MCP), proximal interphalangeal
(PIP), and distal interphalangeal (DIP) joints (left). The MCPs
extend when the wrist is in neutral.
• The tendon junction is allowed to heal for 4 weeks before mobilization.

• Patients can expect to increase their hand grasp ability and have improvement in
activities of daily living.
• Strengthening is initiated at 6 to 8 weeks postoperatively.
See Video 64.2
EVIDENCE
Fridén J, Gorhritz A. Tetraplegia management update. J Hand Surg Am. 2015;40:2489–2500.
This review article summarizes the current concepts in tetraplegia management including the neces-
sary procedures and functional priorities necessary before proceeding with key pinch reconstruction.
586 CHAPTER 74 Restoration of Active Pinch and Grasp: Extensor Carpi Radialis Longus Transfer to Flexor Digitorum Profundus
Revol M, Cormerais A, Laffont I, Pedelucq, Dizien O, Servant J. Tendon transfers as applied to tetraplegia.
Hand Clin. 2002;18:423–439.
The previous two review articles provide an overview of surgery for tetraplegic patients with technical
descriptions of procedures performed to restore active key pinch.
CHAPTER 75
Intrinsic Tendon Reconstruction
INDICATIONS
• The goal of these procedures is to correct the absence of intrinsic function in the
tetraplegic hand and to improve the functional result of extrinsic reconstruction.
• Intrinsic reconstruction can enhance grip in patients who have an extensor carpi
radialis longus (ECRL) to flexor digitorum profundus (FDP) transfer.
• Although the ECRL to FDP transfer restores finger flexion, it brings the fingertips
to the base of the fingers rather than the palm, making it difficult for the patient
to grasp large objects.
• Intrinsic reconstruction can enhance index finger metacarpophalangeal (MCP) joint
flexion for effective pinching.
• The index finger MCP flexion and additional support from the other MCP flexed
fingers are necessary because the thumb must meet the radial aspect of the digit
for effective key pinch.
• The following procedures are useful for tetraplegic patients in certain situations: in-
trinsic tenodesis using tendon graft and flexor digitorum superficialis (FDS) lasso
procedure.
Intrinsic Tenodesis Using Tendon Graft

This procedure is indicated for:
• A static reconstruction to correct MCP hyperextension and improve proximal inter-
phalangeal (PIP)/distal interphalangeal (DIP) extension.
• Most tetraplegic patients, who have few or no functional muscles for transfer
(International Classification for Surgery of the Hand in Tetraplegia [ICSHT] group
2 or less).
• Patients who have significant PIP joint flexion deformities associated with central
slip deficiency.
A single tendon graft is required to correct all four fingers simultaneously.
Flexor Digitorum Superficialis Lasso Procedure

• This dynamic reconstruction is used to correct MCP hyperextension, leading to en-
hanced posture for key pinch.
• It is indicated for tetraplegic patients with functional finger extension, who have re-
served finger extensors (ICSHT group 6 or higher) or successful reconstruction via
INDICATIONS PEARLS
nerve and tendon transfer.
• It provides added benefits for patients with a PIP joint flexion deformity from FDS • The roll-up finger occurs because finger flex-
ion begins at the DIP joint, and fingers bend
spasticity. into flexion rather than following a large arc.
• Even if the FDS tendon is paralyzed, it may be used to enhance passive flexion of • Intrinsic and extrinsic reconstruction can take
the MCP joint when the wrist is in extension. place in the same surgical session to optimize
• It is a rather simple approach that can be used for individual fingers. tendon balancing. In this scenario, a wide-
Patients should have realistic expectations, be motivated to complete postoperative awake approach is ideal.
• The intrinsic tenodesis has better physiologic
therapy, and have a stable support system. restoration than the FDS lasso procedure.
• For patients with spinal cord injury, an organized examination is necessary to docu-
ment the muscle strength of the patient’s upper limb joint flexion/extension and intrin-
sic hand function. The specific pattern of dysfunction depends on the level of injury.
• The available functional muscles are categorized using the ICSHT (Table 69.2).
• The passive range of motion (ROM) of each joint, including the shoulder, elbow,
wrist, and fingers, is assessed for joint and muscle contracture.
587
588 CHAPTER 75 Intrinsic Tendon Reconstruction
FIGURE 75.1 MCP joint hyperextension and IP joint flexion. IP, Interphalangeal; MCP, metacarpo-
phalangeal.
• The general appearance is examined because lack of intrinsic muscles can lead to
MCP joint hyperextension and IP joint flexion deformities (clawing; Fig. 75.1), resulting
in inadequate prehensile grasp and insufficient grip/pinch strength.
Bouvier Maneuver
• The examiner passively corrects the MCP joint hyperextension to check if there is
CLINICAL EXAMINATION PEARLS full active PIP joint extension.
The intrinsic muscles balance the extrinsic flexor • A positive test indicates that the central slip is intact and can function to extend the
and extensor muscles, and they provide smooth PIP joint.
grasp and release without early digital roll-up • If the PIP extensor mechanism is competent, then the patient only needs correction
movement in the functional hand.
of MCP joint hyperextension.
IMAGING
Imaging is unnecessary unless a joint lacks passive ROM. In this case, radiographs are
necessary to evaluate arthrosis at the MCP and IP joints.
SURGICAL ANATOMY
• The seven interosseous muscles (Fig. 75.2) are innervated by the deep branch of the
ulnar nerve.
• Four dorsal interosseous muscles (bipennate muscles) originate between the
metacarpals and abduct the fingers from the axial line. They act with the lumbri-
cals to flex the MCP joints and extend the IP joints.
• Three palmar interosseous muscles (unipennate muscles) are located on the pal-
mar portion of the second, fourth, and fifth metacarpals. They adduct the fingers
toward the axial line and act with the lumbricals to flex the MCP joints and extend
the IP joints.
• The lumbricals run between the metacarpals and originate from the FDP. The
median nerve innervates the first and second lumbricals. The third and fourth
lumbricals are innervated by the deep branch of the ulnar nerve. They flex the
fingers at the MCP joints and extend the IP joints (see Fig. 75.2).
• The interosseous tendons and lumbricals pass palmar to the axis of the
MCP joint to form the common intrinsic tendon, which then divides into a
medial band that inserts along with the central slip into the dorsal base of
the middle phalanx and a lateral band that continues to the dorsal base of
the distal phalanx. They couple MCP joint flexion with IP joint extension
(Fig. 75.3A–B).
POSITIONING
• The procedure is performed with the arm extended on a hand table.
• A sterile tourniquet is placed on the upper arm.
Adductor
Lumbricals pollicis
DI PI
DI
Flexor digiti minimi DI
DI PI DI
Opponens digiti minimi PI
Palmaris brevis Flexor pollicis

brevis
FIGURE 75.2 Innervation of interosseous muscles. DI, Dorsal interosseous; PI, palmar interosseous.
Intrinsic Tenodesis Using Flexor Digitorum Superficialis

Tendon Graft
PROCEDURE
Step 1: Harvest the Ring Finger Flexor Digitorum Superficialis as the
Tendon Graft
• A 4-cm straight incision is created 5 cm proximal to the wrist crease, midline on the
volar side of the forearm (Fig. 75.4A). An additional 2-cm transverse incision is cre-
ated at the base of the ring finger (see Fig. 75.4B).
• The ring finger FDS is harvested from a distal insertion incision at the base of the
ring finger
• The FDS tendon is divided sharply and as distally as possible while the ring finger is
flexing. Then the tendon is withdrawn via the volar forearm incision.
• The tendon is severed at the muscle-tendon junction and longitudinally divided into
two slips.
Step 2: Expose the Lateral Band

• Next, 3-cm curvilinear or oblique incisions are made on the dorsal-radial aspect at
the proximal phalanx level of the second to fifth fingers (Fig. 75.5).
• Subcutaneous dissection is performed to expose the lateral band from the lumbrical
canal to the central slip (Fig. 75.6).
Step 3: Pass and Anchor the Tendon Graft

• Two additional 3-cm dorsal incisions are made at the level of the index and ring
metacarpal necks (see Fig. 75.5).
Terminal tendon
Triangular ligament
Transverse retinacular ligament
Central band
Conjoint lateral band
Lateral band of intrinsic tendon

Medial band of intrinsic tendon
Central slip of long extensor tendon
Lateral slip of long extensor tendon
Common intrinsic tendon
Arciform sheet
Deep transverse metacarpal
ligament
Sagittal band
Interosseous tendon
Lumbrical tendon
Long extensor tendon
A B
FIGURE 75.3 (A-B) Anatomy of intrinsic tendons.
A B
FIGURE 75.4 (A) Incision is created 5 cm proximal to the wrist crease. (B) A 2-cm transverse incision
is planned at the base of the ring finger.
• After weaving one end of the tendon graft to the lateral bands (Fig. 75.7A), the first
FDS tendon slip is tunneled from the radial aspect of the proximal phalanx of the
index finger in the proximal direction along the lumbrical tunnel, which is palmar to
the intermetacarpal ligament (see Fig. 75.7B). Then it is tunneled across the base
of the metacarpal via the incision over the second metacarpal (Fig. 75.8A–B).
• The tendon slip is brought ulnarly under the metacarpal and distally through the
lumbrical canal to reach the radial lateral band of the middle finger.
FIGURE 75.5 Curvilinear or oblique incisions are planned for the second to fifth fingers.
STEP 3 PITFALLS
A free tendon graft has to pass volar to the joint
axis of the MCP joint and dorsal to the joint axis
of the PIP joint with a direct insertion. It pre-
vents MCP joint hyperextension and facilitates
IP joint extension and balanced digital flexion.
STEP 4 PEARLS
• Some surgeons recommend weaving to the
central slip instead of the lateral band.
• The graft could reinforce the central slip
with inadequate extensor mechanism.
FIGURE 75.6 Lateral band and slip of FDS graft. The arrow indicates the radial lateral band of the index • It is essential to avoid weaving the tendon
finger. FDS, Flexor digitorum superficialis. graft too tightly because this could limit
finger flexion.
Step 4: Suture to the Radial Lateral Bands STEP 4 PITFALLS
• With MCP joints kept in 60 degrees of flexion and PIP joints fully extended, the end After intrinsic reconstruction, the PIP joint extension
of the tendon graft is woven to the lateral bands of the respective fingers with non- and MCP flexion of all fingers have to be protected
during the remaining procedures.
absorbable sutures (Fig. 75.9).
Central slip Intrinsic tendon

Lateral band
FDS tendon slip
A B
FIGURE 75.7 (A) Weaving one end of the tendon graft to the lateral bands. (B) First FDS tendon slip is passed along the lumbrical tunnel.
FDS, Flexor digitorum superficialis.
Central slip Intrinsic tendon
FDS tendon slip

A B
FIGURE 75.8 (A-B) First FDS tendon slip is tunneled across the base of the metacarpal. FDS, Flexor digitorum superficialis.
Intermetacarpal
ligament
FDS tendon slip

Intrinsic
tendon
FIGURE 75.9 The end of the tendon graft is woven to the lateral bands. FDS, Flexor digitorum
superficialis.
• Using the other half of the FDS tendon graft, the same procedure is repeated for the
ring and little fingers (Fig. 75.10).

The incision is closed with interrupted dermal absorbable suture and running absorb-
able suture.

• With MCP joints kept at 30 degrees of flexion and PIP joints at full extension, the
hand is protected with a well-made splint for 4 weeks, followed by a blocking splint
to permit passive movement within the restraints of the splint for the next 4 weeks.
Then strengthening exercises are initiated (Fig. 75.11A–B).
FIGURE 75.10 Procedure is repeated for the ring and little fingers.
FIGURE 75.11 (A–B) Two months after left intrinsic tenodesis. The left hand showed a better intrin-
sic-balanced hand posture.
• Extrinsic reconstructive procedures done in conjunction with intrinsic reconstruc-

tions demonstrate greater grip than those done without intrinsic reconstructions.
Flexor Digitorum Superficialis Lasso Procedure

STEP 1 PEARLS
EXPOSURE Use the forceps to grasp the A1 pulley and pull
A 4-cm Bruner zigzag incision is made over the palmar aspect of the MCP joint and can it proximally to see if stimulating the A1 pulley
be extended distally to the proximal phalanx if needed (Fig. 75.12). alone can cause MCP flexion. If it does not, then
the proximal part of the A2 pulley should also be
PROCEDURE folded back because more distal flexion force is
needed to ensure MCP flexion.
Step 1: Pulley and Tendon Exposure
• The flexor tendon sheath is identified through a sharp dissection and the A1 and A2 STEP 1 PITFALLS
pulleys are clearly exposed.
Be careful to avoid injury to the digital neurovascular
• The tendon sheath is entered at the A2 pulley. The FDS tendon is identified inside
bundles, especially at the turn of the incision.
the pulley and transected as distally as possible (Fig. 75.13A–B).
FDS tendon
FIGURE 75.12 A 4-cm Bruner zigzag incision

over the MCP joint. MCP, Metacarpophalangeal.
FIGURE 75.13 (A) Tendon sheath is entered at the A2 pulley. (B) FDS tendon is identified and transected
distally. FDS, Flexor digitorum superficialis.
B
FIGURE 75.14 (A) Transected FDS tendon is folded back over the distal edge of the A1 pulley.
(B) Transected FDS tendon is secured to the FDS tendon proximal to the A1 pulley. FDS, Flexor
digitorum superficialis.
Step 2
STEP 2 PEARLS • The transected tendon end is folded back over the distal edge of A1 pulley, then
When the tension of the FDS over the pulley secured to the FDS tendon proximal to the A1 pulley with nonabsorbable sutures
is checked with the wrist passively flexed, the (Fig. 75.14A–B).
MCP joints should extend fully but not hyperextend
• Tension is set with the wrist in neutral and the index MCP flexed at 60 degrees.
(Fig. 75.15).
• The same procedure is repeated for all the other fingers.
FIGURE 75.15 MCP joints extend fully, but should not hyperextend. MCP, Metacarpophalangeal.

• For 4 weeks, a short-arm dorsal extension block splint is placed for immobilization
to hold the MCP joints at 30 degrees of flexion with slight wrist flexion. The PIP joints
are free to move.
• After 4 weeks of protection, the same position is maintained with a dorsal resting
splint for another 4 weeks. At this point, active ROM and light activities of daily living
are initiated.
See Video 75.1
EVIDENCE
McCarthy CK, House JH, Van Heest A, Kawiecki JA, Dahl A, Hanson D. Intrinsic balancing in recon-
struction of the tetraplegic hand. J Hand Surg Am. 1997;22(4):596–604.
The authors reviewed 183 hand reconstructions in 135 consecutive tetraplegic patients. Comparisons
were made between 103 extrinsic reconstructions with intrinsic balancing procedures and 80 extrin-
sic reconstructions without intrinsic balancing procedures. Intrinsic procedures included primarily the
FDS lasso procedure or the intrinsic tenodesis procedure. Hands reconstructed with intrinsic balanc-
ing versus without intrinsic balancing and with intrinsic balancing using a FDS lasso procedure
versus an intrinsic tenodesis procedure were compared with patients with the same level of spinal
cord function. The results showed patients who underwent reconstructions with intrinsic balancing
had more grip strength, by an average of 13 to 26 N, than those who did not undergo intrinsic bal-
ancing. There was also improvement in grip strength and function in activities of daily living for all
hands, but there was no significant difference between FDS lasso or intrinsic tenodesis procedures.
The authors recommended that digital intrinsic procedures be included in hand reconstruction for
tetraplegic patients exhibiting intrinsic imbalance to help improve digital function and provide
increased grip strength (Level IV evidence).
Muzykewicz DA, Arnet U, Lieber RL, Fridén J. Intrinsic hand muscle function, part 2: Kinematic
comparison of 2 reconstructive procedures. J Hand Surg Am. 2013;38(11):2100–2105.
The authors conducted a study to compare grasp kinematics between two intrinsic balancing proce-
dures: Zancolli-lasso and House. The intrinsic muscles of 12 cadaver hands were reconstructed by
either the Zancolli-lasso or the House procedure (n = 6 each). They compared the results with five
control hands. They found the Zancolli-lasso reconstructed hands flexed first in the IP joints, and
then in MCP joints, resembling an unreconstructed intrinsic-minus hand, whereas the House
reconstructed hands flexed first in the MCP joints and then in the IP joints. Maximal fingertip-to-palm
distance did not differ significantly between the two procedures, and both showed improvement over
unreconstructed controls. The authors concluded that both intrinsic balancing techniques improved
grasp but only the House procedure restored hand kinematics approximating those of an intrinsic-
activated hand. Improvement in fingertip-to-palm distance in Zancolli-lasso hands resulted primarily
from the initial resting MCP joint flexion of 40 degrees (Level V evidence).
Muzykewicz DA, Arnet U, Fridén J, Lieber RL. The effect of intrinsic loading and reconstruction upon
grip capacity and finger extension kinematics. J Hand Surg Am. 2015;40(1):96–101.
The authors used seventeen fresh-frozen hands, which included five intrinsic minus and intrinsic
activation conditions, six with Zancolli-lasso tenodeses, and six with modified House tenodeses, to
compare active and passive reconstructive procedures for tetraplegia and their ability to produce a
powerful grip and allow appropriate finger extension. No successful grasps were recorded in the
intrinsic minus hands for larger diameter cylinders (≥ 70 mm), but multiple successes were seen after
intrinsic activation and after Zancolli-lasso and House procedures. Although active intrinsic and the
House reconstruction hand reached near full extension, this was not true for the Zancolli-lasso
group. The results demonstrated that active and passive intrinsic reconstruction methods improved
basic grasp and release kinematics. Using our model and based on the more optimal kinematics
and full extension of the House procedure, the authors suggested the tenodesis-based intrinsic
reconstruction (Level V evidence).
Fridén J, Lieber RL. Reach out and grasp the opportunity: Reconstructive hand surgery in tetraplegia.
J Hand Surg Eur Vol. 2019;44(4):343–353.
The authors presented some of the fundamental muscle-tendon-joint mechanics studies that allow for
single-stage surgical reconstruction of hand function and early postoperative activity-based training
in patients with cervical spinal cord injuries. They concluded that there are seven consecutive steps
including intrinsic reconstruction as one-stage surgery (Level IV evidence).
CHAPTER 76
Nerve Transfer for Spinal Cord Injuries
Rachel C. Hooper, Chun-Yu Chen, Kevin C. Chung
INTRODUCTION
• Given the success of nerve transfers for the treatment of brachial plexus and peripheral
nerve injuries, many surgeons also use this form of treatment to circumvent the dam-
aged areas of the spinal cord and reestablish essential motor function (Table 76.1).
Nerve transfers can be performed together with tendon transfers or as the primary
treatment for spinal cord injury (SCI) patients in some cases.
• Benefits of nerve transfer:
1. An expendable nerve can be used to power an essential function by reinnervating
one or several muscles.
2. Patients remain immobilized for less time postoperatively compared with tendon
transfers. They are also less likely to have pain and scarring.
3. The donor nerve can be partially spared to maintain some function to native muscle.
4. Unlike tendon transfers, tensioning and proper line of pull do not need to be
considered for nerve transfers.
• Drawbacks of nerve transfer:
1. Time to reinnervation varies among SCI patients.
2. If the donor nerve is weaker than expected (i.e., Medical Research Council [MRC]
, 3), then reinnervation is poor.
INDICATIONS
• Patients are observed for spontaneous recovery for 6 to 12 months before they are
considered for nerve transfer; it is assumed that paralyzed muscles are unlikely to
recover after 6 months.
• SCIs affect the upper motor neurons and are heterogeneous in presentation. There-
fore the recipient muscles continue to receive input from the lower motor neurons
(LMNs) long after injury. Patients with upper nerve injuries remain primed for reinner-
vation longer than brachial plexus and peripheral nerve injury patients, who require
nerve transfer within 1 year of injury.
• Some spinal cord injury patients have both upper motor neuron (UMN) and LMN
injuries; these patients require nerve transfer within 1 year of injury (so the muscle is
still receptive).
• A donor nerve must be available in close proximity to the recipient nerve for direct
coaptation.
Contraindications
• Patients with some type of LMN injury are not eligible for nerve transfers more than
1 year after the injury.
TABLE Common Nerve Transfers for Functional Deficits in Spinal Cord

76.1 Patients
Functional Deficit Nerve Transfer
Elbow extension Posterior deltoid nerve branch to triceps nerve branch
Wrist extension Brachialis nerve to extensor carpi radialis nerve
Finger extension Supinator motor branch to posterior interosseous nerve
Thumb and index flexion Brachialis nerve to anterior interosseous nerve
597
598 CHAPTER 76 Nerve Transfer for Spinal Cord Injuries
• In line with the considerations for tendon transfers, nerve transfers cannot be per-
formed in patients who have significant comorbidities that preclude general anesthe-
sia. Patients also require adequate psychosocial support and should have realistic
expectations regarding their potential functional gains.
• Patients with chronic pain or inadequate donors are also not candidates for surgery.
• An organized examination of the entire upper extremity is performed. See Chapter 69
Tendon and Nerve Transfer for Spinal Cord Injury for details.
• Assess the upper extremity for motor deficits and potential donor nerves. Grade the
donors using the MRC scale (see Table 69.1). Assess muscle tone, bulk, and poten-
tially deep tendon reflexes.
SURGICAL ANATOMY
• Test for supinator muscle with resisted forearm supination and palpation of the
muscle.
• The supinator muscle has two motor branches (medial and lateral) that branch just
proximal to the arcade of Frohse, the tendinous proximal portion of the supinator
muscle itself. The diameter of these branches is around 1.0 to 1.6 mm.
• The posterior interosseous nerve (PIN) is a terminal branch from the radial nerve. Its
average diameter is 3.2 mm, and the two motor branches of the supinator are esti-
mated to provide motor axons to 73% of the PIN, making this a well-matched transfer.
IMAGING AND TESTS

• Nerve conduction studies (NCS) and electromyography (EMG) are required to detect
continuity of the LMNs to the recipient muscle.
• On NCS, the compound action potential should be normal in SCI patients; however,
an abnormal compound action potential in a specific muscle suggests a component
of LMN injury.
• Patients with intact compound muscle action potential (CMAP) to the extensor indi-
cis proprius (EIP) are considered appropriate candidates for supinator to PIN transfer
for hand opening. Patients with intact CMAP to abductor pollicis brevis are consid-
ered appropriate candidates for brachialis to anterior interosseous nerve transfer.
• On EMG, recipient muscles are tested for response to needle insertion; abnormal
spontaneous insertional activity, fibrillations, and polyphasic waves are indicative of
LMN injury.
• Bipolar surface electrical stimulation of paralyzed muscles is used to assess LMN
integrity and is performed at some specialty centers. Assessment of deeper muscles
may be challenging. Lack of perceptible contraction suggests denervated muscles.

• Position the patient supine with arm extended on arm table.
• Nerve stimulation is necessary intraoperatively to identify the function of a chosen
nerve for transfer. Nerve monitoring may also be useful to detect somatosensory and
motor-evoked potentials of recipient and donor muscles before transfer.
• Avoid paralysis in the general anesthetic plan.
SUPINATOR NERVE TO POSTERIOR INTEROSSEOUS NERVE

TRANSFER
• In C6 SCI patients, not all muscles innervated by the radial nerve are paralyzed. The
wrist extensors, brachioradialis, and supinator muscles are often spared. The supi-
nator muscle motor branches are commonly used in nerve transfer to restore finger
and thumb extension.
• The biceps is the strongest supinator; therefore the nerve to the supinator muscle is
expendable. Additionally, because the supinator muscle is seldom used for tendon
transfer, it is an ideal candidate for motor nerve transfer.
• The supinator and PIN nerves are in close proximity, which facilitates direct nerve
coaptation.
CHAPTER 76 Nerve Transfer for Spinal Cord Injuries 599
PROCEDURE STEP 1 PEARL
Step 1 It may be necessary to divide the superficial fibers

of the supinator for adequate exposure.
• Make a 10-cm longitudinal incision in the proximal forearm overlying the radius. Dis-
sect through the subcutaneous tissue and find the interval between the extensor
carpi radialis brevis (ECRB) and extensor digitorum communis (EDC). Incise the
fascia and continue to dissect deeply, spreading the muscle fibers until the arcade
of Frohse (the proximal extent of the supinator) is encountered.
• Spread the supinator muscle fibers along their direction and identify the medial and
lateral motor branches deep. Place a self-retaining retractor (Fig. 76.1)
Step 2 STEP 2 PEARL

• Once the motor nerves to the supinator muscle are located, use a nerve stimulator Although the patient has a spinal cord injury, it only
to observe twitches in the muscle and confirm that the correct nerves have been affects the UMN and therefore the muscles should
identified (Fig. 76.2). twitch in response to electric stimulation. Using
0.5 m Amp stimulation is usually sufficient to
• Palpate the radius proximally and identify the PIN nerve as it rolls under the fingertips.
generate a signal.
Dissect the overlying soft tissue.
• Stimulate the PIN to confirm contraction of the wrist and finger extensors. Stimulate
the EDC and extensor pollicis longus (EPL) to observe motor twitches and the
responsiveness of these muscles.
• Dissect the supinator motor donor branches as distally as possible. Dissect the PIN
as proximally as possible.
Step 3 STEP 3 PEARL

Transfer the cut ends of the medial and lateral motor branches of the supinator to the Fibrin glue can be used as needed to support the
PIN using interrupted 9-0 or 10-0 epineural sutures for coaptation (Figs. 76.3 and 76.4). neurorrhaphy.
BR/ERCL/ERCB
Supinator
muscle
FIGURE 76.1 The supinator muscle is identified deep to the brachioradialis (BR) and other muscula-
ture of the mobile wad. The fibers of the supinator are spread parallel to their direction to identify
the motor branches.
ECRB
EDC
FIGURE 76.2 A 10-cm longitudinal incision made over the radius proximally; dissection is carried
down to the interval between the ECRB and EDC. The fascia between the two is incised. ECRB,
Extensor carpi radialis brevis; EDC, extensor digitorum communis.
600 CHAPTER 76 Nerve Transfer for Spinal Cord Injuries
Supinator muscle
Supinator
branches
PIN
FIGURE 76.3 The motor branches to the supinator are identified after spreading the supinator
muscle fibers. The posterior interosseous nerve (PIN) is palpated over the radial head and identified
after division of the overlying soft tissues.
Supinator medial and lateral branches
Supinator
branches
BTI
A PIN BEM
B
FIGURE 76.4 (A-B) The supinator medial and lateral motor branches have been sutured end-to side to the posterior interosseous nerve (PIN).
B, from Bertelli JA, Tacca CP, Ghizoni MF, Kechele PR, Santos MA. Transfer of supinator motor branches to the posterior interosseous nerve
to reconstruct thumb and finger extension in tetraplegia: Case report. J Hand Surg Am. 2010;35:1647–1651.
Step 4
Perform a layered skin closure. Place the patient in a splint with their elbow in 90 de-
grees of flexion.

• Immobilization should continue for 2 to 3 weeks.
• Active finger and thumb extension can be expected 5 to 6 months postoperatively.
• In some patients, an “augmented tenodesis” is achieved, which enables patients to
pinch small objects and improve activities of daily living (ADLs).
EVIDENCE
Sanjaya F, Midha R. Nerve transfer strategies for spinal cord injury. World Neurosurg. 2013;6:e319–e326.
Fox IK, Novak CB, Krauss EM, et al. The use of nerve transfers to restore upper extremity function in
cervical spinal cord injury. PM R. 2018;10(11):1173–1184.e2.
These articles describe the various options, indications, and methods for nerve transfers in spinal cord
patients as an alternative to or replacement for tendon transfers.
Bertelli JA, Ghizoni MF. Transfer of supinator motor branches to the posterior interosseous neve C7-T1
brachial plexus palsy. J Neurosurg. 2010;113:129–132.
Bertelli JA, Tacca CP, Ghizoni MF, Kechele PR, Santos MA. Transfer of supinator motor branches to the
posterior interosseous nerve to reconstruct thumb and finger extension in tetraplegia: Case report.
J Hand Surg Am. 2010;35:1647–1651.
These articles describe the approach and outcomes of supinator to PIN nerve transfer.
ddsf
SECTION IX
Tendon Conditions
CHAPTER 77 Wide Awake Approach for Tendon Transfers 602
CHAPTER 78 Acute Repair of Flexor Tendon Injuries in
Zones I–V 610
CHAPTER 79 Two-Stage Flexor Tendon Reconstruction with
Silicone Rod 626
CHAPTER 80 A2 Flexor Tendon Pulley Reconstruction with
Free Tendon Graft 635
CHAPTER 81 Tenolysis of Flexor Tendons 637
CHAPTER 82 Acute Repair of Extensor Tendon Injuries:
Zones I to VII 638
CHAPTER 83 Release of Trigger Finger 640
CHAPTER 84 Release of De Quervain Tenosynovitis 641
601
CHAPTER 77
Wide-Awake Approach for Tendon Transfers
INDICATIONS
Many, if not all, tendon and nerve conditions can be approached using wide-awake
local anesthesia. It is also common for arthritic conditions of the fingers and may be
considered for digital fractures as well.
The following are example conditions for which the authors find this technique to be
particularly suitable.
• Tendon conditions, including primary and secondary tendon repair, single and two-
stage tendon reconstruction, tenolysis, trigger finger A1 pulley releases, first dorsal
compartment release, sagittal band repair, and tendon transfers.
• Nerve conditions, including carpal tunnel release, in-situ ulnar nerve decompression at the
cubital tunnel and at the Guyon canal, digital nerve laceration exploration, and primary repair.
• Trauma including phalangeal fractures, collateral ligament repair, and contracture release.
• Arthritic and other conditions, such as metacarpophalangeal and interphalangeal ar-
throdesis, metacarpophalangeal joint silicone arthroplasty, and Dupuytren fasciectomy.
Wide-awake surgery with local anesthesia allows for active participation from the
patient, which can provide an immediate intraoperative assessment of function, espe-
cially for tendon transfers, tenolysis, and contracture releases.
Tension for tendon transfers, repairs, and reconstructions is assessed intraopera-
tively, after provisional suture fixation. If the connection is too tight or too loose and does
not allow for adequate range of motion (ROM), the tension can be adjusted immediately.
The technique spares the patient from systemic anesthetic medications and their
complications, including postoperative nausea and vomiting.
Vasoconstriction from epinephrine can eliminate the need for a tourniquet, whose
use can cause significant patient discomfort on the upper arm.
Contraindications
• Epinephrine should not be used in patients with compromised digital perfusion, in-
cluding those with severe peripheral vascular disease, chronic renal failure, Buerger
disease, scleroderma, and other connective tissue diseases.
• The precise nature of hand and wrist surgery requires that the patient be able to
keep the arm completely motionless during the procedure, except when directed to
test function. Therefore patients who may become too anxious or agitated and can-
not reliably follow commands, including children and some patients with develop-
mental delays, are not good candidates for wide-awake local anesthesia.
POSITIONING AND EQUIPMENT PEARLS
Ensure that the patient is comfortable before CLINICAL EXAMINATION
prepping and draping the extremity so they do not In addition to the appropriate examination for the patient’s condition, the fingers should
need to readjust during the operation.
Even when using epinephrine, a tourniquet be examined for any signs of poor perfusion. Temperature, turgor, color, and capillary
can be placed on the arm outside the anticipated refill of the fingertips should be assessed preoperatively.
operating field, but not inflated, to have as a
backup in case emergency hemostasis is needed. IMAGING
If the procedure is limited to the hand, many Specific imaging, such as angiography, is not needed before proceeding with wide-
patients tolerate a tourniquet on the forearm much
more and for longer than on the brachium. awake surgery, unless the patient has a history of poor digital perfusion.
POSITIONING
POSITIONING AND EQUIPMENT PITFALLS
• The patient should always be lying down before injection of local anesthetic in case
An epinephrine injection may cause patient tremors of a vasovagal response.
or a vasovagal reaction. The patient should be lying • Both supine and lateral decubitus positioning is acceptable based on surgeon pref-
down before the injection to prevent any injury.
erence, patient comfort, and the planned procedure.
602
CHAPTER 77 Wide-Awake Approach for Tendon Transfers 603
EXPOSURES AND EQUIPMENT

Injectable Medications (Table 77.1)
Lidocaine
This is the most commonly used local anesthetic for wide-awake surgery because
it has a very short onset of action (around 5 minutes) and lasts for 30 to 60 minutes
as a local infiltration and around 1 to 2 hours in peripheral nerve blocks. The
maximum dose of subcutaneous injectable lidocaine is 7 mg/kg when administered
with epinephrine (without the delayed systemic absorption caused by epinephrine-
induced vasoconstriction, the maximum dose is 5mg/kg.). Commercial prepara-
tions of lidocaine come in 1% or 2% concentrations with and without epinephrine
added, but these can be diluted with normal saline if a larger volume is needed.
For example, a person weighing 70 kg (155 lbs) may receive up to 490 mg of lidocaine,
or 49 mL of 1% lidocaine with epinephrine (1:100,000) solution. This can be diluted with
50 mL of normal saline to yield 99 mL of a 0.5% lidocaine with epinephrine (1:200,000)
solution or with 150 mL of normal saline to produce 199 mL of 0.25% lidocaine with
epinephrine (1:400,000).
Bupivacaine and Ropivacaine

These anesthetic agents may be added to lidocaine to prolong the duration of the nerve
or field block. Their typical durations of action are 6 to 9 hours of anesthesia, and
bupivacaine or ropivacaine should be mixed with lidocaine for procedures that are
anticipated to last longer than 3 hours or to aid with postoperative analgesia.
Epinephrine
This potent alpha-adrenergic agent causes local vasoconstriction in high doses
(1:50,000–1:100,000), which provides hemostasis and a relatively bloodless field to allow
for safe surgery without a tourniquet. The hemostatic effect has been shown to take
around 26 minutes to reach its maximum. Besides hemostasis, epinephrine provides
additional benefits, as detailed in the following sections.
Prolonged Duration and Reduced Systemic Effects of Local Anesthetics

The vasoconstriction from epinephrine slows systemic absorption of the local anesthet-
ics and delays their metabolism and clearance from the operative field. This prolongs
their effects and permits a higher maximum dose to be administered.
Visual Indicator
Although maximal hemostasis does not occur for 26 minutes, an immediate action
causes skin blanching, which indicates which skin has been infiltrated and anesthetized
(Fig. 77.1).
Sodium Bicarbonate
Local anesthetics, such as lidocaine and bupivacaine, are sold in acidic solutions, and
the acidity is one component of infiltration pain. Sodium bicarbonate can be added to
Table
77.1 Anesthetic agents, doses, and durations
Alone (Without Epinephrine) With Epinephrine
Anesthetic Maximum Dose Duration Maximum Duration
agent Dose
Lidocaine 4 mg/kg 30–60 min 7 mg/kg 2–3 hours
Bupivacaine 2.5 mg/kg 2–4 hours 2.8 mg/kg 4–12 hours
Ropivacaine 2.8 mg/kg 2–4 hours 3.5 mg/kg 4–12 hours
Lirk P, Berde CB. Local anesthetics. In Miller’s Anesthesia. 9th ed. Elsevier Academic Press; 2020:865–890.
FIGURE 77.1 Skin blanching.
604 CHAPTER 77 Wide-Awake Approach for Tendon Transfers
FIGURE 77.2 Injection method.
the local anesthetic mixture to raise the solution pH to physiologic levels, reducing
discomfort of anesthetic injection.
Phentolamine
This alpha-antagonist will reverse the vasoconstriction of epinephrine and can serve as
an injectable antidote in a case of prolonged digital ischemia.
Injection Techniques to Reduce Pain

Several techniques and factors under the surgeon’s control can help reduce the pain of
local anesthetic injection and infiltration.
• Warming: Infiltrations of cold fluid stimulate nociceptive receptors more easily than
injections at body temperature. Furthermore, solutions at higher temperatures dif-
fuse faster than cold molecules, leading to an earlier onset of anesthetic effect.
• pH Balancing: Acidic solutions cause more burning pain than those at physiologic
pH. Using 1 mL of 8.4% sodium bicarbonate in every 10 mL of 1% lidocaine will
bring the solution pH close to 7.4.
• Needle caliber: The narrowest needle will cause the least amount of pain. A 27- or
30-gauge needle is recommended.
• Injection method: Both pinching the surrounding skin and penetrating the skin at 90
degrees help minimize the sharp pain of the needle (Fig. 77.2). Pinching the skin
causes a sensory stimulation that distracts from the needle insertion. A steady, per-
pendicular needle disrupts fewer nerve fibers than a wobbly one inserted at an
oblique angle. Injecting intradermally similarly irritates many nerve fibers; be sure to
be subcutaneous before pushing any medication.
• Infiltration speed: Injecting medication slowly causes less discomfort than anesthetic,
EXPOSURES PEARLS which is “pushed” at a high rate. Furthermore, a slow infiltration speed allows the already
Stabilize your injecting hand to prevent any painful injected anesthetic to take effect locally, which numbs the area for additional injection.
needle “wobble.”
PREPARATION OF LOCAL ANESTHETIC AGENTS FOR
EXPOSURES PITFALLS
INJECTION
Anticipation of the needle stick can cause Step 1
significant anxiety for patients. Do everything in
• We have found many of Dr. Don Lalonde’s techniques useful to reduce pain and
your power to make this as painless as possible.
achieve adequate anesthesia.
• Review the patient’s allergies to ensure that there are no reactions to any of the
medications in the planned anesthetic solution.
• Draw into syringes the required amount of 1% lidocaine with epinephrine (1:100,000).
Ensure that the total dose is less than 7 mg/kg.
• Add 1 mL of 8.4% sodium bicarbonate to every 10 mL of 1% lidocaine with epineph-
rine (1:10 volume ratio).
Step 2
Warm the entire solution to body temperature before injection. STEP 2 PEARLS
• The injection may be performed in the preoper-
INJECTION TECHNIQUE FOR EXTENSOR INDICIS PROPRIUS ative area to allow time for the maximal hemo-
TO EXTENSOR POLLICIS LONGUS TRANSFER static from epinephrine (roughly 26 minutes).
• Patients may feel “jittery” after injection with
epinephrine. If this happens, advise them that
Step 1 it should subside in 15 to 20 minutes.
• We use approximately 20 mL of local anesthetic mixture in the subcutaneous tissues.
• Begin 3 cm proximal to the radial styloid and inject 10 mL dorsally to create a field
block of the dorsal sensory branches of the radial nerve (Fig. 77.3). STEP 1 PEARLS
• Use a 27-gauge needle and inject it perpendic-
Step 2 ular to the skin to minimize needle-stick pain.
• Inject the first 2 mL slowly and let it take effect
Inject another 5 mL subcutaneously around the planned dorsal index finger incision
before moving the needle to inject more.
site. Start at least 1 cm proximal to the start of the incision. • The dorsal sensory branch of the radial nerve
is variable in its course and branches. Thus
Step 3 injecting over a large area is the most effective
• Inject the remaining 5 mL of local anesthetic subcutaneously under the planned way to ensure it is anesthetized.
dorsal thumb incision (Fig. 77.4).
• Epinephrine-induced hemostasis allows for a clean operative field without the use of STEP 1 PITFALLS
a tourniquet.
• Care should be taken to avoid injection into the
• After tendon transfer and provisional tenorrhaphy, the patient should verify active radial artery on the dorsal wrist.
joint motion and evaluate the ROM. The tension may be adjusted easily at this point • If the needle needs to be reinserted for addi-
if needed (Fig. 77.5). tional injection, it should be done in an area
• Time during the operation can be used to educate the patient on postoperative in- already blanched by epinephrine.
structions, rehabilitation, and expectations.
STEP 2 PEARLS
INJECTION TECHNIQUE FOR COMBINED PRONATOR TERES
TO EXTENSOR CARPI RADIALIS BREVIS, FLEXOR CARPI If the dorsal sensory branch of the radial nerve
has been adequately blocked in Step 1, the
RADIALIS TO EXTENSOR DIGITORUM COMMUNIS, AND patient should experience minimal discomfort with
PALMARIS LONGUS TO EXTENSOR POLLICIS LONGUS FOR subsequent distal injections.
RADIAL NERVE PALSY
• Add enough normal saline and sodium bicarbonate to 1% lidocaine with epinephrine • The surgeon and patient can test active motion
(1:100,000) to create 200 mL of local anesthetic solution. The total dose should be to ensure proper tension and no gap formation.
• If the incisions are covered with clean
less than 7 mg/kg.
sponges, the drapes can be lowered to show
the patient their own active motion.
FIGURE 77.3 Field block of dorsal FIGURE 77.4 Injection under the
sensory branches of the radial nerve. planned dorsal thumb incision. FIGURE 77.5 Tendon transfer.
• For example, for a 70 kg patient, 49 mL of 1% lidocaine with epinephrine (1:100,000)

STEP 1 PEARLS is diluted with 5 mL of 8.4% sodium bicarbonate and 146 mL of normal saline. The
resulting 200 mL mixture is approximately 0.25% lidocaine with epinephrine (1:400,000).
A generous area should be infiltrated in the
dorsoradial midforearm to ensure that the patient • The authors frequently add 20 mL of 0.5% bupivacaine to the solution because the
feels no pain with dissection to harvest the pronator combination of procedures makes for prolonged operating time.
teres (PT) tendon.
Step 2
• Inject about 30 mL in the middle of the radial forearm roughly over the pronator teres
insertion (Fig. 77.6).
STEP 3 PEARLS
• The infiltration should be subcutaneous and deep to muscle on periosteum where
the tendon will be harvested.
• Check for a palmaris longus (PL) tendon before
surgery.
• The area of local injection should be large Step 3
enough to cover the insertions of both the PL Inject 30 mL subcutaneously over the middle and radial aspects of the volar forearm at
and FCR for harvest and proximally for several the wrist crease and along the flexor carpi radialis (FCR) tendon (Fig. 77.7).
centimeters to accommodate tunneling around
the radius. Step 4
The area over the dorsal wrist should be anesthetized using 30 mL of solution, starting
proximal to Lister tubercle and extending distally and radially (Fig. 77.8).
STEP 5 PEARLS
If the dorsal sensory branch of the radial nerve has Step 5
been adequately blocked in previous steps, the Inject 10 mL of local anesthetic subcutaneously under the planned dorsal thumb incision.
patient should experience minimal discomfort with
subsequent distal injections. Step 6
• Use the remaining local anesthetic to inject into any area of planned tendon tunneling
which is not already tumescent or blanched from previous injections.
STEP 6 PEARLS • All areas of planned dissection or tunneling should have at least a 2 cm border area
infiltrated with anesthetic.
• The surgeon may ask the patient to turn the
forearm to active at the PT to extensor carpi • One long radial incision may be used (Figs. 77.9 and 77.10). Ensure that all areas
radialis brevis (ECRB) transfer, and to flex the that will be accessed have adequate local infiltration.
wrist to activate the thumb and finger extensor • After each transfer, tension can be adjusted to achieve an appropriate resting hand
transfers. position (Fig. 77.11), and active motion may be trialed in a cooperative patient.
• The tenodesis effect should also be used to • Once tension is correct, additional sutures should be placed to reinforce each tenor-
passively check thumb and finger extension.
rhaphy site.
FIGURE 77.7 Injection at the wrist crease

FIGURE 77.6 Injection over the and along the flexor carpi radialis (FCR)
pronator teres insertion. tendon. FIGURE 77.8 Injection at the dorsal wrist.
EPL
PL
ECRB PT
EDC
FCR
FIGURE 77.9 Radial incision.

FIGURE 77.10 Tendon transfers.
FIGURE 77.11 Tension adjustment to achieve appropriate resting hand position.
INJECTION TECHNIQUE FOR FLEXOR DIGITORUM

SUPERFICIALIS TRANSFER TO CORRECT CLAW HAND
DEFORMITY
STEP 2 PEARLS
Step 1
Start by injecting 10 mL of 1% lidocaine with epinephrine (1:100,000) at the base of the As the local anesthesia from the long finger
injection diffuses ulnarly, the injection site for the
long finger metacarpal head on the volar side of the hand (Fig. 77.12). ring and small finger will be numb.
Step 2
• Use another 10 mL of 1% lidocaine with epinephrine (1:100,000) to administer digi-
tal blocks to the ring and small fingers in a similar fashion.
• Ensure that there is ample local anesthesia in the palm between the long, ring, and
small fingers because the transferred tendons will tunnel under this area (Fig. 77.13).
Step 3
Wait around 25 minutes between injection and incision to allow the epinephrine to
achieve its maximal vasoconstriction effects.
INJECTION TECHNIQUE FOR PHENTOLAMINE RESCUE OF

ISCHEMIC DIGITS
Step 1
Dissolve 1 mg of phentolamine in 10 mL of normal saline. For large areas, this mixture
can be scaled up in a 1 mgL:10 mL ratio, with a maximum cumulative dose of 5 mg.
FIGURE 77.12 Injection at the base of the long finger FIGURE 77.13 Injection at the palm.
metacarpal head.
Step 2
Inject the phentolamine solution subcutaneously in any area where epinephrine was
STEP 2 PEARLS previously injected.
Phentolamine may take up to 85 minutes to
completely reverse the vasoconstriction. POSTOPERATIVE CARE AND EXPECTED OUTCOMES
• Although the reported duration of action is only 2 to 3 hours for lidocaine with epi-
nephrine, patients frequently report their fingers feeling numb for 4 to 5 hours.
POSTOPERATIVE PEARLS • If the procedure is expected to last longer than 2 hours, 10 mL of 0.25% bupivacaine
or 0.5% ropivacaine should be added to the local solution. The patient should be
• Because the patient is awake during the setup,
procedure, and closure, there are many oppor- counseled accordingly that their extremity will be insensate for longer.
tunities to provide patient education, • The wide-awake approach helps minimize errors in tendon tensioning and tendon
including the signs and symptoms of rupture rates by confirming active ROM and lack of tendon connection gapping in-
prolonged digital ischemia. traoperatively.
• If only lidocaine with epinephrine is used as
• There is very little recovery time needed in an ambulatory setting and minimal post-
the anesthetic agent, patients should seek
medical attention if the fingers are not pink operative nausea because the patients do not receive systemic sedation.
6 hours after surgery.
EVIDENCE
Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3110
consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical
phase. J Hand Surg Am. 2005;30(5):1061–1067.
In this seminal article, epinephrine was shown to be safe to use in the hand and fingers in a consecu-
tive series of 3110 cases. In 1340 procedures, fingers were injected and the hand was injected in the
remaining 1770 cases. There were no incidents of finger infarction, skin necrosis, or tissue loss of
any kind, and no cases needed phentolamine rescue.
Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am.
2013;38:2025–2028.
Dr. Lalonde provides tips for wide-awake local anesthesia without a tourniquet to achieve a pain-free
and bloodless operative field. Specific advice is given for numerous procedures including carpal
tunnel release, trigger finger release, Dupuytren fasciectomy, and trapeziectomy.
Bashir MM, Qayyum R, Saleem MH, Siddique K, Khan FA. Effect of time interval between tumescent
local anesthesia infiltration and start of surgery on operative field visibility in hand surgery without
tourniquet. J Hand Surg Am. 2015;40(8):1606–1609.
This randomized clinical trial compared hemostasis and operative field visibility in procedures starting
either 10, 15, or 25 minutes after injection of lidocaine with epinephrine. Seventy-five patients were
randomized to one of the three groups; waiting 25 minutes after injection was found to have a 29
times higher rate of a bloodless field and excellent visibility.
Ayhan E, Akaslan F. Patients’ perspective for carpal tunnel release with WALANT or intravenous
regional anesthesia. Plast Reconstr Surg. 2020;145:1197–1203.
To evaluate patient experiences of wide-awake surgery, 24 patients with bilateral carpal tunnel syn-
drome were randomized to have one surgery using the wide-awake technique with local anesthesia
and the other arm under Bier block. In total, 83% of patients preferred the wide-awake approach
over Bier block and 91% reported that the local anesthesia was easier than expected.
Hong J, Kang HJ, Whang JI, et al. Comparison of the wide-awake approach and conventional ap-
proach in extensor indicis proprius-to-extensor pollicis longus tendon transfer for chronic extensor
pollicis longus rupture. Plast Reconstr Surg. 2020;145(3):723–733.
The authors retrospectively reviewed 29 consecutive extensor indicis proprius to extensor pollicis
longus transfers: 11 performed with the wide-awake approach and 18 under general anesthesia.
Those performed wide-awake had better ROM at all time points (6 weeks and 2, 4, and 6 months).
Disabilities of the Arm, Shoulder, and Hand (DASH) scores were also better in the wide-awake
group. Pinch strength and complications were similar between groups.
CHAPTER 78
Acute Repair of Flexor Tendon Injuries
in Zones I to V
INDICATIONS
• Early surgical treatment (ideally immediate primary repair) of flexor tendon injury is
preferred, but repair within 1 to 2 weeks of injury still produces good results.
• Surgical repair is essential for complete tendon lacerations.
• See specific indications under each zone of injury.
• In partial tendon injuries, associated symptoms such as triggering, entrapment, or
delayed rupture can occur.
• Partially injured tendons involving less than 60% of a cross-sectional area do not
need to be repaired, but frayed ends may be debrided to prevent triggering. Patients
with greater than 60% laceration will benefit from reinforcement with a core and a
running epitendinous suture (see “General Suture Repair”).
Contraindications
• Digits with severely damaged soft tissue may need to have skin coverage and
vascularity addressed before flexor tendon repair. If three or more tissue systems
(i.e., tendon, skin, vessels, nerves, bones/joints) are compromised, severe limita-
tion in finger function is likely and the patient may be better served with a digital
amputation.
• Flexor tendon lacerations may not need repair in the setting of fixed interphalangeal
joint contractures.
• Continuity of the flexor digitorum superficialis (FDS) tendon is evaluated by asking
the patient to flex the finger voluntarily while the examiner holds the metacarpopha-
langeal (MCP) and interphalangeal (IP) joints of the uninvolved fingers in full exten-
sion (Fig. 78.1A). FDS of the small finger may be difficult to isolate and is absent in
a percentage of the normal population.
• Continuity of the flexor digitorum profundus (FDP) tendon is evaluated by asking the
patient to flex the distal interphalangeal (DIP) joint while the examiner holds the
proximal interphalangeal (PIP) joint (see Fig. 78.1B) in full extension.
• The flexor pollicis longus (FPL) tendon is also evaluated by asking the patient to flex
the IP joint of the thumb.
IMAGING
• A plain radiograph is required to exclude a fracture, foreign body, or any other bony
etiologies.
• An associated distal phalanx avulsion fracture may indicate the location of
the proximal end of the tendon if the bony fragment remains attached to the
tendon.
SURGICAL ANATOMY
• The FDS tendons insert onto the base of the middle phalanx and function primarily
to flex the finger at the PIP joint with eventual flexion at the MCP joint. The FDP ten-
dons insert onto the base of the distal phalanx to flex the finger at the DIP joints, with
eventual flexion at the PIP and MCP joints. Intrinsic muscles of the hand are primar-
ily responsible for initiating MCP joint flexion. The FDS tendon fibers decussate to
610
CHAPTER 78 Acute Repair of Flexor Tendon Injuries in Zones I to V 611
FDS
FDP
B
Camper’s chiasm
FIGURE 78.1 (A–B) Evaluating the continuity of the flexor digitorum FIGURE 78.2 Illustration of flexor digitorum superficialis (FDS)
superficialis (FDS) and flexor digitorum profundus (FDP). and flexor digitorum profundus (FDP) insertion.
form two slips, which wrap around the FDP tendon to insert on the middle phalanx
at Camper’s chiasm (Fig. 78.2).
• A commonly used classification of flexor tendon injury location was described by
Kleinert (Fig. 78.3).
• Zone I is distal to the insertion of the FDS tendon.
• Zone II extends from the proximal aspect of the A1 pulley to the FDS insertion. Zone
II contains both FDS and FDP tendons as they pass through the fibro-osseous flexor
II
TI
TII
III
TIII
IV
FIGURE 78.3 Zones of injury for flexor tendons. (Fig. 64.3 from Chung KC. Operative Techniques:
Hand and Wrist Surgery, 3rd ed. Elsevier; 2017.)
612 CHAPTER 78 Acute Repair of Flexor Tendon Injuries in Zones I to V
tendon sheath together in the distal palm and digit. This area has been known as
“no man’s land” because of historically poor results after tendon lacerations repairs.
The tight tendon sheath in zone II may cause adhesion between the FDS and FDP
tendons.
• Zone III encompasses the palm of the hand proximal to the tendon sheath and
distal to the transverse carpal ligament. Here, the lumbricals originate from the
radial aspect of the respective FDP tendons.
• Zone IV refers to the carpal tunnel. Isolated zone IV tendon injuries are rare be-
cause of osseous protection of the contents of the carpal tunnel by the hook of
the hamate and the trapezium; their prominence often limits penetrating injuries
from reaching the underlying tendons.
• Zone V contains the flexor tendons and their musculotendinous junctions in the
forearm proximal to the wrist crease.
EXPOSURES
• Repairs of lacerations in zones I to IV benefit from the wide-awake approach in se-
lect cooperative patients because the surgeon can confirm lack of gapping of the
tendon repair and verify appropriate gliding of the tendon repair relative to the intact
pulleys. In this approach, epinephrine-induced vasoconstriction can reduce bleed-
ing without use of a pneumatic tourniquet. Usually, the wide-awake approach is
performed without IV sedation.
• For injuries in zone V, a field block or regional anesthesia is recommended.
• The midaxial approach (Fig. 78.4A) is the preferred surgical approach to preserve
normal tissue directly over the tendon sheath and to reduce wound tension with
postoperative digital motion.
• The Bruner incision (see Fig. 78.4B) provides wide exposure and is commonly
used. If the patient has had a previous oblique incision or laceration, it is often
incorporated.
Midaxial approach
Midaxial approach
Bruner
incision
Bruner incision
FIGURE 78.4 (A–B) Midaxial and Bruner incisions.

PROCEDURE
General Suture Repair
• Suture type, suture caliber, the number of core suture strands crossing the repair
site, core suture purchase, and the addition of an epitendinous suture all affect the
strength of a tendon repair.
• Classic two-strand suture methods (Kessler, modified Kessler, or Tajima techniques;
Fig. 78.5) can be used, as well as newer multistrand suture methods (Fig. 78.6).
• Based on the caliber of the injured tendon, 3-0 or 4-0 sutures are chosen.
• Tendon lacerations should be repaired with at least four-strand core suture tech-
niques with an epitendinous repair (Fig. 78.7) for early motion therapy. Repair tensile
strength increases with a higher number of core strands across the repair site.
• Ex vivo experiments have shown that “locking” core suture repair shows greater
strength than “grasping” suture (Fig. 78.8A–B).
• The epitendinous repair theoretically smooths the repair site to facilitate improved
gliding, increases the strength of repair site by approximately 10% to 50%, and
decreases adhesions of the repaired tendons.
• The authors prefer a six-strand Tang repair (using a looped braided nylon suture
[Fig. 78.9A] or a Tajima-Strickland suture [see Fig. 78.9B] if a looped suture is not
available). In addition, a running locking epitendinous suture of 6-0 nonabsorbable
monofilament is added for all zone I and zone II repairs and at the surgeon’s discre-
tion for more proximal zones if needed for added strength.
Kessler Tajima “Modified Kessler”
FIGURE 78.5 Two-strand suture methods.
Non-locking cruciate Winters-Gelberman
FIGURE 78.6 Multistrand suture method.
Simple running Running locking
FIGURE 78.7 Epitendinous repair.

“Locking” suture
A
“Grasping” suture
A M-Tang repair (6-strand)
FIGURE 78.9 (A) M-Tang repair. (B) Tajima-Strickland suture. ([A] From Tang
JB, Zhou X, Pan ZJ, Qing J, Gong KT, Chen J. Strong digital flexor tendon
B repair, extension-flexion test, and early active flexion: Experience in 300 ten-
FIGURE 78.8 (A–B) Comparison of locking core to grasping suture. dons. Hand Clin. 2017;33(3):455–463.)
Zone I Injury
INDICATIONS
• Zone I injuries involve only the FDP tendon and are divided into open (laceration) and
closed (avulsion) injuries.
• According to the FDP avulsion classification of Leddy (Fig. 78.10), type I injuries,
which have the greatest retraction of the proximal end of FDP tendon, require acute
Type I Type II Type IIIa Type IIIb
FIGURE 78.10 Leddy classification for flexor digitorum profundus (FDP) avulsion.
repair within at least 3 weeks before contracture of the muscle. This type of injury
has a worse prognosis because rupture of the vincular system diminishes the seg-
mental blood supply to the tendon.
• If the distal FDP remnant is at least 1 cm, the tendon can be repaired directly (see
“Procedure for Zone II Injury”). Otherwise, the pullout technique with either a button
or suture anchors can be used to repair the tendon to the bone.

Retrieval of Proximal Tendon Stump A pediatric feeding tube (typically size 8–10
• Expose the injured tendon ends by opening the flexor sheath distal to the A4 pulley French) slides easily through the pulley system and
(Fig. 78.11). can be sutured to the tendon stump for retrieval.
• If the proximal tendon end is not visualized (Leddy type I; see Fig. 78.10), a separate
incision can be made in the palm at the A1 pulley to find the retracted proximal end STEP 1 PITFALLS
(Fig. 78.12). The exposure to locate the proximal end of the FDP in the palm is
If the repaired tendon is unable to pass through the
similar to the exposure for trigger finger release (see Chapter 83). The origin of the
A4 pulley, the pulley should be divided to permit
lumbrical muscles from the FDP tendons prevents more proximal retraction of the free motion. As long as the A2 pulley remains
proximal tendon end. intact, the chances of bowstringing are low.
• While flexing the wrist to decrease the tension on the proximal tendon, a small feed-
ing catheter can be threaded through the flexor sheath to bring the proximal tendon
end into the distal injury site for repair (Fig. 78.13).
• The proximal end of the tendon is held in place with a 25-gauge needle placed
through the tendon and pulley. STEP 2 PEARLS
• Gentle pulling of the tendon end can relax the FDP muscle to reach the distal pha-
• Alternatively, a suture anchor into the distal
lanx. Alternatively, the tendon can be lengthened by step-cut lengthening at the phalanx may be used for an “all-inside”
musculotendinous juncture via a separate incision in the forearm, which may gain an fixation. We prefer to use an anchor with
additional 2 to 4 cm of tendon length (see Chapter 100). 3-0 braided nonabsorbable suture and a
Bunnell crossing suture configuration with the
Step 2 sutures from the anchor. Care must be taken
to ensure that the tendon edge is flush to the
• In the case of open zone I lacerations, a distal tendon end will likely be present to bone surface when the suture is tied.
perform a primary tendon repair. For closed avulsion injuries, a distal stump is un- • For a Leddy type III injury, either a Kirschner
likely to be present with the FDP tendon avulsed directly from its attachment at the wire (K-wire) or screws can be used to secure
base of the distal phalanx. the fracture. If screw fixation is chosen, the
bone fragment must be at least 2.5 times
• If no distal tendon stump is present, the volar base of the distal phalanx is ex-
larger than the diameter of the screw.
posed to establish the repair site for the proximal tendon. A rongeur or curette is
A4 pulley
Proximal tendon end
FIGURE 78.11 Exposure of injured tendon ends. FIGURE 78.12 Locating the proximal tendon in the palm.
Feeding tube
passed from Curette
distal to proximal
FIGURE 78.13 Feeding tube brings the proximal tendon FIGURE 78.14 Curette exposes cancellous bone to
stump into the distal injury site. heal an avulsed tendon.
STEP 2 PITFALLS used to create a corticotomy to expose cancellous bone to heal to the avulsed
tendon (Fig. 78.14).
Care should be taken to avoid drilling into the nail
base to prevent injury to the germinal matrix and • Use a 3-0 nonabsorbable monofilament suture (e.g., Prolene) to repair the distal end
possible nail deformity (Fig. 78.18). of the tendon. A smooth, strong suture can be pulled out from the tendon and bone
postoperatively after sufficient time for healing (Fig. 78.15). Kessler and Bunnell
crossing sutures are both possible techniques to use to capture the proximal ten-
don. To better capture the tendon end to the bone, however, we prefer the Bunnell
type of suturing (Fig. 78.16).
• The suture is passed through the distal phalanx via two Keith needles drilled into the
bone obliquely (Fig. 78.17A–B). The Keith needles are angled to exit through the
sterile matrix or hyponychium.
3-0 prolene
suture
A needle placed through

the tendon and pulley
FIGURE 78.15 3-0 nonabsorbable monofilament suture repairs the distal tendon. FIGURE 78.16 Bunnell-type suture.
Avoid drilling into

the nail base
A B
FIGURE 78.17 (A–B) Suture passed through distal phalanx.
Button
Nail base
Flexor tendon
FIGURE 78.18 Avoid the nail base when passing the suture.

Tie the suture ends over a button or a felt pad on the nail plate at maximal tension. The tendon-bone junction site should be observed
Check that the tendon is in contact with the bone trough and that the proper tension is directly before final tying of the suture to ensure
set (Fig. 78.19A–C). that the tendon is in contact with cancellous bone
at the repair site (Fig. 78.20).
Step 4
Close the wound and apply a soft dressing and a dorsal extension block splint
(Fig. 78.21).
Proper tension Proper tension
A B C
FIGURE 78.19 (A–C) Suture ends are tied over a button with proper tension.
FIGURE 78.20 Tendon in contact with cancel-

FIGURE 78.21 Dorsal extension block split.
lous bone at repair site.

• A splint is applied with the MCP joints flexed at 50 to 70 degrees and the IP joints
fully extended. The wrist may be splinted in neutral or slight flexion. Within 1 week,
passive blocking exercises can be initiated.
• If the repair is performed under WALANT (wide awake, local anesthesia, no tour-
niquet) and no gapping from the bone-tendon interface is seen with intraopera-
tive active flexion, an early active motion protocol may be started during the first
week.
• After 4 weeks, exercises are progressed weekly to include active motion at greater
degrees of wrist extension. If the pullout technique is performed with a button, the
suture is removed at 8 weeks postsurgery.
• The dorsal blocking splint is discontinued at 6 to 8 weeks.
• Strengthening exercises are initiated at 3 months postoperatively.
• Approximately 80% of zone I flexor tendon injuries attain excellent-to-good (.75%
of normal) total active motion.
• The difference in healing mechanisms and outcomes between tendon-to-bone and
tendon-to-tendon repair is unknown.
• If postoperative rupture of the repaired tendon is suspected, the re-exploration and
repair should be performed immediately. Delay in repairing a postoperative tendon
rupture may result in inability to perform primary repair because of further retraction
and shortening of the proximal tendon.
Zone II Injury
INDICATIONS
• Zone II injuries usually involve both the FDP and FDS tendons.
• The only way to regain adequate function of the injured tendons is through surgical
repair.
• Operative repair is recommended within 1 to 2 weeks after the injury. Emergency
repair is needed, however, for a tendon injury associated with an ischemic digit.
• An isolated injury to the FDS or FDP can be left unrepaired, but only after sufficient
discussion with the patient regarding the potential decreased function and/or grip
strength of the digit.
Bruner incision
incorporating
laceration
FDP tendon
proximal stump
FIGURE 78.22 Bruner incision. FIGURE 78.23 Flexor digitorum superficialis (FDS) tendon
ends exposed.

• An appropriate incision is selected for full exposure of the tendon laceration for re- The authors prefer midaxial incisions if possible
pair. A midaxial or Bruner incision is preferred, depending on ease of incorporating so that volar skin covers the tendon and prevents
the laceration (Fig. 78.22). desiccation in the case of slow wound healing.
• The tendon sheath is entered between the A2 and A4 pulleys to expose the tendon
ends (Fig. 78.23). The A3 pulley can be divided completely. If necessary, the A2 or STEP 1 PITFALLS
A4 pulleys may be divided to provide further exposure for the tendon repair. If the Care should be taken not to make the skin flap too
entire A2 pulley is injured, pulley reconstruction is recommended (see Chapter 80). thin to avoid skin necrosis.
• The distal end of the tendon should be present near the level of the laceration. If it
is not visualized at the level of the laceration, the tendon was likely cut with the digit
in the flexed position. The tendon can be brought into view by passively flexing the
DIP joint (Fig. 78.24).
• If the proximal tendon end is not accessible, one should try milking the digit (using
a proximal-to-distal massage of the finger) with the wrist and the MCP joints flexed.
FDP tendon
distal stump
FIGURE 78.24 Passive flexion brings the flexor digitorum superficialis (FDS) tendon stump into view.
A B
FIGURE 78.25 Retrieving the flexor pollicis lon- FIGURE 78.26 (A–B) A feeding tube delivers the proximal end of the flexor pollicis longus
gus (FPL) tendon from the distal forearm. (FPL) to the repair site.
Alternatively, a single attempt with a fine-tipped mosquito forceps passed into the
sheath may be attempted to grasp the proximal tendon. Nevertheless, care must be
taken to avoid too much trauma to the tendon. No more than a single blind attempt
at grasping the proximal tendon end is recommended. If neither of these maneuvers
is successful, the tendon may be located in the palm or forearm.
• The FDP tendon can be reliably found in the palm as previously described for zone I
repair. If the FDS tendon is not visible at the A1 pulley, however, it may be located in
the distal forearm. The FPL tendon, with no lumbrical origin, frequently retracts to,
and must be retrieved from, the distal forearm (Fig. 78.25). The proximal tendon end
is then delivered to the distal repair site by attaching it to a pediatric feeding catheter
(Fig. 78.26A–B).
• Once the proximal tendon end is delivered into the repair site, it should be held in
place with a 25-gauge or Keith needle inserted through the annular pulleys (Fig. 78.27).
Keith needle
FIGURE 78.27 Keith needle secures proximal tendon at repair site.

Repaired FDP
tendon
FIGURE 78.28 Preserving orientation of the Camper’s chiasm of the flexor digitorum superficialis
(FDS) tendon.

• It is important to repair the FDS and FDP in their proper anatomic relationship, pre- • Knowledge of the injury mechanism is critical
serving the orientation of the Camper’s chiasm of the FDS tendon (Fig. 78.28; see in planning the repair strategy and informing
also Fig. 78.2). In cases in which the FDS and FDP repair does not glide freely at the the proper rehabilitation protocol.
FDS decussation, one slip of the FDS should be resected. • The FDS is frequently lacerated at a level
• A six-strand core suture (with 3-0 or 4-0 braided permanent suture) is commonly where it is too flat to be repaired with core
sutures. In some cases, to prevent bulk and
used for repair of the FDP tendon. The core suture techniques (see “General Suture facilitate adequate gliding, only the FDP should
Repair,” discussed earlier, and Figs. 78.5–78.9) can be selected based on the caliber be repaired. Nevertheless, using horizontal
of the injured tendon and surgeon preference. suture repair can reapproximate the flat FDS
• For early motion therapy, at least a four-strand core suture technique with a running tendons close to its insertion and the repaired
6-0 Prolene epitendinous suture is recommended. FDS provides a smooth gliding surface for the
repaired FDP tendon.
Step 3
• After tendon repair is performed, a flexion-extension test (Fig. 78.30) helps check STEP 2 PITFALLS
that the repair neither gaps when the digit is in full extension nor catches on a pulley
When placing subsequent core sutures, care is
edge or at the FDS decussation in flexion. This check of tendon excursion after re- taken to prevent cutting a previously placed stitch
pair is most accurate with the wide-awake approach when patients can perform with the suture needle (Fig. 78.29).
active range of motion (ROM), but it is also useful passively.
• If there is triggering, the pulley can be partially released before skin closure.
• Careful hemostasis is achieved using bipolar electrocautery.
• Upon wound closure, a soft dressing and a dorsal extension blocking splint should
be applied.

• Patient compliance is crucial, and emphasis should be placed on the importance of
postoperative rehabilitation protocols.
• The surgical splint should maintain the position of wrist in slight flexion (10–30 degrees),
the MCP joints flexed (50–70 degrees), and both IP joints at either zero or slight flexion
(see Fig. 78.21).
• Use a strict graded rehabilitation protocol under the supervision of a qualified hand
FIGURE 78.29 Avoid cutting a previously placed
therapist.
stitch.
• We prefer an early active motion protocol in compliant patients with strong tendon
repairs. Therapy should begin 2 to 3 days postoperatively and starts with active mo-
tion to a partial (50%) fist in addition to place-and-hold and passive ROM exercises
within a dorsal blocking splint. Active motion and place and hold exercises enable
Preserved pulley
Tendon repair site
Finger moderately
flexed
Finger moderately
flexed
FIGURE 78.30 Flexion-extension test after repair of tendon. (From Tang JB, Zhou X, Pan ZJ, Qing J,
Gong KT, Chen J. Strong digital flexor tendon repair, extension-flexion test, and early active flexion:
Experience in 300 tendons. Hand Clin. 2017;33(3):455–463.)
POSTOPERATIVE PEARLS differential gliding of FDS and FDP tendons, which theoretically decreases adhesion
formation even more than early passive ROM exercises.
The removable dorsal blocking splint should be
made with the wrist at 10 degrees extension, • Active ROM is increased gradually over the next several weeks to full flexion, and
MCP joints flexed to 45 degrees, and IP joints fully the dorsal blocking splint is discontinued around week 6.
extended. • The patient may return to unrestricted activity 4 to 6 months after surgery.
• Patients unable to participate in active hand therapy should begin the Duran proto-
col at their postoperative visit. This passive motion protocol is based on the theory
that approximately 3 to 5 mm of tendon gliding is needed to decrease adhesion
formation. A dorsal blocking splint is fabricated and the patient starts passive ROM,
followed by active ROM at 3 to 4 weeks postoperatively. Passive extension stretch-
ing and blocking active flexion exercises are started at 5 to 6 weeks, and progressive
resistive exercises are permitted at 8 weeks.
• Approximately 80% of patients (range of 70%–96% reported in the literature) under-
going zone II tendon repair achieve excellent to good (.75% of normal) total arc
of motion.
• On average, the rate of ruptures after surgery is 4% to 10% for zone II and 3% to
17% for FPL tendon repairs.
• Concomitant flexor tendon and digital nerve repairs may need to progress slower
with rehab depending on the nerve repair. Many studies show nerve repairs to be a
slight risk factor for poor outcomes of flexor tendon repairs (Fig. 78.31).
Repaired
FDP
tendon
Lacerated
digital nerve
FIGURE 78.31 Concomitant flexor digitorum profundus (FDP) tendon and digital nerve injury.
Zone III To V Injury

INDICATIONS
• Knowledge of the cross-sectional anatomy of each zone is the key to identifying
injured structures.
• The tendon repair techniques are similar to injuries in zone II.
• Isolated tendon injuries rarely occur in zones III to V.
• Zone III injuries often include digital nerves or vessels.
• With a zone IV injury, release of the carpal tunnel should be performed to avoid
compression of the median nerve and to facilitate visualization of the tendon ends
for the repair. Injuries to zone IV are rare.
• Zone V injuries are often associated with injury to multiple tendons, the median
nerve, the ulnar nerve, the radial artery, or the ulnar artery. Carpal tunnel release can
facilitate visualization of the injured tendons and associated structures under tourni-
quet control. Structures should be identified from deep to superficial, and the
proximal and distal ends of the injured structures are marked with sutures as they
are identified.
• Observation of joint movement after pulling on the distal tendon ends will enable
the distal tendons to be easily identified. The proximal ends of the tendons are
identified based on anatomic location. FDP tendons are the deepest structures in
the forearm and are arranged side by side in the same plane. FDS tendons are
superficial, with the index and small finger tendons deeper than the middle and ring
finger tendons. STEP 1 PEARLS
• Primary repair of injured tendons and neurovascular structures is recommended by • Injured structures should be identified from
using a systematic approach. deep to superficial.
• Selective passive flexion and extension of the
PIP and DIP joints help differentiate distal FDS
Step 1 and FDP tendon stumps.
• An extensile incision is needed to identify all injured structures. Any traumatic lac- • Core and epitendinous sutures may still be
eration should be extended to visualize the anatomy beginning outside of the zone used in zone III to create a strong repair
of injury (Fig. 78.32A–B). (Fig. 78.34A–B).
• For the forearm, it is often preferred to perform the arterial repairs first, followed by
tendons and nerves.
STEP 1 PITFALLS
• Using a 3-0 suture, a four- to six-strand core suture is recommended (Fig. 78.33; see
also Figs. 78.6 and 78.9A–B). Given the lack of tendon sheath in these zones, an The proximal ends of the injured tendons can be
epitendinous suture is not required to facilitate gliding, and some repair bulk may be more difficult to identify; it is best to identify and
label the distal ends first.
helpful to add strength to the repair site.
B
Tendons repaired,
FIGURE 78.32 (A–B) Yellow dashed line indicates planned extensile incision deep to superficial
for exposing a zone V tendon injury. FIGURE 78.33 Repair of flexor tendon in zone V.
A B
FIGURE 78.34 (A–B) Core and epitendinous sutures create a strong repair for zone III flexor tendon
injury.

• Good-to-excellent outcomes in ROM and tendon function can be expected, given
the lack of tendon sheath in these zones. Nevertheless, more variation in outcome
often is seen in patients with associated nerve injuries. Younger patients generally
demonstrate improved results.
• Early motion therapy with use of dynamic splinting has shown better outcomes than
static splinting and is recommended if possible.
See Videos 78.1, 78.2, and 78.3
EVIDENCE
Frueh FS, Kunz VS, Gravestock IJ, et al. Primary flexor tendon repair in zones 1 and 2: Early passive
mobilization versus controlled active motion. J Hand Surg Am. 2014;39:1344–1350.
This study shows the effect of controlled active motion protocol on total active motion 4 weeks after
surgery. The rupture rate was lower in patients with use of controlled active motion compared with
patients using early passive mobilization protocols.
Trumble TE, Vedder NB, Seiler JG III, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: A
randomized prospective trial of active place-and-hold therapy compared with passive motion
therapy. J Bone Joint Surg Am. 2010;92(6):1381–1389.
This multicenter randomized controlled trial of 119 zone II flexor tendon repairs (in 103 patients) com-
pared early active motion with place-and-hold exercises against a traditional passive motion rehabili-
tation protocol. All patients had surgery within 2 days of injury and tendons were repaired with four
core strands and an epitendinous suture. Patients were followed closely at numerous time points and
106 digits were evaluated at 1 year. IP motion was greater at all time points in the early active group,
with smaller flexion contractures and significantly greater satisfaction scores. Smokers and those with
digital nerve injuries had less final motion. Two digits ruptured in each group.
Zhou X, Li XR, Qing J, Jia XF, Chen J. Outcomes of the six-strand M-Tang repair for zone 2 primary
flexor tendon repair in 54 fingers. J Hand Surg Eur Vol. 2017;42(5):462–468.
The authors reviewed their experience of 54 zone II flexor digitorum profundus tendon repairs (45 patients)
using an M-Tang six-strand core suture configuration with 4-0 looped nylon augmented with an epiten-
dinous running suture. Twenty-eight fingers were followed up with for longer than 1 year. In total, 43 had
good or excellent results, 8 had fair results, and 3 had poor results. The little finger and fingers with
digital nerve injuries had worse final motion. Good or excellent results were more common in fingers
where the A2 pulley was vented compared with fingers with an A2 pulley that was left intact. No
tendon ruptures were reported.
Rigo IZ, Røkkum M. Predictors of outcome after primary flexor tendon repair in zone 1, 2 and 3.
This study examined the results of 356 flexor tendon repairs in zones I, II, and III over a 5-year period.
Follow up averaged 7 months (range 3–98 months) and combined IP (PIP and DIP) motion averaged
114 degrees. Only 107 of 225 (48%) achieved good or excellent results at the final follow-up. The
repair rupture rate was 4%. A reoperation was required for 13% of patients. Predictors of poor
outcomes were increased age, smoking, little finger, extensive soft tissue damage, concomitant
fracture, delay to surgery, two-strand repair, pulley preservation or repair, and unrepaired FDS.
CHAPTER 79
Two-Stage Flexor Tendon Reconstruction
with Silicone Rod
INDICATIONS
• A two-stage flexor tendon reconstruction is typically used to reconstruct a severely
damaged flexor tendon system in patients who cannot undergo single-stage tendon
grafting. when significant joint contracture release is needed (Fig. 79.1A-B), or pulley
reconstruction is required.
• The first stage requires placement of a silicone rod in the tendon bed to permit
formation of a pseudosheath to receive a tendon graft in the future.
• The second stage is the placement of the tendon graft, which is performed
approximately 3 months after the first operation.
• The patient must understand the complexity of the injury and be willing to participate
in the time-consuming postoperative rehabilitation. In some instances, arthrodesis
or amputation may be a better alternative.
• Frequently, patients undergoing two-stage flexor tendon reconstruction require te-
nolysis to improve motion sometime after the second stage. Patients should be
counseled about this common complication, often referred to as the “third stage.”
Contraindications
• Active infection and significant soft tissue and/or skin loss are contraindica-
tions for two-stage reconstruction. Stiff fingers with permanent insults to mul-
tiple tissue types (skin, nerve, vessel, tendon, bone) may be better served with
amputation.
• Patient compliance and diligence with therapy is essential. Two-stage reconstruction
should not be attempted in patients who cannot or will not participate in the post-
operative rehabilitation.
IMAGING
• Radiographs may be taken if evaluation of bone and joint structures is needed.
• A hand radiograph before the second stage of the operation is useful to make sure
the silicone rod has not migrated.
A B
FIGURE 79.1 (A–B) Indication for two-stage flexor tendon reconstruction.
626
CHAPTER 79 Two-Stage Flexor Tendon Reconstruction with Silicone Rod 627
EXAMINATION
• The preoperative examination should localize the area of tendon injury and assess
for scarring and joint contractures in the fingers and palm. Frequently, the need to
address contractures and stiffness necessitates a two-stage reconstruction rather
than a primary repair or immediate tendon graft.
• Scars should be supple, fingers should be free of edema, and joints should have
regained passive flexibility before embarking on the second stage of the reconstruc-
tion (tendon graft placement).
SURGICAL ANATOMY
• The flexor tendons have five annular (ring-shaped) and three cruciate pulleys, and
the thumb has two annular and an oblique pulley (Fig. 79.2).
• Usually the proximal end of the tendon graft is repaired to the proximal end of the na-
tive flexor digitorum profundus (FDP) tendon in the palm because the lumbrical mus-
cle, if uninjured, prevents further proximal retraction of the FDP tendon. If the palm and
lumbrical muscles are also injured, the proximal juncture should be placed in the wrist.
EXPOSURES
• Usually, Bruner incisions are designed from the middle of the distal phalanx to the
midpalm to expose the damaged tendons (Fig. 79.3). Previous incisions should be
incorporated into the exposure.
• Neurovascular bundles should be identified and must be protected during the pro-
cedure.
A5
C3
A4
C2
A3
C1
A2
A1
Oblique pulley
FIGURE 79.2 Key anatomic landmarks for flexor tendons. FIGURE 79.3 Bruner incision.
628 CHAPTER 79 Two-Stage Flexor Tendon Reconstruction with Silicone Rod
Flexor tendon
scar to be
resected A2 pulley
A1 pulley
FIGURE 79.4 Scarred tissue over flexor tendon. FIGURE 79.5 Preserve A2 and A4 pulley if present.
STEP 2 PEARLS STAGE 1 – SILICONE ROD PLACEMENT

• The excised FDS and FDP tendons should be Step 1: Assessment of Pulleys
used for pulley reconstruction if needed. Even
if the A2 and A4 pulleys are present, we will • Scarred pulleys are excised (Fig. 79.4) and an attempt should be made to preserve
form a series of new pulleys using the excised the most important A2 and A4 pulleys if present (Fig. 79.5).
tendons. • Lateral remnants of the A2 and A4 pulleys should be preserved to anchor to the
• Joint release (closed or open capsulotomies excised tendons for pulley reconstruction.
and direct release of tight collateral/checkrein
ligaments) can be performed during the first
stage to achieve full passive range of motion Step 2: Tendon Debridement
(ROM; see Chapter 103). • Excise the damaged FDP and flexor digitorum superficialis (FDS) tendons.
• Approximately 1 cm of the FDP insertion on the distal phalanx is preserved to attach
the silicone rod distally.
• Keep these excised tissues, because they can be used to make a series of pulleys
by sewing them to the remnant tissues along the path of the digit. They will form the
gliding surface of the silicone-induced tendon sheath in time for the second stage
of reconstruction. There is no need to harvest tendon grafts to reconstruct the new
pulleys.
STEP 3 PEARLS Step 3: Silicone Rod Placements

• When tendon reconstruction is needed from • The silicone rod is made from a polyester and silicone elastomer, which can range
the fingertip to the distal forearm, the palmaris from 2 to 6 mm in width and 24 to 25 cm in length.
longus (PL) tendon may be too short to reach. • The appropriate width is selected that will pass through the remaining pulleys if
Thus the plantaris tendon may be considered. present and will glide well with passive finger motion. The selected silicone rod is
Alternatively, if the superficialis tendon from
passed under the preserved and reconstructed pulleys along the length of the digit
the injured finger is still intact, it can be har-
vested to be used as a tendon graft. (Fig. 79.6).
• The silicone rod should extend more proximally • The distal end of the rod should be cut to expose the inner polyester so that it can
than any scarring in the digit or palm and end hold sutures. The silicone rod is sutured to the preserved distal FDP tendon stump,
in untraumatized, healthy tissue. the distal interphalangeal (DIP) joint volar plate, and the surrounding soft tissue using
4-0 monofilament suture (Fig. 79.7).
STEP 3 PITFALLS • If pulley reconstruction is needed, it is performed over the silicone rod using the
The proximal end of the rod must be left free in excised FDS or FDP tendon graft at this time (see Fig. 79.6). The tendon graft used
the palm or distal forearm. If it is sutured to the for pulley reconstruction is attached to remaining remnants of the native pulleys.
proximal end of the FDP, it may lead to a rupture of Alternatively, if there are no pulley remnants remaining, the tendon graft may be
distal end of the rod. If the distal end ruptures, the
wrapped around the proximal or middle phalanges (for reconstruction of the A2 and
important pseudosheath will fail to form.
A4 pulleys, respectively; see Chapter 80).
Distal FDP stump
Reconstructed
pulleys using
tendon graft
Suture
Silicone rod
FIGURE 79.7 Silicone rod placement. FDP, Flexor digitorum profundus.

FIGURE 79.6 Reconstructed pulleys using tendon graft.
FIGURE 79.8 Proximal end of the silicone rod is left in FIGURE 79.9 Closure.
the palm.
• The proximal end of the rod is left free in the palm (Fig. 79.8) or the distal forearm,
depending on where the least scarred area is.
Step 4: Wound Closure STEP 4 PEARLS

• The tourniquet is released and careful hemostasis is achieved using bipolar electro- If there is a skin defect, a local skin flap or
cautery. cross-finger flap (see section “Cross-Finger
• The wound is closed with interrupted sutures (Fig. 79.9), and a soft dressing is Flap” in Chapter 87) is used for soft tissue
coverage (Fig. 79.10A–B).
applied to enable digit ROM.

• Dorsal blocking splints are not needed because the proximal silicone rod is not su-
tured to a tendon. The patient can start aggressive passive ROM exercises, with the
goal of achieving full passive motion of the involved digit.
• Usually, at least 3 months are needed to permit formation of the pseudosheath
and to optimize soft tissue conditions before reoperation. The patient must also
Skin defect
Covered with
dorsal skin flap
A B
FIGURE 79.10 (A–B) Flap coverage for skin defect.
maximize passive ROM during this time before pursuing the second stage of
reconstruction.
• A radiograph is taken just before the second stage to confirm the rod has not
migrated proximally.
STAGE II – SILICONE ROD REMOVAL AND PLACEMENT

OF TENDON GRAFT
Exposure
Small access incisions are made on the volar distal phalanx, palm, and tendon graft
harvest sites (Fig. 79.11).
Step 1: Harvest of Tendon Graft

• The PL tendon is initially exposed through a 1-cm transverse incision at the level of
the distal wrist. Care is taken to identify and protect the nearby median nerve. The
exposed PL tendon is cut and held with a hemostat. The tendon graft is freed distal
to proximal at each incision site (Fig. 79.12) until sufficient graft length is harvested
FIGURE 79.11 Marking the tendon graft harvest sites. FIGURE 79.12 Harvest of tendon graft.
FIGURE 79.13 Tendon graft with sufficient length.
(Fig. 79.13). Alternatively, an appropriately sized tendon stripper can be used from STEP 1 PEARLS
an incision in the distal volar wrist.
The harvested tendon graft is kept in moist gauze
• Although the PL tendon is most commonly used, it is absent in approximately 20% to prevent desiccation.
to 25% of patients. In these patients, a plantaris tendon or FDS tendon graft should
be used.
• The plantaris tendon is exposed through a 3- to 5-cm vertical incision just anterior
to the Achilles tendon at the level of the medial malleolus. The tendon is divided as
far distally as possible, and a tendon graft harvester is passed along the tendon
length proximally with the knee held in an extended position to avoid injury of neu-
rovascular structures in the popliteal area (Figs. 79.14A–B and 79.15).
Step 2: Tendon Repair STEP 2 PEARLS
• The graft is sutured to the proximal free end of the silicone rod. The distal end of the • Prolene suture is recommended for the distal
silicone rod is released from the FDP stump and pulled out of the distal wound to graft end to enable the suture to pull out from
the bone and tendon smoothly. Other types of
bring the graft through the pseudosheath (Fig. 79.16). suture material do not slip as easily to facili-
• Care is taken to clamp the proximal end of the tendon graft to prevent the graft from tate removal postoperatively.
pulling entirely out of the sheath as the rod is being pulled distally. • Using the wide-awake approach permits im-
• After releasing the graft from the rod, the tendon repair is performed. The distal end is proved setting tension of the tendon graft by
repaired first to promote easier visualization of the repair with the finger in extension. asking the patient to perform active movement
of the finger (Fig. 79.21A–B).
• Cancellous bone is exposed at the base of the distal phalanx. A Bunnell suture using
Prolene is placed at the end of the tendon graft. Two Keith needles are drilled
obliquely through the base of the distal phalanx and used to bring the suture through
FIGURE 79.14 (A–B) Exposure of the plantaris tendon. FIGURE 79.15 Plantaris tendon graft harvested.
Distal graft end
Proximal graft end
FIGURE 79.16 Tendon graft pulled through pseudosheath.
Bunnell
suture
3-0 Prolene
Keith needle
A B
FIGURE 79.17 (A–B) Bunnell suture placed at end of the tendon graft, with Keith needles securing
the graft.
STEP 2 PITFALLS the nail plate or hyponychium to secure the graft. The sutures are tied over a button
• With the pull-out suture technique, the tendon bolster over the nail plate (Fig. 79.17A–B; see Chapter 78 for details). The remaining
graft must be in contact with cancellous bone FDP stump is sutured side to side over the tendon graft.
of the distal phalanx to assure proper adher- • Next, the proximal end of the graft is repaired to the proximal remnant of the FDP. The
ence of the tendon graft to the bone. FDP is distinguished from the FDS by its lumbrical muscle attachment (Fig. 79.18).
• Care is taken to not drill the Keith needle into A Pulvertaft weave technique is performed to secure the proximal stump of the FDP
the germinal matrix, which would lead to nail
deformity. tendon to the tendon graft using nonabsorbable braided suture. Care should be taken
to make sure the tension is not too tight or too loose (Fig. 79.19A–C). The tension
should be set such that the digit is in slightly greater flexion than the normal cascade
(Fig. 79.20).
• The tourniquet is released, and careful hemostasis is achieved using bipolar electro-
cautery.
• The wound is closed, and a soft dressing and dorsal blocking splint are applied.

• A dorsal blocking splint is used for 6 weeks after the surgery, with the wrist in neu-
tral, metacarpophalangeal (MCP) joints at 45 degrees of flexion, and interphalangeal
(IP) joints in extension.
• In general, early active motion therapy is strongly recommended. Guided, passive
ROM exercises usually begin within a few days after the operation, followed by
gentle place-and-hold exercises at 2 weeks postoperatively. Blocked flexion exer-
cises may start at 4 weeks and more aggressive exercise at 6 weeks (if the tendon
A Tight B Appropriate
FDP tendon
(lumbrical muscle
attachment)
C Loose
FIGURE 79.18 Proximal remnant of the FDP is
tied to the graft. FDP, Flexor digitorum profundus. FIGURE 79.19 (A–C) Ensure appropriate tension.
FIGURE 79.20 Digit should have slightly greater

B
tension than normal cascade.
FIGURE 79.21 (A–B) Active motion permits setting of tension.
and repair sites are considered sufficiently strong). The pull-out suture is removed
8 weeks postoperatively. Joint contracture can be countered with dynamic splinting
at 6 to 8 weeks.
• Tendon adhesion and joint contracture can develop. Guided, strict rehabilitation af-
ter both stages is crucial to obtaining the best possible outcome. See Fig. 79.22A–B
for 4-month follow-up.
A B
FIGURE 79.22 (A–B) Four-month follow-up.
EVIDENCE
Coyle Jr MP, Leddy TP, Leddy JP. Staged flexor tendon reconstruction fingertip to palm. J Hand Surg
Am. 2002;27:581–585.
This is a retrospective study of 35 fingertip-to-palm, staged flexor tendon reconstructions using the
FDP tendon as the proximal recipient and PL tendon graft. The result of the reconstruction shows
69% of patients achieved good-to-excellent ROM.
LaSalle WB, Strickland JW. An evaluation of the two-stage flexor tendon reconstruction technique.
J Hand Surg Am. 1983;8(3):263–267.
A classic early review of results after two-stage flexor tendon reconstruction reports outcomes and
complications of 43 tendon reconstructions in 39 patients. The authors excluded MP motion in their
evaluations, focusing only on combined PIP and DIP motion. Initially, only 39.5% of patients achieved
good or excellent motion (defined as >50% of normal). Tenolysis was required in 47% (20 tendons)
with improvement in 12 fingers.
Unglaub F, Bultmann C, Reiter A, Hahn P. Two-staged reconstruction of the flexor pollicis longus
tendon. J Hand Surg Br. 2006;31(4):432–435.
This retrospective study examined the results of 16 patients who underwent two-stage flexor pollicis
longus (FPL) reconstruction using silicone rod placement followed by tendon graft insertion. Follow-up
averaged 52 months after final reconstruction. Average active thumb IP joint motion was 32 degrees
(versus 75 degrees at the uninjured thumb). Three of 16 patients could not oppose the thumb to the
little finger and only 6 patients could touch the little finger palmar digital crease. Pinch and grip
strengths were significantly weaker than the contralateral side, but patient reported outcomes were
satisfactory. Two patients needed reoperations
Darlis NA, Beris AE, Korompilias AV, Vekris MD, Mitsionis GI, Soucacos PN. Two-stage flexor tendon
reconstruction in zone 2 of the hand in children. J Pediatr Orthop. 2005;25:382–386.
The authors report outcomes after two-stage flexor tendon reconstruction in nine children (mean age
6.9 years). The mean total active motion was 196 degrees, and eight patients achieved a good-to-
excellent result. Staged flexor tendon reconstruction can achieve satisfactory results even in very
young children.
CHAPTER 80
A2 Flexor Tendon Pulley Reconstruction With Free
Tendon Graft

This chapter includes the following videos: Video 80.1 – A2 Flexor Tendon Pulley
Reconstruction With Free Tendon Graft.
KEY CONCEPTS
• Surgical intervention is indicated in patients with spontaneous A2 pulley insuffi-
ciency with local tenderness caused by tendon bowstringing (after the failure of
Flexor
tendon
Extensor
tendon
Proximal
phalanx
Tendon
graft
FIGURE 80.9 (B) In the three loop technique, the tendon graft is wrapped around the proximal phalanx
three times circumferentially to reconstruct the A2 pulley.
635
636 CHAPTER 80 A2 Flexor Tendon Pulley Reconstruction With Free Tendon Graft
conservative therapy). Climbing activity is associated with pulley injury for many
patients. Postoperative A2 pulley insufficiency may occur after aggressive pulley
release associated with trigger finger release, tendon repair, or tenolysis.
• Although flexor tendon pulley reconstruction is not common, several surgical tech-
niques have been described, including grafting to pulley remnants, Lister’s single
loop of extensor retinaculum, Widstrom’s loop-and-a-half technique, and the triple
loop technique.
• Looped tendon pulley reconstructions have been shown to be stronger than other
methods in biomechanical studies, and the clinical literature has shown that return to
activity and satisfactory results can also be obtained after operative reconstruction.
• Damage or resection of the flexor tendon pulley system results in volar displacement
of the tendons and a decrease of interphalangeal (IP) joint motion. The A2 and A4
pulleys are the most important pulley structures. If half or more of the system is
damaged, tendon bowstringing and loss of IP joint motion may occur.
• Wide awake, local anesthesia, no tourniquet (WALANT) procedures can be used
with epinephrine in selected patients who have no history of vascular insufficiency.
This approach facilitates judging the tension and outcome of the pulley repair.
• One can use palmaris longus tendon (ipsilateral/contralateral), plantaris tendon,
extensor retinaculum, or flexor carpi ulnaris tendon for the graft.
CHAPTER 80
A2 Flexor Tendon Pulley Reconstruction
with Free Tendon Graft
Overview
• Although flexor tendon pulley reconstruction is not common, several surgical tech-
niques have been described, including grafting to pulley remnants, Lister’s single
loop of extensor retinaculum, Widstrom’s loop-and-a-half technique, and the triple
loop technique.
• Some surgeons prefer to use the triple loop technique because of the superior bio-
mechanical result compared with the other reconstruction techniques, but using the
pulley remnants is also acceptable (Fig. 80.1A–B)
INDICATIONS
• Surgical intervention is indicated in patients with spontaneous A2 pulley insufficiency
with local tenderness caused by tendon bowstringing (after the failure of conservative
therapy). Climbing activity is associated with pulley injury for many patients.
• Postoperative A2 pulley insufficiency may occur after aggressive pulley release as-
sociated with trigger finger release, tendon repair, or tenolysis.
• Severe open injury may require A2 pulley reconstruction.
Contraindications
• Digit ischemia, poor soft-tissue coverage, and joint contractures are contraindica-
tions to pulley reconstruction.
• All related joint contractures must be treated and fingers should have passive flexi-
bility before pursuing pulley reconstruction.
• Damage or resection of the flexor tendon pulley system results in volar displacement of
the tendons and a decrease of interphalangeal (IP) joint motion. The A2 and A4 pulleys
are the most important pulley structures. If half or more of the pulley system is damaged,
tendon bowstringing (Fig. 80.2A–B) and loss of IP joint motion (Fig. 80.3) may occur.
• In patients with spontaneous A2 pulley insufficiency, a ring or other circumferential digit
support orthotic (Fig. 80.4) can reduce symptoms of tenderness and improve motion.
• Pre-operative examination should confirm the presence or absence of the palmarislon-
gus tendon. If absent, an alternative tendon graft may be used.
Tendon
Fibrous rim graft
Extensor tendon
A B 3 loops
FIGURE 80.1 Diagrams of weaving the graft through pulley remnants (A), compared with a triple loop (B).
(From Clark TA, Skeete K, Amadio PC. Flexor tendon pulley reconstruction. J Hand Surg Am 2010;
35[10]:1685–1689.)
636.e1
636.e2 CHAPTER 80 A2 Flexor Tendon Pulley Reconstruction with Free Tendon Graft
Ruptured A2 pulley
Tendon separation from

phalanx creates bowstringing
Flexor tendon bowstringing
FIGURE 80.2 (A–B) Tendon bowstringing. (From Mcnally E. Chapter 15. In: FIGURE 80.3 Limited active flexion at interphalangeal (IP) joint,
Practical Musculoskeletal Ultrasound. 2nd ed. Elsevier; 2014:150–164). indicated by arrow.
IMAGING
Standard hand radiographs should be obtained to rule out joint or other bony abnor-
malities.
SURGICAL ANATOMY
• The flexor tendon pulley system includes five annular (ring-shaped) and three cruci-
ate pulleys. The most important pulleys to prevent bowstringing are the A2 and A4
pulleys (Fig. 80.5).
• The A1, A3, and A5 pulleys originate from the volar plate and bony surfaces of the
joints, whereas the A2 and A4 pulleys originate from and insert on the bony surfaces
of the proximal and middle phalanges, respectively.
• The A2 and A4 pulley lengths average almost 17 mm and 7 mm, respectively. The
A2 pulley is thickest at its distal end, up to 0.75 mm thick.
EXPOSURES
• The operation can be performed with local or regional anesthesia under tourniquet
control. Wide awake, local anesthesia with no tourniquet (WALANT) can be used
with epinephrine in selected patients who have no history of vascular insufficiency.
FIGURE 80.4 Orthotic ring. This approach facilitates judging the tension and outcome of the pulley repair.
CHAPTER 80 A2 Flexor Tendon Pulley Reconstruction with Free Tendon Graft 636.e3
A1 Synovial sheath
A5 C3 A4 C2 A3 C1 A2
FIGURE 80.5 Illustration of flexor pulley system.
FIGURE 80.6 Markings for incisions.
• If a pneumatic tourniquet is used during the operation, it should be placed on the EXPOSURES PITFALLS
upper arm, so as to not block motion of the flexor tendons or interfere with harvest • Care is taken to avoid making the skin flap too
of the palmaris longus tendon graft. thin when exposing the flexor pulley system.
• Standard Bruner incisions, midaxial incisions, or previous surgical scars are used to • Digital neurovascular bundles must be identified
and protected carefully during the operation.
expose the flexor pulley system (Fig. 80.6).
• A few small transverse incisions are used to harvest a palmaris longus tendon graft
(see Fig. 80.6).

Alternatively, if there are strong remnants of the
Step 1 A2 pulley attached to the proximal phalanx, a
• The flexor tendon is exposed, leaving the tendon sheath intact when possible. Pulvertaft weave-style repair may be used (see
• All adhesions should be released and full tendon gliding restored before pulley re- Fig. 80.1A).
construction.
• Excise all scars posterior to the tendon until the phalanges in the area of bowstring-
STEP 1 PITFALLS
ing are clearly exposed (Fig. 80.7).
• Both ulnar and radial borders of the proximal phalanx are exposed, ensuring adequate Care should be taken to preserve the perforators
from the digital arteries feeding the tendon sheath.
space for passage of the tendon graft circumferentially around the proximal phalanx.
FIGURE 80.7 Exposure.

PL graft
FIGURE 80.8 Harvesting the palmaris longus (PL) graft.
Step 2
• One can use palmaris longus tendon (ipsilateral/contralateral), plantaris tendon (see
Flexor tendon
Chapter 79 for tendon graft harvest details), extensor retinaculum, or flexor carpi
Tendon graft
ulnaris tendon for the graft.
• The most commonly used tendon graft is palmaris longus, which has adequate
length for a triple loop construct (Fig. 80.8). About 18 to 24 cm of graft is needed to
Proximal phalanx complete three loops around the phalanx.
Step 3
Extensor tendon
• The tendon graft is passed around the proximal phalanx deep to the extensor ten-
A
don and lateral bands with a suture passer or right angle (Fig. 80.9A). The graft is
wrapped around three times circumferentially (see Fig. 80.9B).
• The extensor tendon, lateral bands, and neurovascular bundles should remain free
Flexor from the tendon graft.
tendon • After setting tension of the tendon loop, the flexor tendon should remain close to the
Extensor bone surface but have smooth motion during active digital flexion (Fig. 80.10).
tendon
• The graft is sutured to the remnants of the A2 pulley and to itself using 3-0 or 4-0
Proximal
phalanx nonabsorbable suture (Fig. 80.11).
Tendon
graft
FIGURE 80.9 (A–B) Passage of the tendon graft. FIGURE 80.10 Flexor tendon retains smooth gliding motion during flexion.
CHAPTER 80 A2 Flexor Tendon Pulley Reconstruction with Free Tendon Graft 636.e5
FIGURE 80.12 Placement of graft. From Dy CJ, Daluiski A.

Flexor pulley reconstruction. Hand Clin 2013;29:
FIGURE 80.11 Graft sutured to remnants of A2 pulley. 235–242.

• The tourniquet is released, and careful hemostasis is achieved using bipolar electro- • Each loop of donor tendon provides roughly
cautery. 5 mm of pulley length.
• The wound is closed, and a soft dressing is applied. • If the A4 pulley is being reconstructed around
the middle phalanx, then the graft should be
POSTOPERATIVE CARE AND EXPECTED OUTCOMES passed superficial to the extensor apparatus,
because the terminal tendons at this level are
• Looped tendon pulley reconstructions have been shown to be stronger than other tightly adherent to the bone (Fig. 80.12).
methods in biomechanical studies, and the clinical literature has shown that return to • Setting tension is important and should be
activity and satisfactory results can also be obtained after operative reconstruction. assessed carefully both visually and manually
while asking the patient to voluntarily flex the
• The postoperative rehabilitation after the reconstruction is not well established;
finger.
rather, it is largely based on surgeon preference. Application of a ring-type splint • The patient should be awake enough to accu-
over the proximal phalanx for several weeks and initiation of gentle passive ROM rately assess the tension of the tendon with
exercises within the first few postoperative days is preferred. active range of motion (ROM).
• Fig. 80.13A–B demonstrates 7-month follow-up, with improved IP joint motion.
Pre-Op 7 months Post-Op
A B
FIGURE 80.13 (A–B) Preoperative and postoperative photos.

EVIDENCE
Okutsu I, Ninomiya S, Hiraki S, Inanami H, Kuroshima N. Three-loop technique for A2 pulley recon-
struction. J Hand Surg Am. 1987;12(5 Pt 1):790–794.
The authors used the three-loop A2 pulley reconstruction technique in six fingers and report outcomes
after an average of 21 months. Patients were 9 to 38 years old. Total active motion averaged 205 de-
grees, which was an improvement of 30 degrees from the preoperative motion. Only one patient out
of six was able to get the finger completely to the palm.
Schöffl VR, Einwag F, Strecker W, Schöffl I. Strength measurement and clinical outcome after pulley
ruptures in climbers. Med Sci Sports Exerc. 2006;38:637–743.
This article reports excellent clinical outcome (Buck-Gramcko score of 3) in 21 climbers treated conser-
vatively for pulley insufficiency. Patients were assessed through a patient-rated questionnaire, ultra-
sound, and digital strength. Although nonsurgical treatment of single-pulley ruptures is effective for
most patients with spontaneous A2 pulley insufficiency, surgical reconstruction must be considered
in cases with persistent symptoms or bowstringing.
El-Shebly A, El Fahar M, Mohammed H, Bahaa Eldin A. Outcomes of repair of the lacerated A2 pulley with
extensor retinaculum during primary flexor tendon repair. J Hand Surg Eur Vol. 2017;42(9):903–908.
The authors report their results of A2 pulley reconstructions using an extensor retinaculum graft in 10
patients with lacerations to the flexor tendon and pulley. The flexor tendons were repaired with four-
strand core sutures and then, because tendon bowstringing was noted intraoperatively, the A2 pulley
was reconstructed by suturing an extensor retinaculum graft to the pulley remnants. Mean follow-up
was 6 months, and at that time average motion was 54 degrees at the distal IP joint (84% of contra-
lateral), 90 degrees at the proximal IP joint (90%), and 89 degrees at the metacarpophalangeal joint
(97%). Fingers were graded with four excellent, five good, and one fair results.
CHAPTER 81
Tenolysis of Flexor Tendons

This chapter includes the following video: Video 81.1 – Tenolysis of Flexor Tendons.
KEY CONCEPTS
• Flexor tendon tenolysis is a difficult procedure, in which it is frequently more chal-
lenging to obtain a good outcome than primary tendon repair. Patients who cannot
or will not actively participate in an extensive rehabilitation protocol should not un-
dergo tenolysis.
• If both flexor and extensor tenolysis and joint releases are needed, the procedures
should be performed in two stages. The first stage begins with the dorsal side, fol-
lowed by aggressive postoperative rehabilitation. Release of flexion contractures
and flexor tenolysis should be done at a second stage, again followed by aggressive
• Tenolysis is recommended after failure to improve active motion or plateau in active
motion without improvement for at least 6 weeks with aggressive therapy.
• Tenolysis is performed at least 6 months after primary tendon repair. This minimum
time allows for scar maturation, stabilization of the initial inflammatory process, and
resolution of edema and permits healing of tendons so that they are strong enough
to endure removal of adhesions that serve as extrinsic blood supply.
• The greater the amount of soft-tissue release required to achieve motion of the
proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, the worse the
outcome. This occurs because of recurrent scarring or periarticular swelling.
• A synergistic motion protocol (with place-and-hold exercises) is recommended for
immediate postoperative therapy starting within 5 days of surgery for patients for
whom there is not high concern for tendon rupture. Aggressive active and passive
range-of-motion therapy is necessary to maintain active finger motion that was ob-
tained intraoperatively.
FDP
FDS
Cut line
FIGURE 81.7 If it is impossible to preserve both flexor digitorum profundus (FDP) and flexor digito-
rum superficialis (FDS) tendons, one or both slips of the FDS tendon may be excised.
637
CHAPTER 81
Tenolysis of Flexor Tendons
OVERVIEW
• Flexor tendon tenolysis is a difficult procedure, in which it is frequently more chal-
lenging to obtain a good outcome than primary tendon repair, and should not be
taken lightly without ensuring patient cooperation. Patient selection plays an impor-
tant role in successful tenolysis.
• If both flexor and extensor tenolysis and joint releases are needed, the procedures
should be performed in two stages. The first stage begins with the dorsal side, fol-
lowed by aggressive postoperative rehabilitation. Release of flexion contractures
and flexor tenolysis should be done at a second stage, again followed by aggressive
INDICATIONS
• In patients without radiographic joint abnormalities, range of motion (ROM) limitation
can be attributable to joint contracture or tendon adhesions. If joint contracture ex-
ists, both active and passive ROM are limited but equal. Tendon adhesions are
suspected when the patient shows greater limitation in active ROM (tendon excur-
sion is curtailed) than passive ROM (joint is freely mobile; i.e., there is an active-
passive discrepancy).
• Tenolysis is recommended after failure to improve active motion or plateau in active
motion without improvement for at least 6 weeks with aggressive therapy.
• Tenolysis is performed at least 6 months after primary tendon repair. This minimum
time allows for scar maturation, stabilization of the initial inflammatory process,
and resolution of edema and permits healing of tendons so that they are strong
enough to endure the removal of adhesions that serve as the extrinsic blood sup-
ply. Skin must be soft and pliable before tenolysis. Any operation in an already
inflamed tissue bed will further limit digit ROM and decrease the chances of a suc-
cessful outcome.
Contraindications
• Tenolysis should not be performed until all digital inflammation and edema has re-
solved and maximal passive ROM had been achieved with therapy.
• Open soft tissue defects, active infection, and joint arthrosis are all contraindications
to tenolysis.
• Patients who cannot or will not actively participate in an extensive rehabilitation
protocol should not undergo tenolysis.
IMAGING
Radiographs may be indicated to rule out an associated joint abnormality.
SURGICAL ANATOMY
• Adhesions between the tendon and nearby anatomic structures prevent differential
gliding and effective active ROM of the finger flexor muscle-tendon unit. Affected
tissues may include scar and any anatomic structure between bone and skin.
• The flexor digitorum profundus (FDP) tendon and flexor digitorum superficialis (FDS)
tendon contribute to active flexion. These tendons both connect the muscle bellies
in the forearm to the digits and pass through the carpal tunnel at the wrist and the
tendon sheath at the distal palm and digits.
• The FDS inserts on the base of the middle phalanx to flex the finger at the metacar-
pophalangeal (MCP) joint and proximal interphalangeal (PIP) joint. The FDP inserts
637.e1
637.e2 CHAPTER 81 Tenolysis of Flexor Tendons
FDS
Insertion of deep FDP
flexor tendon
Insertion of
superficial
flexor tendon
Camper’s chiasm
A B
A5
C3 VLP
A4 FDP
FDS
C2
A3
C1
VBP
A2
VBS
VLS
A1
FIGURE 81.1 (A–B) Insertion of FDS and FDP. FDP, Flexor digitorum profundus; FDS, flexor digitorum
superficialis; VBP, vinculum breve profundus; VBS, vinculum breve superficialis; VLP, vinculum longum
profundus; VLS, vinculum longum superficialis.
on the base of the distal phalanx and flexes the finger at the MCP, PIP, and distal
interphalangeal (DIP) joints (Fig. 81.1A–B).
• Each tendon receives its vascular supply and nutrition through vincula longus and
brevis and from synovial diffusion. The vincular attachments may also limit proximal
retraction of lacerated tendons. Care should be taken not to injure the vincula to
prevent further adhesions caused by bleeding (Fig. 81.2).
• The flexor tendons have five annular (ring-shaped) and three cruciate pulleys. The
most important pulleys to prevent bowstringing are the A2 and A4 pulleys, which
must be preserved during tenolysis if possible.
EXPOSURES
EXPOSURES PEARLS
• The operation is usually performed with local anesthesia. An awake patient can move
• The approach should start from the proximal the digit to identify and help break up adhesions that may not be detected under
unscarred area into the distal scarred areas
but also identify and preserve the general anesthesia. Our preference is the wide-awake approach (see Chapter 77).
neurovascular bundles. • The flexor system may be approached by either Bruner zigzag or midaxial incisions,
• The midaxial incision continues across the and by using prior laceration/incision scars (Fig. 81.3A–B).
palm at the level of the distal palmar crease • The midaxial approach preserves normal tissue directly over the tendon sheath and
and can be extended proximally if palmar has little wound tension with postoperative digital motion. The Bruner incision provides
exposure is required.
wide exposure (Fig. 81.4). If the patient has a previous incision, it is incorporated.
CHAPTER 81 Tenolysis of Flexor Tendons 637.e3
VLP
VBS VLS
VBP
FDS
FDP
Distal trans.
digital a.
Distal zone of
vascularization
Interphalangeal Proximal trans. Branch to VLS

trans. digital a. digital a.
FIGURE 81.2 Vascular supply to FDS and FDP. FDP, Flexor digitorum profundus; FDS, flexor digito-
rum superficialis; VBP, vinculum breve profundus; VBS, vinculum breve superficialis; VLP, vinculum
longum profundus; VLS, vinculum longum superficialis.
Bruner
incision
Midaxial incision
on fingers,
zigzag incision
on palm
A B
FIGURE 81.3 (A–B) Bruner zigzag and midaxial incision.
FIGURE 81.4 Bruner incision markings.


• Conserve as much of the pulley/sheath system Step 1
as possible.
• If annular pulleys are absent or attenuated by • Skin flaps are elevated superficial to the tendon sheath, with care to protect digital
more than 50%, one should consider pulley neurovascular bundles (Fig. 81.5).
reconstruction (see Chapter 80). • The flexor pulley system is identified and protected. Only the significantly scarred
flexor tendon sheath is excised.

If an awake technique is used, the patient may • For careful release of adhesions, it is important to select appropriate instruments
be asked to flex the finger while the surgeon (small knife blades, special tenolysis knives, and small elevators).
selectively isolates the FDP and then the FDS
• Separate adhesions between the FDP and the FDS, using a Freer elevator to slide
tendons to separate residual adhesions.
between the two tendons.
• Using a retractor to separate the two tendons from one another will demonstrate
STEP 2 PITFALLS whether adhesions between FDS and FDP remain (Fig. 81.6).
• Overly aggressive tenolysis may lead to tendon • If it is impossible to preserve both tendons, one or both slips of the FDS tendon may
rupture. be excised (Fig. 81.7). Alternatively, a single combined tendon using the proximal
• Performing PIP joint capsulotomy (see muscle belly and tendon of FDS and distal tendon of FDP can be created.
Chapter 103) and tenolysis during the same
procedure has a high risk for recurrent adhe-
sions. Ideally, one should focus on joint release,
Step 3
followed by tenolysis at a later date. If tenolysis • Confirm that the patient can achieve satisfactory active digit flexion after tenolysis
is performed at the same time as joint release, (Fig. 81.8A–B).
patients should be advised of the potential need • Alternatively, if the patient cannot participate in active ROM because of sedation, an
for repeat tenolysis in the future.
Allis clamp can be placed around the tendon and turned gently to check tendon
excursion (Fig. 81.9A–B).
Step 4
• Release the tourniquet and carefully achieve hemostasis using bipolar electrocautery.
• The incisions are sutured and a bulky dressing is applied.
Radial digital nerve
FDS
FDP
Ulnar digital nerve
FIGURE 81.5 Neurovascular bundles are identified. FIGURE 81.6 Retractor separates FDP and FDS. FDP, Flexor
digitorum profundus; FDS, flexor digitorum superficialis.
FDP
FDS
Cut line
FIGURE 81.7 One or both slips of the FDS tendon may be excised. FDP, Flexor digitorum profundus;
FDS, flexor digitorum superficialis.
CHAPTER 81 Tenolysis of Flexor Tendons 637.e5
A B
Before tenolysis After tenolysis

FIGURE 81.8 (A–B) Intraoperative active flexion after tenolysis.
A B
FIGURE 81.9 (A–B) Allis clamp permits a check of tendon excursion.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES STEP 3 PEARLS

• The greater the amount of soft tissue release required to achieve motion of the PIP • Assess the quality of the tendon and pulley
and DIP joints, the worse the outcome. This occurs because of recurrent scarring or system carefully before skin closure. If greater
periarticular swelling. than 30% of the affected tendon width has
been lost or if the tendon gap is only main-
• Although interpositional biologic and artificial inlays have been described to prevent tained by scarred tissue or pseudotendon,
adhesions after tenolysis, neither has achieved reliable results. there is a high risk for secondary tendon rup-
• A synergistic motion protocol (with place and hold exercises) is recommended for ture during postoperative rehabilitation therapy.
immediate postoperative therapy starting within 5 days of surgery for patients for • If the quality of the tendon is poor, tendon re-
whom there is not high concern for tendon rupture. Aggressive active and passive construction with a tendon graft should be
considered (see Chapter 79).
ROM therapy is necessary to maintain active finger motion that was obtained intra-
operatively. Progressive resistance exercises are allowed at 6 weeks after tenolysis.
Scar management is required to reduce the risk for recurrent contracture and further
limitations in finger motion.
• Outcomes tend to be worse among patients with severe joint contractures, crush or
avulsion injuries, and replantation of more than two digits on the same hand. See
Fig. 81.10A–B for 2-month follow-up.
See Video 81.1
A B
FIGURE 81.10 (A–B) Two-month postoperative outcome.
EVIDENCE
Breton A, Jager T, Dap F, Dautel G. Effectiveness of flexor tenolysis in zone II: A retrospective series of
40 patients at 3 months postoperatively. Chir Main. 2015;34:126–133.
The authors report the results of tenolysis after zone II flexor tendon injury, with or without dorsal tenol-
ysis or PIP arthrolysis in 40 patients. Mean increase in total active motion (TAM) for patients who un-
derwent tenolysis alone was 60 degrees, whereas the improvement in patients who underwent tenol-
ysis with arthrolysis was 90 degrees. Good-to-excellent functional outcome (Strickland classification)
at 6 weeks was achieved in 70% of cases. Nevertheless, deep flexor tendon rupture occurred in
7 cases.
Eggli S, Dietsche A, Eggli S, Vögelin E. Tenolysis after combined digital injuries in zone II. Ann Plast
Surg. 2005;55:266–271.
This is a retrospective study of 23 patients with zone II digital injuries treated with tenolysis. After an
average 5-year follow-up, notable functional improvement was obtained in 28 digits (88%). Total
active motion improved on average 55 degrees after palmar tenolysis, and 63 degrees after
combined dorsopalmar tenolysis. Twenty-three digits reached good-to-excellent results using
the Buck-Gramcko scoring system.
Moriya K, Yoshizu T, Tsubokawa N, Narisawa H, Maki Y. Incidence of tenolysis and features of adhe-
sions in the digital flexor tendons after multi-strand repair and early active motion. J Hand Surg Eur
Vol. 2019;44(4):354–360.
The authors examined 148 consecutive fingers that underwent zone 1 or 2 flexor tendon repair and an
early active motion protocol. Seven patients (4.7%) required tenolysis, two of which were performed
early (weeks 4 and 6) for suspected tendon rupture and the rest after 12 weeks. All fingers requiring
tenolysis had both FDP and FDS repairs and 6 of 7 had notable adhesions between the tendons.
At final follow-up, active PIP and DIP motion averaged 123 degrees, with good or excellent ratings in
five, fair in one, and poor in one.
Yamazaki H, Kato H, Uchiyama S, Ohmoto H, Minami A. Results of tenolysis for flexor tendon adhe-
sion after phalangeal fracture. J Hand Surg Eur Vol. 2008;33(5):557–560.
This study reports the results of twelve patients undergoing tenolysis for flexor tendon adhesions after
phalanx fractures (11 proximal, 1 middle). Five fractures were open injuries. Preoperative total active
motion (MP+PIP+DIP; TAM) averaged 112 degrees (range 70 degrees to 170 degrees), compared
with 213-degree average passive motion (range 155 degrees to 240 degrees). After an average follow
up of 15 months, the mean TAM improved to 219 degrees. When graded with the original Strickland
criteria, the outcome was excellent in three patients, good in five, and fair in four. There were no
tendon ruptures or reoperations.
Jupiter JB, Pess GM, Bour CJ. Results of flexor tendon tenolysis after replantation in the hand. J Hand
Surg Am. 1989;14(1):35–44.
This classic article details the authors’ experience after tenolysis for stiffness in replanted digits and
thumbs. Thirty-seven fingers and four thumbs in 25 patients underwent tenolysis at an average of
10 months after replantation. Mean TAM improved from 72 degrees to 130 degrees and no digits
were lost. Poor results were seen in crush injuries, those with more than 2 fingers replanted, those
needing PIP capsulotomy, and thumbs.
CHAPTER 82
Acute Repair of Extensor Tendon Injuries:
Zones I to VII

This chapter includes the following video: Video 82.1 – Thumb Extensor Tendon
Repair (Zone TIV).
KEY CONCEPTS
• Extensor tendons from the level of the distal interphalangeal (DIP) joint to the wrist joint
are categorized into zones, from I to VII. Each joint corresponds with the odd num-
bered zones: zone I overlies the DIP joint, zone III overlies the proximal interphalangeal
(PIP) joint, and so on. TI indicates the thumb interphalangeal (IP) joint, TIII the thumb
metacarpophalangeal (MCP) joint, and TV the level of the extensor retinaculum.
• Extensor tendons over the fingers are thinner, flatter, and lie closer to bony struc-
tures compared to flexor tendons. The surgeon must be aware of the numerous
patterns of aberrant extensor anatomy, including the possible presence of extensor
carpi radialis intermedius, extensor medii proprius, extensor digitorum brevis ma-
nus, and others. These accessory tendons may be sources of graft if needed.
• Surgical treatment is considered for most open injuries and for closed injuries proxi-
mal to the PIP joint. The extensor indicis proprius (EIP) and the extensor digiti minimi
DIP
PIP joint
Central
Lateral
slip
band
Sagittal
band
MCP joint
FIGURE 82.22 If there is loss of central slip substance, the gap can be reconstructed using a
tendon flap or tendon graft. DIP, Distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal
interphalangeal.
638
PROCEDURE 82 Acute Repair of Extensor Tendon Injuries: Zones I To VII 639
(EDM) tendons permit independent extension of the index and small fingers. There-
fore isolated injuries of the EIP or EDM tendons do not always need to be repaired.
• The suture method of extensor tendon repair depends on the tendon thickness at
the level of injury. Extensor tendons become thin and flat distally. Commonly used
core suture techniques, based on surgeon preference, include horizontal mattress,
figure of eight, modified Bunnell, and modified Kessler techniques. The authors pre-
fer a four- to six-strand horizontal mattress repair using a 3-0 or 4-0 braided suture
for most extensor tendon lacerations.
CHAPTER 82
Acute Repair of Extensor Tendon Injuries:
Zones I to VII
INDICATIONS
• Extensor tendon injuries are relatively common.
• The mechanism of finger extension is more complicated than that of flexion. It is
achieved through the synergistic action of both extrinsic and intrinsic muscles with
contribution from several passive ligamentous structures.
• Extensor tendons over the fingers are thinner, flatter, and lie closer to bony struc-
tures than flexor tendons (Fig. 82.1).
Sagittal band MCP Transverse

retinacular
Central slip PIP ligament
Dorsal, volar DIP

interosseous
muscles
Terminal
Lumbrical tendon
muscle
Lateral band Oblique
retinacular
ligament
DIP
Oblique
Triangular retinacular
ligament ligament
Transverse
retinacular
PIP ligament
Central
Lateral
slip
band
Sagittal
MCP
band
Dorsal, volar
interosseous
muscles Lumbrical
muscle
FIGURE 82.1 DIP, Distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal interphalangeal.
639.e1
639.e2 CHAPTER 82 Acute Repair of Extensor Tendon Injuries: Zones I to VII
• Surgical treatment is considered for most open injuries and for closed injuries
proximal to the proximal interphalangeal (PIP) joint.
• Specific considerations apply to each zone of injury.
Contraindications
• Extensor tendon repair should not be attempted in the setting of active or suspected
infection.
• Severe joint contractures and patient inability to comply with the postoperative
rehabilitation protocol are also relative contraindications to extensor tendon
repair.
The Elson test (Fig. 82.2A) may detect a closed central slip injury. The patient should
flex the PIP joint 90 degrees over the edge of an examination table and try to actively
extend the PIP joint against resistance by the examiner or against a flexed finger of the
contralateral hand (see Fig. 82.2B-E). As the patient attempts PIP joint extension (but
kept at 90 degrees by resistance), tension across the distal interphalangeal (DIP) joint
is assessed. If the central slip is ruptured, the DIP joint will be tight or will hyperextend
because of increased tension across the lateral bands and terminal tendons with at-
tempted digit extension. When the central slip is intact, it acts as a checkrein to prevent
proximal lateral band motion and the DIP joint remains relaxed during resisted exten-
sion of the PIP joint.
IMAGING
A plain radiograph is required to exclude a fracture, foreign body, or other bone and
joint abnormalities.
SURGICAL ANATOMY
• A commonly used classification of extensor tendon injury level was described by
Kleinert and Verdan (Fig. 82.3).
• Extensor tendons from the level of the DIP joint to the wrist joint are categorized into
zones, which go from I to VII.
• Each joint corresponds with the odd numbered zones: zone I overlies the DIP joint,
zone III overlies the PIP joint, and so on. (TI indicates the thumb interphalangeal [IP]
joint, TIII the thumb metacarpophalangeal [MCP] joint, and TV the level of the exten-
sor retinaculum).
• The extensor indicis proprius (EIP) and the extensor digiti minimi (EDM) tendons per-
mit independent extension of the index and small fingers. For that reason, isolated
injuries of the EIP or EDM tendons do not always need to be repaired (Fig. 82.4).
• The juncturae tendinae are stout bands that connect the ring finger extensor tendon
to the middle and small finger tendons over the hand. There is also a less substantial
band between the index and middle finger. With proximal extensor tendon injuries,
the patient may still be able to extend the finger to a degree through the adjacent
junctura.
• The surgeon must be aware of the numerous patterns of aberrant extensor anatomy,
including the possible presence of extensor carpi radialis intermedius, extensor
medii proprius, extensor digitorum brevis manus, and others. These accessory ten-
dons may be sources of graft if needed.
EXPOSURES
• Appropriate anesthesia is required for wound exploration or tendon manipulation.
Use local or digital blocks for injuries in zones I to IV and field or regional nerve
blocks for injuries in zones V to VII.
• A wide-awake approach is recommended in select patients with extensor tendon
injuries to evaluate the strength of the tendon repairs and immediate motion (see
Chapter 77).
CHAPTER 82 Acute Repair of Extensor Tendon Injuries: Zones I to VII 639.e3
Elson test
1
2
3
4
5 T1
T2
T3
Intact Ruptured 6
T4
7 T5
A
8
Intact central
slip
9
Relaxed
lateral band
B C
FIGURE 82.3 Extensor tendon injury zones.
Disrupted
central slip
EIP EDM
ECRB
ECU
ECRL
D E EDC
EPL
FIGURE 82.2 (A) Elson test. The red arrow indicates the examiner resisting proximal interphalangeal
joint extension. (B–E) Illustration of examiner performing Elson test. (Fig. 48.18B–E, from Roberts JR, EPB
Custalow CB, Thomsen TW, et al. Roberts and Hedges’ Clinical Procedures in Emergency Medicine
and Acute Care. 7th ed. Elsevier; 2018.) APL
FIGURE 82.4 APL, Abductor pollicis longus;

ECRB, extensor carpi radialis brevis; ECRL,
extensor carpi radialis longus; ECU, extensor
carpi ulnaris; EDC, extensor digitorum commu-
nis; EDM, extensor digitorum minimi; EIP, exten-
sor indicis pollicis; EPB, extensor pollicis brevis;
EPL, extensor pollicis longus.
PROCEDURE
General Suture Repair
• In general, the suture method of extensor tendon repair depends on the tendon
thickness at the level of injury. Extensor tendons become thin and flat distally.
• Commonly used core suture techniques, based on surgeon preference, include
horizontal mattress, figure of eight, modified Bunnell, and modified Kessler tech-
niques (Fig. 82.5A–D).
• Many studies have been undertaken to establish the best suture techniques for each
zone, and techniques with the greatest load strength include a running interlocked
horizontal mattress (Fig. 82.6A–B), the modified Bunnell, modified Kessler, and
modified Becker techniques. The extensor tendons are thin and flat, however, and
so it can be difficult to apply complicated suture techniques.
• We prefer a four- to six-strand horizontal mattress repair using a 3-0 or 4-0 braided
suture for most extensor tendon lacerations.
A Horizontal mattress inner core suture B Figure-of-eight stitch
C Modified bunnell D Modified kessler

FIGURE 82.5 Tendon repair techniques.
A B
FIGURE 82.6 (A–B) Running interlocked horizontal mattress.
ZONE I INJURY (MALLET FINGER)

Indications
• According to Doyle’s classification of mallet finger injuries (Table 82.1), type I (closed)
injury (Fig. 82.7) is the most common and is managed nonoperatively with continu-
ous splinting of the DIP joint for 6 to 8 weeks. A mallet deformity can be improved
by splinting up to 6 months from the injury, but this treatment may be less effective
with chronic deformities.
• If the type I mallet deformity remains after 8 weeks of splinting, additional splinting
can be attempted or surgical treatment (such as simple Kirschner wire [K-wire] fixa-
tion of the DIP joint) can be applied.
• Type II, III (open injury), and unstable type IV (mallet fracture) injuries generally re-
quire surgical treatment. Type IVB may be treated conservatively if there is no DIP
joint subluxation or instability.
• Patients who are unable to comply with uninterrupted splinting of a mallet deformity
may be treated with K-wire fixation of the DIP joint.
TABLE
82.1 Classification of Mallet Finger
Type Image Definition
I Closed injury
II Associated with overlying skin laceration
III Associated with tendon and loss of overlying

skin (deep abrasion)
IVA Transphyseal injury in skeletally immature digit
IVB Associated with avulsion fracture involving

20%–50% of articular surface
IVC Associated with avulsion fracture involving

.50% of articular surface
Mallet finger
FIGURE 82.7 Mallet finger.

REPAIR OF TYPE II AND III (OPEN) MALLET INJURIES

Step 1
• Many types of incisions can be used for open repair based on the surgeon’s prefer-
ence and configuration of the previous laceration (Fig. 82.8).
• The laceration is incorporated into the incision and extended for exposure to facili-
tate visualization of tendon ends (Fig. 82.9).
Step 2
Fix the DIP joint in a slightly hyperextended position using one or two 0.045-inch (1.14-
mm) K-wires in a retrograde fashion (Fig. 82.10).
Step 3
Repair the terminal tendon with or without a tendon graft. Most often, a horizontal mat-
tress repair with 4-0 braided suture is used (Fig. 82.11).
FIGURE 82.9 Repair of open mallet injury.

FIGURE 82.8 Incision planning.
FIGURE 82.10 Distal interphalangeal joint fixation with two FIGURE 82.11 Illustration of repair of terminal
Kirschner wires (K-wires). tendon.

If there is skin loss, use a local skin flap or cross-finger flap for soft tissue coverage (see
To avoid skin necrosis, ensure proper skin flap
Chapter 87). thickness.
• The DIP joint should remain hyperextended with K-wire fixation for 4 to 6 weeks
(Fig. 82.12A–B).
• After K-wire removal, a splint can be used for several weeks and the patient can be
permitted to move the DIP joint gradually after 6 to 8 weeks, with close observation
for recurrence of DIP joint extensor lag.
• A 10-degree extensor lag is common.
REPAIR OF TYPE IV-B/C INJURIES

See Chapter 8 for extension block pinning technique for operative repair of displaced
and unstable mallet fractures (types IV-B and IV-C).
ZONE II INJURY
• Treat with the same strategy as zone I injury.
• A wide C-shaped or curvilinear incision is used to expose both tendon ends
(Fig. 82.13).
• A single lateral band is sufficient to achieve full DIP joint motion. Although it is rare,
if both lateral bands are injured, repair of an open injury can be performed with or
without tendon graft.
A B
FIGURE 82.12 (A–B) Immediate postop appearance of mallet finger after Kirschner wire (K-wire) fixation.
FIGURE 82.13 Numerous skin incisions may be used, based on injury pattern.
Ruptured ends of extensor tendon
A B
FIGURE 82.14 (A–B) Repair of ruptured zone II extensor tendon.
A B
FIGURE 82.15 (A–B) One-month follow-up showing excellent extensor tendon function.
PL tendon grafts
Defect
FIGURE 82.16 Open zone II injury with large

tendon defect.
FIGURE 82.17 Palmaris longus tendon grafts are used

to repair a large tendon defect.
• Fig. 82.14A–B shows the repair of a ruptured zone II extensor tendon. Fig. 82.15–B
shows excellent return of extensor tendon function of this patient at 1-month follow-up.
• In the case of open zone II injury with a large tendon defect (Fig. 82.16), palmaris
longus (PL) tendon grafts are sutured to the terminal tendon and both lateral bands
using a side-to-side horizontal mattress suture technique (Fig. 82.17). (See Chapter 79
for harvest of PL tendon grafts.)
• Postoperatively, the DIP joint is pinned in an extended position, enabling immediate
PIP joint motion. The pin is removed at 6 weeks and DIP motion is begun.
ZONE III INJURY

Indications
• Central slip injury results in PIP joint extensor lag and DIP joint hyperextension (bou-
tonnière deformity; Fig. 82.18A–B).
• In the case of closed zone III injury, the PIP joint is splinted in a fully extended posi-
tion for 6 weeks that permits active DIP joint flexion exercises.
• Open injury of two lateral bands or a central slip laceration (50% or greater) should
be repaired operatively. Nevertheless, most open injuries need surgical exploration
to confirm the degree of laceration.
STEP 2 PEARLS
REPAIR FOR OPEN INJURY IN ZONE III
• If there is loss of central slip substance, the
Step 1 gap can be reconstructed using a tendon flap
or tendon graft. A distally based flap from the
• Extend the original wound through a curvilinear incision (Fig. 82.19 incorporates
midportion of the central slip can be elevated
previous incision). and reinserted into the insertion site using
• Expose the ruptured central slip with blunt and sharp dissection (Fig. 82.20). a bone anchor as previously discussed
(Fig. 82.22).
Step 2 • The authors prefer to use titanium anchors
with 4-0 nonabsorbable sutures when repair
• For a simple laceration with a proximal and distal end, at least a six-strand horizontal
down to the bone is needed.
mattress repair with 4-0 braided suture is recommended (Fig. 82.21).
A B
FIGURE 82.18 (A–B) Central slip injury.
Laceration encompasses
majority of central slip
FIGURE 82.19 Curvilinear incision marking for repair

of zone III extensor tendon. FIGURE 82.20 Laceration of central slip.
Central slip repaired

with horizontal mattress
4-0 Ethibond suture
FIGURE 82.21 Central slip repaired.
DIP
PIP joint
Central
Lateral
slip
band
Sagittal
band
MCP joint
FIGURE 82.22 A distally based flap from the middle of the central slip can be elevated and placed
into the insertion site using a bone anchor. DIP, Distal interphalangeal; MCP, metacarpophalangeal;
PIP, proximal interphalangeal.
STEP 2 PITFALLS • For an avulsion injury in which there is no distal end for repair, a bone anchor is
If one uses a suture anchor for an avulsion injury, placed at the base of the middle phalanx. A suture from the bone anchor is passed
insert the bone suture anchor before K-wire fixation through the central slip for reattachment to the middle phalanx.
(if needed) into the middle phalanx for reinsertion • Repair any lateral band lacerations if present.
of the central slip.
Step 3
A skin defect can be addressed with a local skin flap or cross-finger flap (see
Chapter 87).

• The PIP joint should remain splinted in extension for 4 to 6 weeks. Active motion at
the DIP joint should be emphasized during initial postoperative rehabilitation.
• The patient can begin gradual PIP joint motion 4 to 6 weeks after surgery. Slight PIP
joint extension lag or DIP joint hyperextension is common (Fig. 82.23A–B displays
6-week follow-up).
ZONE IV INJURY
Indications
• Tendon injury in this area is similar to zone II injury and is often associated with an
underlying fracture (Fig. 82.24).
• Open injury is relatively common.
• Complete tendon laceration or partial laceration (greater than 50%) requires surgical
repair.
REPAIR FOR OPEN INJURY IN ZONE IV

Step 1
Expose the proximal and distal tendon ends through a curvilinear or linear incision.
Step 2
• A four- to six-strand horizontal mattress repair with 4-0 braided suture is recom-
mended (Fig. 82.25).
• Care should be taken not to perform a repair that is too tight. Bunching of the tendon
ends at the repair site can lead to an MCP joint extension contracture.
Tendon laceration
Underlying fracture
FIGURE 82.24 Tendon laceration in zone IV with under-

A
lying fracture.
Horizontal mattress repair with 4-0 suture
FIGURE 82.23 (A–B) Six-week postoperative outcome of central slip FIGURE 82.25 Zone IV extensor tendon injury repair
repair. with horizontal mattress 4-0 suture.

• The rehabilitation protocol generally begins within the first week after the operation.
A splint is made to hold the PIP and the MCP joints extended for 4 to 6 weeks, with
active motion permitted at the DIP joint for rehabilitation. After 4 weeks, the patient
can begin MCP and PIP joint motion. Blocking exercises are started at 5 weeks and
the splint is generally continued at night until 8 weeks.
• If the patient performs early motion therapy, one can use a dynamic extension splint,
which provides passive PIP joint extension within a limited range of flexion. The
degree of PIP joint flexion permitted within the splint depends on the strength of the
repair and is case dependent.
• Adhesions are common. An associated fracture can cause damage to the gliding
surface between the bone and tendon. Nevertheless, early motion therapy may still
not be suitable for all patients. If there is a sufficiently strong repair (at least four core
strands), early motion therapy may be considered.
ZONE V, VI, OR VII INJURY

• Tendon laceration, human bite wounds, and sagittal band lacerations are included in
these zones.
• Anatomic repair is essential for these zones (Fig. 82.26A–B shows a zone V injury).
• In zones VI and VII, tendon transfer to a nearby intact tendon may be considered if
there is loss of tendon substance preventing primary repair.
• In zone VII, the extensor retinaculum must be released to visualize the injured ten-
don. If the tendon repair is bulky, however, closure of the retinaculum may be diffi-
cult. The retinaculum may be step-cut (Fig. 82.27) or Z-lengthened to permit the
repaired tendons to glide smoothly under it.
Indications
• Indications include open injury with tendon laceration and human bite wounds.
REPAIR FOR A ZONE V, VI OR VII INJURY

Step 1
• Extend the laceration in a curvilinear fashion to expose the involved tendon ends.
• After surgical debridement, the injured extensor digitorum communis (EDC) tendon
ends are exposed (Fig. 82.28A).
Ruptured EIP Horizontal mattress repair with 3-0 suture
A B
Ruptured EDC
FIGURE 82.26 (A) Ruptured extensor indicis proprius (EIP) and extensor digitorum communis (EDC). (B) Repair of EIP and EDC with
horizontal mattress 3-0 suture.
FIGURE 82.27 Extensor retinaculum is step-cut to permit repaired tendons to glide smoothly
underneath.
Ruptured Ruptured EDC and EDM repaired with

EDC tendon EDM horizontal mattress suture
FIGURE 82.28 (A) Ruptured extensor digitorum communis (EDC) and extensor digiti minimi (EDM). (B) Repair with horizontal mattress suture.

A four- to six-strand horizontal mattress repair is performed with 3-0 braided suture A repair that is too tight will lead to MCP joint
(see Fig. 82.28B). extension contracture (Fig. 82.29A–B). If a tendon
defect is present, reconstruction with a PL tendon
POSTOPERATIVE CARE AND EXPECTED OUTCOMES graft may be considered.
• Either a static, dynamic, or relative extension splint may be used postoperatively.
The splint should keep the MCP joint extended and enable IP joint motion.
• For patients with zone V injury, the MCP joint should be immobilized in 40 degrees
of flexion for 4 to 6 weeks in a way that permits active range-of-motion (ROM) exer-
cises of the IP joints. After this initial period of immobilization, MCP joint motion is
gradually increased.
• For zone VI and zone VII repairs, the wrist is extended in 30 degrees of extension for
4 to 6 weeks in a volar wrist splint in a way that enables full active motion of the MCP
and IP joints. After this initial period of immobilization, active ROM of the wrist is
begun.
MCP joint
extension
contracture
FIGURE 82.29 (A–B) Metacarpophalangeal joint extension contracture owing to tendon repair that
was too tight.
• For patients with zone VII injury, care is taken to prevent or minimize postoperative
adhesions.
• The tendon repair will need at least four core strands and will need to be strong
enough to resist the forces of active motion to start an early motion therapy protocol.
ZONE TI OR TII INJURY

• Use the same strategy as zone I and II injuries. After surgical debridement, perform
standard core suture repair with a 4-0 synthetic material.
• For patients with TII injury (Fig. 82.30A–B), splint the IP joint postoperatively in an
extended position, with the MCP joint flexed at 0 to 10 degrees of flexion.
Tendon lacerations
6-strand repair
A B
FIGURE 82.30 (A–B) TII extensor tendon injury that underwent six-strand repair.
Repair with horizontal

mattress core suture
A B
Partial EPL laceration

FIGURE 82.31 (A) Partial extensor pollicis longus (EPL) laceration. (B) Repair with horizontal mattress core suture.
ZONE TIII OR TIV INJURY

• It is sometimes hard to detect extensor pollicis longus (EPL) or extensor pollicis
brevis (EPB) tendon rupture clinically. One should closely examine the associated
open wound to determine whether the tendon is ruptured. Partial lacerations may be
found on exploration (Fig. 82.31A).
• Tendons should be repaired similar to zone III and IV digital extensor tendon repairs,
with 3-0 nonabsorbable suture in a horizontal mattress configuration (see Fig. 82.31B).
• After surgical repair, splinting is used to fix the MCP and IP joints in full extension for
4 weeks. The IP joint may be left free in an isolated EPB tendon injury.
See Video 82.1
EVIDENCE
Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation: A prospective trial
comparing three rehabilitation regimes. J Hand Surg Br. 2005;30:175–179.
The authors compared three different rehabilitation regimes (static splint, static splint with IP joints free,
and early active mobilization within a thermoplastic splint) for complete zone V and VI lacerations.
The authors reported no difference in total active ROM between the groups. Nevertheless, improved
grip strength was seen in the IP joint-free and active motion groups compared with the static splint
group at 12 weeks.
Altobelli GG, Conneely S, Haufler C, Walsh M, Ruchelsman DE. Outcomes of digital zone IV and V and
thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress tech-
nique. J Hand Surg Am. 2013;38(6):1079–1083.
This study reviews the results of extensor tendon laceration repairs in zones IV and V (and thumb TI to
TIV) using a novel running interlocking horizontal mattress suture pattern followed by an immediate
controlled active motion rehabilitation protocol. There were six digital and three thumb lacerations
with a mean follow-up of 15 weeks. All repairs achieved good or excellent results, with no extensor
lag and no patient requiring a secondary surgery.
Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V
and TI to TIII extensor tendon repairs. J Hand Surg Am. 2012;37(5):933–937.
Seventeen patients with 19 simple extensor tendon lacerations in zones IV and V and thumb TI to TIII
were repaired with a four-core strand and a running epitendinous suture. All patients began using a
dynamic extension orthosis within a week, and active motion was started at 4 weeks. Average follow-
up was 3 months and 16 of 17 patients achieved good or excellent results. One patient with fair re-
sults had a loss of 25 degrees of flexion.
Collocott SJF, Kelly E, Foster M, Myhr H, Wang A, Ellis RF. A randomized clinical trial comparing early
active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion
extension program for zones V and VI extensor tendon repairs. J Hand Ther. 2020;33(1):13–24.
This randomized controlled trial of patients with zone V and VI extensor tendon repairs compared post-
operative rehabilitation with a relative motion extension orthosis (RME) to a conventional controlled
active motion protocol with a wrist-hand-finger extension splint. Both groups had 21 participants and
both groups wore a wrist-hand-finger extension splint at night. The Sollerman hand function test,
QuickDASH (Disabilities of the Arm, Shoulder, and Hand) and total active finger motion were better in
the RME group at 4 weeks, but by 8 weeks the outcome scores were equivalent. There were no
tendon ruptures in either group.
von Schroeder HP, Botte MJ. Anatomy of the extensor tendons of the fingers: Variations and multiplicity.
J Hand Surg Am. 1995;20:27–34.
The authors reported the anatomic variations of digital extensor tendons in a cadaveric study. In 43
adult hand cases, the most common patterns of extensor tendon anatomic variation were examined.
Frequent variations included a double extensor indicis proprius, a double or triple extensor digitorum
communis (EDC)-long, a single or triple EDC-ring, and a single or double EDC-small. Knowledge of
potential tendon multiplicity and variations may help the surgeon in identification and repair of these
tendons.
CHAPTER 83
Release of Trigger Finger
KEY CONCEPTS
• Trigger finger is a mechanical impingement of the often-enlarged flexor tendons as they
pass through a stenotic pulley at the level of the metacarpophalangeal (MCP) joint. The
patient often complains of tenderness and a palpable nodule over the A1 pulley.
• Secondary trigger finger is often seen in patients with diabetes, rheumatoid arthritis
(RA), chronic kidney disease, and other metabolic or autoimmune diseases. These
patients may be less responsive to nonoperative treatment compared with patients
with primary trigger finger.
• Trigger finger release is recommended for patients who do not respond to one or two
steroid injections or those with demonstrable catching with a fixed flexion contrac-
ture of the proximal interphalangeal (PIP) joint.
• Trigger finger release is an ideal surgery to be performed using the wide awake, local
anesthesia, no tourniquet (WALANT) approach.
• In patients with RA, triggering symptoms are commonly related to tenosynovitis or
intratendinous nodules. Simple A1 pulley release is not recommended; instead,
open synovectomy and excision of intratendinous nodules are performed, leaving
the A1 pulley intact.
• The radial digital nerve of the thumb crosses obliquely over the A1 pulley and may
be vulnerable to being cut as the scissors divide the A1 pulley proximally.
• If awake, the patient is instructed to take the finger through several cycles of active
motion to ensure a complete release.
• Triggering usually resolves immediately after the release of the A1 pulley. Rehabilitation
is unnecessary except for the patients who have preoperative PIP joint contractures.
A1 pulley
FIGURE 83.7 Dissecting scissors may be used for longitudinal release of the A1 pulley.
640
CHAPTER 83
Release of Trigger Finger
• Primary trigger finger is commonly seen in healthy middle-aged women with a fre-
quency two times that of men.
• Commonly affected sites are the thumb and middle and ring fingers.
• Secondary trigger finger is often seen in patients with diabetes, rheumatoid arthritis
(RA), chronic kidney disease, and other metabolic or autoimmune diseases. These
patients may be less responsive to nonoperative treatment compared with patients
with primary trigger finger.
INDICATIONS
• Trigger finger release is recommended for patients who do not respond to one or two
steroid injections.
• An indication is demonstrable catching with a fixed flexion contracture of the proxi-
mal interphalangeal (PIP) joint.
• Another indication involves children with persistent congenital trigger thumb/finger.
See Chapter 105 for the treatment of pediatric trigger digits.
• The phenomenon of trigger finger is a mechanical impingement of the often-
enlarged flexor tendons as they pass through a stenotic pulley at the level of the
metacarpophalangeal (MCP) joint.
• The patient often complains of tenderness and a palpable nodule over the A1 pulley.
• The PIP joint may also become sore as the central slip strains to extend the finger
against the triggering flexor tendon.
• The patient sometimes experiences a locked finger/thumb as symptoms become
worse. This should be distinguished, however, from MCP joint locking from collateral
ligament injury or sesamoid or osteophyte entrapment, which are less common than
trigger finger.
• Patients with RA may have snapping phenomenon, which can be confused with
trigger digits, and is often related to flexor tendon synovial inflammation at the carpal
tunnel or early swan-neck deformity as the hyperextended PIP joint pops when re-
duced in flexion.
IMAGING
• Radiographs are rarely necessary.
• Ultrasound examination is rarely needed but may be useful to estimate the degree
of tendon/pulley thickness or to guide injection within the tendon sheath.
SURGICAL ANATOMY
• The phenomenon of trigger digits almost always occurs at the proximal edge of the
A1 pulley (Fig. 83.1).
• The A2/A4 pulleys in the fingers (and the oblique pulley in the thumb) are essential
to prevent flexor tendon bowstringing (Fig. 83.2).
• The radial digital nerve of the thumb crosses obliquely over the A1 pulley and may
be vulnerable to being cut as the scissors divide the A1 pulley proximally (Fig. 83.3).
EXPOSURES
• Trigger finger release is an ideal surgery to be performed using the wide awake, local
anesthesia, no tourniquet (WALANT) approach. In anxious patients, IV sedation may
be added.
640.e1
640.e2 CHAPTER 83 Release of Trigger Finger
A5
C3
A4
C2
A3
C1
A2
A1
Site of incision of pulley

Oblique pulley
Enlarged flexor tendon
A1 pulley
FIGURE 83.1 Trigger digits almost always occur at the proxi-
mal edge of the A1 pulley. (Modified Fig. 18.2, from Neligan
PC. Plastic Surgery: Volume 6: Hand and Upper Extremity.
5th ed. Elsevier; 2018)
FIGURE 83.2 Key anatomic structures in the flexor pulley system.
A1 pulley
Radial digital
nerve of thumb
Thenar muscle
FIGURE 83.3 Proximity of digital nerves to A1 pulley.

CHAPTER 83 Release of Trigger Finger 640.e3
FIGURE 83.4 Incision markings. FIGURE 83.5 Chevron marking for A1 pulley release of the
thumb.
• A forearm tourniquet may be applied if the procedure is performed in an operating EXPOSURES PITFALLS
room. Even in awake patients, a tourniquet on the forearm for a short duration is well
To prevent complications, the radial digital nerves
tolerated. to the thumb must be retracted gently during the
• A 1-cm transverse, longitudinal (Fig. 83.4), or chevron-shaped incision is made over operation of trigger thumb if they are identified.
the A1 pulley (Fig. 83.5). A chevron-shaped incision gives exposure along the tendon
sheath, with an acceptable scar appearance over the palm. Skin creases that lie
over the A1 pulley may be incorporated into the incision.
PROCEDURE
After the skin incision, expose the tendon sheath and A1 pulley using scissors to spread Take care to prevent injury to the radial digital nerve
longitudinally over the metacarpal head. Use small, blunt retractors to separate subcutane- to the thumb during release of trigger thumb. The
entire A1 pulley must be visualized before release.
ous tissues and protect neurovascular bundles on both sides of flexor tendon (Fig. 83.6).
A1 pulley exposed
FIGURE 83.6 A1 pulley exposed at thumb base.

MCP flexion
crease
A1 pulley
A2 pulley
A1 pulley
Digital artery
and nerve
A
B
FIGURE 83.7 (A) Scalpel creates longitudinal release of A1 pulley. (B) Dissecting scissors creates longitudinal release of A1
pulley. (Fig. 56.9, from Wolfe S, Pederson W, Kozin SH, Cohen M. Green’s Operative Hand Surgery. 7th ed. Elsevier; 2016.)

• An unusually thick pulley, synovial tissue hyper- • The pulley should be opened carefully with a scalpel in a longitudinal fashion in line with
trophy, or associated ganglion should be excised. tendon fibers to prevent inadvertent tendon injury (Fig. 83.7A). Alternatively, dissecting
• A Freer elevator may be inserted beneath the scissors may also be used for longitudinal release of the A1 pulley (see Fig. 83.7B).
thumb A1 pulley to help identify its proximal
• Infusion of sedating medications should be stopped immediately after injection of the
edge and protect the flexor tendon during
division of the A1 pulley (Fig. 83.9). local anesthetic to have the patient awake to voluntarily move the affected digit to con-
firm absence of catching after A1 pulley release. Wide-awake anesthesia using epineph-
rine and bicarbonate solution obviates the need for sedation and a tourniquet (Fig. 83.8).
Step 3
• If awake, the patient is instructed to take the finger through several cycles of active
motion to ensure a complete release. Fig. 83.10A–B shows a trigger finger release
using the WALANT approach; the patient was immediately able to confirm the
absence of triggering after release of the A1 pulley (see Fig. 83.10C-D).
• The wound is closed with interrupted sutures, and a soft dressing is applied to allow
digit range of motion (ROM).
Epinephrine,
bicarbonate,
lidocaine solution
FIGURE 83.8 Injection of epinephrine, lidocaine, and bicarbonate for WALANT. WALANT, Wide awake, FIGURE 83.9 Freer elevator passed underneath
local anesthesia, no tourniquet. A1 pulley to protect flexor tendon.
CHAPTER 83 Release of Trigger Finger 640.e5
A1 pulley released
Flexor tendon
A B
C D
FIGURE 83.10 (A) Triggering of middle finger. (B) Release of A1 pulley under WALANT. (C–D) Active motion under WALANT confirms absence of triggering.
WALANT, Wide awake, local anesthesia, no tourniquet.
STEP 2 PITFALLS
• Take care to prevent injury to the A2 pulley
• The surgical dressings are maintained for a few days postoperatively.
(and oblique pulley of the thumb) during divi-
• Finger ROM is encouraged as the wound heals. sion of the A1 pulley.
• Triggering usually resolves immediately after the operation. • In patients with RA, triggering symptoms are
• Rehabilitation is unnecessary, except for the patients who have preoperative PIP commonly related to tenosynovitis or intratendi-
joint contractures. nous nodules. Simple A1 pulley release only is
not recommended; open synovectomy and ex-
cision of intratendinous nodules are performed
EVIDENCE in a way that leaves the A1 pulley intact. Divi-
sion of the A1 pulley in patients with RA can
Hansen RL, Søndergaard M, Lange J. Open surgery versus ultrasound-guided corticosteroid injection for
lead to bowstringing or ulnar drift of the digit.
trigger finger: A randomized controlled trial with 1-year follow-up. J Hand Surg Am. 2017;42(5):359–366.
This randomized clinical trial compared open trigger finger release with ultrasound-guided corticoste-
roid injection in 165 fingers. Patients with insulin-dependent diabetes and RA were excluded. At
3 months, resolution of pain and triggering were achieved in 86% of injections and 99% of surgeries.
By 1 year, 51% of the injection group had recurrence, at an average of 6.5 months, but there were
no recurrences in the surgery group. There were three surgical patients with superficial wound
infections treated with oral antibiotics.
Bauer AS, Bae DS. Pediatric trigger digits. J Hand Surg Am. 2015;40:2304–2309.
This article is a comprehensive literature review of pediatric trigger thumb and finger. Trigger finger in
children is often associated with anatomic abnormalities of the flexor tendons or some other meta-
bolic, inflammatory, and infectious etiologies. As previous studies have shown for trigger thumb,
surgical treatment is common.
Wojahn RD, Foeger NC, Gelberman RH, Calfee RP. Long-term outcomes following a single
corticosteroid injection for trigger finger. J Bone Joint Surg Am. 2014;96:1849–1854.
This retrospective case series analyzed 366 first-time corticosteroid injections in flexor tendon sheaths
over a period of 8 years. Forty-five percent of patients demonstrated long-term treatment success
after a single injection, and in particular, female patients presenting with their first trigger finger had
the highest rate of treatment success. Patients who continued symptom free for 2 years after
injection were likely to maintain long-term success (Level IV evidence).
Werner BC, Boatright JD, Chhabra AB, Dacus AR. Trigger digit release: Rates of surgery and complica-
tions as indicated by a United States Medicare database. J Hand Surg Eur Vol. 2016;41(9):970–976.
This large database study evaluated surgical factors and complications after trigger finger release from
insurance claims. A total of 209,634 patients were analyzed. The middle finger was the most
common finger to be released, followed by the ring finger. The revision surgery rate within the first
3 years was less than 1%. Stiffness was reported to be less than 2% and infection less than 1%.
Increased failures were associated with Dupuytren disease, rheumatoid arthritis, liver disease,
obesity, tobacco use, peripheral vascular disease, and diabetes mellitus.
Kazmers NH, Holt D, Tyser AR, Wang A, Hutchinson DT. A prospective, randomized clinical trial of
transverse versus longitudinal incisions for trigger finger release. J Hand Surg Eur Vol. 2019;
44(8):810–815.
The authors randomized 86 patients undergoing trigger finger release to either transverse or longitudinal
incisions in this study. At 1 year, 71% of patients were evaluated and at both early and long-term time
points, there was no difference in scars or outcomes from either a patient or observer point of view.
Superficial dehiscence occurred in one patient in the transverse group and two patients in the longitu-
dinal group. All patients had resolution of triggering.
CHAPTER 84
Release of De Quervain Tenosynovitis

This chapter includes the following video: Video 84.1 – Release of de Quervain
Tenosynovitis.
KEY CONCEPTS
• De Quervain tenosynovitis is characterized by entrapment of the first dorsal extensor
compartment and inflammation of the tendon sheath. A more proper term to describe
the pathology is thus tenovaginitis (vag means “sheath”) to illustrate that the problem
exists in the thickened tendon sheath rather than as an abnormality of the tendon itself.
• The patient classically has pain over the first dorsal extensor compartment at the
level of the radial styloid, often with associated soft-tissue swelling.
• Conservative therapy includes one to two steroid injections, nonsteroidal antiinflam-
matory medications, splinting, and avoiding activities that cause symptoms. Surgery
is indicated for cases that do not respond to conservative therapy.
• The first dorsal extensor compartment generally contains the abductor pollicis longus
(APL) and extensor pollicis brevis (EPB) tendons but can have numerous variations.
The APL tendon has multiple slips, whereas the EPB is absent in 5% to 7% of
patients. In about 40% to 70% of patients, the compartment may be divided com-
pletely or incompletely by a septum.
• Complete division of all intervening septa and identification of each tendon slip,
especially the EPB, is essential.
• After all sheaths are released, ask the patient to voluntarily palmar abduct the thumb
and flex the wrist to confirm absence of subluxation of first compartment tendons. If
subluxation is noted, a nonconstricting retinacular flap is created to resist subluxation.
• Symptoms usually disappear immediately after the operation. Persistent symptoms
may indicate unrecognized subsheaths in the compartment.
radial nerve
brevis
Abductor
pollicis
longus
FIGURE 84.3 Terminal branches of the superficial radial sensory nerve run along the first compart-
ment in the subcutaneous layer and must be protected during the operation.
641
CHAPTER 84
Release of de Quervain Tenosynovitis
INDICATIONS
• Surgery is indicated for cases that do not respond to conservative therapy.
• Conservative therapy includes one to two steroid injections (usually performed
with or without ultrasound guidance), nonsteroidal anti-inflammatory medications,
splinting, and avoiding activities that cause symptoms. If it is suspected that a
separate subsheath or septum is present for the extensor pollicis brevis (EPB)
tendon (see the EPB entrapment test later in this chapter), surgical management
is also recommended.
• The patient classically has pain over the first dorsal extensor compartment at the
level of the radial styloid, often with associated soft tissue swelling. More proximal
forearm swelling, pain, and crepitus may indicate intersection syndrome.
• The Eickhoff test (commonly and erroneously termed the Finkelstein test) is used to
confirm de Quervain tenosynovitis. The patient grasps their thumb inside a closed
fist while the examiner ulnarly deviates the hand (Fig. 84.1). Pain over the radial
styloid with this motion indicates a positive test.
• The true Finkelstein test, which may also help diagnose de Quervain disease, requires
the examiner to pull the thumb quickly in a distal and ulnar direction. Pain suggests
irritation of the first dorsal compartment tendon sheath.
• The EPB entrapment test consists of two parts: (1) The examiner resists thumb metacar-
pophalangeal (MCP) joint extension, and (2) the examiner resists thumb palmar abduc-
tion. If the pain produced by (1) is greater than (2), then the test is positive (Fig. 84.2A–B).
A positive EPB entrapment test is more commonly seen in patients with a separate EPB
compartment.
IMAGING
Radiographs may be taken to exclude bony etiologies (arthritis of the thumb, carpo-
metacarpal joint, or scaphotrapezial-trapezoid joints; scaphoid fracture; or arthrosis of
the radiocarpal or intercarpal joints).
FIGURE 84.1 Eickhoff test. (Fig. 74.1, from Waldman S. Pain Management. 2nd Q3 ed. 2011:622–623.)
641.e1
641-e2 CHAPTER 84 Release of de Quervain Tenosynovitis
A B
FIGURE 84.2 (A–B) EPB entrapment test. EPB, Extensor pollicis brevis.
SURGICAL ANATOMY
• De Quervain tenosynovitis is characterized by entrapment of the first dorsal exten-
sor compartment and inflammation of the tendon sheath. A more proper term to
describe the pathology is thus tenovaginitis (vag means “sheath”) to illustrate that
the problem exists in the thickened tendon sheath and is not an abnormality of the
tendon itself.
• Two or three terminal branches of the superficial radial sensory nerve run along the
first compartment in the subcutaneous layer and must be protected during the op-
eration (Fig. 84.3). Most operative complications are related to traction of the nerve,
radial nerve
brevis
Abductor
pollicis
longus
FIGURE 84.3 Illustration of superficial branch of radial nerve.
CHAPTER 84 Release of de Quervain Tenosynovitis 641.e3
leading to persistent pain at the incision site and occasional numbness and pares-
thesias over the dorsal first webspace.
• The first dorsal extensor compartment generally contains the abductor pollicis
longus (APL) and EPB tendons but can have numerous variations.
• The APL tendon has multiple slips, whereas the EPB is absent in 5% to 7% of
patients.
• In about 40% to 70% of patients, the compartment may be divided completely or
incompletely by a septum (Fig. 84.4).
• The authors prefer to perform the operation using wide awake, local anesthesia, no The radial sensory nerve branches must be
retracted gently during the operation to prevent
tourniquet (WALANT) in cooperative patients. If needed, patients may receive IV irritation.
sedation with local anesthesia.
• Using a pneumatic forearm tourniquet may provide a bloodless field for identifying
EXPOSURES PITFALLS
nerve branches and anatomic variations if sedation is given.
• A 2-cm, chevron-shaped, longitudinal or transverse incision is made over the first A transverse incision, although cosmetically
extensor compartment just proximal to the radial styloid for full exposure of the appealing, may be more likely to injure the
superficial radial nerve branch.
sheath (Fig. 84.5A).
PROCEDURE
Step 1
• Blunt dissection through subcutaneous adipose tissue exposes the retinaculum
overlying the first extensor compartment along its entire length (see Fig. 84.5B).
• The sheath is incised at the site of its dorsal surface to prevent volar tendon sublux-
ation (Fig. 84.6).
Radius
1st dorsal
compartment
EPB
Septum
APL
FIGURE 84.4 Illustration of first dorsal compartment. APL, Abductor pollicis longus; EPB, extensor
pollicis brevis.
Distal margin of radial styloid
Blunt dissection
exposes extensor
compartments
A B
FIGURE 84.5 (A) Incision markings. (B) Blunt dissection exposes extensor compartments.
Incised
tendon
sheath
EPB
APL
FIGURE 84.6 Incising the dorsal aspect of the tendon sheath. APL, Abductor pollicis longus;
EPB, extensor pollicis brevis.
EPB
Multiple slips
of APL
FIGURE 84.7 EPB lies dorsal to the slips of the APL. APL, Abductor pollicis longus; EPB, extensor
pollicis brevis.
Septum between
APL & EPB
STEP 1 PEARLS
• Complete division of all intervening septa and
identification of each tendon slip, especially
the EPB, is essential.
FIGURE 84.8 Septum between APL and EPB. APL, Abductor pollicis longus; EPB, extensor pollicis
• Unusually thick septa can be excised entirely.
brevis.
STEP 1 PITFALLS
• Both the APL (keeping in mind that it often has multiple slips) and EPB (absent in
Failure to recognize these anatomic variations will 5% to 7% of cases) tendons must be identified. The EPB tendon lies dorsal to the
lead to incomplete surgical release and persistent APL tendons (Fig. 84.7; see also Fig. 84.4).
symptoms.
• If present, the EPB subsheath is released (Fig. 84.8).
CHAPTER 84 Release of de Quervain Tenosynovitis 641.e5
FIGURE 84.9 Closure of incision.
Step 2
• After all sheaths are released, ask the patient to voluntarily palmar abduct the thumb
and flex the wrist to confirm absence of subluxation of first compartment tendons.
• If subluxation is noted, a nonconstricting retinacular flap is created to resist
subluxation.
Step 3
• The wound is closed (Fig. 84.9) and a soft dressing or thumb spica splint is applied
(based on surgeon preference). We do not splint the patient but rather cover with a
soft dressing to permit use of the hand for self-care.

• The use of a thumb spica splint for 1 to 2 weeks postoperatively is based on surgeon
preference. Splints can be useful in patients who are unlikely to limit their activity
postoperatively, particularly patients with young children or manual laborers. Other-
wise, soft dressings are left in place 2 to 3 days postoperatively.
• Vigorous activity, heavy gripping, and repetitive motion of the involved digit are re-
stricted for 4 to 6 weeks. Patients who do not limit manual activities in the early
postoperative period may have slower resolution of symptoms. Symptoms usually
disappear immediately after the operation but may improve more slowly in manual
laborers.
• If symptoms persist, one must consider failure of releasing unrecognized sub-
sheaths in the compartment.
See Video 84.1
EVIDENCE
Ahuja NK, Chung KC. Fritz de Quervain, MD (1868-1940): Stenosing tenovaginitis at the radial styloid
process. J Hand Surg Am. 2004;29:1164–1170.
This article summarizes Dr. de Quervain’s life and his accomplishments. One of his works for treatment
of tenosynovitis of the first dorsal compartment remains important to hand surgery today. Clinical
maneuvers to confirm de Quervain disease are outlined, including an accurate description of the
original Finkelstein test, which is often misunderstood in routine practice. The Eickhoff test (asking
patients to clench their fist over the thumb, followed by forced ulnar deviation of the wrist) is often
incorrectly referred to as the Finkelstein test.
Alexander RD, Catalano LW, Barron OA, Glickel SZ. The extensor pollicis brevis entrapment test in the
treatment of de Quervain’s disease. J Hand Surg Am. 2002;27:813–881.
The author introduced the EPB entrapment test to evaluate patients with de Quervain disease. The test
showed 81% sensitivity in identifying patients with a separate EPB compartment.
Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: Surgical or nonsurgical treatment. J Hand
Surg Am. 1990;15:83–87.
The authors found that one or two steroid injections had a good response for 80% of the patients (in 45
of 63 wrists) with de Quervain disease. Separate compartments for APL and EPB tendons were seen
in the cases that failed steroid injection and required surgical release (in 10 of 11 wrists that required
surgical release).
Garçon JJ, Charruau B, Marteau E, Laulan J, Bacle G. Results of surgical treatment of De Quervain’s
tenosynovitis: 80 cases with a mean follow-up of 9.5 years. Orthop Traumatol Surg Res.
2018;104(6):893–896.
In this retrospective review, patients who underwent de Quervain release were contacted at a minimum
of 1 year after surgery (mean 9.5 years follow-up). Their surgical technique included a standard first
dorsal compartment release with the addition of sutures from the dorsoulnar end of the extensor reti-
naculum flap to the skin in an attempt to prevent volar tendon subluxation. A total of 74 patients
(80 operative wrists) were contacted. There were no immediate complications but 10 showed signs
of complex regional pain syndrome. Sixty-five patients were pain-free at follow up and only three
patients still had constant pain. Seventy-two of 74 patients were satisfied.
Bernstein DT, Gonzalez MA, Hendrick RG, Petersen NJ, Nolla JM, Netscher DT. Impact of septated
first dorsal compartments on symptomatic de Quervain disease. Plast Reconstr Surg.
2019;144(2):389–393.
The authors reviewed 85 consecutive wrists (in 79 patients) undergoing de Quervain release and
96 matched cadaver wrists for the presence of a separate EPB subsheath. In the surgical patients,
61% had a septum in the first dorsal compartment and 73% of cadaver wrists did as well. They
also examined whether wrists with a first dorsal compartment septum underwent greater or fewer
corticosteroid injections before electing surgical treatment; no difference was found.
ddsf
SECTION X
Flaps and Microsurgery

CHAPTER 85 Management of Mangled Extremities 643
CHAPTER 86 Local Tissue Rearrangement for Treatment
of Scar Contractures 653
CHAPTER 87 Flap Coverage of Fingertip Injuries 663
CHAPTER 88 Flap Coverage of Thumb Defects 664
CHAPTER 89 Dorsal Metacarpal Artery Flap and Dorsal
Metacarpal Artery Perforator Flap 666
CHAPTER 90 Pedicled Forearm Flap 673
CHAPTER 91 Groin and Abdominal Based Flap 674
CHAPTER 92 Lateral Arm Flap 684
CHAPTER 93 Venous Flap 694
CHAPTER 94 Revascularization and Replantation
of Digits and Hand 704
CHAPTER 95 Toe to Thumb Transfer 715
CHAPTER 96 Digital Artery Sympathectomy for Raynaud’s
Phenomenon 728
CHAPTER 97 Ulnar Artery to Superficial Arch Bypass with
a Vein Graft 736
642
CHAPTER 85
Management of Mangled Extremities
Kevin C. Chung and Natalie B. Baxter
INDICATIONS FOR RECONSTRUCTION

• The word mangled derives from a French word meaning “cut to pieces,” or a Latin
word for to “cut or lop off.” Mangled extremities are typically defined as the result of
a traumatic injury that harms three or more structures. Crush, avulsion, and blast
injuries are common causes of mangled upper extremities.
• It is often preferable to save a hand with rudimentary function rather than perform
an amputation. Although more sophisticated prostheses are in development, com-
mercially available options do not provide the sensory feedback that is vital for hand
function. Instead, the patient must watch the hand in space and practice extensively
to modulate the precise force needed to manipulate objects.
• A clear discussion with the patient and family members is essential so that everyone
recognizes the potential outcomes and need for extensive rehabilitation. It is also
important to understand the patient’s goals and expectations, social support, and
occupation when deciding which procedures to perform. For example, farmers may
want to return to work sooner, so a more limited reconstruction with decreased dis-
ability time would be ideal.
• Reconstruction should always be attempted in children because they have a great
capacity for healing and recovery of nerve function.
• Surgeon skill is the major determinant of outcomes. The surgeon must be well
versed in reconstruction of all injured structures, including bone, tendons, nerves,
vessels, and soft tissue coverage, before undertaking complex reconstruction of
mangled extremities.
INDICATIONS FOR AMPUTATION

• Although most hand and upper limb injuries can be saved, amputation is a form of
reconstruction as well (see Chapter 4 Proximal Upper Extremity Amputation).
• It is important to put forth the caveat of life before limb; if the patient has life-threat-
ening injuries in addition to a mangled extremity, it is sensible to perform a guillotine
amputation to save the patient’s life and prevent ongoing blood loss as more urgent
needs are being addressed.
• Amputation is also indicated if there is severe contamination or if the patient has
significant comorbid conditions. For example, underlying obstructive vascular con-
ditions may be exacerbated if dramatic fluid shifts take place during reconstruction.
• Multiple complex surgical procedures may not be desired or suitable for patients
with advanced age or mental disorders because of the need for multiple operations
and extensive rehabilitation. Therefore communication with the patient to reach a
consensus on future goals is essential when deciding to pursue complex procedures
versus amputation.
PATIENT HISTORY
• Obtain the mechanism of injury from the patient or bystanders to determine the
amount of energy that was imparted through the tissues and the potential for con-
tamination. This will inform the urgency and organization of treatment.
• High-energy injuries, such as those caused by industrial or farming accidents,
often cause tremendous tissue damage throughout the hand. There is also a
risk for contamination if the tissues are embedded with soil or other bacteria-
laden material. The debris within the wound will cause infection unless radical
debridement and early cleaning are carried out to prevent seeding throughout
the hand.
643
644 CHAPTER 85 Management of Mangled Extremities
FIGURE 85.1 Tissue damage not visible at the skin level.
• Severe crush injuries (Fig. 85.1) cause obvious bruising and often damage the
underlying muscles. As a result, the muscles swell in the unyielding fascia and
cause compartment syndrome and skeletal, nerve, and vascular injuries.
• Motor vehicle accidents may overtake industrial accidents as the major cause of
mangled extremities in more developed areas of the world.
• Large caliber projectile and blast mechanisms are a common cause of mangled
extremities in many areas of conflict around the world. In the United States, civil-
ian gun injuries are not uncommon from hunting accidents or personal assault.
• Determine whether the patient has any vascular, pulmonary, or cardiac conditions.
• Gather information about the patient’s social history, including smoking status
(greater risk for wound complications and vascular problems) and occupation, as
well as hand dominance.
• Mangled extremities can detract attention from more life-threatening injuries. Thus it
is important to strip the patient naked and evaluate the entire body for further damage.
• Trauma assessment is critical because intraabdominal injuries can be devastating to
the well-being of the patient. Remember the primary survey of ABCs: assess the
airway, breathing, and circulation.
• Contamination in the hand may spread throughout the upper extremity and to other
parts of the body. Thoroughly evaluate the extent of damage and coordinate with the
trauma team to ensure that all injured and contaminated tissues are accounted for
in the treatment plan.
• Perform a hand evaluation if the patient is conscious. An understanding of the vas-
cularity, sensation, and function of the distal hand and fingers, as well as the level of
injury, is necessary to determine the operative needs based on what tissues were
lost and which structures are still present.
• One should not probe the wound to determine the type of injuries that are present
and structures that are damaged. A coherent hand examination should give the
surgeon an excellent catalog of structures that are intact or lost.
RECONSTRUCTIVE PRIORITIES
• The American Medical Association (AMA) established an impairment rating system to
gauge the functional loss associated with digit or extremity amputation (Table 85.1).
• It is important to keep in mind that impairment indicates a loss of structure but not
necessary a loss of function, whereas disability describes a loss of function or an
inability to cope with the impairment.
• As noted in Table 85.1, the thumb accounts for 40% to 50% of hand function and is
therefore a reconstructive priority.
• It is essential to reconstruct the thumb with one, or ideally two, opposable digits so
that the patient can perform tripod pinch. If possible, save the ring and little finger
to restore power grip function.
• It is unreliable to use a numerical severity score to predict mangled upper extremity
reconstruction outcomes because of the varied injury patterns and reconstruction
options.
TABLE Estimated Percentage of the Effect of an Upper Extremity Impairment

85.1 on Activities of Daily Living
% Impairment
Amputation hand Upper extremity Whole body
Index or long finger 20 18 11
Ring or little finger 10 9 5
Thumb 40–50 36–45 22–27
Hand __ 90 54
Upper extremity __ __ 60
(Data from Cocchiarella L, Andersson GBJ, eds. AMA Guidelines of Permanent Impairment. 5th ed. American
Medical Association; 2001.)
EARLY MANAGEMENT OF ISCHEMIA AND BLEEDING EARLY MANAGEMENT PEARLS
• Keep track of the time since injury. Greater than 6 hours of warm ischemia leads to Direct pressure is the best way to stop bleeding.
Ideally, place a compressive dressing and an ace
muscle death. If the limb is devascularized, establish vascular flow in the arm using
bandage right over the bleeding area. Prolonged
vein grafts or a temporary vascular shunt so that the limb can be perfused while tight tourniquet proximal to the arm risks
more urgent needs are being addressed. permanent ischemia to all tissues distal to the
• If ischemia lasts more than 6 hours, then perform a mandatory prophylactic fasciotomy tourniquet when the compressive pressure can be
(see Chapter 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm) of excessive.
the upper arm if necessary, the forearm, and the hand compartments. Otherwise, swell-
ing of the muscles in the tight fascia compartments will restrict blood flow to the EARLY MANAGEMENT PITFALLS
muscles and tissues, particularly when the arm is reperfused after revascularization. • Do not place a tourniquet over the upper arm
• Stop all severe bleeding as soon as possible by placing direct pressure over the to stop the bleeding. Although this is common,
bleeding site. In most cases, local pressure suffices until the patient is adequately inappropriate tourniquet placement causes
resuscitated with fluids and/or blood products. diffuse ischemic damage to the entire upper
• If the bleeding is not controlled with local pressure, then place a bulky dressing over limb. If the team loses track of tourniquet time,
then the distal tissues will be irreparably
the open wound to tamponade the bleeding vessel. damaged.
• Bleeding sources are most often partially cut vessels that cannot retract and seal off • Vicious clamping of an arterial bleed can trau-
the blood flow. If the arterial bleed is identified, it is prudent to carefully ligate the matize the adjacent, uninjured structures, such
arterial source under a good light source. as critical nerves that are essential for recov-
ery of sensory and motor functions.
OPERATIVE STRATEGIES
The general operative strategies are explained in the following sections and then two STEP 1 PEARLS
cases are presented to convey the key points of mangled upper extremity management.
• A thorough understanding of upper limb anat-
omy is critical because all structures are ar-
Step 1: Perform Aggressive Debridement and Organize Structures ranged and organized in topographic order.
• Proceed to the operating room and perform aggressive debridement to viable tissues. • Antibiotic use for hand injuries is controversial.
• Organize and identify the injured structures. List them on a chart from superficial to When severe contamination is present, it is
deep and radial to ulnar. most effective to perform radical debridement
and administer broad-spectrum antibiotics,
• Tag each structure with suture or temporary clamps to facilitate identification and
such as first-generation Cephalosporin.
excision later. • After aggressive debridement, antibiotics can be
• Scrub the ends of the bones to remove contamination. It is preferable to excise the administered in the first operative setting and
bone ends using a saw if extensive contamination is present to prevent osteomyelitis. continue for 24 to 48 hours. Long antibiotic use
• Irrigate the wound with a copious amount of irrigant under gravity, which is less is not necessary because of the judicious and
aggressive debridement efforts.
traumatic to the tissue when compared with pulse irrigation.
Step 2: Structural Stabilization STEP 1 PITFALLS

• Stabilize the bones to reestablish the foundation of the limb and set the stage for Evidence indicates that pulse irrigation is not
subsequent reconstruction. suitable because it damages the tissue and drives
• If the wound is still severely contaminated after debridement and stabilization of the contaminants into other compartments of the hand
skeleton, delay repair of other structures to avoid further contamination. Temporizing and upper extremity.
the wound with vacuum-assisted closure (VAC) or moist dressing is suitable before
definitive treatment, which should be completed within 1 week of injury.
STEP 3 PEARLS
Step 3: Tendon and Muscle Repair
• The patient can return to the operating room after 24 to 48 hours for a second de-
If there is vascular damage, the vascular repair
takes precedence after structural stabilization. bridement; if the wound appears to be clean at that time, proceed with tendon and
muscle repair.
• If the wound is still contaminated, then perform another radical debridement so that
the wound is as clean as possible before reconstruction and soft tissue coverage are
carried out simultaneously.
Step 4: Vascular and Nerve Repair

• Vascular repair may occur earlier in the reconstruction process if ischemia is present.
• Nerve repair can be performed if the nerve is not severely crushed. Digital, ulnar, and
median nerve repair are described in Chapters 60, 61, and 62, respectively.
• A homograft can be used as a temporary dressing for 48 hours up to a few days,
until adequate supplies and personnel are organized to perform complex soft tissue
coverage.
STEP 5 PEARLS Step 5: Soft Tissue Coverage

• Although muscle flaps do not permit easy glid- • It is mandatory to cover tendon, nerve, or vascular reconstruction with soft tissue
ing of the underlying tissue, they are a suitable early to avoid desiccation of the exposed structures.
option for large wounds and sealing dead
spaces. • Earlier free-flap coverage is associated with a higher rate of success because the
• Keep in mind the donor site morbidity when tissue anatomy is still well defined, and the muscles are not encased in scar tissue.
selecting the ideal free-flap option. Granulation tissue can form a few days after injury, which makes the tissue planes
more difficult to identify.
• Soft tissue reconstruction is determined by the size of the wound. No skin flap is suf-
ficient in size to cover circumferential wounds. Instead, a muscle flap, such as the
latissimus dorsi or the rectus muscle, is used to cover an extensive soft tissue defect.
• A fasciocutaneous flap is preferable when the wound is limited in size because it
permits tendon gliding under the adipose tissue and fascia plane.
REPAIR OF A COMPLEX CRUSH INJURY TO THE FOREARM

This patient was a 35-year-old male who experienced a complex crush injury to the
right forearm (Fig. 85.2). His wound was contaminated with grease and there was bone
loss in the distal radius (Fig. 85.3), compartment syndrome, and extensive tissue loss.
Step 1: Radical Debridement and Structural Organization

• We performed extensive, aggressive debridement, excised the necrotic and crushed
tissues using a sharp knife, and then irrigated the wound with normal saline.
• We performed an open carpal tunnel release (see Chapter 55 Open Carpal Tunnel
Release) to prevent postoperative swelling, which could cause compartment syn-
drome of the hand.
FIGURE 85.2 Mangled extremity. FIGURE 85.3 X-rays demonstrating bone loss in the midforearm.
• We used a saw to excise the bone ends and remove all contaminants.
• We explored the extensor compartment and evaluated its content; the patient had
ruptures of tendons within first and second dorsal extensor compartments: abductor
pollicis longus (APL), extensor pollicis brevis (EPB), extensor carpi radialis longus
(ECRL), and extensor carpi radialis brevis (ECRB). The communis tendons of the ring
and little fingers were also ruptured. The brachioradialis (BR) muscle and radial sen-
sory nerve were also avulsed. We tagged all injured structures for later reconstruction.
• We clipped the radial artery proximally and distally to control blood loss.
• The patient had avulsion of the muscle belly of the flexor digitorum superficialis
(FDS). We approximated the muscles using 0 Ethibond sutures in a horizontal mat-
tress fashion.
Step 2: Structural Stabilization, Part One

• We used a plate to immobilize the radius (see Chapter 32 Fragment-Specific Fixation
of Distal Radius Fractures). A 5-cm bone fragment was missing, and thus a bone
grafting procedure was required once the wound was reasonably clean.
• Bleeding points were cauterized with a bipolar, and a homograft was placed over the
entire wound.
Step 3: Structural Stabilization, Part Two

We returned to the operating room 48 hours later. We harvested a cortical cancellous
bone block from the iliac crest, sculpted it to fit the bone defect over the midshaft of
the radius (Fig. 85.4), and fixated it with plates and screws (Fig. 85.5).
FIGURE 85.4 Bone graft sculpted to repair the radius.
FIGURE 85.5 Bone graft in place.

FIGURE 85.6 Tendons identified.
Step 4: Tendon and Muscle Repair

We determined which tendons were available for transfer and whether to harvest tendon
grafts. We performed tendon transfers to repair the APL, extensor pollicis longus (EPL),
ECRB, and extensor digitorum communis (EDC) of the little and ring fingers (Fig. 85.6).
Step 5: Nerve Repair

We harvested a sural nerve graft to replace the defect in critical injured nerves. In this
case, only the superficial radial nerve was injured, which is not a critical structure.
Step 6: Soft Tissue Coverage

• Soft tissue coverage was necessary to permit gliding of the tendon transfers. We
designed a parascapular free flap measuring 20 by 18 cm in size, based on the cir-
cumflex scapular artery (Fig. 85.7).
• We transferred the flap to the forearm and sutured it to the ligated proximal radial
artery using 9-0 interrupted sutures and sutured the concomitant vein to the para-
scapular venous pedicle (Fig. 85.8).
Outcomes
The patient had rapid healing and acceptable function after 2 months (Fig. 85.9A–B).
REPAIR OF UPPER ARM GRINDING INJURY

The patient was a 5-year-old boy who sustained a near complete amputation of his up-
per left arm when it was caught in a tomato picker machine. He had transection of the
median nerve and brachial artery, and he fractured his humerus and ulna (Fig. 85.10).
He was transferred to us 12 hours after the injury. Although this delay would usually
mandate amputation of the arm in an adult patient, children have a greater capacity for
FIGURE 85.7 Parascapular flap design and recovery and thus reconstruction was attempted.
harvest.
FIGURE 85.8 Flap in place.

A B
FIGURE 85.9 (A–B) Postoperative outcomes.
Step 1: Vascular Repair and Structural Stabilization

• There was poor blood flow in the arm and thus vascular repair was prioritized to
revascularize the limb. We performed a brachial artery repair using the right greater
saphenous vein.
• A rod was inserted to stabilize the humerus and the damaged median nerve was
tagged for easier identification for repair at a later time.
Step 2: Fasciotomies
The patient had significant swelling of the muscles of his forearm and hand after the
revascularization. We undertook fasciotomies over the hand to relieve the pressure
within the compartments after ischemia reperfusion of the muscles.
Step 3: Debridement and Irrigation

• We returned to the operating room the next day for continued debridement.
• We debrided the necrotic tissues and any dusky or gray muscle until obvious bleeding
was seen.
• We irrigated the wound with normal saline and covered it with homograft.
FIGURE 85.12 Intact median nerve and brachial artery.

FIGURE 85.11 Pediatric mangled extremity.
Step 4: Further Debridement and Wound Exploration

• We return to the operating room after 48 hours for wound washout and preparation
for definitive closure (Fig. 85.11).
• We removed the homograft and confirmed that the underlying tissues appeared to
be viable. We sharply excised any necrotic skin.
• We inspected the tagged median nerve ends and repaired brachial artery to ensure
that they were still viable (Fig. 85.12).
Step 5: Median Nerve Repair

• We harvested two 15-cm lengths of sural nerve grafts from both legs and transferred
them to the median nerve under magnification using 9-0 interrupted nylon sutures
(Fig. 85.13).
• The distal nerve ends were covered using a slip of the biceps muscle.
Outcomes
• The skin grafts had fully taken at 3 days postoperatively (Fig. 85.14) and remained
viable in the early postoperative period (Fig. 85.15).
• He had good return of intrinsic function of the hand and strong elbow flexion (Fig. 85.16).
• At 2 years follow-up, he had full recovery of his function (Fig. 85.17A–B).
See Video 85.1
FIGURE 85.13 Long sural nerve grafts.

FIGURE 85.14 Three-day postoperative outcomes.
FIGURE 85.15 Full skin graft in place.
FIGURE 85.16 Six-month postoperative outcomes.

FIGURE 85.17 (A–B) Two-year postoperative outcomes.
EVIDENCE
Miller EA, Iannuzzi NP, Kennedy SA. Management of the mangled upper extremity: A critical analysis
review. JBJS Rev. 2018;6(4):e11.
In this review, the authors describe principles of treatment of the mangled upper extremity. They review
infection prevention and antibiotic use, debridement strategies, skeletal stabilization, reconstruction,
and rehabilitation.
Harrison BL, Lakhiani C, Lee MR, Saint-Cyr M. Timing of traumatic upper extremity free flap recon-
struction: A systematic review and progress report. Plast Reconstr Surg. 2013;132(3):591–596.
In this systematic review, the authors reported that there was no statistical difference in flap loss,
infection rates, or bony nonunion between groups who had flap reconstruction emergently, earlier
(within 5 days) or later. There was a signification association between early reconstruction and a
shorter hospital stay. Publication bias may be present because most of the data were derived from
leading health centers with expert surgeons. Surgeons in supportive healthcare systems had the
best outcomes after complex flap reconstruction or soft tissue coverage.
Bernstein ML, Chung KC. Early management of the mangled upper extremity. Injury. 2007;38
(Suppl 5):S3–S7.
In this review, the authors describe the need for aggressive treatment during the initial management
of mangled upper extremities. After evaluation of vascularity and salvageability in the emergency
department, early debridement is critical to prevent invasive infections and further tissue loss. The
goal is to clean the wound thoroughly so that reconstruction can begin as soon as possible.
CHAPTER 86
Local Tissue Rearrangement for Treatment of Scar
Contractures
INTRODUCTION
• As with reconstruction elsewhere on the body, surgeons must keep in mind the “recon-
structive ladder” when repairing hand defects. Consider treatment options that range
from “simple to complex” and from “local to distant.”
• Local flaps are composed of skin and subcutaneous tissue that is adjacent to the re-
cipient site and has an independent blood supply. These flaps are preferred (Fig. 86.1)
because the local tissue and recipient site are similar in color, texture, structure, sensa-
tion, and hairiness. When adequate tissue is available locally on the hand, a local flap
can be used for coverage of exposed tendons, joints, and bones (see procedures in
Table 86.1).
• Local flaps are defined according to the relative position of the skin flap and the
receiving site. They can be designed in a triangle, rectangle, trapezoid, or rhomboid
shape to match the defect.
• The blood supply for a local flap can be random or axial (see Table 86.1).
• Random pattern flaps are supplied by a random pattern of subdermal plexus. The
size is limited by the length-to-width ratio, which is usually 1:1.
• Axial pattern flaps have a known artery that directly supplies a specific skin terri-
tory. The size of the axial flap is not limited by the ratio of length to width and
depends on the perfusion area of the main donor vessel.
• The size of the local flap depends on the mobility of the skin. Typically, larger flaps
can be designed on the dorsal hand where the skin is more elastic. Meanwhile, the
stiffness of palmar tissue limits the size of a local flap.
• Various types of Z-plasties are described in this chapter for the treatment of scar
contractures. These are random pattern flaps, with blood supply provided by the
subdermal plexus.
INDICATIONS
• Burn, scald, electric, and other thermal injuries often cause thick, hard scar bands or
contractures. Contractures are often located on the volar side of the hand (Fig. 86.2)
or at the joints, where they limit finger movement. In addition to the skin, contractures
can affect the subcutaneous soft tissue, fascia, muscles, and joint capsule.
• Because the resultant wound is typically larger after release of a contracture or scar
band, local tissue rearrangement is usually necessary to facilitate primary closure.
Local flap Regional flap Distant flap

FIGURE 86.1 According to the location of the flap and defect, the flap can be divided into three
types: local flap, regional flap, and distant flap.
653
654 CHAPTER 86 Local Tissue Rearrangement for Treatment of Scar Contractures
TABLE
86.1 Classification of Hand Flaps
Rectangle flap
Triangle (V-Y) flap
Advancement flap (Chapter 87I)
Bipedicled and
keystone flap
Rotation flap
Local flap (harvested Pivot flap Rhomboid flap
next to the injured
zone) Bilobed flap
Z-plasty
Multiple Z-plasties
Location
Transposition skin flap 4-flap
5-flap Z-plasty
W-plasty
Thenar flap (Chapter 87III)
Regional flap Cross-finger flap (Chapter 87II)
(harvested from
adjacent zone) Homodigital island flap (Chapter 87IV)
Dorsal metacarpal artery flap (Chapter 88II)
Distal flap (harvested Groin flap (Chapter 91)
away from the
injured hand) Lateral arm flap (Chapter 92)
Random flap Supplied by a random pattern

Blood of subdermal plexus
circulation
Axial flap Supplied by a known artery
FIGURE 86.2 The thick scar band of the second webspace with restriction of adduction/abduction.
• Scar contracture may appear as a linear or webbed scar (Fig. 86.3). The goal of
treating a scar contracture is to interrupt the scar line, change the direction of the
scar, and lengthen the long axis of the scar. This is often necessary to permit greater
mobility of the hand and extension of the digits.
CHAPTER 86 Local Tissue Rearrangement for Treatment of Scar Contractures 655
Narrowed 1st webspace requires long Narrowed 2nd–4th webspaces

and smooth opening require deepening
FIGURE 86.3 Webbed scars.
Contraindications
• If the defect is too large or there is a paucity of local tissue, then more distant options
are considered, such as tissue expansion or use of a free flap.
• Z-plasties are only used to repair linear scars or webbed scars. Lamellar scars,
sheets of scar, or skin defects may instead be repaired with advancement, pivot
flaps, or regional flaps (see Chapters 87 and 88).
• Avoid performing Z-plasty in keloids and hypertrophic scars that may recur along the
lengthened scar.
• Determine whether normal skin is available on either side of the contracture or scar
and identify any previous scars.
• If the skin is under high tension, pull and stretch the skin to evaluate its mobility.
• Consider the length of the scar and whether a web contracture is present when
selecting the appropriate type of Z-plasty.
SURGICAL ANATOMY
• The Z series consists of Z-plasty, multiple Z-plasties, and five-flap Z-plasty.
• Determine whether or not to remove the scar based on its characteristics. If the scar
is soft and the blood supply is rich, then the scar tissue can be retained.
Z-Plasty
• Z-plasty, also called a converging triangular flap, is the basic technique for a trans-
position flap and is commonly used for postburn reconstruction.
• Z-plasty is designed using three limbs of equal length: the central limb (ab) on the
scar axis and lateral limbs on both sides (ac and bd), which can be opened to form
two triangular flaps with equal angles (Fig. 86.4A).
• When the two flaps exchange position, they break the original linear scar and
change the direction of the axis (see Fig. 86.4D). At the same time, the scar is
lengthened because inserting the skin flaps facilitates straightening of a digit or
deepening of a webspace.
• Theoretically, a scar can be lengthened by 25% for each 15-degree angle increase;
however, it is more difficult to transfer a flap with larger angles (Table 86.2 and Fig. 86.5).
• Z-plasties with 60-degree angles are most commonly used because they enable
sufficient scar lengthening and are usually easier to transfer. Although flaps with
c a
c 1 a
Flap A
Flap A Flap B
Flap B
2
d
d b
b
A B
c a
c Flap B
Flap A Flap B
Flap A
d d
b
C
b
D
FIGURE 86.4 Z-plasty. (A) Z-plasty design for scar contracture. (B) Two triangular flaps A and B are elevated.
(C) Transposition of flaps A and B. (D) Axis changed. (From Fig. 14.9 in Frodel JL, Pawar SS, Wang TD. Z-plasty.
In Baker S. Local Flaps in Facial Reconstruction. Elsevier; 2014:317–338.)
TABLE Scar elongation that can be a

30°
86.2 achieved with various flap angles 60°
45°
Angle The proportion of 45° 60°
lengthened scar 30°
b
30 degrees 25% elongation
Distance
60 degrees 75% elongation a1
90 degrees 125% elongation.
b1
25% longer
50% longer
75% longer
FIGURE 86.5 aTb is the original length of the central limb, and a1b1 is the final length of the limb
after the flaps are transposed. (From Frodel JL. Creative uses of Z-plasty technique. Operative
Techniques in Otolaryngology- Head and Neck Surgery, 2011;22(1):30–34.)
greater angles can elongate the scar even further, they are more difficult to close
without undue tension.
• The minimum angle of the flap should be 30 degrees to avoid necrosis of the flap tip.
Multiple Z-Plasties
• Multiple Z-plasties with shorter limbs are used to treat longer scar contractures
when there is insufficient normal skin to perform one large Z-plasty (Fig. 86.6).
FIGURE 86.6 Multiple Z-plasties. (From Frodel JL. Creative uses of Z-plasty technique. Op Tech
Otolaryng. 2011;22(1):30–34.)
A E
a e
B D
C
A
b d
A E
A C E
B D
B D
C
B C
FIGURE 86.7 5-flap Z-plasty. (A) Five-flap Z-plasty design. (B) The five flaps—A, B, C, D, and E—
are elevated. (C) Flaps A and B insert into flaps C, D, and E. (From Galvez MG, Chang, J. Hand
burn reconstruction. In Chang J, ed. Global Reconstructive Surgery. Elsevier; 2020:276–280.)
• The use of multiple Z-plasties requires the design of smaller triangular flaps
along the contracture line. This distributes the release more evenly than a single
Z-plasty.
Five-Flap Z-Plasty
• Five-flap Z-plasty, also known as the jumping-man flap, contains two opposing Z-
plasties and one Y-V advancement flap in the middle (Fig. 86.7). It is often used to
treat webbed scars, especially in the first webspace.
• Visually, there are two flaps above the scar line (flaps A and E) and three flaps below
the scar line (flaps B, C, and D). The webbed scar is lengthened and deepened
through transposition of the upper and lower flaps.
• In general, design large flaps, rather than multiple small flaps, to yield even longer
lengthening.
POSITIONING
Place the patient in a supine position with their arm on a hand table. After general or
plexus anesthesia, apply a tourniquet (250 mm Hg) to the upper arm.
FIGURE 86.8 Z-plasty design in webspace.
STEP 1 PEARLS Z-PLASTY

Avoid tip necrosis by designing large flaps with ends Step 1: Flap Design
that taper but do not form a sharp point (Fig. 86.8).
• Design the central limb (ab) of the Z-plasty on the axis of the scar or the webspace
line, and two lateral limbs (ac and bd) of equal length at each end of the line (see
STEP 1 PITFALLS Fig. 86.4A).
If the two lateral limbs are different lengths, then • The flap angles are typically designed at 60 degrees.
additional contouring of the flaps may be necessary
before inset. Step 2: Flap Elevation
• Use a no. 15 blade to sharply incise the skin through the scar into soft subcutaneous
STEP 2 PEARLS tissue (see Fig. 86.4B).
• Identify and protect the digital nerves, vessels, and tendons as needed.
• Keep the blade perpendicular to the skin.
• Avoid blind dissection into deeper tissue be- • Place skin hooks at the tip of the flap and sharply elevate the flap from distal to
cause this risks injury to deeper structures. proximal, keeping some fat on the flap.
• Sharply release any surrounding scar bands with gentle spreads, using tenotomy
scissors to achieve maximal mobilization (see Fig. 86.4C).
Step 3: Flap Transposition

• After the release, either extend the finger or abduct the webspace to facilitate flap
transposition into the appropriate new positions. The tip of flap A is transferred from
point “a” to point “d.” Similarly, the tip of flap B is transferred from point “b” to point
“c” (see Fig. 86.4D).
• This rearrangement places the new scar axis perpendicular to the axis of the original
scar.
Step 4: Flap Inset

• The tips of flap A and B are sutured in place using 4-0 Nylon suture.
• The wound is closed with interrupted 4-0 Nylon sutures (Fig. 86.9).
MULTIPLE Z-PLASTIES
STEP 1 PITFALLS Step 1: Flap Design
Each Z-plasty should be designed and tailored • Determine the number of Z-plasties and the length of each limb according to the
to the local conditions. Do not assume that each position and length of contracture scar. When the contracture scar is located on the
limb and angle should be the same size for all scar finger, the length of each limb is typically around 1 cm.
types (Fig. 86.10).
• The central limb is designed on the axis of the scar. The angles are typically 60 degrees.
Step 2: Flap Elevation

tissue.
B
D
A
C
FIGURE 86.9 Wound closure. FIGURE 86.10 The flaps AB and CD are two separate Z-plasties
with limbs of different lengths.
B
D
A
C
FIGURE 86.11 Four flaps are elevated.
• Place the skin hook at the tip of the flap and sharply elevate the flap from distal to
proximal, keeping some fat on the flap (Fig. 86.11).
scissors to achieve maximal mobilization.
• Adequately dissect the surrounding subcutaneous tissue to achieve proper mobili-
zation of the flaps. Then harvest the flaps (flaps A, B, C, and D in Fig. 86.11).

• After the release, extend the finger to facilitate flap transposition into the appropriate
new positions.
• Flap A is transposed with flap B, and flap C is transposed with flap D (Fig. 86.12).
Step 4: Flap Inset

• The tips of flaps A, B, C, and D are sutured in place using 4-0 Nylon sutures.
• The wound is closed with interrupted 4-0 Nylon sutures without tension (Fig. 86.13).
FIVE-FLAP Z-PLASTY
Step 1: Flap Design
• The central limb (ae) is designed on the line of webspace. Two opposing Z-plasties
are designed on either side of the central limb, and an additional limb is designed to
form a “Y” in the middle. The flap angles are typically designed to be 60 degrees and
the limbs are all the same length, at about 1 cm (see Fig. 86.7A).
B B D
D A
A C
C
FIGURE 86.13 Wound closure.

FIGURE 86.12 Every two flaps are transposed around each other.
A E
B D
C
FIGURE 86.14 Flap C must be on the dorsal side.
• Flap C should be designed on the dorsal side of the hand because it is an advance-
ment flap, and adequate mobility is necessary for transfer. The dorsal skin is thinner
and provides greater mobility than the volar skin (Fig. 86.14).
Step 2: Flap Elevated

tissue.
• Place a skin hook at the tip of the flap and sharply elevate the flap from distal to
proximal, keeping some fat on the flap (Fig. 86.15).
scissors to achieve maximal mobilization.
A E
A
E
B
B
C
D
C D
FIGURE 86.15 Five flaps are elevated. FIGURE 86.16 The two flaps A and E insert into flaps B, C, and D.
E D
A
B C
FIGURE 86.17 Wounds closed without tension.
• Adequately dissect the surrounding subcutaneous tissue to achieve proper mobili-

zation of the flaps. Then harvest the five flaps (flaps A, B, C, D, and E).

• If necessary, release both the first dorsal interosseous and the adductor muscle to
ensure adequate thumb abduction.
• After the release, abduct the webspace to facilitate flap transposition into their ap-
propriate new positions.
• Flap A is transposed with flap B, and flap D is transposed with flap E. Flap C is
advanced forward to the volar side, forming a “V” rather than a “Y” (Fig. 86.16).
Step 4: Flap Inset

• The tips of flaps A, B, C, D, and E are sutured in place using 4-0 Nylon sutures.
• The wound is closed with interrupted 4-0 Nylon sutures without tension (Fig. 86.17).

• The patient is placed in a volar splint after the operation.
• The patient will return to the clinic in 1 week for a wound check and to initiate
therapy for scar massage exercises.
• As with all flap repairs, there may be complications such as necrosis, hematoma,
infection, and incision dehiscence. Most complications can be prevented by careful
manipulation during the operation.
See Video 86.1
EVIDENCE
Brown M, Chung KC. Postburn contractures of the hand. Hand Clin. 2017;33(2):317–331.
The authors review four key points of postburn contractures. Burn contractures present as a spectrum
of deformities that significantly limit hand function. Appropriate care during the acute burn phase can
limit the incidence or severity of postburn contracture. Surgical release with graft or flap coverage is
the primary treatment modality. Postoperative splinting, hand therapy, and scar care are vital to a
successful outcome (Level V evidence).
Rehim SA, Chung KC. Local flaps of the hand. Hand Clin. 2014;30(2):137–151.
The authors review the classification of local skin flaps of the hand and offer a practical reconstructive
approach for several soft tissue defects of the hand and digits (Level V evidence).
Wainwright DJ. Burn reconstruction: The problems, the techniques, and the applications. Clin Plast
Surg. 2009;36(4):687–700.
The authors review a detailed description of all the techniques available for the treatment of burn defor-
mities (Level V evidence).
CHAPTER 87
Flap Coverage of Fingertip Injuries

This chapter includes the following videos: Video 87.1 – Fingertip Reconstruction
Using Thenar Flap; Video 87.2 – Homodigital Neurovascular Island Flap Coverage of
Fingertip Injury.
KEY CONCEPTS
• Local flaps of the hand, including the palmar V-Y advancement flap, cross-finger
flap, and thenar flap, are often used to cover the soft-tissue defect of the fingertip to
preserve the nail and distal interphalangeal (DIP) joint.
• The V-Y flap is a random pattern advancement flap that is best suited for transverse
or dorsal oblique fingertip amputations, within Tamai Zone I.
• The cross-finger flap is indicated for volar soft-tissue defects of the proximal, mid-
dle, or distal phalanx with exposure of tendon or bone.
• The thenar flap is indicated for fingertip injuries of the index, middle, or ring finger
with bone or tendon exposed.
• The anterograde homodigital neurovascular island flap is an axial pattern flap that is
capable of providing durable and sensate soft-tissue coverage in a single stage. This
flap is indicated for fingertip defects distal to the interphalangeal joint (IP) of any
finger.
• The reverse homodigital island flap is versatile to cover both dorsal and volar defects
but is especially useful for larger volar oblique amputations. In these types of inju-
ries, a volar V-Y advancement is usually not an option. Unlike the cross-finger flap
or thenar flap, the reverse homodigital island flap does not require prolonged im-
mobilization or multiple operations. It remains a suitable option in older patients and
those at high risk for postoperative stiffness.
• V-Y advancement flap
• Cross-finger flap
• Thenar flap
• Homodigital neurovascular island flap
• Reverse homodigital island flap
FIGURE 87.10 Cross-finger flap for coverage of thumb tip injury.
663
CHAPTER 87
Flap Coverage of Fingertip Injuries
The fingertip refers to the part of the finger that is distal to the insertion of the flexor and
extensor tendons. Local flaps of the hand, including the palmar V-Y advancement flap,
cross-finger flap, and thenar flap, are often used to cover the soft tissue defect of the
fingertip to preserve the nail and distal interphalangeal (DIP) joint.
V-Y Advancement Flap

INDICATIONS
• The V-Y flap is a random pattern advancement flap that is best suited for transverse
or dorsal oblique fingertip amputations, within Tamai Zone I.
• Ideal candidates present with exposed bone distal to the midportion of the nail bed
(Fig. 87.1).
Contraindications
Contraindications include defects with volar skin and soft tissue loss and Tamai Zone
II injuries that would require flap design that violates the DIP joint crease.
• The flap should be used for defects that are free from infection.
• The surgeon must define the defect and determine the adequacy of local flap cover-
age. The volarly based V-Y flap (Atasoy-Kleinert) has a maximum advancement of
10 mm.
• The remaining adjacent soft tissue should not be affected by the initial injury or pres-
ent with a disturbance of blood supply.
IMAGING
A radiograph of the injured finger is useful in patients with a posttraumatic defect to rule
out any associated distal phalangeal fractures. Sometimes small residual fracture frag-
ments that result from a crushing injury can be seen on a radiograph.
SURGICAL ANATOMY
• The volar digital neurovascular bundles and their terminal branches provide vascular
and sensory supply to the flap (Fig. 87.2).
• The fibrous septa that anchor the overlying skin to the periosteum of the distal
phalanx and the flexor tendon sheath limit the movement of the pulp (Fig. 87.3). To
advance the V-Y flap distally, these fibrous septa must be divided.
Transverse
Volar Dorsal
Terminal
branches
Proper palmar Proper palmar

digital nerve digital artery
FIGURE 87.1 Transverse or dorsal oblique fingertip amputa-

tions are good candidates for V-Y advancement flap. FIGURE 87.2 Neurovascular supply to V-Y flap.
663.e1
663.e2 CHAPTER 87 Flap Coverage of Fingertip Injuries
PROCEDURE
Step 1: Flap Design
The boundaries of the V-Y advancement flap are designed as a proximally-based V on
the volar side of the distal phalanx (Fig. 87.4). The apex of the flap is located at the DIP
joint crease, and the base extends distally to the edge of the defect.
Step 2
Fibrous septa The skin on the boundaries of the flap is incised, just through the dermis, until subcu-
FIGURE 87.3 Fibrous septa must be divided to taneous fat is visible.
permit flap advancement.
Step 3
STEP 1 PEARLS A scalpel is used to divide the fibrous septa, from distal to proximal, extending to the
deep margin of the flap, so that the flap is dissected off the periosteum and the fine
• Avoid placing incisions proximal to the DIP joint
crease. Subsequent scarring across the DIP blood vessels from the periphery of the flap are maintained (Fig. 87.5).
joint may limit extension.
• The distal aspect of the flap should be the Step 4
same width or slightly narrower than the The flap is advanced distally using a skin hook, and the lateral subcutaneous tissues
defect. Flaps that are too wide may result in
are carefully divided using microscissors until the flap can reach to cover the defect
a flattened tip.
without tension (Fig. 87.6A–B).

The skin incision should be placed through the • The leading edge of the flap is sutured to the nail bed using a 5-0 chromic suture.
dermis only. Be careful not to cut too deeply to • The lateral and proximal incisions are then closed in a Y shape with 4-0 nylon suture
avoid damaging the underlying vessels. (Fig. 87.7).
STEP 4 PEARLS
Poor perfusion is often attributed to excessive
tension after flap inset. The flap should be
advanced easily into place.
STEP 4 PITFALLS
• This step should be carried out under loupe
magnification to avoid dividing the small
neurovascular branches.
• Do not compromise flap viability by attempting
aggressive closure. A loose closure that heals
secondarily is preferable to tension-induced
flap necrosis.
STEP 5 PEARLS
• Only suture the skin to avoid suturing the un-
derlying digital vessels.
• About 0.5 to 1.0 cm of advancement can be
obtained using the V-Y method.
STEP 5 PITFALLS
FIGURE 87.4 Proximally-based V on the volar aspect of the distal phalanx.
The nail bed should not extend distal to the
underlying bone. A hook nail deformity will develop
if the nail bed is drawn volarly by the suture. All
the tension of closure should be placed over the
proximal flap advancement so that the flap is
resting without tension over the tip of the digit.
FIGURE 87.5 Flap is dissected off the periosteum.

CHAPTER 87 Flap Coverage of Fingertip Injuries e3
FIGURE 87.6 (A) Illustration of flap advancement. (B) Flap is advanced distally. FIGURE 87.7 Incisions closed in a Y shape.

The tourniquet is released and the perfusion of the flap is checked.
• Reperfusion of the flap may be delayed for
5 minutes.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • If perfusion of the flap is poor, check and
• The finger is placed in a moist, petroleum-based gauze and soft dressing that should remove the tight sutures. The subcutaneous
be changed 2 to 5 days after the procedure. Permanent sutures are removed tissue protruding between the flap and the
2 weeks after the procedure. defect can heal by secondary intention.
• This flap can provide excellent soft tissue replacement with good contour and fin-
gertip padding (Fig. 87.8). Normal or nearly normal sensation of the fingertip can be STEP 6 PITFALLS
expected postoperatively.
Do not shorten the remaining distal phalanx
to decrease the tension unless it is absolutely
Cross-Finger Flap necessary.
INDICATIONS
• One indication is volar soft tissue defects involving the proximal, middle, or distal
phalanx with exposure of tendon or bone (Fig. 87.9).
FIGURE 87.9 Volar soft tissue defect

FIGURE 87.8 Postop V-Y flap. with exposed tendon.
FIGURE 87.10 Thumb tip injury repaired with cross-finger flap.
• The crossing of a flap from the dorsum of the middle finger can repair a thumb tip
injury (Fig. 87.10).
Contraindications
• A contraindication is any patient at high risk for postoperative stiffness, including
those with pre-existing arthritis or over the age of 40 years.
• Flaps from the dorsum of the finger lack bulk and often have hair follicles. Transfer-
ring this tissue to the volar finger may produce a suboptimal aesthetic result. This
flap option is relatively easy to conduct but does not replace glabrous tissue over
the volar finger. The donor and recipient appearance are not ideal.
• The posture of the injured finger against the donor finger should be checked before
the operation to ensure that it can be positioned comfortably.
• The planned donor digit should be assessed for stable, pliable skin with intact range
of motion (ROM).
• The cross-finger flap transfers thin, dorsal skin with minimal bulk. Other reconstruc-
tive options may be more suitable if the defect includes the distal fingertip with de-
ficient pulp.
• Patients should be selected carefully and need to be healthy enough to undergo two
surgical procedures (one for initial inset and another for flap division). After the initial
operation, the digits remain sutured to one another by the dorsal skin bridge and are
immobilized for 2 to 3 weeks. This may result in proximal interphalangeal (PIP) joint
stiffness because of joint flexion and immobilization. Patients should be screened
and carefully counseled regarding the risk of postoperative stiffness.
IMAGING
In the setting of trauma, plain radiographs should be obtained to rule out underlying
fractures.
SURGICAL ANATOMY
• The traditional cross-finger flap borrows skin and subcutaneous tissue from the
dorsal finger to cover volar defects.
• From superficial to deep, relevant dorsal structures include the skin, subcutaneous
tissue, and the extensor apparatus.
• Within the subcutaneous tissue lies the dorsal neurovascular network, which is made
up of perforators from the proper digital arteries, the venous plexus, and sensory
branches from dorsal radial or ulnar nerves.
• The flap is raised in a plane just superficial to the paratenon of the extensor
mechanism.
CHAPTER 87 Flap Coverage of Fingertip Injuries 663.e5
Step 1: Flap Design • A precise pattern is helpful to estimate the size

and location of the flap. A cut end of an Es-
The flap is outlined as a rectangular or a rhomboidal shape on the dorsum of the middle march bandage can be used as a template.
phalanx of the adjacent finger. The side of the flap adjacent to the injured finger is de- • If part of the defect is located on the lateral
signed as the hinge or pedicle (Figs. 87.11 and 87.12). side of the finger, the pedicle should be de-
signed long enough to ensure that this part is
Step 2 covered after flap division.
• The incision is made over the dorsum of the donor finger and the flap is sharply
elevated in the plane between the paratenon and subcutaneous fat. STEP 1 PITFALLS
• The flap is raised in an open-book fashion (Fig. 87.13). • The cross-finger flap is a random pattern flap,
and the flap length-to-width ratio should be
limited to 2:1.
• Flap design should not cross the interphalan-
geal (IP) joints; elevation distal to the DIP joint
may damage the nail bed; elevation over the
PIP joint may lead to extension contracture.
• The flap should not be harvested from the pal-
mar surface of digits because of the propensity
for scarring and the development of flexion
contractures.
STEP 2 PEARLS
• Subcutaneous veins should be cauterized and
contained within the flap.
• The paratenon of the underlying extensor
tendon must be preserved to enable the
skin graft to cover the defect.
• If needed, the ligamentous fibers from the skin
at the midlateral plane of the finger to the
phalanx can be cut to make the pedicle longer.
FIGURE 87.11 Preoperative photo. FIGURE 87.12 Flap is designed on the finger adjacent
to the injury site.
FIGURE 87.13 Flap is raised in open-book fashion.

Step 3
The flap is reflected 180 degrees on its hinge and sutured to the defect on the volar
surface of the injured finger (Fig. 87.14).
Step 4
A full-thickness skin graft is then secured over the donor finger defect and the pedicle.
Step 5
The tourniquet is released to check the flap perfusion.
Step 6
Division and inset of the flap is performed after 2 to 3 weeks.

• After initial flap inset, the fingers are placed in a soft dressing with wet cotton packed
between them.
• The fingers are placed in a volar splint or dorsal blocking splint to avoid detachment
of the flap and allow for skin graft healing. The splint remains on for about 1 week.
In our experience, immobilization with Kirschner wires (K-wires) is unnecessary.
• After subsequent flap division and inset, patients should be referred to a hand
FIGURE 87.14 Flap is reflected on its hinge and
therapist to promote passive and active ROM.
sutured to volar defect. • Long-term shortcomings of the cross-finger flap include poor two-point discrimi-
nation and thin skin that can lead to pulp dystrophy. Appropriately selected
patients can expect thin, pliable soft tissue coverage, without appreciable flexion
contractures. Fig. 87.15A–B shows cross-finger flap appearance at 1 month
postoperatively.
STEP 3 PEARLS
Thenar Flap
The PIP joint of the recipient finger should be
slightly flexed to avoid undue tension on the flap. INDICATIONS
• A thenar flap is mainly indicated for fingertip injuries of the index, middle, or ring
STEP 4 PEARLS finger with bone or tendon exposed (Fig. 87.16).
Skin graft donor site options include the ipsilateral • This flap provides a durable coverage option that can restore both fingertip pulp and
medial arm, hypothenar eminence, and groin glabrous skin.
crease. Grafts taken from the groin crease may be
less aesthetically pleasing because of hair growth
and color mismatch.
STEP 6 PEARLS
The skin of the pedicle can be returned to the
donor site or used to cover the defect at the lateral
side of the injured finger.
A B
FIGURE 87.15 (A–B) One-month postoperative photo of cross-finger flap.

FIGURE 87.16 Fingertip injury with exposed bone.
Contraindications
• Similar to the cross-finger flap, the thenar flap is a two-stage operation that requires
finger immobilization in a flexed position for 2 to 3 weeks.
• Avoid this flap in patients at high risk for postoperative stiffness, including patients
with pre-existing arthritis and perhaps patients over the age of 40 years. Neverthe-
less, because of the excellent aesthetic outcomes for replacing glabrous skin over
the fingertip pulp, we use this flap liberally and will accept some finger stiffness.
Motion of the injured finger needs to be examined. An alternative method should be
considered if there is joint stiffness before the operation.
IMAGING
In the setting of trauma, plain radiographs should be obtained to rule out any underlying
fractures.
SURGICAL ANATOMY
• The thenar area refers to the palm at the base of the thumb. The thenar eminence is
made up of the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis.
(Fig. 87.17). This flap should not be harvested from the base of the thumb, as it was
taught traditionally.
• The digital nerve of the thumb lies anterior to the midaxial line of the thumb (Fig. 87.18).
Care should be taken to avoid damage of the radial digital nerve of the thumb during
flap elevation.
PROCEDURE
STEP 1 PITFALLS
Step 1: Flap Design
• The three joints of the finger should be in
• The location of the flap donor site on the thenar region is determined by gently flex- medium flexion. Excessive or insufficient
ing the injured finger toward the thenar eminence. flexion will result in the incorrect flap site.
• The shape of the flap is determined by the finger defect. The length and width of the • The flap should be designed on the thenar
flap should be designed slightly larger than the defect. region rather than the midpalm. The midpalm
• The pedicle can be based proximally, distally, radially, or ulnarly, depending on the is more prone to postoperative tenderness
and hypersensitivity.
exact location and contour of the defect. If possible, the longitudinal axis of the flap
should be directed along the longitudinal axis of the thumb (Fig. 87.19). A large flap
can be harvested, even if the donor site cannot be closed after detachment because
the palmar hand often heals with minimal deformity.
STEP 2 PITFALLS
Step 2
Be careful not to injure the underlying radial digital
The skin is incised and the flap is sharply dissected superficial to the underlying thenar
nerve of the thumb.
muscles (Fig. 87.20).
Abductor pollicis brevis Digital nerve of

the thumb
Median nerve
FIGURE 87.17 Anatomic structures that comprise the thenar FIGURE 87.18 Digital nerve of the thumb.
eminence.
FIGURE 87.19 The longitudinal axis of the thumb is parallel with that
of the flap. FIGURE 87.20 The flap is sharply dissected.
STEP 3 PITFALLS
• A few simple interrupted sutures are permissi- Step 3
ble. Complete closure may constrict the pedi- The donor site is sutured closed around the fingertip by burying the fingertip into the
cle and is unnecessary because secondary
healing will leave an acceptable scar over the thenar wound (Fig. 87.21). During division, more skin can be harvested from the thenar
thenar area. The entire fingertip is buried into area to cover the fingertip.
the thenar wound so that there is no open
wound that may collect debris. Step 4
• If the defect is large, a full-thickness skin graft The flap is sutured in place, providing full coverage of the defect with the finger in
is applied to the donor site, but this is often
not necessary. flexion.
Step 5
STEP 6 PEARLS The tourniquet is released to check perfusion of the flap.
After flap division, any excess skin from the pedicle can
be returned to cover the donor defect. Alternatively, Step 6
additional skin can be harvested from the donor area
Flap division is performed after 3 weeks. The pedicle is transected from the thenar
to cover critical wounds over the fingertip.
eminence (Fig. 87.22).
FIGURE 87.21 Donor site closure. FIGURE 87.22 Flap division.

• After initial inset, the hand is placed in a splint for 1 week to help the patient become
acclimated to the finger position. After 1 week, the unaffected fingers are allowed to
start ROM exercises. The sutures are removed at 2 weeks.
• After flap division and inset, hand therapy and full ROM exercises are critical.
• Excellent appearance, fingertip bulk, and normal motion of the finger can be ex-
pected. Fig. 87.23A–B shows the fingertip appearance at 1 month postoperatively.
Homodigital Neurovascular Island Flap

INDICATIONS
• The anterograde homodigital neurovascular island flap is an axial pattern flap that is
capable of providing durable and sensate soft tissue coverage in a single stage.
• This flap is indicated for fingertip defects distal to the IP of any finger (Fig. 87.24).
Contraindications
• Avoid this flap in patients with questionable patency of paired radial and ulnar digital
vessels. Patency can be assessed by performing a digital Allen test, as will be de-
scribed.
• The flap may also be compromised in patients with underlying small vessel disease
including vasculitis, advanced peripheral arterial disease, and those with a history of
embolic events.
A B
FIGURE 87.23 (A–B) One-month postoperative photos.

• Pre-existing arthritis and advanced age are relative contraindications. Although this
is a single-stage flap, the IP and metacarpophalangeal (MCP) joints often require
immobilization in the flexed position during the early postoperative period.
• Assess the defect and the zone of injury. Wounds secondary to an avulsion mecha-
nism may compromise digital vessel and flap reliability and should be approached
with caution.
• A digital Allen test is performed preoperatively to ensure the patency of each digital
artery. To perform the Allen test, the surgeon asks the patient to tightly flex the af-
fected digit while the examiner occludes the digital arteries on each side of the digit
(Fig. 87.25A). The patient is then asked to extend the affected finger (see
Fig. 87.25B). Blanching of the finger should be seen, indicating compression of the
digital arteries. The compression on the digital artery on the radial side of the finger
is released. If the artery is patent, color will immediately return to the patient’s finger
(see Fig. 87.25C). If color does not return to the finger, the Allen test is considered
positive for occlusion of the digital artery on the radial side of the finger. The test is
then repeated, with the examiner this time releasing the artery on the ulnar side of
FIGURE 87.24 Left ring finger with large open the artery first. If that digital artery is patent, color will return to the finger. If color
wound and completely exposed middle phalanx does not return to the finger, the Allen test is positive for occlusion of the digital
head.
artery on the ulnar side of the affected finger (see Fig. 87.25D).
IMAGING
Plain radiographs should be obtained to rule out any underlying fractures.
A B
C D
FIGURE 87.25 Digital Allen test. (A) Examiner flexes patient’s finger and occludes bilateral digital
arteries. (B) Patient extends finger and blanching is observed. (C) Examiner releases pressure from
radial digital artery; brisk capillary refill indicates patent radial digital artery; (D) Examiner releases
pressure from ulnar digital artery; persistent blanching indicates ulnar digital artery occlusion or
compromised arterial flow.
SURGICAL ANATOMY
• The digital neurovascular bundles of the finger run along the midaxial line of each
side of the finger. The nerves are volar to the digital arteries.
• The neurovascular bundles are dorsal to the Grayson ligament and volar to the Cle-
land ligament. The Grayson ligament originates from the flexor tendon sheath.
• To facilitate flap mobilization, these ligaments must be released (Fig. 87.26).
PROCEDURE STEP 1 PITFALLS

Step 1: Flap Design • Avoid harvesting the flap from the radial as-
pect of the index, long, and ring fingers, if pos-
• A template is used to determine the precise size of defect. This area is marked on
sible. Radial incisions may secondarily impair
the skin immediately adjacent to the defect, centered over either the radial or ulnar thumb-pinch sensation.
digital neurovascular bundle. • Avoid harvesting the flap from the ulnar aspect
• A midaxial incision is designed to trace the neurovascular bundle proximally, into the of the small finger. Additional incisions on the
palm (Fig. 87.27A–C). ulnar aspect of the hand may develop into a
hypersensitive resting surface.
• The digital-palmar crease should be crossed at a 60-degree angle.
Step 2: Incision and Pedicle Identification STEP 2 PEARLS

• The midaxial and palmar extension incisions are made and flap dissection proceeds Before making any incisions around the flap itself,
in proximal-to-distal fashion (Fig. 87.28). confirm the pedicle location within the flap. Up
to this point, the flap design can be tailored to
• The neurovascular bundle is identified and the location of the pedicle along the
centralize it over the neurovascular bundle.
central axis of the flap is confirmed.
Step 3: Flap Elevation STEP 3 PEARLS

• The neurovascular bundle is gently isolated and dissected free from constraining
• Once the neurovascular bundle has been
structures (Fig. 87.29A–B). Small neurovascular side branches and the tight Cleland isolated, atraumatic technique is especially
and Grayson ligaments will tether the pedicle and impede flap advancement if left important.
intact. • Bipolar electrocautery and microsurgical
• After the pedicle has been dissected, the flap itself is then sharply incised. instruments should be used at this point.
• Flap elevation proceeds proximal-to-distal, taking care to remain deep to the neuro-
vascular bundle.
• The flap is sharply dissected free from the underlying flexor tendon sheath.
Palmar digital Dorsal veins

artery
Cleland
ligament
Cleland A4 pulley
ligament
Grayson
ligament
A3 pulley
A2 pulley
Palmar digital Palmar digital

nerve artery
FIGURE 87.26 Anatomic relationships among Grayson ligament, Cleland ligament, and neurovascular bundles.
Neurovascular
bundle
Middle phalanx head
Skin incision
Skin incisions
Neurovascular bundle
A B
C
FIGURE 87.27 (A–B) Flap design demonstrating volar and dorsal skin incisions. Volar incisions should adhere to core hand surgery principles and
traverse the PIP and MCP joints at an angle. The course of the neurovascular bundle, slightly volar to the midaxial line, is also marked. (C) Illustration
of flap design. MCP, Metacarpophalangeal; PIP, proximal interphalangeal.
Neurovascular bundle
Flexor sheath
A B
FIGURE 87.29 (A) The flap is elevated on the ulnar digital neurovascular bundle. This variation of the
anterograde homodigital neurovascular island flap advances skin and subcutaneous tissue from the
entire length of the ulnar digit and often does not require donor site grafting. (B) Illustration of the
flap elevated on neurovascular bundle.
FIGURE 87.28 Illustration of pedicle exposure

and identification. Step 4: Flap Insetting
• After complete mobilization of the flap and pedicle, the digit is flexed at the MCP and
STEP 4 PEARLS IP joints to allow for comfortable inset.
The anterograde neurovascular island flap takes • The flap is loosely sutured in place (Fig. 87.30).
advantage of the relative elasticity of the digital
neurovascular bundle, with the digit in flexion. If Step 5: Hemostasis and Incision Closure
additional advancement is necessary, the pedicle
can be dissected as far proximally as its origin at • The tourniquet is deflated and flap perfusion is confirmed.
the common digital vessel. • The incisions over the pedicle are loosely closed.
• A full-thickness skin graft is used facilitate donor site closure.
STEP 5 PEARLS
• Assess flap perfusion critically. The neurovas- POSTOPERATIVE CARE AND EXPECTED OUTCOMES
cular bundle supplying the flap is relatively
elastic, but it is not immune to undue tension. • The patient is placed in a dorsal-blocking plaster splint for the first week postoperatively.
• Troubleshooting steps aim to relieve excess • At the first postoperative visit, the patient is transitioned to a removable, dorsal-
tension by releasing insetting sutures, dissect- blocking splint and instructed on hand therapy exercises.
ing the pedicle more proximally, and increasing • Early active and passive exercises are critical for restoring full ROM and preventing
digital flexion.
stiff, flexed digits.
FIGURE 87.30 Flap inset and closure. Note the flexed posture of the MCP and IP joints. MCP, Meta-
carpophalangeal; IP, interphalangeal.
• With appropriate engagement in postoperative therapy, patients can expect to

achieve full ROM with durable, sensate soft tissue coverage. Fig. 87.31 shows the
postoperative appearance at 3 weeks.
Reverse Homodigital Island Flap

INDICATIONS
• This flap is indicated for fingertip defects distal to the IP joint of any finger (see
Fig. 87.24).
• The flap is versatile to cover both dorsal and volar defects, but it is especially useful
for larger volar oblique amputations. In these types of injuries, a volar V-Y advance-
ment is usually not an option.
• Unlike the cross-finger flap or thenar flap, the reverse homodigital island flap does not
require prolonged immobilization or multiple operations. For this reason, it remains a
suitable option in older patients and those at high risk for postoperative stiffness.
Contraindications
• The reverse homodigital island flap is an axial pattern flap based on intact, retro-
grade flow through paired digital arteries.
• Do not attempt this flap in patients with questionable patency of radial and ulnar
digital arteries (see the previous description of the digital Allen test).
• The pedicle of the flap is reliant on the connections between the radial and ulnar
digital arteries at the proximal aspect of the DIP joint. If the injury extends proximally
to the volar aspect of the DIP joint and middle phalanx, this flap is not reliable.
FIGURE 87.31 On-course healing at 3 weeks postoperatively following ulnar homodigital island flap
for coverage of exposed ring finger middle phalanx head.
• The flap may also be compromised in patients with vasculitis, advanced peripheral
arterial disease, and prior surgery around the volar DIP joint.
• Defect analysis is performed. The injured and exposed structures are noted.
• A digital Allen test is performed preoperatively to ensure the patency of each digital
artery.
IMAGING
Plain radiographs should be obtained to evaluate for underlying fractures.
SURGICAL ANATOMY
• The digital neurovascular bundles of the finger run along the midaxial line of
each side of the finger. The nerves are volar to the digital arteries. The neuro-
vascular bundles are dorsal to the Grayson ligament and volar to the Cleland
ligament. To facilitate flap mobilization, these ligaments need to be released
(see Fig. 87.26).
• The radial and ulnar digital arteries have multiple interconnections along the digit.
The three most consistent anastomoses are on the volar side of the digit at the
proximal cruciate ligament, distal cruciate ligament, and distal to the flexor digitorum
profundus insertion. These anastomoses are called the transverse digital palmar
arches. The reverse homodigital island flap is perfused by the contralateral digital
artery through the transverse palmar digital arch at a level just proximal to the DIP
joint. Venous outflow relies on the venules and capillaries in the perivascular soft
tissues (Fig. 87.32).
• In cases where dorsal finger injuries include part of the terminal tendon, a vascular-
ized tendon (part of lateral band) can be incorporated into the island flap to recon-
struct the combined soft tissue and tendon defect (Fig. 87.33).
• An innervated island flap using the digital nerves can be created to cover a finger
pulp defect. The transferred nerve is connected to the contralateral digital nerve for
reinnervation.
The pedicle is based on

the anastomoses
between bilateral digital
arteries at the level of
the distal cruciate ligament.
Palmar digital
artery
Grayson A4 pulley
ligament
A3 pulley
A2 pulley
FIGURE 87.33 Vascularized tendon can be incorporated for in-

FIGURE 87.32 Vascular supply for reverse homodigital island flap. juries with concomitant tendon defects.
Step 1: Flap Design • An extended reverse homodigital island flap

can be designed to include the skin along the
• The flap is designed at the base of the digit, according to the shape and size of the side of the MCP joint. This extension increases
defect. The central axis of the flap is placed along the digital artery. the risk for venous congestion of the flap.
• A midaxial incision is designed along the radial or ulnar side of the digit to expose • A template of the defect may help simulate
the digital neurovascular bundle (Fig. 87.34A–B). flap movement from the donor site.
• The pivot point of the flap is 5 mm proximal to the DIP joint.
• The maximum dimensions of the flap are 3.5 cm in length and 2.5 cm in width. Smaller
donor site defects are closed primarily and larger flaps are closed with a skin graft.
Step 2: Incision and Pedicle Identification STEP 2 PEARLS

• A longitudinal incision is made proximal to the flap. The neurovascular bundle is When a sensate flap is required, the digital nerve
identified and the location of the pedicle along the central axis of the flap is con- should not be separated from the digital artery.
firmed. If necessary, the flap design is adjusted after this step to centralize it over The proximal end of the digital nerve is dissected
the neurovascular bundle (Fig. 87.35). more proximally than the digital artery to gain more
• The remaining skin incisions are made. Volar and dorsal skin flaps are raised in a length and facilitate tension-free nerve coaptation
with the contralateral digital nerve (Fig. 87.38).
subdermal plane (Fig. 87.36).
Flap
A B
FIGURE 87.34 (A) Flap design, with central axis along the digital artery. (B) Illustration of flap design.
FIGURE 87.35 Longitudinal incision proximal to the flap.

Digital artery
Separated digital nerve

FIGURE 87.36 Pedicle identification. FIGURE 87.37 Digital artery is separated from the digital nerve.
STEP 2 PITFALLS
• The neurovascular bundle is identified both proximal and distal to the flap. The neu-
Avoid isolating the digital artery from the surrounding
soft tissues. This will injure the small venules in the rovascular bundle is dissected along its course until 5 mm proximal to the DIP joint.
perivascular tissue. • The digital artery is then separated from the digital nerve. A cuff of the subcutaneous
tissue is maintained around the vascular pedicle to preserve the perivascular
venules (Fig. 87.37).
STEP 3 PITFALLS
Too much retraction on the skin paddle during Step 3: Flap Elevation
mobilization may avulse the skin island from the • The digital artery at the proximal edge of the flap is ligated and then cut.
underlying pedicle. • The flap is elevated from proximal to distal. The flap and its pedicle are raised to-
gether and separated from attachments to the lateral paratenon. The pedicle of the
STEP 4 PITFALLS flap is mobilized until the pivot point is reached.
Tunneling under a skin bridge is difficult in the Step 4: Flap Insetting
distal finger. It is easier to incise and set the pedicle
into a defect. Raise the skin edges to allow easier • The flap is raised and transferred to cover the fingertip defect (Fig. 87.39).
inset of the flap pedicle. It may be useful to extend • The skin bridge between the flap and defect is incised and the pedicle is passed
the flap distally so that when the flap is rotated to through this incision.
cover the defect, the distal flap extension will cover • The flap is inset over the defect.
the pedicle (Fig. 87.40).
Digital nerve
Nerve
coaptation for
sensate flap
FIGURE 87.38 Approach for sensate flap. FIGURE 87.39 Flap raised to cover fingertip defect.
Distal skin paddle

extension, it will cover
the pedical when flap
is inset.
Hypothenar
graft
Flap
FIGURE 87.40 Extending the flap distally permits coverage of

the pedicle when the flap is rotated to cover the defect. FIGURE 87.41 Full-thickness skin grafting complements flap coverage.
Step 5: Hemostasis and Incision Closure STEP 6 PEARLS

• The tourniquet is released, and hemostasis is performed. • The color and turgor of the flap is assessed
• The vascular status of the flap is checked. after insetting and tourniquet release. If the
• The incision over the pedicle of flap is closed loosely. The donor site is closed flap is pale, possible causes of vascular com-
promise include tension on the flap or pedicle,
primarily.
kinking or twisting of the pedicle, and com-
pression over the pedicle. These causes are
individually evaluated and corrected.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • When the donor site defect or skin closure
• The hand is placed in a splint for 1 week. of the pedicle cannot be closed primarily,
full-thickness skin grafting is indicated
• After 1 week, ROM exercises are started.
(Fig. 87.41).
• Sutures are removed at 2 weeks.
• There is no difference between sensate and insensate flaps regarding sensory re-
covery. The average of static two-point discrimination is 7.1 mm. POSTOPERATIVE PEARLS
• Fig. 87.42A–B shows the postoperative appearance at 3 months. If ROM is started early, patients should not have
See Videos 87.1 and 87.2 any functional deficits from flap harvest.
A B
FIGURE 87.42 (A–B) Three-month postop photos of reverse homodigital neurovascular island flap.
EVIDENCE
Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated fingertip
with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am. 1970;52:921–926.
In this classic article, Atasoy and colleagues describe their technique of the volar V-Y advancement
flap. They also report the outcomes of the volar V-Y advancement flap in 56 patients with finger am-
putation at different levels. All of the patients had excellent appearance and normal motion of the fin-
ger with normal or nearly normal sensation.
Barbato BD, Guelmi K, Romano SJ, Mitz V, Lemerle JP. Thenar flap rehabilitated: A review of 20 cases.
Ann Plast Surg. 1996;37:135–139.
A series of 20 patients with fingertip injuries treated using a thenar flap were reviewed in this article.
Flap sensibility was good (average Weber of 6.5 mm) and no patient had PIP joint contracture after
operation. The authors believed this flap was reliable and could provide excellent tissue coverage for
the missing finger pulp.
Fitoussi F, Ghorbani A, Jehanno P, Frajman JM, Penneçot GF. Thenar flap for severe fingertip injuries in
children. J Hand Surg Br. 2004;29:108–112.
The authors retrospectively reviewed distally based thenar flaps in 11 children with severe fingertip inju-
ries. The injuries were palmar oblique amputations or avulsion injuries involving the pulp and the nail
bed. The flap divisions were performed 18 to 25 days after the initial operation. There was no IP joint
stiffness and donor site morbidity. Two-point discrimination averaged 5 mm in the flaps at the final
follow-up period. Patients reported satisfaction with the appearance of their fingertips.
Kappel DA, Burech JG. The cross-finger flap. An established reconstructive procedure. Hand Clin.
1985;1:677–683.
The authors studied the subjective and objective outcomes in a random group of 23 patients who were
treated with cross-finger flaps for reconstruction of injured fingers. Eighty percent of patients be-
lieved they could use their injured hand normally. Patients under 50 years of age had good motion of
the finger. Except for two patients with other previous injuries, five patients older than age 50 had a
minimal decrease in motion. Average two-point discrimination in the flap was 8.25 mm. The authors
suggested the cross-finger flap was reliable and flexible in its application.
Katz RD. The anterograde homodigital neurovascular island flap. J Hand Surg Am. 2013;38(6):1226–1233.
The author presents a case series of two patients along with a detailed description of anatomic consid-
erations and surgical technique. The author stresses the importance of preserving and reconstructing
the fingertip and argues that “surgeons are quick to ‘shorten and close’” and fail to consider viable
alternatives. Excellent results are reported in this limited series, with reliable coverage and full sensi-
bility at 3 mm and 4 mm of two-point discrimination. The author noted a 15-degree extensor lag in
one patient, at 3-month follow-up.
Chen QZ, Sun YC, Chen J, Kong J, Gong YP, Mao T. Comparative study of functional and aesthetically
outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair.
J Hand Surg Eur Vol. 2015;40:935–943.
This study compares the functional and aesthetic outcome of two flaps for fingertip reconstruction. The
reverse digital artery island flap was used in 12 patients and the reverse dorsal homodigital island
flap in another 11 patients. Flap sensibility was assessed using the Semmes–Weinstein monofilament
test and static two-point discrimination test. Patient satisfaction, active motion of the finger joints,
complications, and cold intolerance were evaluated. The static two-point discrimination and Michi-
gan Hand Outcomes Questionnaire (appearance) of the fingers treated with a reverse digital artery
flap were significantly better than those with a reverse dorsal homodigital flap. The static two-point
discrimination of the skin-grafted donor sites after dorsal homodigital flap were poorer than that in
the contralateral finger. No significant differences were found between the two flaps for pressure or
touch sensibility, active ranges of digital motion, complications, and cold intolerance.
CHAPTER 88
Flap Coverage of Thumb Defects

This chapter includes the following videos: Video 88.1 – Moberg Flap Transfer to
Repair Thumb Defect; Video 88.2 – First Dorsal Metacarpal Artery Flap Reconstruction
for Skin Defect of the Thumb.
KEY CONCEPTS
• The major goals of thumb reconstruction include maintenance of stability, sensation,
length, mobility, and appearance. The approach to reconstruction is dictated by
exposed structures (tendon, bone, vessels, fat), concomitant injuries to the hand,
and defect size.
• The Moberg flap is a bipedicled advancement flap based on the radial and ulnar
digital arteries to the volar thumb skin, designed to provide soft, pliable, and sensate
skin to the thumb tip. Because the dorsal thumb skin has an independent vascular
supply arising from the first dorsal interosseous artery, raising this flap will not cause
thumb necrosis, unlike in the fingers that have the sole blood supply deriving from
the digital arteries. This flap should not be used for the fingers because flexion con-
tracture in the fingers is not tolerated and there is a lack of independent dorsal finger
blood supply.
• The first dorsal metacarpal artery (FDMA) flap is a sensate pliable flap for thumb
reconstruction when the defect measures greater than 2 cm2 and it is a priority to
preserve maximum thumb length. The FDMA flap is designed over the index finger
proximal phalanx dorsal skin and is based on the ulnar branch.
• The reverse homodigital dorsoradial flap is useful for defects larger than 2 cm2 in
size that affect the dorsal or volar distal thumb and have exposed bone or tendon.
As a reverse pedicled flap, the retrograde flow of the homodigital dorsoradial flap is
Flap transposed
to thumb defect.
Fasciocutaneous
pedicle with flap.
Midaxial incision to
connect flap with defect
Incise skin and spread
subQ enough to lay flap
Close donor site first.
FIGURE 88.7 Transposition of the first dorsal metacarpal artery flap for thumb reconstruction.
664
CHAPTER 88 Flap Coverage of Thumb Defects 665
dependent on its connection with the volar arterial system that is most commonly
seen at the midproximal phalanx.
• Moberg flap
• First dorsal metacarpal artery flap
• Reverse homodigital dorsoradial flap
CHAPTER 88
Flap Coverage of Thumb Defects
Introduction
The thumb is an essential part of the hand and plays a key role in power and precision
grip, together with the fingers. The major goals of thumb reconstruction vary from pa-
tient to patient, but may include maintenance of stability, sensation, length, mobility,
and appearance. Exposed structures (tendon, bone, vessels, fat), concomitant injuries
to the hand, and defect size dictate the choice of reconstruction. This chapter will pres-
ent the most commonly used local flaps for thumb coverage including Moberg, first
dorsal metacarpal artery, and heterodigital island flaps.
Moberg Flap
• This is a bipedicled advancement flap based on the radial and ulnar digital arteries
to the volar thumb skin, designed to provide soft, pliable, and sensate skin to the
thumb tip.
• Because the dorsal thumb skin has an independent vascular supply arising from the
first dorsal interosseous artery, raising this flap will not cause thumb necrosis, unlike
in the fingers, which have their sole blood supply deriving from the digital arteries.
This flap should not be used for the fingers because flexion contracture in the fingers
is not tolerated and there is a lack of independent dorsal finger blood supply.
INDICATIONS
• One indication is the need for sensate, pliable volar thumb distal tip coverage for
defects less than 2 cm in size.
• Although the Moberg flap is ideally used to cover defects distal to the thumb inter-
phalangeal (IP) joint that are less than 2 cm in size, a V-Y modification of the flap
proximally can facilitate additional advancement of the flap distally to cover larger
defects (Fig. 88.1).
Contraindications
• Typically, the Moberg flap is not used to cover defects greater than 2 cm in size or
proximal to the thumb IP joint.
• It is also contraindicated if there is injury to the radial or ulnar digital vessels of the
volar thumb or injury to the dorsal thumb skin vascular supply that increases the risk
for thumb dorsal skin necrosis.
• Examine the wound for signs of infection and ensure adequate debridement before
flap elevation and inset.
• Examine the dorsal hand for lacerations that may place the dorsal thumb skin at risk
for devascularization if the flap is elevated.
SURGICAL ANATOMY
• The hand receives its vascular supply from the radial and ulnar arteries, which com-
bine to form the deep and superficial arches. Specific to the thumb, the radial artery
gives off the princeps pollicis artery, which subsequently divides into the radial and
ulnar digital arteries of the thumb.
• The Moberg flap is a bipedicled flap raised on the radial and ulnar digital arteries to
the volar thumb skin. The arteries are accompanied by the proper digital nerves and
run along the radial and ulnar side of the flexor tendon sheath. The nerves typically
run volar to the vasculature.
665.e1
665.e2 CHAPTER 88 Flap Coverage of Thumb Defects
Note hook nail and paucity

of soft tissue padding
A B C
FIGURE 88.1
• Unique to the thumb, there is an independent dorsal blood supply that is derived
from the first dorsal interosseous artery branches; this facilitates elevation of this flap
without the significant risk for dorsal skin necrosis that occurs with other digits of
the hand.
PROCEDURE
• The procedure is performed under regional anesthesia with upper arm tourniquet.
• Consider use of a lead hand to hold the thumb in a hypersupinated position.
STEP 1 PEARLS
To identify the midaxis, place the thumb into flexion Step 1: Flap Design
and place a dot along the apexes of the MCP and The flap is designed along the radial and ulnar midaxial lines of the thumb and extends
IP skin volar skin creases. Straighten the thumb proximally to the metacarpophalangeal (MCP) flexion crease (Fig. 88.2). In certain cases
and connect the dots longitudinally. This will form
where additional mobility is required, the flap may be extended proximally over the
the midaxial line.
thenar crease to create a V-Y advancement proximally.
Radial and ulnar midaxial

incision designs
V-Y modification
for additional
length
A B
FIGURE 88.2
CHAPTER 88 Flap Coverage of Thumb Defects 665.e3
Flap
Radial and ulnar digital

A
neurovascular bundles
identified
Radial midaxial incision to
expose the neurovascular bundle B
and elevate it with the flap
FIGURE 88.3

Incise the skin at full thickness along the radial side of the flap first and identify the
Dissect perpendicular to the tissue straight down
Cleland ligament, which is dorsal to the neurovascular bundle (Fig. 88.3). The plane of through the skin to the depth of the Cleland
dissection is just above this. Elevate the neurovascular bundle with the flap from the ligament, rather than beveling. Beveling (oblique
distal to proximal direction. dissection) risks injury to the neurovascular bundle
supply to the flap.
Step 3
Once the radial side neurovascular bundle is identified, the dissection continues across STEP 4 PEARLS
the tendon sheath toward the ulnar side to identify the ulnar neurovascular bundle.
• Put more tension on the proximal flap, which is
Once the ulnar neurovascular bundle (NVB) is identified, the flap can be elevated from well vascularized, to facilitate equal tension
distal to proximal off the flexor pollicis longus tendon sheath (see Fig. 88.3). distribution across the flap. Closure may start
proximally by “pushing the flap” toward the
Step 4 distal end so that the distal portion of the flap
• Once the flap is adequately mobilized, let the tourniquet down and evaluate perfusion. sits over the defect and is sutured without any
tension (Fig. 88.4).
• Check that the flap can be adequately advanced, first with the thumb in extension. Flex • To advance the flap without excessive IP
the thumb IP joint as needed to adequately advance the flap to cover the distal tip. flexion, a V-Y advancement can be designed
• The flap is inset with interrupted 4-0 or 5-0 nylon sutures (consider chromic sutures proximally onto the thenar eminence because
in pediatric patients). this provides additional mobility to the flap.
The resulting defect is closed in a V-Y fashion.
This permits primary closure of the flap
distally without need for IP joint flexion.
STEP 4 PITFALLS
Minimal trimming of the distal phalanx can be
performed if excessive tension exists. The nail bed
should be trimmed minimally to avoid a hook nail
Flap advanced
deformity.
and inset
Slight IP
flexion
required and
maintained
with K-wire
A B
FIGURE 88.4

• The thumb is placed in a dorsal-blocking thumb spica splint for 5 to 7 days, then
transitioned to a removable plastic orthosis.
• Sutures are removed and gentle active range-of-motion (ROM) exercises are initiated
at 2 weeks.
• Delayed wound healing at the tip is possible if there is excess tension and should be
managed with dressing changes.
• In older patients with arthritis, thumb IP stiffness is possible if excessive flexion is
required for flap inset.
• This flap provides a well-shaped, pliable, sensate reconstruction of the thumb tip.
First Dorsal Metacarpal Artery Flap

INDICATIONS
• The first dorsal metacarpal artery (FDMA) flap is a sensate pliable flap for thumb
reconstruction when the defect measures more than 2 cm2 and it is a priority to
preserve maximum thumb length.
• Although it can be used for thumb pulp reconstruction, the darker, hairy dorsal skin
may result in a less satisfying appearance.
The dorsal first webspace, second metacarpal, and proximal phalanx of the index finger
are examined to identify any previous injuries that may have injured the FDMA or its
branches.
SURGICAL ANATOMY
• The FDMA originates from the radial artery distal to the scaphotrapezial-trapezoid
joint. It branches into three arteries: a radial branch to the thumb, an intermediate
branch to the first webspace, and an ulnar branch to the index finger.
• The FDMA flap is designed over the index finger proximal phalanx dorsal skin and is
based on the ulnar branch.
• The venous drainage of the FDMA flap is accomplished by either venae comitantes that
travel with the artery or via the superficial cutaneous veins included with the flap skin.
• The FDMA flap based over the dorsum of the proximal phalanx of the index finger is
innervated by the superficial branches of the radial nerve. One of these branches
should be included in the flap to maintain sensation in the transposed position.
PROCEDURE
The procedure is performed under regional anesthesia with tourniquet control.
Step 1: Defect Assessment

The defect is debrided, and a template is made based on the defect size (Fig. 88.5).
STEP 2 PEARLS
• The 1-cm-wide skin paddle along the pedicle Step 2: Flap Design
can be designed to achieve tension-free clo- • The flap matching the defect is outlined over the dorsum of the proximal phalanx of
sure and prevent vessel injury during flap har- the index finger. Increase the size by 10% to 15% if possible, to account for contrac-
vest (see Fig. 88.5). This technique also avoids
tunneling of the pedicle and possible kinking tion and prevent tension during the closure.
when transposing the flap to the defect. The • The most lateral extent of the flap is the midaxial line on the radial and ulnar side of
dorsal skin is lax enough to permit primary the index finger.
closure. • Doppler out the FDMA ulnar branch along its course and design a 1 cm area (0.5 cm
• The length of the pedicle is determined by the on each side of the pedicle) to elevate the pedicle with a fasciocutaneous cuff rather
distance between the proximal border of the
defect and the pivot point. Once the flap and than skeletonizing the pedicle. This modification prevents the need to make a
pedicle are designed, use a template, RayTec potentially constrictive tunnel over the thumb and permits ease of inset by leverag-
gauze, or suture to simulate the transposition ing the looseness of the skin over the dorsal hand.
of the flap from the index finger to the thumb • Alternatively, if it is better to elevate the pedicle alone, an S-shaped or longitudinal
to ensure that the flap will reach and there is incision can be designed over the course of the FDMA, with the pivot point located
adequate pedicle length.
at the anatomic snuff box.
Defect template
design
Flap design
Flap pivot simulation
A B C
FIGURE 88.5
Dissection
proceeds
subfascially
at the level of
the radial
sagittal band
Flap
“Cutaneous tail” Flap

fasciocutaneous
pedicle
Elevate skin flaps

away from FDMA
flap to preserve veins
A B
FIGURE 88.6
STEP 3 PITFALLS
Step 3: Elevation of the Flap Care should be taken to preserve the paratenon
of the underlying extensor tendon over the index
• The distal and lateral borders of the flap over the proximal phalanx of the index finger finger proximal phalanx to ensure the survival of
are incised and the flap is elevated off the extensor tendon (Fig. 88.6). Be careful to the skin graft and avoid tendon adhesion.
preserve the paratenon. The proximal border is incised at partial thickness through
the dermis.
• The incision for the fasciocutaneous cuff over the pedicle is made through the dermis STEP 4 PEARLS
into the subcutaneous tissue and skin flaps are elevated along the radial and ulnar • To preserve the FDMA and its ulnar branch, the
sides, away from the skin paddle over the pedicle (see Fig. 88.6). pedicle dissection switches to the subfascial
plane proximal to the sagittal band to incorpo-
Step 4: Elevation of the Pedicle rate the fascia of the first interosseous muscle.
There can be many small muscular bleeders
Dissection of the flap is then performed in a distal-to-proximal direction over the from the interosseous muscle—judicious use
paratenon of the extensor tendon of the index finger. Once over the radial sagittal band of bipolar cautery is recommended.
of the index finger, the dissection is transitioned to a subfascial plane below the interos- • In addition to the FDMA with its ulnar branch,
seous muscle fascia to avoid injury to the pedicle (see Fig. 88.6). The fascia and pedicle one or more subcutaneous veins or a cutane-
ous branch of the radial nerve is incorporated
are elevated with the flap to the base of the index metacarpal to permit sufficient pivot-
in the pedicle and flap.
ing to the defect.
STEP 4 PITFALLS
Step 5: Transposition of the Flap
After ensuring sufficient pedicle length, the flap is transferred into the defect via an
Dissecting in a subcutaneous plane proximal to
the sagittal band risks injury to the pedicle. Do not open tunnel. Make a midaxial incision along the ulnar side of the thumb, avoiding
attempt to skeletonize the pedicle. the webspace to facilitate transposition of the flap without compression of the pedicle
(Fig. 88.7).
Step 6: Flap Inset and Skin Graft Harvest

• Release the tourniquet and evaluate flap perfusion. Achieve hemostasis as needed.
• The donor site is closed proximally with interrupted 4-0 nylon sutures, and a full-
Flap transposed thickness skin graft (FTSG) from the proximal ulnar forearm or the lateral groin is
to thumb defect.
used to resurface the proximal phalanx of the index finger.
• The flap is inset in a tension-free manner with interrupted nonabsorbable sutures
(Fig. 88.8). A skin graft is harvested from the medial forearm. After the skin graft is
secured to the defect, a tie-over bolster is placed to prevent shearing of the graft
(Fig. 88.9).
Fasciocutaneous
pedicle with flap.
• The patient is placed in a thumb spica splint with a volar component that does not
place tension or pressure on the flap or pedicle. The patient is transitioned to a re-
movable orthosis 1 week after the procedure.
• The sutures are removed in about 2 weeks, and the patient can initiate gentle ROM
Midaxial incision to exercises after that.
connect flap with defect
Incise skin and spread • The FDMA flap is a reliable flap with a high survival rate. It provides elastic and du-
subQ enough to lay flap rable coverage for large thumb defects. Because a branch of the superficial radial
Close donor site first. nerve is transferred with the flap, sensation is perceived as originating from the dor-
sum of the index finger.
FIGURE 88.7 • The full-thickness skin graft on the dorsum of the index finger typically heals well
and fades over time to blend nicely into the surrounding skin.
STEP 5 PEARLS
The flap can also be inset through a subcutaneous Reverse Homodigital Dorsoradial Flap
tunnel if the tunnel is spacious enough and does
not compress the pedicle to the flap. INDICATIONS
This flap is useful for defects greater than 2 cm2 in size that affect the dorsal or volar
distal thumb and have exposed bone or tendon.
Examine the dorsal radial side of thumb and the anatomic snuff box (between the ex-
tensor pollicis longus [EPL] and extensor pollicis brevis [EPB] tendons) for prior lacera-
tions/injuries that could compromise the pedicle of the flap.
Close donor
site
Inset flap
Inset flap
Preserved first webspace
FTSG from volar forearm
A B C
FIGURE 88.8
FTSG
from volar
forearm Inset
Inset
A B C
FIGURE 88.9 A: Bolster dressing over full-thickness skin graft to donor site. B: Flap inset
IMAGING
The dorsoradial artery should be auscultated preoperatively using a Doppler probe
along its course from the anatomic snuff box to the pivot point at the radial side of the
midproximal phalanx of the thumb (Fig. 88.10).
SURGICAL ANATOMY
• The dorsoradial artery originates directly from the radial artery at the anatomic snuff-
box, passes volar to the EPB tendon, and then runs distally along the radial dorsal
side of the thumb (Fig. 88.11). Notably, the presence of this artery ranges from 52%
to 70% in the literature.
• As a reverse pedicled flap, the retrograde flow of the homodigital dorsoradial flap is
dependent on its connection with the volar arterial system that is most commonly
seen at the midproximal phalanx. There are three radial-ulnar anastomoses between
the dorsal radial artery and dorsal ulnar artery (radial branch of the FMDA), which are
located in the middle third of the proximal phalanx, at the IP joint, and at the distal
phalanx.
• There is no named vein for venous drainage, and the venous outflow of the flap relies
on the identification and inclusion of large veins in the dissected soft tissue of the flap.
A B
C D
FIGURE 88.10 (A–D) Anatomical location of the dorsoradial artery of the thumb identified by Doppler
sonography. Examples of different flap designs for varying defect sizes.
FIGURE 88.11 The course of the dorsal radial artery of the thumb and basic landmarks for dissection:
A, extensor pollicis brevis tendon; B, radial artery; C, dorsoradial artery of the thumb; D, connection
with the palmar vessels of the thumb.
STEP 1 PEARLS
• Determine the necessary pedicle length by • Branches of the superficial radial nerve will be seen accompanying the vascular
measuring the distance between the proximal pedicle. They should be included with the flap to maintain blood supply to the trans-
edge of the defect and the pivot point, which is ferred tissue because the nerve branches intermingle with the vascular supply.
at the level of the IP joint or slightly proximal.
Use a RayTec sponge to simulate rotation of POSITIONING
the flap into the defect.
• Defect sizes as large as 5 cm by 4 cm can be • The patient is placed supine on the operating room table with the arm abducted and
successfully reconstructed using this flap; extended on a hand table.
however, increasing flap size increases the • The procedure is performed under regional anesthesia under tourniquet control.
chances of venous congestion and partial flap
necrosis.
• Depending on the flap size and pedicle length, PROCEDURE
incorporating a skin paddle (“cutaneous tail”)
over the pedicle helps to achieve a tension- Step 1: Flap Design
free closure after flap rotation by bringing ad- The course of the dorsoradial artery and pivot point at the midproximal phalanx is
ditional tissue and avoidance of flap tunneling identified by Doppler probe and marked on the skin. Measure the defect and design a
toward the defect.
slightly larger flap (around 10%) centered over the longitudinal axis of the pedicle.
STEP 2 PEARLS Step 2: Flap Elevation

Include a 1-cm-wide perivascular cuff to improve • The flap is incised down to the paratenon of the extensor tendon and muscle fascia
venous drainage via the plexus veins. and raised in a proximal-to-distal direction in the epiparatendinous plane.
• At the proximal incision, a branch of the superficial radial nerve that accompanies
STEP 3 PITFALLS the dorsoradial artery is identified and included with the flap.
Avoid tunneling to prevent pressure and tension on Step 3

the pedicle and flap.
Incise the skin between the defect and the pivot point longitudinally and elevate the
flaps enough to allow the flap to be rotated and inset in a tension-free manner.
STEP 4 PEARLS
If the defect cannot be closed primarily, a full- Step 4
thickness skin graft is applied. • Deflate the tourniquet and ensure flap viability.
• Close the donor defect and skin overlying the pedicle directly (Fig. 88.12).
STEP 4 PITFALLS
Do not place pressure on the pedicle during skin POSTOPERATIVE CARE AND EXPECTED OUTCOMES
closure because it can lead to venous congestion,
• The thumb is placed in a pressure-free splint for about 10 days. The sutures are
arterial insufficiency, and flap failure. Close the
skin with sutures removed or tied loosely if the flap removed at 2 weeks.
appears compromised. • Venous congestion is the most common complication and can be minimized by tak-
ing a wide area of subcutaneous tissue around the pedicle to ensure sufficient vein
capture for outflow.
• This flap is a reliable flap procedure for thumb reconstruction based on the dorsora-
dial artery. This flap minimizes donor site morbidity to other digits of the hand and is
useful when heterodigital flaps are not available.
A B C
FIGURE 88.12 (A–C) Ten days after reconstruction with the reverse homodigital dorsoradial flap of the thumb.
EVIDENCE
Bang H, Kojima T, Hayashi H. Palmar advancement flap with V-Y closure for thumb tip injuries. J Hand
Surg Am. 1992;17:933–934.
The authors present the technique for Moberg flap with V-Y closure applied in two patients with thumb
tip injuries. The V-Y modification facilitated more distal advancement of the flap compared with a
conventional Moberg flap. The proximal defect was closed directly and skin graft coverage was not
required.
Baumeister S, Menke H, Wittemann M, et al. Functional outcome after the Moberg advancement flap
in the thumb. J Hand Surg Am. 2002;27:105–114.
The authors retrospectively examined the functional outcomes of Moberg palmar advancement flaps for
pulp reconstruction of the thumb in 25 patients. The average follow-up period was 27 months. There
were no flap failures. Normal sensitivity was achieved in 17 cases. No permanent flexion contracture
occurred in any patient. There was no reduction in grip strength in the cases without additional bony
amputation.
Lemmon JA, Janis JE, Rohrich RJ. Soft tissue injuries of the fingertip: methods of evaluation and
treatment. An algorithmic approach. Plast Reconstr Surg. 2008;122:105e–122e.
In this review article, the authors provide an algorithmic approach to the management of fingertip
injuries. In particular, they describe the surgical indications, techniques, and limitations of the
traditional Moberg, Moberg with V-Y modification, and first dorsal metacarpal advancement flap.
Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast
Reconstr Surg. 1979;63:344–349.
This is the first description of the FDMA flap (kite flap). The authors describe relevant anatomy and
surgical technique. They carried out the flap in 12 consecutive cases without failure. The authors
summarized that the flap could provide reliable coverage of the thumb in a one-stage procedure.
Moschella F, Cordova A. Reverse homodigital dorsal radial flap of the thumb. Plast Reconstr Surg.
2006;117:920–926.
Moschella first described the surgical technique of homodigital dorsal radial flap and reported the out-
comes in 16 patients. The patients had a dorsal or volar defect of the tip of the thumb secondary to
tumor excision, injuries, painful scar or burn reconstruction. The flap size ranged from 2 by 2 cm to
5 by 4 cm. Primary closure of donor site was achieved in 14 cases, and skin graft was used to repair
donor defect in 2 cases. Partial necrosis occurred in one case because of venous congestion, and all
the others survived completely. All the results were satisfactory and donor scars were acceptable.
The mean two-point discrimination over the flap was 9.7 mm, and only one flap was reinnervated by
suturing a branch of superficial radial nerve to the digital nerve. The authors conclude that this flap is
a suitable alternative for the reconstruction of distal thumb defects.
Hrabowski M, Kloeters O, Germann G. Reverse homodigital dorsoradial flap for thumb soft tissue
reconstruction: Surgical technique. J Hand Surg Am. 2010;35:659–662.
The authors provide an excellent description of the indications, surgical technique, and pitfalls of per-
forming a homodigital dorsoradial flap for thumb reconstruction.
CHAPTER 89
Dorsal Metacarpal Artery Flap and Dorsal
Metacarpal Artery Perforator Flap
Yu Zhou and Kevin C. Chung
INTRODUCTION
• The dorsal metacarpal artery (DMA) flap is a vascularized skin flap from the dorsum
of the hand. It can be based on the second, third, or fourth DMA and its cutaneous
perforators. The flap also can be based on the cutaneous perforators alone, in which
case it is termed a dorsal metacarpal artery perforator flap.
• The DMA flap can be designed as an advancement, transposition, or island flap. The
DMA island flap can have antegrade or retrograde flow.
INDICATIONS
• The use of the second DMA flap is similar to the first dorsal metacarpal artery (FDMA)
flap (see Chapter 88), which is used to repair soft tissue defects of the thumb. The
second DMA is relatively anatomically consistent and rarely absent (Fig. 89.1). It can
also cover the webspace, proximal volar side, and almost the entire dorsal side of the
index or middle fingers. Keep in mind, however, that the color, texture, and skin thick-
ness of the dorsal and volar sides do not match, especially in dark-skinned individuals.
• The third and fourth DMA flaps are similar to the second DMA flap in that they can
be designed to cover defects in adjacent fingers. Given that the arteries of these
Second dorsal
metacarpal artery
Third dorsal
metacarpal artery
Fourth dorsal
metacarpal artery
FIGURE 89.1
666
CHAPTER 89 Dorsal Metacarpal Artery Flap and Dorsal Metacarpal Artery Perforator Flap 667
digits are small in size and have inconsistent anatomy, they are typically used to
design retrograde flaps based on the trunk of the DMA and its perforators.
• Multiple DMA flaps can be raised simultaneously to cover more than one defect of
the fingers.
• The DMA flap can be combined with segments of the extensor tendons or the meta-
carpal bone to form a compound flap to reconstruct complex finger defects.
Contraindications
• The DMA flap should not be performed if there is infection of the recipient site or
inadequate debridement resulting in unhealthy tissue.
• The presence of scar tissue in the donor site and blood vessel damage are additional
contraindications.
• The defects should be free of infection before flap coverage.
• The flap should not be considered if the donor area is involved in the initial injury.
Swelling or a subcutaneous hemorrhage on the dorsum of the hand may indicate
that the vulnerable venae comitantes are damaged, which may result in flap failure
secondary to venous congestion.
• Previous injuries at or distal to the intermetacarpal space at the level of the metacar-
pal neck need to be carefully considered to rule out perforator injuries.
IMAGING
• A radiograph of the injured hand is necessary to rule out any metacarpal head fractures.
The perforators may be injured because of their close proximity to the metacarpal head.
• A preoperative Doppler may be used to locate the DMAs (Fig. 89.2), especially for
the third and fourth metacarpal arteries, because they may be absent in up to 30%
of the individuals. It is not useful in locating the perforators because the Doppler
signals of the intermetacarpal perforator are often disturbed with the signals arising
from the DMA itself.
SURGICAL ANATOMY
• The second, third, and fourth DMAs usually arise from the dorsal carpal arch that is
formed by the anastomosis of the dorsal carpal branch of the radial artery with the
dorsal carpal branch of the ulnar artery (see Fig. 89.1). These arteries run distally in
the second to fourth intermetacarpal spaces and lie in the fascial layer between the
extensor tendons and the dorsal interosseous muscles (Fig. 89.3).
• The DMA usually gives off 6 to 8 cutaneous perforators that run proximally and lie
superficial to the extensor tendon paratenon. The distal third perforators, one of
which is found just distal to juncturae tendinae at the level of the metacarpal neck,
are larger and more consistent in size (Fig. 89.4). Therefore it is possible to raise an
anterograde flow metacarpal artery perforator flap and pivot it to repair the periph-
eral soft tissue defect in the form of a propeller flap (Fig. 89.5).
Dorsal metacarpal
artery
Extensor
tendon
Metacarpal Dorsal interosseus

bone muscle
FIGURE 89.2 A preoperative Doppler used to locate the DMA. DMA,
Dorsal metacarpal artery. FIGURE 89.3
668 CHAPTER 89 Dorsal Metacarpal Artery Flap and Dorsal Metacarpal Artery Perforator Flap
Perforating branches Dorsal

Dorsal perforating branches
from dorsal metacarpal a. metacarpal a.
from proper digital a.
DMA perforator
Basal Dorsal
metacarpal metacarpal a.
arch
Proper
Distal Deep
digital a. Proximal
dorsopalmar palmar arch
dorsopalmar Common
anastomosis Palmar
anastomosis digital a.
metacarpal a. Proper
Superficial
palmar arch digital a.
FIGURE 89.4
FIGURE 89.5 Distal perforator of DMA. DMA, Dorsal metacarpal artery.
STEP 1 PEARLS • The DMA has two dorsopalmar anastomoses: (1) Palmar communicating branches
from the DMA and perforators from the palmar metacarpal artery make up the
• Vertically, the flap design extends between the
distal edge of the extensor retinaculum proximally proximal dorsopalmar anastomosis at the neck of the metacarpal, and (2) terminal
and the webspace distally and between the outer branches of the DMA in the dorsal aspect of the proximal phalanx along with the
borders of the adjoining metacarpals from side to dorsal perforating branches of the proper digital artery form the distal dorsopalmar
side (see the black dotted line in Fig. 89.10). anastomosis plexus at the base of the proximal phalanx (see Fig. 89.4).
• Pinch the dorsal skin of the hand to determine
• These two anastomoses provide reverse flow to the DMA flap. The perforator
the width of the flap. In general, a donor site on
the dorsal hand less than 2 cm in width can be combined with the DMA can form a long vascular pedicle, which can have a wide
closed directly (Fig. 89.11). If necessary, free rotation arc and repair the homodigital, adjacent finger, and even the adjacent
skin graft can be used to cover the donor site. fingertip (Fig. 89.6).
• To cover a more distal defect, the pivot point • Venous drainage of the flap depends on the venous network in the pedicle and on
can be shifted up to 1.5 cm closer to the mar-
the venae comitantes that accompany the DMA and its perforators.
gin of the webspace by division of the meta-
carpal artery proximal to the perforator so that
the flap is nourished by the distal dorsopalmar PROCEDURE
anastomosis (see Fig. 89.6).
• To increase the length of the flap, the flap can Step 1: Flap Design
be designed as a curved ellipse rather than a
• Assess the recipient area for defects (Fig. 89.7), debride the necrotic tissue aggres-
straight ellipse, which adds 8 to 10 mm in
length after it is straightened (Fig. 89.12). sively, and remove any granulation tissue (Fig. 89.8A–B). Repair any fractures or
tendon defects before flap transfer.
• The DMA with its perforators closest to the defect is usually selected as the blood
STEP 1 PITFALLS supply for the flap.
To avoid tension when the flap is sutured, the • The longitudinal axis of the flap runs in the center of the intermetacarpal space. The
dimension of the flap is designed a little larger than shape of the flap is determined by the shape of the defect and is usually designed
the size of the defect and the pedicle is designed as an ellipse (Fig. 89.9).
a little longer than the distance between the pivot
point and the proximal edge of the defect. • If the flap is used to cover a defect in the webspace or proximal phalanx, it can be
based on the cutaneous perforator alone. The midpoint of the intermetacarpal space
at the level of the metacarpal neck (around 2.5 cm from the margin of the webspace),
DMA perforator Second

Dorsal DMA
metacarpal a.
Proper
digital a.
FIGURE 89.6 DMA and perforator, retrograde flap. DMA, Dorsal meta- FIGURE 89.7 Right middle finger open wound with extensor
carpal artery. tendon exposure.
A B
FIGURE 89.8 (A) Granulation tissue over the tendon. (B) Tendon defect and exposed joint.
Pivot point
6x2cm flap
FIGURE 89.9 Tendon defect and exposed joint.
where the distal cutaneous perforators arise from the DMA, serves as the pivot point
(Fig. 89.10).
STEP 2 PEARLS
Step 2
The skin and subcutaneous tissue on the radial border of the flap are incised under • When a compound DMA flap is needed, the
flap should be elevated under the interosseous
tourniquet control. A loose areolar plane superficial to the extensor tendon paratenon muscles to include the DMA (Fig. 89.13).
is identified as the plane of flap elevation. • A tourniquet is used but limited so that the
limb is not exsanguinated, which helps to
Step 3 identify the vessels.
The flap is elevated from the radial to ulnar side. The DMA and perforator are identified
during flap elevation (Fig. 89.14).
STEP 3 PEARLS
Step 4 Veins and dorsal sensory nerve branches that pass

through the flap are divided and enclosed in the
• After the ulnar border of the flap is incised, flap dissection is continued from proximal flap. The nerve branches are dissected and divided
to distal toward the pivot point. proximally to avoid neuroma formation under the
• At this point, the DMA flap is rotated 180 degrees. If the DMA flap is long enough, incision.
then its distal edge is incised and dissected to the pivot point in the same plane and
an island propeller DMA flap is harvested (Fig. 89.15; see also Fig. 89.5).
• If the tip of the flap cannot cover the distal end of the wound completely, then the STEP 3 PITFALLS
metacarpal artery perforator flap can be dissected to the distal perforator of the The distal and largest perforator arises immediately
DMA at the level of the base of the proximal phalanx. The DMA is divided and ligated distal to the juncturae tendineae. Great care should
be taken once the extensor tendon juncturae are
proximal to the perforator, which permits further distal advancement of the flap
visualized.
based on the reverse flow from the distal dorsopalmar anastomosis (see Fig. 89.6).
DMA perforator
Dorsal
metacarpal a.
Proper
digital a.
Distal limit
(metacarpo-
phalangeal
joint)
DMA perforator
Lateral limit
(lateral border
of metacarpal)
Proximal limit
(distal edge of
extensor retinaculum)
A
B
FIGURE 89.10
FIGURE 89.11 FIGURE 89.12 Curved ellipse.

DMA perforator
Dorsal metacarpal a.
FIGURE 89.13 A compound DMA flap includes the DMA and perfora-
tor. DMA, Dorsal metacarpal artery.
2nd DMA
FIGURE 89.14 The vessel was on top of the interosseous muscle.
FIGURE 89.15 An island DMA propeller flap is harvested. DMA, Dorsal

metacarpal artery. FIGURE 89.16 Propeller flap rotation.

• After flap elevation, an open tunnel is prepared between the defect and pivot for flap • For dorsal defects, a closed tunnel can be
rotation (Fig. 89.16). used if the dorsal skin is lax enough to accom-
• The proximal end of the flap is sutured and fixed with surrounding tissue to prevent modate the pedicle (Fig. 89.18). If, however,
there is not enough space for the pedicle, it is
avulsion of the pedicle (Fig. 89.17).
necessary to incise the skin and convert it to
an open tunnel to avoid compression.
Step 6 • For palmar defects, an open tunnel is recom-
The tourniquet is released and the flap is checked for perfusion. mended because making a closed tunnel in
the palmar skin is difficult. The constrictive fi-
Step 7: Skin Closure brous septae can compromise venous return.
• The recipient site is closed with interrupted 4-0 nylon sutures.
STEP 6 PEARLS
• The donor site is also primarily closed using horizontal mattress sutures to keep the
skin everted for better healing (Fig. 89.19). • A very slow reperfusion of the retrograde flap
with a delay of 10 to 15 minutes may occur
POSTOPERATIVE CARE AND EXPECTED OUTCOMES because the flap requires more time to adapt
to the new vascular flow pattern.
• Standard flap monitoring should be performed for the first 24 hours. • This time can be used to achieve adequate
• The MCP and proximal interphalangeal (PIP) joints are splinted in full extension for hemostasis.
1 week before starting on range-of-motion (ROM) exercises. The patient may begin
normal activities after the sutures are removed at 2 weeks.
STEP 7 PEARLS
Keeping the metacarpophalangeal (MCP) joint in
full extension will take tension off of the pedicle.
STEP 7 PITFALLS
• Avoid placing tight sutures so that venous
drainage is not compressed.
• If the flap width is more than 3 cm, the donor-
site defect may not be able to be closed directly
and a small skin graft may be required.
FIGURE 89.17 Suture was used to stabilize the flap.
Dermoadiposal
FIGURE 89.19 The flap appeared to be pinkish.
bridge segment
within dorsal
skin tunnel
FIGURE 89.18 Closed skin tunnel.

FIGURE 89.20 Nineteen days postoperative.
• The dorsal metacarpal artery flap is easy to raise, especially when it is based on the
cutaneous perforators alone. It provides color match and durable skin reconstruction
of the dorsal aspect of the finger with acceptable donor-site morbidity (Fig. 89.20).
See Video 89.1
EVIDENCE
Webster N, Saint-Cyr M. Flaps based on the dorsal metacarpal artery. Hand Clin. 2020;36(1):75–83.
The author describes the history, indications, contraindications, anatomy, and surgical application of
DMA flaps. Anatomic photos, diagrams and case pictures are used to describe this flap.
Feng SM, Sun QQ, Cheng J, Wang AG. A novel approach for reconstruction of finger neurocutaneous defect:
A sensory reverse dorsal digital artery flap from the neighboring digit. Orthop Surg. 2017;9(4):372–379.
The author uses 16 cases to describe how to reconstruct finger neurocutaneous defects using a sensory
reverse dorsal digital artery flap from the neighboring digit and to evaluate the efficacy of this technique.
CHAPTER 90
Pedicled Forearm Flaps

This chapter includes the following video: Video 90.1 – Perforator Flap from Radial
Artery.
KEY CONCEPTS
• Pedicled forearm flaps are commonly used for coverage of hand defects. These
flaps are reliable and effective and can be performed in a single stage without ad-
vanced microsurgical techniques.
• The reverse radial forearm flap, dorsal ulnar artery flap, and reverse posterior inter-
osseous artery flap are based on septocutaneous perforators that consistently travel
between specific muscles.
• Debride the recipient site before using any flap to ensure that it is free of infection
and devitalized tissues. Exposed hardware is ideally removed. Tendon and nerve
reconstruction can be performed at the time of coverage but may be delayed until
the wound has healed.
• The reverse radial forearm flap is the most reliable and versatile flap for hand cover-
age because of its constant vascular supply and long pedicle. It can reach any area
of the hand or digits. Raising the pedicled radial forearm flap is straightforward, and
advanced microsurgery technique is not required. The flap can provide pliable and
thin soft tissue for reconstruction of hand defects.
• The dorsal ulnar artery flap is smaller and less versatile than the reverse radial fore-
arm flap. An advantage, however, is that it does not sacrifice a major axial vessel. It
is indicated for defects over the ulnar half of the hand and dorsal and volar wrist.
• The reverse posterior interosseous artery flap has a valuable role in coverage of the
dorsum of the hand proximal to the metacarpophalangeal (MCP) joint and for recon-
struction of first webspace contractures.
• Reverse radial forearm flap
• Dorsal ulnar artery flap (Becker flap)
• Reverse posterior interosseous artery flap
End-to-end
Vein graft anastomosis
End-to-side anastomosis
Radial artery flap

FIGURE 90.8 Reverse radial forearm flap.
673
CHAPTER 90
Pedicled Forearm Flaps
INTRODUCTION
• Three pedicled forearm flaps, including the reverse radial forearm flap, ulnar artery
perforator flap (Becker flap), and posterior interosseous artery (PIA) flap, are com-
monly used for coverage of hand defects (Table 90.1).
• These flaps are reliable and effective, and they can be performed in a single stage
without advanced microsurgical techniques.
• The flaps are similar in that they are based on septocutaneous perforators that con-
sistently travel between specific muscles (Fig. 90.1; see also Table 90.1).
• Before using any flap, the recipient site must be debrided to ensure that it is free of
infection or devitalized tissues. Exposed hardware is ideally removed. Tendon and
nerve reconstruction can be performed at the time of coverage but may be delayed
until the wound has healed.
Reverse Radial Forearm Flap

INDICATIONS
• The reverse radial forearm flap is the most reliable and versatile flap for hand cover-
age because of its constant vascular supply and long pedicle. It can reach any area
of the hand or digits (Fig. 90.2).
• The flap can be harvested as a fascia-only flap without the skin paddle. The flap
sacrifices one of the two major forearm arteries supplying the hand. Before the op-
eration, the patient should understand the risks for development of cold intolerance,
pain, edema, and hand ischemia, even though the preoperative investigations are
normal.
TABLE
90.1 Pedicled Forearm Flaps for Coverage of Hand Defects
Reverse Radial Artery Flap Ulnar Artery Perforator Flap Reverse PIA Flap
Source vessel Radial artery Ulnar artery perforator (dorsal ulnar PIA
artery perforator, ascending branch)
Interval BR and FCR Between ECU and FCU EDQ and ECU
Axis Radial artery Pisiform to medial epicondyle of Lateral epicondyle to DRUJ in
humerus. neutral pronosupination
Pivot point Volar wrist crease Ulnar border of the FCU, 2–6 cm 2 cm proximal to the dorsal
proximal to the pisiform DRUJ
Location of skin Volar forearm Distal two-thirds of ulnar forearm Dorsal proximal third of forearm
paddle
Size of skin paddle Large: width is one-half the width of the Width: ideally what can close primarily 30–90 cm2
forearm; proximal margin is just distal Length: distal two-thirds of forearm,
to the antecubital crease, distally at ending at wrist crease
the wrist crease
BR, Brachioradialis; DRUJ, distal radial ulnar joint; ECU, extensor carpi ulnaris; EDQ, extensor digiti quinti; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris;
PIA, posterior interosseous artery.
673.e1
673.e2 CHAPTER 90 Pedicled Forearm Flaps
Flap
Palmaris longus
Brachioradialis Flexor digitorum

Radial artery superficialis

Flexor pollicis
longus Ulnar artery
Extensor carpi
radialis longus
Flexor digitorum
Pronator teres
profundus
Extensor carpi Abductor pollicis
radialis brevis longus
Supinator Extensor pollicis
longus
Extensor carpi
Extensor digitorum ulnaris
Posterior interosseous artery

FIGURE 90.1
A B
C D
FIGURE 90.2
Contraindications
There are few contraindications:
• Acquired absence of the radial artery, either from coronary artery bypass grafting or
trauma
• Preexisting perfusion abnormalities, including Raynaud phenomenon, Buerger disease
(thromboangiitis obliterans), or hypothenar hammer syndrome
• The Allen test is mandatory to demonstrate patency of the radial artery, ulnar artery, and
palmar arches. Perfusion of the hand by the ulnar artery alone must be established.
CHAPTER 90 Pedicled Forearm Flaps 673.e3
• The flap should not be performed in the following situation: vascular insufficiency of
the hand resulting from loss of continuity of the radial or ulnar artery and incomplete
palmar arches.
IMAGING
• A Doppler examination is useful to assess the patency of the radial and ulnar artery.
The Doppler can also be used to map out the artery’s course preoperatively, al-
though palpation and familiarity with the anatomy are often sufficient.
• An arteriogram is required only when the results of the Allen test and Doppler ex-
amination are questionable.
SURGICAL ANATOMY
• The flap is based on the radial artery and its perforators to the skin (see Fig. 90.1).
• The radial artery originates from the brachial artery at the midpoint of the cubital
fossa and then runs distally on the radial side of the forearm (Fig. 90.3). In the
proximal forearm, it passes deep to the ulnar margin of the brachioradialis (BR) and
superficial to the pronator teres. In the distal forearm, the radial artery courses more
superficially in the lateral intermuscular septum between the BR and the flexor carpi
radialis (FCR) muscles. At the level of the wrist crease, it can be palpable through
the skin. It turns dorsally to the anatomic snuff box under the abductor pollicis lon-
gus (APL) and extensor pollicis brevis (EPB) tendons and then passes between the
heads of the first dorsal interosseous muscle to the palm and forms the deep palmar
arch with the deep branch of the ulnar artery.
• In the proximal forearm, the radial artery gives off about 10 septocutaneous perforators
that travel between the FCR and BR to supply the skin of the anterolateral aspect of the
forearm via the subdermal fascia. The artery also sends the perforators to the adjacent
muscles and radius in its course, so that the flap can be applied as a composite tissue
transfer, including a bone segment of the radius or portions of the FCR and BR if required.
• The ulnar artery, through the superficial and deep palmar arches, permits the retro-
grade blood flow to the reverse-flow radial artery flap (see Fig. 90.3).
• A pair of venae comitantes accompanies the radial artery along its course and pro-
vides venous drainage.
• The lateral antebrachial cutaneous nerve of the forearm can be harvested with a
traditional antegrade radial artery flap; however, it has a reverse design, and the
nerve is divided. Therefore it is not a sensate flap.
• The superficial branch of the radial nerve travels between the BR and ECRL and is
most easily damaged in the distal arm, near the pedicle dissection in the reverse flap
design. It should be protected with identification and gentle retraction as necessary.
POSITIONING
• The patient is positioned supine with the affected extremity on a hand table.
• The flap raising is performed under tourniquet control and without exsanguination to
make vessel identification easier.
Deep superficial Superficial

palmar arch palmar arch Ulnar artery FCR Pronator teres
Radial artery Brachioradialis
FIGURE 90.3

• The maximum width of the flap is approxi- Step 1: Marking
mately one-half the circumference of the fore-
arm. The proximal limitation of the flap lies just • The radial artery is marked using a Doppler probe and serves as the axis of the flap.
below the origin of the radial artery, and distal • The pivot point at the wrist crease is marked.
limitation lies at the crease of the wrist. • A template of the defect is created using a bandage or surgical glove packaging.
• Overestimate the pedicle length required for • The required pedicle length for rotation is measured, and the defect template is
rotation to keep the pedicle tension-free. Gen-
erally, overestimate by 10% to 15%. placed this distance from the pivot point along the axis of the radial artery (Fig. 90.4).
• The skin paddle can extend distally to provide
a narrow cover of the entire pedicle, creating a Step 2: Identify Intermuscular Septum Distally
“tennis racquet” pattern, where the racket • Dissection is started distally, where the flap interval can be readily identified by view-
handle is the skin covering the pedicle, and ing the distal muscle tendons.
the wider head is the skin paddle for defect
coverage. The skin on either side of the handle • Skin and deep fascia at the ulnar border of the flap are incised first, and the fascia
will close primarily if designed appropriately. and all superficial structures are elevated in an ulnar to radial direction toward the
The pedicle can then be laid en route to the radial margin of the FCR.
defect area through an open incision and with- • At the radial margin of the FCR, the septum with cutaneous perforators from the
out tunneling. This prevents pedicle compres- radial artery to the overlying skin bridge can be seen (Fig. 90.5).
sion and improves venous drainage.
Step 3: Ulnar Flap Elevation
STEP 1 PITFALLS • Now that the intermuscular septum is identified distally, the dissection can proceed
The flap should not be designed over the more proximally along the ulnar border of the flap.
distal forearm, if possible, because the underlying • The skin and fascia incision is continued proximally following the flap markings.
tendons exposed during flap elevation will make it • Dissection is carried down to the deep fascia and then radially toward the intermus-
difficult to close the donor side with a skin graft. cular septum. Any superficial veins are ligated. Superficial nerves are dissected free
or crushed and buried.
STEP 2 PEARLS
• Once the septum is encountered, dissection proceeds deep and ulnar to the radial
artery. Leave as much loose areolar tissue surrounding the radial artery as possible
• The dissection plane is deep to the deep fas-
(Fig. 90.6).
cia, superficial to the muscle belly. It is better
to stay deeper as the septum is approached.
• The fascia is temporarily sutured to the skin to Step 4: Radial Flap Elevation
prevent shearing during flap elevation. • Now that the ulnar dissection is complete, the radial border of the flap is incised, dis-
• Because only septocutaneous perforators are tally first. The septum is identified distally, and then dissection proceeds proximally.
raised with the flap, any muscular perforators
• Dissection takes place deep to the deep fascia, like for the ulnar flap elevation (Fig. 90.7).
of the radial artery can be coagulated in a
bipolar fashion or ligated and divided during
flap elevation. Step 5: Division of the Proximal Radial Artery
• If a skin bridge covering the distal radial artery • Once the proximal aspect of the flap has been incised, dissection continues deep to
is not used, incise over the radial artery distally identify the radial artery, which lies proximal to the flap skin paddle (see Fig. 90.7).
and identify the interval between the FCR and
BR. This will serve as a reference point for
proximal flap dissection.
STEP 2 PITFALLS
• The paratenon of the FCR tendon is preserved
to enable the skin graft to cover the defect.
• As the FCR muscle is dissected from the sep-
tum, great care should be taken to preserve FIGURE 90.4
the integrity of the septum, which contains the
perforators communicating the vascular pedi-
cle and the flap.
Septocutaneous
perforator Radial artery
FCR belly
FIGURE 90.5
Flap
Radial artery
Brachioradialis
Palmaris longus
Radial sensory Flexor digitorum

nerve superficialis

Flexor pollicis
longus Ulnar artery
Extensor carpi
radialis longus
Flexor digitorum
Pronator teres
profundus
Extensor carpi Abductor pollicis
radialis brevis longus
Supinator Extensor pollicis
longus
Extensor carpi
Extensor digitorum ulnaris
Posterior interosseous artery

FIGURE 90.6 STEP 3 PEARLS
• Nerves can also be dissected proximally, divided,
and coapted to donor nerves if the distal area
Radial artery is
in this interval FCR
requiring flap coverage has suitable donors.
• To help in dissection, the FCR muscle is pulled
away from the septum, and the septum is
sharply removed off of the muscle.
• To best protect the intermuscular septum and
cutaneous perforators within the septum aris-
ing from the radial artery, the FCR will have no
fascia covering it after dissection is complete.
The tendons will have paratenon only.
STEP 4 PITFALLS
BR
• The superficial branch of the radial nerve lat-
FIGURE 90.7
eral to the septum must be identified and dis-
sected from the flap.
• The lateral antebrachial cutaneous nerve may
• The radial artery is ligated proximal to the skin paddle. be sacrificed or harvested for neurotization, as
• The septum deep to the radial artery is dissected from the underlying muscles and mentioned previously.
radius so that the flap with its vascular pedicle is elevated toward the pivot point,
from proximal to distal (see Fig. 90.7).
STEP 5 PEARLS
Step 6: Flap Inset • The pedicle dissection plane should be deep

enough to ensure that the vascular pedicle and
• The flap is rotated into the defect through the connecting incision and then sutured perforators are included.
to the defect (Fig. 90.9). • The tourniquet can be let down at this step to
• The incisions are secured using 3-0 chromic or 4-0 nylon sutures (Fig. 90.10). confirm viability of the entire hand, and then
• A skin graft is used to cover the donor defect. brought back up for further dissection. If inad-
equate perfusion of the hand is detected, it is
POSTOPERATIVE CARE AND EXPECTED OUTCOMES necessary to reconstruct the radial artery. A
reverse saphenous vein or cephalic vein is
• The patient’s hand is immobilized in a short-arm splint to allow healing of the harvested to bridge the radial artery with an
skin graft. The patient is admitted in the hospital for 48 hours. Standard flap end-to-end anastomosis in the proximal end
monitoring every hour is performed for the first 24 hours. Active range-of-motion and an end-to-side anastomosis in the distal
(ROM) exercise starts once the skin graft and flap are stable, about 2 weeks end. The flap remains a pedicled flap with this
reconstruction (Fig. 90.8).
postoperatively.
STEP 5 PITFALLS End-to-end

Vein graft anastomosis
The cephalic vein plays no role in the venous
drainage of the flap, so it can be dissected free or
ligated at the distal border of the flap rather than
be included in the flap.
STEP 6 PEARLS
• The flap can also be transposed through a
subcutaneous tunnel by making sufficient
space to accommodate the pedicle.
• If the tendon is exposed, the adjacent muscle
bellies can be sutured to cover it to secure End-to-side anastomosis
healing of the skin graft.
• Typically, the donor defect can only close Radial artery flap
primarily if the width is less than 3 cm. FIGURE 90.8
STEP 6 PITFALLS
Make sure there is no twisting or kinking of the
pedicle, which usually results in venous congestion.
FIGURE 90.9
FIGURE 90.10
• Raising the pedicled radial forearm flap is straightforward and advanced microsur-
gery technique is not required. The flap can provide pliable and thin soft tissue for
reconstruction of the hand defects (Fig. 90.11). One of the major disadvantages of
this flap is sacrificing a major limb vessel, which may lead to vascular morbidity of
the hand and forearm, although rarely. The other disadvantage is poor appearance
caused by scarring from the skin graft (see Fig. 90.11).
Dorsal Ulnar Artery Flap (Becker Flap)

INDICATIONS
• The dorsal ulnar artery (DUA) flap is smaller and less versatile than the reverse radial
forearm flap. One advantage, however, is that it does not sacrifice a major axial
FIGURE 90.11
vessel. It is indicated for defects over the ulnar half of the hand and dorsal and volar
wrist (see Fig. 90.2).
• The defects should not be beyond the metacarpophalangeal (MCP) joint because of
the considerably shorter vascular pedicle.
The flap pedicle arises from the ulnar border of the flexor carpi ulnaris (FCU), usually 2
to 6 cm proximal to the pisiform. The skin paddle extends proximally, roughly one-third
the length of the forearm. The hand should be examined for trauma or prior surgery that
would compromise the integrity of the pedicle or the skin paddle.
IMAGING
A preoperative Doppler examination is used to assess the patency of the ulnar artery and to
identify the DUA, emerging 2 to 6 cm proximal to the pisiform on the ulnar border of the FCU.
SURGICAL ANATOMY
• The DUA flap is based on a dorsal branch of the ulnar artery and its ascending
branch (Fig. 90.12). The DUA originates from the ulnar artery 2 to 6 cm proximal to
the pisiform. It runs superficial to the ulnar nerve and ulnar and deep to the FCU as
a short trunk (2–3 cm).
• After it passes between the FCU and extensor carpi ulnaris (ECU), it bifurcates into
two cutaneous branches: the descending branch and the ascending branch. The de-
scending branch, accompanied by the dorsal branch of the ulnar nerve, curves along
the ulnar dorsal side of the hand. The ascending (ascending proximally) branch, which
is the nourishing vessel of the DUA flap, runs along the line connecting the pisiform
and medial humeral epicondyle in the forearm. It forms the anastomoses plexus with
other perforators of the ulnar artery to supply the overlying skin during its course.
• The venous drainage in the flap territory is dependent on both the deep venae co-
mitantes and the superficial venous system. The venous drainage of the flap mainly
depends on the deep venae comitantes, but the superficial basilic vein within the flap
may be preserved to anastomose with the recipient vein to improve venous outflow.
POSITIONING
• The patient is positioned supine on an operating table.
• The affected arm is placed on a hand table with a tourniquet on the upper arm.
• The flap is harvested with the forearm in supination.
PROCEDURE
Step 1: Markings
• The pisiform and FCU tendons are palpated and marked.
• The flap axis is marked: pisiform to medial epicondyle.
Ascending Descending
branch branch
Dorsal branch
of ulnar artery
FCU Ulnar
artery
Ulnar nerve
FIGURE 90.12
STEP 1 PEARLS • The DUA perforator is detected by Doppler and marked. This forms the flap’s pivot
point.
• The maximum width of the flap can reach the
midline of the volar and dorsal forearm. The • A defect template is created and placed along the flap’s axis, from the pisiform to
proximal limitation of the flap is the proximal the medial epicondyle of the humerus, with enough length of pedicle to permit ad-
third of the forearm, and the distal limitation equate rotation for coverage (see Fig. 90.2D).
lies at the crease of the wrist (Fig. 90.13). • Either a cutaneous bridge or adipofascial bridge is designed to protect the pedicle
• We recommend that the pedicle is designed as and permit venous drainage.
an adipofascial bridge segment to prevent kink-
ing of the pedicle (Fig. 90.14). If the tunneling
required for this is too tight, a cutaneous exten- Step 2: Identify Pedicle
sion over the pedicle can be designed so that • An exposure is made over the pivot point to identify the DUA in case of anatomic
the flap can lay on an open area connecting variation: the radial/volar marking over the FCU is incised sharply down to the deep
the defect and flap harvest wounds. fascia.
• The FCU is identified and retracted radially.
• Careful dissection ulnarly is necessary to identify the DUA pedicle.
A B
FIGURE 90.13
Ulnar artery
Ulnar nerve
Descending branch
Ascending branch
FIGURE 90.14
Cephalic vein is dissected via a anatomic snuff box STEP 1 PITFALLS

incision and anastomosed to the preserved vein
within the flap. The length of the pedicle depends on the distance
between the perforator and the proximal edge of
the defect, and it should be oversized by 10% to
avoid an inadequate arc of rotation.
STEP 3 PEARLS
• Based on the location of the DUA, the pivot
point is confirmed or modified as required.
• A Doppler probe can be used to help through-
out the dissection.
FIGURE 90.15
STEP 3 PITFALLS
There is no need to expose the cutaneous branches
FCU tendon - This of the DUA (the ascending or descending).
tendon will be
retracted radially to Adipofascial tail
expose the pedicle. covering the pedicle STEP 4 PEARLS
• The pedicle exits the deep fascia between the
FCU and ECU. Therefore distal dissection by
Dorsal cutaneous the pedicle should be on top of these tendons,
ulnar nerve raising the deep fascia off of them.
• The medial antebrachial cutaneous nerve may
be transected or harvested for a sensate flap.
In this case, the nerve must be coapted to a
donor nerve because it will be divided proxi-
mally to permit rotation.
• To avoid poor venous drainage, a superficial
vein (usually the basilic vein) is preserved 2 to
3 cm proximal to the flap. If venous congestion
is present after the flap is harvested, the proxi-
mal end of the superficial vein can be anasto-
FIGURE 90.16
mosed to a recipient site vein to improve
venous drainage (Fig. 90.15).
• The pedicle is very small and should not be
dissected completely unless the surgeon is
highly experienced with this flap. Instead, an
adipofascial “tail” can be left covering and
padding the flap to prevent kinking of the pedi-
cle during inset (Fig. 90.16). Alternatively, an
overlying skin paddle can be left to cover the
pedicle during inset. This will also improve
venous drainage if large flaps are used.
• The dorsal cutaneous ulnar nerve should be
protected during flap elevation and inset. It
FIGURE 90.17 arises from the ulnar nerve and passes dorsal
to the FCU about 5 to 8 cm proximal to the pisi-
form. The main nerve or some of the branches
may occasionally course within the flap, so it
Step 4: Flap Elevation must be separated to free the flap.
• Once the DUA pedicle is identified, dissection is continued from the radial incision • The descending branch of the DUA travels
proximally along the flap markings, and the deep fascia is raised. along with the dorsal branch of the ulnar
nerve. It may need to be ligated to enable flap
• Once the most distal marking is reached, dissection can include either an adipofas-
movement.
cial bridge or narrow skin paddle overlying the pedicle. • No attempt is made to skeletonize the DUA
and its branches because the soft tissue sur-
Step 6: Flap Inset rounding the artery makes up the draining vein
• The intervening skin segment between the defect and the pivot point is laid open to plexus.
accommodate the pedicle for flap inset (see Fig. 90.16).
• The tourniquet is released for flap reperfusion in its native position.
• The flap is rotated 180 degrees in a propeller fashion and into the defect (Fig. 90.17).
• The flap is assessed for perfusion and venous congestion.
• Final flap inset is achieved with either absorbable or permanent sutures (Fig. 90.18).
STEP 6 PEARLS
• Because an empty vessel is more likely to be
kinked than a vessel with flow, the flap rotation
should be done after tourniquet release.
• A wide tunnel between the defect and pivot
point can also be made to cover the pedicle.
• This time can be used to achieve adequate
hemostasis.
• The flap is now dependent on the new vascu-
lar flow pattern from only the DUA and its as-
cending branch for blood supply. It may take a
longer time (10–15 min) for flap reperfusion. FIGURE 90.18
• If venous congestion is identified, the preserved
superficial vein is anastomosed to a recipient
vein, such as the cephalic vein, to improve ve-
Step 7: Donor Site Closure
nous drainage after flap inset (Fig. 90.19). The donor defect is closed primarily or with a skin graft.
• If a suitable vein in the recipient site cannot be
found for anastomosis, the large, turgid super- POSTOPERATIVE CARE AND EXPECTED OUTCOMES
ficial vein within the flap at the level of the
• The limb is splinted for a week, followed by active and passive mobilization if there
wrist (distal to the perforator) can be ligated to
make rotating the flap easier and decrease the is no other tissue reconstruction involved.
venous congestion. • The patient can be admitted to observe for venous congestion if the cephalic vein
was not anastomosed during the procedure.
• The DUA perforator flap is easy to raise and has minimal donor site morbidity with-
STEP 8 PEARLS out compromising the major arteries in the forearm like the radial forearm flap. It
A skin graft is required if the donor defect is more provides single-stage, thin, soft, and pliable skin, with good color and texture match
than 6 cm in width. for dorsal defects. The donor site scar at the ulnar border of the forearm is hairless
and less conspicuous than the donor sites of other forearm flaps (see Fig. 90.19B).
Reverse Posterior Interosseous Artery Flap

INDICATIONS
• The reverse PIA flap has a valuable role in coverage of the dorsum of the hand
proximal to the MCP joint.
• It is also a good option for reconstruction of contracture of the first webspace.
Contraindications
The flap is contraindicated when injury or prior surgery compromises the pedicle
around the distal radioulnar joint.
FIGURE 90.19A–B
The reverse PIA flap is best used with isolated hand injuries because dorsal and volar
forearm injuries can compromise the anterior interosseous artery (AIA) and the PIA,
both of which are required for this flap; the forearm should be thoroughly examined for
signs of previous injury or surgery.
IMAGING
• Preoperative vascular imaging is not routinely used, however perforators can be
identified with a handheld doppler.
SURGICAL ANATOMY
• The course of the PIA is on the distal two-thirds of the line connecting the lateral
epicondyle of the humerus to the distal radioulnar joint under the neutral pronosupi-
nation (Fig. 90.20).
• The point 2.5 cm proximal to the distal radioulnar joint on the course of the PIA serves
as the pivot point, where the PIA anastomoses with the AIA, proximal to the distal
radial ulnar joint (DRUJ). The anastomosis is confirmed by Doppler examination.
• A large cutaneous perforator based on the PIA in the middle third of the forearm is
also usually detected and marked on that line (Fig. 90.21).
• The PIA flap is based on the PIA that originates from the common interosseous
artery off of the ulnar artery (see Fig. 90.1).
Lateral
Pivot point epicondyle
Cutaneous perforator
FIGURE 90.20
PIA
Distal anastomosis
with AIA

Supinator
EDM EDC
B PIA ECU
FIGURE 90.21A–B
• In the proximal part of its course, the artery runs between the supinator and the APL,
covered by superficial extensor muscles. In the distal part of its course, the artery
turns superficial and travels between the extensor digiti minimi (EDM) and the ECU
muscles (see Fig. 90.21).
• The artery gives off 9 to 20 branches to the muscles of the posterior compartment
of the forearm. It also gives off 5 to 13 fasciocutaneous perforators within the intra-
muscular septum to supply the skin of the dorsum of the forearm. A larger cutaneous
perforator is constantly given off by the PIA in the middle third of the forearm.
• After the proximal PIA is transected, the retrograde flow of the flap is provided by
the distal anastomosis of the PIA with the AIA, which is located at about 2.5 cm
proximal to the distal radial ulnar joint. This anastomosis is absent in about 5% of
individuals.
• The venous drainage is from two venae comitantes accompanying the PIA and its
cutaneous perforators.
• The posterior interosseous nerve (PIN) runs alongside the PIA in the proximal fore-
arm and gives off the muscular branches to the adjacent muscles. The PIN and its
branches must be preserved during flap harvesting (see Fig. 90.21).
POSITIONING
The patient is supine, a tourniquet is used, and the flap is harvested with the arm in full
Pivot point
pronation.
Lateral
Skin
handle
epicondyle
PROCEDURE
Step 1: Markings
• The distal radius, distal ulna, and DRUJ are marked.
• The flap axis is marked, from the lateral epicondyle to the DRUJ.
• The distal anastomosis between the AIA and PIA is found by Doppler signal 2.5 cm
proximal to the DRUJ and marked. This is the flap’s pivot point.
Cutaneous perforator
• The strong cutaneous perforator in the middle of the dorsal forearm is found by Doppler
and marked (Fig. 90.22).
FIGURE 90.22
• The pedicle is designed with a 1-cm-wide overlying skin handle to avoid strangula-
tion of the pedicle during closure (see Fig. 90.22).
STEP 1 PEARLS
• The length of the pedicle is determined by the Step 2: Distal Dissection and Septum Identification
distance from the pivot point to the proximal • Dissection is started distally where the interval can be identified with confidence and
edge of the defect. An extra 10% length of the then traced proximally.
pedicle is required to rotate the flap without • The radial incision is made first, sharply down to the deep fascia to expose the ex-
tension.
• The flap is located on the dorsum of the fore- tensor digiti quinti (EDQ) tendon.
arm and should not extend beyond the lateral • Dissection proceeds ulnarly until the septum between the EDQ and ECU is identified.
midline of the forearm. • The ulnar incision can then be made with greater confidence over the ECU tendon.
Dissection proceeds radially toward the septum.
Step 3: Proximal Dissection and Flap Elevation

• Once the septum is identified, the incision is taken proximally along the skin mark-
ings. Dissection is done sharply down to the deep fascia, and the fascia is raised
with the flap.
• As the skin paddle widens proximally, the dissection still proceeds in both radial and
ulnar directions toward the septum, which is identified distally.
• The ECU is retracted ulnarly, and a large cutaneous perforator from the PIA to the
flap is identified within the intermuscular septum (Fig. 90.23).
Step 4: Deep Dissection

• Once the septocutaneous perforator to the flap skin paddle is identified, the PIA
pedicle proximal to this perforator is ligated.
• Dissection then proceeds distally, and the pedicle is raised off the deeper structures
(Fig. 90.24).
• The PIN is carefully dissected free from the vascular pedicle.
Skin paddle STEP 2 PEARLS

covering the
pedicle Cutaneous perforator PIA • The skin paddle overlying the pedicle can be
made wider to ensure that the septum is not
violated. The radial incision can be taken down
to the deep fascia over the EDC tendons with
greater confidence because this compartment
has multiple tendons, whereas both the ECU
and EDQ compartments have only one tendon.
Therefore starting the radial dissection over
the EDC means the next ulnar compartment
is the EDQ, with a single tendon.
• The same can be done starting ulnarly, noting
the cutaneous border of the ulna separates the
FCU and ECU; however, these compartments
all have only one tendon and therefore the
safest starting point is radially over the EDC.
ECU
• The distal anastomosis between the PIA and
FIGURE 90.23 AIA may not be present in all the cases. A pre-
liminary short incision over the pivot point can
be made to ascertain the presence of this
Cutaneous perforator EDM anastomosis if the result of the preoperative
Doppler is unclear.
STEP 3 PEARLS
• The dissection is carried out over the muscle
belly to preserve the subcutaneous plexus of
the flap.
• Usually, one large cutaneous perforator is ade-
quate for blood supply of the flap.
ECU STEP 3 PITFALLS

FIGURE 90.24 The fascia is secured to the skin with a few interrupted
sutures to avoid separation during the dissection.
STEP 4 PEARLS
• The pedicle should include the PIA, venae co-
mitantes, the intermuscular septum, and the
wide subcutaneous tissue with deep fascia.
• The pedicle is dissected free until it is able to
pivot into the defect without tension; no further
dissection is required (Fig. 90.25).
FIGURE 90.25
STEP 4 PITFALLS
• No attempt is done to isolate the vessels in the
Step 5: Flap Inset pedicle.
• An incision is made to connect the flap with the defect (Fig. 90.26). • During flap raising, the small muscular perfo-
rators are coagulated.
• The flap is secured with absorbable or permanent sutures.
• The pedicle can be clamped proximally before
• A skin graft can be used to cover the donor site if the skin paddle is greater than being ligated to confirm flap perfusion. If the
3 to 4 cm and cannot be closed primarily (Fig. 90.27). reversed flow is not adequate to supply the
flap, the proximal pedicle will be kept long to
POSTOPERATIVE CARE AND EXPECTED OUTCOMES convert a pedicled flap into a free flap transfer.
• The hand and forearm are placed in a volar splint after the operation. The sutures
will be removed at about 10 days postoperatively. Patients are discharged after STEP 5 PEARLS
24 hours of flap monitoring in the hospital and advised to keep the limb elevated.
A skin graft is typically needed to close the donor
• The patient can initiate ROM exercises for the fingers after 1 week.
site.
• The PIA flap, which is a fasciocutaneous flap, does not sacrifice a major artery of the
forearm. It can provide favorable color match and texture for defect coverage over the
first webspace and the dorsum of the hand (Fig. 90.28). The flap has minimal donor site
morbidity, but the donor skin graft scar may be visible over the dorsum of the forearm.
See Video 90.1
STEP 5 PITFALLS
A subcutaneous tunnel is not recommended
because the skin over the dorsum of the forearm is
tight, and the tunnel may cause venous congestion
of the flap.
FIGURE 90.26
FIGURE 90.27
FIGURE 90.28
EVIDENCE
Acharya AM, Bhat AK, Bhaskaranand K. The reverse posterior interosseous artery flap: Technical con-
siderations in raising an easier and more reliable flap. J Hand Surg Am. 2012;37:575–582.
The authors introduced the details of the PIA flap technique based on their experience. They also re-
ported outcomes of a total of 21 cases that underwent this flap procedure with an average 6-month
follow-up period. The size of the flaps ranged from 90 to 30 cm2. All of the flaps succeeded without
major complications. The authors noticed the flap resulted in a visible donor defect in the forearm
and the flap did not match color for palmar defects.
Becker C, Gilbert A. The ulnar flap. Handchir Mikrochir Plast Chir. 1988;20:180–183.
The authors first described the dorsal ulnar artery flap. They found the constant dorsal branch of the ul-
nar artery by dissecting 100 fresh cadaveric forearms. This flap was applied on eight cases for cover
defects of the dorsal and palmar aspects of the hand and wrist and the thenar and the hypothenar
eminence. They suggested the flap was indicated for small defects (no more than 10 × 5 cm) at the
ulnar side of the hand.
Costa H, Pinto A, Zenha H. The posterior interosseous flap—A prime technique in hand reconstruction.
The experience of 100 anatomic dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg.
2007;60:740–747.
The authors reported their experience of 102 clinical cases and 100 anatomic dissections using the PIA
flap. The anastomosis between the PIA and AIA was found in all the cadaveric dissections, but the
anastomosis was not identified in three clinical cases because the PIA appeared to terminate in the
middle third of the forearm. Ninety-four flaps survived, four flaps had partial necrosis, and one flap
had complete necrosis. The authors suggested the PIA flap could be used for reconstruction of the
first webspace up to the interphalangeal joint of the thumb, dorsal hand defects up to the metacarpal
joints, and large defects on the palm-ulnar border of the hand.
Meland NB, Lincenberg SM, Cooney WP III, Wood MB, Hentz VR. Experience with the island radial
forearm flap in local hand coverage. J Trauma. 1989;29:489–493.
The authors applied the island radial forearm flaps for soft tissue coverage of hand and forearm after
mutilating injuries, chemotherapeutic injection sloughs, and tumor excisions in 28 cases. Twenty-six
were reversed flow flaps, and the other two flaps were the antegrade-flow flaps. Three of the
26 reversed flaps had partial loss of the distal tip. Four patients had minor sloughing of the skin graft
of the donor site. Postoperative problems including swelling, cold intolerance, weakness, and sen-
sory change, which might be because of the traumatic nature of the injury and unrelated to the flap.
The authors believed this flap could provide local hand and forearm coverage with acceptable donor
site problems when local tissue was unavailable.
Unal C, Ozdemir J, Hasdemir M. Clinical application of distal ulnar artery perforator flap in hand
trauma. J Reconstr Microsurg. 2011;27:559–565.
The authors reported the clinical application of the dorsal ulnar artery perforator flap in a series of nine
cases with composite injuries of the hand and wrist. The defects are located on the dorsum of the
hand, volar, and dorsal side of the wrist and palm. The size of the flap performed in a single proce-
dure ranged from 2× 3 cm to 5× 8 cm. The authors anastomosed a superficial antebrachial vein in-
cluded in the flap with the vein of the receipt site when venous congestion occurred. All flaps sur-
vived and no complications related to the flap were found at a mean 18-month follow-up period. The
author noted two patients concerned with the appearance of the grafted donor site.
Zaidenberg EE, Farias-Cisneros E, Pastrana MJ, Zaidenberg CR. Extended posterior interosseous
artery flap: Anatomical and clinical study. J Hand Surg Am. 2017;42(3):182–189.
The authors describe the anatomic basis for an extended reverse PIA flap based on the intermetacarpal
artery, a pivot point distal in the hand that permits more distal coverage than the pivot point at the
DRUJ. They report 19 clinical cases with no flap losses.
CHAPTER 91
Groin Flaps
INTRODUCTION
• The pedicled groin flap is an axial vascular flap based on the superficial circumflex iliac
artery (SCIA). As an axial flap, it can be designed to cover a larger length-width ratio
than what is possible with random abdominal flaps. It predominantly serves as a dis-
tant pedicled flap and is seldom raised as a free flap because of the short vascular
pedicle. It is a workhorse pedicled flap for hand and forearm coverage (Fig. 91.1).
• The pedicled abdominal flap is also an axial flap, based on the superficial inferior
epigastric artery (SIEA). It can be added to a groin flap to provide robust coverage
of dorsal and volar hand wounds when a single pedicled groin flap is not large
enough (see Fig. 91.1D).
INDICATIONS
• Pedicled groin flaps are most often indicated for hand and forearm coverage when
the patient is too unstable for free flap coverage and for thumb resurfacing in
B
A
SIEA flap
SCIA flap
C D
FIGURE 91.1 (A-D) Pedicled groin and abdominal flaps are workhorse flaps for coverage of hand
and forearm soft tissue defects.
674
CHAPTER 91 Groin Flaps 675
anticipation of toe-to-thumb transfer, because this avoids other pedicled flaps

based on forearm tissue. These flaps can also be used in salvage procedures when
free flaps fail.
• The pedicled groin flap requires that the injured hand is attached to the ipsilateral
groin for about 3 to 4 weeks, which may result in stiffness of the joints of the upper
limb, especially in elderly patients. Alternative reconstruction such as a forearm flap
or free flap may be more suitable for these patients.
• The groin flap can also be used as a free tissue transfer in a single-stage procedure,
but this is seldom done because of its shortcomings, which include a short pedicle
and anatomic variations.
• The groin flap scar is well-hidden and often preferred by patients with specific aes-
thetic concerns.
Contraindications
• The groin flap is contraindicated in patients with prior femoral vessel surgery, hernia
repair, lymph node biopsy, or vein stripping.
• Determine whether the patient is psychologically stable and has adequate social
support; they must be able to cope with having a nonfunctional extremity attached
to the groin for 3 to 4 weeks before flap division, which may impede with activities
of daily living.
• The donor groin should be inspected to identify previous surgery or wounds that
could have injured the pedicle.
• In addition to flap inset and division, thinning, debulking, or tissue rearrangement
procedures may be required to achieve an aesthetic result. Before surgery, the pa-
tient should be well informed of this possibility.
IMAGING
• Routine imaging is not required for flap planning.
• Computed tomography (CT) angiogram can demonstrate the presence and course
of each pedicle. Nevertheless, input from experienced radiology colleagues is nec-
essary to interpret these complex studies.
SURGICAL ANATOMY
• The arterial inflow to the groin flap is supplied from the SCIA. The SCIA most often
ascends from the femoral artery directly, from a common trunk with the SIEA. It may
also, however, come off the superficial femoral or profunda femoral artery.
• Two landmarks are useful when planning a pedicled groin flap: the SCIA always
pierces the deep fascia medial to the sartorius muscle and distal to the inguinal
ligament (typically 2 cm distal to the inguinal ligament, and lateral to the femoral
artery; Figs. 91.2 and 91.3).
• The superficial branch of the SCIA gives off superficial cutaneous perforators above
the fascia to supply the overlying skin on its way to the anterior superior iliac spine
(ASIS).
• There is a rich anastomotic plexus connecting SCIA, the deep circumflex iliac artery,
SIEA, the superior gluteal, and the lateral circumflex femoral artery in the lower part
of the abdomen. These vascular anastomosis plexuses enable the distal part of the
flap to extend beyond the ASIS in a random pattern.
• The venous drainage of the flap depends on the deep venae comitantes of the SCIA
and the superficial circumflex iliac vein (SCIV) that drains directly into the femoral
vein or indirectly through the saphenous bulb.
• There is no cutaneous nerve along the longitudinal axis of the groin flap, so the groin
flap does not serve as a sensate flap without direct neurotization.
• The lateral femoral cutaneous nerve of the thigh courses within the groin flap terri-
tory and is encountered when the flap is raised. It emerges under the inguinal liga-
ment in the septum between the tensor fascia lata and the sartorius. Then the nerve
runs down close to the medial border of the sartorius and divides into branches to
676 CHAPTER 91 Groin Flaps
Anterior
superior
iliac spine
Inguinal
ligament
2 cm
Superficial
circumflex
iliac artery
Femoral
artery
FIGURE 91.2 Two landmarks are useful in planning a pedicled groin flap: the superficial circumflex
iliac artery (SCIA) always pierces the deep fascia medial to the sartorius muscle, and distal to the
inguinal ligament (typically 2 cm distal to the inguinal ligament and lateral to the femoral artery).
Superficial
inferior
epigastric
artery
Anterior
superior
iliac spine
Inguinal
ligament
6XSHUILFLDO
FLUFXPIOH[
LOLDFDUWHU\
6&,$
ASIS Lateral femoral
Pubic outaneous nerve
tubercle SIEA
SCIA
Femoral Deep branch
artery of SCIA
Pubic Inguinal ligament Tensor fascia lata

symphysis Femoral artery
Sartorius
A
Femoral vein
B and SCIV
FIGURE 91.3 Two landmarks are useful in planning a pedicled groin flap: the superficial circumflex iliac artery (SCIA) always pierces the deep fascia medial
to the sartorius muscle, distal to the inguinal ligament (typically 2 cm distal to the inguinal ligament), and lateral to the femoral artery. The lateral femoral
cutaneous nerve of the thigh courses within the groin flap territory and will be encountered when the flap is raised. It emerges under the inguinal ligament
in the septum between the tensor fascia lata and the sartorius. Then the nerve runs down close to the medial border of the sartorius, and divides into
branches to supply the skin of the lateral thigh. Depending on the course of the nerve it may need to be transected; however, every effort should be made
to preserve it. ASIS, Anterior superior iliac spine; SCIV, superficial circumflex iliac vein; SIEA, superficial inferior epigastric artery.
supply the skin of the lateral thigh (see Fig. 91.3B). Depending on the course of the STEP 1 PEARLS
nerve, it may need to be transected. Every effort should be made, however, to pre-
• After the defect is measured out, one team
serve it to maintain sensation to the lateral thigh. can perform reconstruction of the recipient site
while another team harvests the groin flap.
POSITIONING Keep in mind that taking more time to plan the
• The patient is placed in a supine position on an operating table. flap leads to more efficient harvest.
• The extreme medial boundary of the flap is the
• The pedicled flap is raised from the ipsilateral groin.
femoral artery, but it is safer to stop dissecting
• A bump can be placed under the ipsilateral hip while the distal part of the flap be- at the medial border of the sartorius to avoid
yond the ASIS is dissected. the need for pedicle dissection.
• All wounds requiring coverage are thoroughly debrided to healthy tissue before cov- • The distal extent of the flap extends beyond
erage (Fig. 91.4). Nerve repair, tendon reconstruction, and fracture fixation can be the ASIS as a random flap, in which the width
is equal to the length (Fig. 91.5A–B). Therefore
performed at the same time if the wound is ready.
the extreme lateral boundary is dictated by
what will permit primary closure.
PEDICLED GROIN FLAP • The most proximal part of the flap serves as
the pedicle. Ensure that there is sufficient lax-
Step 1: Marking ity over the medial flap so that the hand can
be covered fully and rest comfortably over the
• Mark the ASIS, pubic tubercle, and inguinal ligament.
groin area. If the length of the flap is too short,
• Mark the expected course of the sartorius. then the flap may not cover the hand without
• Mark the femoral artery by palpation or Doppler exam. undue tension over the pedicle.
• The SCIA arises from the femoral artery roughly 2 to 3 cm distal to the inguinal liga- • Although the distal part of flap can be trimmed
ment and runs laterally and slightly upward to the ASIS. Its course is confirmed using thin to the dermal layer, the flap must be
larger than the defect, especially if the recipi-
a Doppler probe and forms the flap’s main axis.
ent site has a curved surface.
• Use a template to mark out the required flap; two-thirds of the flap is located above • The maximum size of the groin flap is about
this axis, and one-third is below this axis (Fig. 91.5A–B). 13 cm by 10 cm.
Step 2: Lateral to Medial Dissection

• The lateral incisions of the flap are made first. The flap is raised, leaving the deep STEP 1 PITFALLS
fascia down. Progress medially and ligate perforating vessels as they are encoun-
A longer flap provides more joint movement
tered (Fig. 91.6).
at the elbow and shoulder and thus increases
• Identify the sartorius muscle as dissection proceeds medially; if flap design requires postoperative mobility and comfort. Do not,
dissection medial to the sartorius, the sartorius fascia is entered over the lateral however, misuse the well-vascularized tissue at the
muscle border, and dissection proceeds medially deep to the deep fascia (Fig. 91.7). donor site to make a flap that is too long.
• Dissection ceases when the flap is long enough to permit flap inset.
• Perforating vessels can be seen exiting the deep fascia lateral to the medial border
STEP 2 PEARLS
of sartorius. Other vessels may be part of the SCIA pedicle. The SCIA and its venae
comitantes serve as the vascular pedicle and can be seen in the fascia from the • The sartorius muscle is easily recognized be-
cause it arises from tendinous fibers from the
undersurface of the proximal part of the flap (see Fig. 91.6).
ASIS, medial to the tensor fasciae lata, and
travels obliquely to the medial side of the knee.
• Flap thinning can be technically easier to per-
form when raising the flap, rather than during
flap inset. Nevertheless, we recommend thin-
ning at a second stage unless the surgeon is
highly experienced.
• During dissection from the ASIS to the medial
border of the sartorius, the lateral femoral cu-
taneous nerve of the thigh is identified as it
pierces the deep fascia to pass through the
subcutaneous tissue. Every effort should be
taken to avoid injury to this nerve.
• The dissection of the pedicled flap ceases as
far as 2 to 3 cm medial to the sartorius. To
raise the flap from the sartorius, the deep
branch of the SCIA is mobilized,
ligated, and divided carefully at the medial
border of the sartorius (Fig. 91.8).
• The course of the deep branch from its origin
to the sartorius is very short; it is better to
ligate and divide it within the substance of the
muscle to avoid damaging the main trunk of
A B the SCIA. There is no need to isolate the SCIA
and its superficial branch.
FIGURE 91.4 (A–B) Failed thumb replantation, salvaged with groin flap.
Femoral Random portion

artery SIEA ASIS
ASIS
Inguinal
ligament
SCIA
Femoral
artery
Sartorius
B
SCIA
FIGURE 91.5 Two examples of pedicled groin flaps. (A) Smaller flap for thumb coverage, based on the superficial circumflex iliac artery (SCIA). Vessels
were identified by Doppler examination. (B) Larger flap for hand coverage, based on both SCIA and superficial inferior epigastric artery (SIEA). ASIS, Anterior
superior iliac spine.
Posterior
superior
iliac spine
External oblique
aponeurosis
Superficial Iliac crest

circumflex
iliac artery Anterior
superior
iliac spine
Tensor fascia lata
Inguinal
ligament
Sartorius
FIGURE 91.6 The lateral incisions of the flap are made first. The flap is raised, leaving the deep fas-
cia down, progressing medially and ligating perforating vessels as they are encountered. Take note
of the sartorius muscle as dissection proceeds medially, and either stop at this landmark or prepare
to enter the deep fascia and proceed with dissection medially deep to the deep fascia.
Divided branch to
sartorius muscle
Axial portion
of flap
Random
portion of
flap
Anterior
superior
iliac spine
Inguinal
ligament
Superficial
circumflex
iliac artery
Tensor fascia lata
Sartorius
Fascia from
sartorius and
fascia lata
SCIA, entering Sartorius, covered

flap by fascia
FIGURE 91.7 Take note of the sartorius muscle as dissection proceeds medially; if flap design
requires dissection medial to the sartorius, the sartorius fascia is entered over the lateral muscle
border, and dissection proceeds medially, deep to the deep fascia. SCIA, Superficial circumflex
iliac artery.
STEP 3 PEARLS
• The distal margin of the flap is thinned radi-
cally for ease of inset. Axial portion
• The distal part of the flap can be thinned Random of flap
safely as a random pattern because the ves- portion of
sels are superficial, and the flap relies on the flap
subdermal plexus.
Anterior
superior
STEP 3 PITFALLS iliac spine
• The fat on the proximal part of the flap is Inguinal
trimmed carefully using blunt-point scissors to ligament
avoid damaging the vascular pedicle. A thin
SCIA
layer of fat below the subdermal plexus will be Tensor fascia lata
left because the vessels are in the deep fascia.
• There is no need to thin the part of the flap
that serves as the pedicle. This part will be Sartorius
returned to the donor site after flap division.
Deep branch of SCIA
Fascia from
sartorius and
fascia lata Femoral artery
STEP 4 PEARLS
• The donor defect can be closed primarily if the
width of the flap is less than 10 cm.
• Hip flexion is helpful to reduce the tension and
FIGURE 91.8 The dissection of the pedicled flap ceases as far as 2 to 3 cm medial to the sartorius.
close the defect.
To raise the flap from the sartorius, the deep muscular branch of the superficial circumflex iliac artery
• If the donor-site defect is too wide to be closed
(SCIA) is mobilized, ligated, and divided carefully at the medial border of the sartorius.
directly, a split-thickness skin graft is used to
cover it.
Step 3: Flap Thinning

STEP 5 PEARLS The flap is thinned to match the volume of the recipient defect.
• Suture the flap to the defect nicely because
the revascularization relies on the healing Step 4: Donor Site Closure
of the edge attachment. The donor defect is closed primarily from medial to lateral using 2-0 or 0-0 Vicryl and
• The flap and recipient site should be com-
pletely sealed to prevent the need for intensive 2-0 nylon after careful hemostasis (Fig. 91.9).
wound care during the 3 to 4 weeks that the
hand is in the groin (see Fig. 91.10). This is Step 5: Flap Inset
often made easier by tubing the very proximal Stitch the free border of the flap to the recipient defect by using a few sutures first, and
part of the flap (Fig. 91.11).
then close the wound with simple 3-0 nylon interrupted sutures as the involved upper
• Make sure that the flap and pedicle are not
kinked or twisted. limb is placed in a comfortable position (Fig. 91.10).
FIGURE 91.9 The donor defect is closed primarily from medial to lateral using 2-0 or 0-0 Vicryl and
2-0 nylon after careful hemostasis.
FIGURE 91.10 Thumb coverage. (A-B) The flap should completely seal over the recipient hand to
limit wound problems over the 3 to 4 weeks that the hand is in the groin.
FIGURE 91.11 The inset flap should be carefully protected by supporting surrounding structures,
with clear instructions for nursing staff.
FIGURE 91.12 Division of the pedicle flap is carried out 3 to 4 weeks after the flap is inset to the
defect, when the flap has developed revascularization from the recipient site. Note a likely pressure
sore from the pin that should have been cut shorter.
STEP 6 PEARLS
Step 6: Flap Division
Division of the pedicle flap is carried out 3 to 4 weeks after the flap is inset to the defect,
• Excess skin from the flap, usually any tubed
portion covering the pedicle, can be returned when the flap has developed revascularization from the recipient site (Fig. 91.12).
to the donor site after the flap is divided
(Fig. 91.13). POSTOPERATIVE CARE AND EXPECTED OUTCOMES
• To make it easier for the therapist and the • The involved upper limb is immobilized for a few days until the patient is comfortable
patient to recover motion, the surgeon can with the hand position.
manipulate stiff joints of the involved upper
limb when the patient is under anesthesia, • The hip remains flexed for a few days after surgery and straightens gradually.
after the flap is divided. • The frequency of dressing change depends on whether there is raw area left.
• To test the flow before flap division, a rubber • The patient starts mobilizing all available joints after they get used to the hand position.
tourniquet can be placed around the tube ped- • The pedicled groin flap is a versatile flap for covering a large soft tissue defect
icle to block blood flow from the axial vessels. (Fig. 91.14). It can be quickly raised, especially if dissection is limited lateral to the
This is done only when the flap viability is
questionable. sartorius. Although the donor scar may be wide, an advantage is that it is located
in a hidden area and can be concealed by clothing (see Fig. 91.14). The disadvan-
tages of the groin flap include the requirement of multiple procedures, bulky
appearance, and long-time upper limb attachment. The short and relatively non-
constant vascular pedicle prevents frequent application of the free groin flap.
FIGURE 91.13 Excess skin from the flap, usually any tubed portion covering the pedicle, can be
returned to the donor site after flap is divided. Note that in pediatric patients, less skin redundancy
can lead to wounds closed primarily under high tension.
A B
FIGURE 91.14 (A–B) Result at division.
• A flap debulking procedure, which can be done by liposuction or using an open POSTOPERATIVE PEARLS
technique, should be delayed for at least 3 to 6 months. • A pillow placed under the elbow can help to
See Video 91.1 relax the arm and reduce the tension on the
flap while the patient is in bed. When the
patient is getting out of bed, he or she may
EVIDENCE need help to avoid pulling on the flap.
Lister GD, McGregor IA, Jackson IT. The groin flap in hand injuries. Injury. 1973;4:229–239. • The donor scar will always spread because of
The authors described the basis and the operative technique of the pedicled groin flap. They also retro- the tension, so the large sutures should not be
spectively reported over 50 groin flaps applied in various procedures and 16 flaps in reconstruction removed until flap division.
of acute hand injuries. They divided or delayed the pedicles 3 weeks after flap inset depending on
whether the portion of the pedicle was required for subsequent insetting on the hand. Some mar-
ginal necrosis occurred in three flaps. Two of them were excessively long flaps, and the axial artery of POSTOPERATIVE PITFALLS
another flap was found damaged in a previous herniorrhaphy. The authors summarized that the groin
• Great care should be taken when the patient
flap was appropriate for hand defects.
wakes up from anesthesia. The surgical team
Wray RC, Wise DM, Young VL, Weeks PM. The groin flap in severe hand injuries. Ann Plast Surg.
must hold the involved arm to prevent the nat-
1982;9:459–462.
ural tendency of the patient to move the hand
The authors performed 28 groin flaps in 27 patients with soft tissue defects in the hand. Flap necrosis
to the mouth to pull the tube out, which may
developed in 18% of the flaps because of ischemia after flap division. There was no statistically sig-
result in flap avulsion. Awakening younger
nificant difference in flap necrosis between flap division and immediate inset versus flap division and
patients with dexmedetomidine can provide a
delayed inset. They found flap necrosis would not develop if the pedicle was divided in two stages.
longer, but calmer, emergence.
They believed a preliminary delay procedure including either preliminary ligation of the SCIA or full-
• In the first few days, the flap must be in-
thickness division of a portion of the width of the flap would avoid flap necrosis.
spected frequently to ensure that it is not
Acharya AM, Ravikiran N, Jayakrishnan KN, Bhat AK. The role of pedicled abdominal flaps in hand and
kinked or twisted.
forearm composite tissue injuries: Results of technical refinements for safe harvest. J Orthop.
2019;16(4):369–376.
The authors report on their experience with 68 patients who underwent coverage of a combination of
volar and dorsal hand and forearm wounds. Their smallest flaps were for multiple fingertip injuries and
measured 2 cm by 3 cm, whereas their largest flaps were for combination volar and dorsal coverage
and measured 25 cm by 10 cm. Donor site skin grafting was needed in 84% of patients. They per-
formed flap delay in 26% of the cases when the length-to-width ratio was less than 1:1.5. Marginal
flap necrosis was seen in 22% of patients. They provide helpful diagrams and technical tips to im-
prove outcomes, such as pinning the metacarpophalangeal joints at 90 degrees to prevent stiffness,
flap thinning, flap tubing, flap delay, and how to manage secondary division or partial flap necrosis.
CHAPTER 92
Lateral Arm Flap
INDICATIONS
• In both free antegrade and pedicled reverse designs, the lateral arm flap is useful for cov-
erage and resurfacing of forearm, elbow, and dorsal hand wounds. It is thin, has fascia to
provide a tendon gliding surface, and has a consistent vascular pedicle that does not re-
quire intramuscular perforator dissection. The donor site can often be closed primarily.
• The free antegrade lateral arm flap is based on the posterior radial collateral artery
and is useful for first webspace contracture release. Its proximal pedicle can be
anastomosed to the radial artery in the distal wrist and remains covered with flap
skin, avoiding the need for the pedicle to travel in a potentially compressive tunnel.
• The pedicled reverse lateral arm flap is based on the radial recurrent artery and can
be used to cover exposed hardware of the olecranon or resurface the antecubital
fossa after contracture release.
• The free lateral arm flap can reconstruct a composite defect with loss of bone, ten-
don, or nerve using a vascularized segment of the humerus bone, triceps tendon, or
posterior cutaneous nerve, respectively.
• Although the donor site defect can be closed directly, the scar is visible on the lateral
arm. Aesthetic considerations should be taken into account.
Contraindications
• The lateral arm flap should be avoided in patients who find a long scar on the lateral
arm cosmetically unacceptable.
• Other thin flap options can also be considered based on availability and appearance,
• The flap axis is along the line between the
such as a groin flap, super thin anterolateral thigh flap, or medial sural artery perfora-
deltoid insertion and the lateral epicondyle. The
cutaneous perforators are given off within the tor flap.
distal half of the line, and the most distal • A free flap should not be performed if there are any previous injuries to the intended
perforator is 3 to 5 cm proximal to the lateral recipient vessels.
epicondyle (Fig. 92.1).
• The pedicled reverse lateral arm flap is often CLINICAL EXAMINATION
used for coverage of the elbow, exposed olec-
ranon hardware, or the antecubital fossa after • Examine the lateral arm and epicondyle for sequelae of prior trauma or surgery that
contracture release. The pivot point is at the could compromise flap reliability.
lateral epicondyle and brachioradialis (BR), • Estimate whether enough laxity exists to close the donor site primarily after flap
which is where the radial recurrent artery harvest.
anastomoses with the posterior radial collateral
• Use a handheld Doppler to mark the perforators that the skin paddle is centered on.
artery through a rich vascular plexus.
IMAGING
A preoperative angiogram is not necessary. It can be useful, however, to confirm the
presence of an intact pedicle if adjacent tissue is traumatized.
SURGICAL ANATOMY
• The free antegrade flap is based on the posterior radial collateral artery and its sep-
tocutaneous perforators (see Fig. 92.1).
• The posterior radial collateral artery travels in the lateral intermuscular septum, be-
tween the triceps and brachialis proximally (Fig. 92.2) and the triceps and BR and
triceps and extensor carpi radialis longus (ECRL) distally. Thus, starting with the
posterior dissection as described later, the triceps is raised off the septum, and the
intermuscular septum is then raised off the brachialis, BR, and ECRL.
• The posterior radial collateral artery anastomoses with the radial recurrent artery. This
forms the basis for the pedicled reverse lateral arm flap, which relies on retrograde
flow from the radial recurrent artery.
684
Deltoid
Axillary artery
Profundis brachial
artery
Profunda
brachii Brachial
artery artery Brachial
Profunda brachii artery artery
PRCA ARCA
PRCA ARCA
Septocutaneous
perforator
Vascular
anastomosis Vascular
plexus anastomosis
plexus
Radial
recurrent Flap Radial
artery recurrent
artery
Ulnar artery
Radial artery Ulnar artery
Radial artery
A
B
FIGURE 92.1 The pedicle of the free lateral arm flap is the posterior radial collateral artery (PRCA). The pedicle for pedicled reverse lateral arm flap is the
radial recurrent artery. (A) The course of the posterior radial collateral artery is between the deltoid insertion and the lateral epicondyle. (B) The cutaneous
perforators are given off within the distal half of the line joining deltoid insertion and lateral epicondyle. The most distal perforator is 3 to 5 cm proximal to
the lateral epicondyle. ARCA, anterior radial collateral artery.
• The radial recurrent artery comes off the radial artery in the antecubital fossa, ulnar
to the biceps tendon. This is also known as the Leash of Henry and is a compression
point for the radial nerve in the radial tunnel. Because the radial recurrent artery
anastomoses with the posterior radial collateral artery, it comes off the radial artery
ulnar to BR, travels superficially through BR to the lateral elbow, and then merges
with the posterior radial collateral artery. It courses over the lateral epicondyle not as
a macroscopic axial vessel, but as a rich anastomostic network above the deep
fascia. The pivot point for the reverse flap is centered over the BR and lateral epi-
condyle to capture these vessels.
686 CHAPTER 92 Lateral Arm Flap
Medial intermuscular septum
Musculocutaneous nerve Biceps brachii

muscle
Cephalic vein Brachial fascia
Brachial artery
Brachialis and veins
muscle
Basilic vein
Lateral Ulnar nerve

intermuscular
septum
Radial nerve
Lateral head Medial head Long head
Triceps brachii muscle

FIGURE 92.2 The posterior radial collateral artery travels within the lateral intermuscular septum,
between the triceps long head and brachialis in the proximal dissection.
• The brachial artery gives off the profunda brachii artery just after the axillary artery
becomes the brachial artery distal to teres major. The profunda brachii travel
through the triangular interval with the axillary nerve, coursing along the spiral
groove of the humerus between the deltoid insertion and origin of the medial head
of the triceps.
• At the lateral intermuscular septum, the profunda brachii bifurcates into the anterior
and posterior radial collateral arteries. The anterior radial collateral artery is of incon-
sistent caliber and continues with the radial nerve as it enters the anterior compart-
ment of the arm between the brachialis and BR.
• The posterior radial collateral artery is larger and more consistent. It remains in the
lateral intermuscular septum and travels distal toward the lateral epicondyle, termi-
nating in a rich vascular network about the lateral elbow.
• The venous flow of the free lateral arm flap is provided by one or two venae comi-
tantes of the posterior radial collateral artery. The diameter of the venae comitantes
is approximately 2 mm.
• The posterior antebrachial cutaneous nerve travels with the flap.
POSITIONING
• The patient is positioned supine with the limb placed on a hand table. The flap is
harvested with the arm in pronation and the elbow in flexion.
• The entire donor arm, extending to the shoulder, should be prepped up to the
axilla.
• A sterile tourniquet is placed as proximally as possible.
• The flap can be harvested from the ipsilateral or contralateral limb.
FREE LATERAL ARM FLAP

Step 1: Markings
• The deltoid insertion is marked.
• The lateral epicondyle is marked.
• A line is marked connecting the deltoid insertion and the lateral epicondyle.
• A handheld Doppler is used to identify perforators along this axis (Fig. 92.3).
STEP 2 PEARLS
• Most of the dissection is done sharply with a
knife or dissection scissors, except when per-
forators from the pedicle into the triceps are
FIGURE 92.3 Mark the deltoid insertion and the lateral epicondyle and draw a line connecting them. taken down with bipolar cautery.
A Doppler is used to find perforators located along this axis. • The triceps is more adherent to the septum
proximally than distally.
• Use Allis clamps to grasp the triceps tendon.
• The triceps is dissected off the intermuscular
septum. Therefore only triceps is dissected
Step 2: Posterior Elevation Toward the Intermuscular Septum posteriorly, leaving everything else in the inter-
• Incise the skin with a knife and use Bovie electrocautery to dissect down from the muscular septum anterior.
skin to the deep fascia and triceps tendon. Be careful not to divide this fascia. • If a vascularized tendon graft is required, then
• An assistant can use skin hooks to provide gentle retraction while the flap is dis- a segment of the triceps tendon is included in
the flap.
sected off the muscle from posterior to anterior toward the lateral intermuscular
septum (Fig. 92.4). Use tenotomy scissors—not Bovie electrocautery—to avoid in-
juring the septocutaneous perforators as the flap is dissected anteriorly.
• The perforators from the flap pedicle that enter the triceps muscle are taken down STEP 3 PEARLS
with bipolar cautery. • Make certain that there are no nearby vessels
before dividing the septum.
Step 3: Expose the Radial Nerve and Flap Pedicle • Typically, the first visualized nerve is the poste-
rior antebrachial cutaneous nerve. The radial
• The proximal intermuscular septum is divided proximal to the first cutaneous nerve usually requires more dissection and
perforator. runs longitudinally with the axis of the flap,
• The flap pedicle, radial nerve, and posterior antebrachial cutaneous nerve are iden- deep on the humerus. The posterior brachial
tified and protected. cutaneous nerve runs up toward the skin with
the flap perforators.
• You can only be certain you have identified the
radial nerve once both nerves are visualized in
the field.
Pedicle located
within the lateral
intermuscular
Brachialis septum
Distal Proximal
Perforator Perforator Triceps

entering going to
triceps skin paddle
FIGURE 92.4 The posterior dissection is performed first, dissecting the triceps off the intermuscular
septum. Perforators from the pedicle into the triceps should be taken, whereas those going into the
skin paddle should be protected.
Distal Proximal
Brachialis and
brachioradialis
STEP 4 PEARLS
• The flap will be mobile and fall with gravity, dis-
torting the three dimensions of the septum. Ei-
ther bevel out to avoid the septum or support the
pedicle so that the septum orientation is correct.
• Perforators from the posterior radial collateral
artery supplying the flap may continue beyond
the skin paddle into the anterior arm. These
can be divided safely.
• The brachialis is more firmly attached to the
intermuscular septum proximally than distally,
similar to how the triceps is more firmly
attached proximally.
• The posterior collateral radial vessels and the Posterior collateral radial vessels
cutaneous perforators can be identified within FIGURE 92.5 The anterior dissection is performed second, after the critical structures are identified:
the septum (see Fig. 92.4). radial nerve, posterior antebrachial cutaneous nerve, flap pedicle, and perforators from the pedicle
into the flap. The brachialis and brachioradialis are dissected off the intermuscular septum.
STEP 4 PITFALLS
Although the anterior dissection is performed Brachialis and
similarly to that of the posterior side, it can be more brachioradialis
difficult because the fascia of the anterior side is
slightly more adherent to the muscle than that of Distal Proximal
the posterior side.
STEP 5 PEARLS
• Take a periosteal cuff up with the flap to
ensure that the pedicle within the intermuscu- Pedicle with
lar septum is protected. perforators
• If an osteocutaneous flap is required, then a entering the
section of the lateral humerus bone is skin flap
harvested with the periosteum.
STEP 6 PEARLS
• The tourniquet should be removed if it im-
pedes the pedicle dissection.
• To obtain a longer pedicle, the incision can be FIGURE 92.6 The flap is dissected from distal to proximal, taking a cuff of periosteum off the humerus
extended proximally between the triceps and to protect the septum.
deltoid. After the anterior radial collateral artery
is cut and ligated, the profunda brachii artery
can serve as the vascular pedicle; however, Step 4: Anterior Dissection Toward Intermuscular Septum
this dissection is difficult to perform. • The anterior border of the flap is incised and deepened to the brachialis and BR
• Before pedicle division, the vessels are freed muscles.
of fat and adventitia at the anticipated anasto-
mosis site. • The brachialis and BR are dissected off the intermuscular septum (Fig. 92.5).
Step 5: Elevate the Flap and Intermuscular Septum off the

STEP 6 PITFALLS Humerus
• Great care should be taken to protect the ra- After elevating the distal end of the flap from the lateral epicondyle, the flap with the
dial nerve when the proximal half of the flap septum deep to the vessels is dissected proximally (Fig. 92.6).
and the pedicle are dissected (see Fig. 92.7).
• Bleeding from the flap edge should be cauter-
ized before the pedicle division.
Step 6: Divide the Pedicle
• The posterior antebrachial cutaneous nerve is divided once it is distinct from the
radial nerve.
STEP 7 PITFALLS
• After checking perfusion to the flap, the vascular pedicle, including the posterior
Wound closure that is too tight may result in radial radial collateral artery with its venae comitantes, is suture ligated after adequate
nerve compression.
pedicle length is obtained (Fig. 92.7).
Anterior radial collateral artery

(diminutive in this patient)
radial nerve
Distal Proximal
Pedicle with perforators

entering the skin flap
FIGURE 92.7 The vascular pedicle is divided once enough length is obtained.
A B
FIGURE 92.8 (A–C) The flap can be thinned as needed.
Step 7: Closure
The triceps muscle is loosely sutured to the brachialis and BR muscles, and the donor
defect is closed primarily.
Step 9: Debulking
A flap debulking procedure is performed to reduce bulkiness if necessary (Fig. 92.8).

• Standard postoperative free flap protocols are followed.
• The donor site typically heals well with a linear scar (Fig. 92.9). Most patients have
numbness over the lateral side of the forearm because the posterior cutaneous
nerve of the forearm is divided during flap dissection, but few complain that this is
an impairment.
STEP 1 PEARLS
• The distance from the tip of the flap to the
pivot point should be 15% to 20% longer than
that from the most distant point of the defect
to the pivot point to achieve tensionless in-
setting of the flap.
• The pedicled reverse lateral arm flap is based
on a rich anastomotic network of small nonax-
ial vessels between the posterior radial collat- FIGURE 92.9 The donor site is closed primarily.
eral artery and radial recurrent artery; there-
fore the flap is designed not as a propeller flap
but as a peninsular flap.
PEDICLED REVERSE LATERAL ARM FLAP
STEP 1 PITFALLS Step 1: Marking
If a scar or defect exists around the lateral • Designing the position and shape of the flap is extremely important, especially for a
epicondyle, identify the exact course of the radial pedicled flap.
collateral artery to decide whether the vessels can • A Doppler probe is used to identify the course of the posterior radial collateral artery
be used as a pedicle for the flap. If a scar crosses and to identify the point where the most distal perforator arises from the radial recur-
the expected course of radial collateral artery, rent artery. This is usually proximal to the lateral epicondyle and serves as the distal
choose a different donor site.
pivot point of the flap.
• After thorough debridement, evaluate the size and shape of the defect. Similar to
the free flap design, outline the skin paddle over the posterior radial collateral artery
STEP 3 PEARLS (Fig. 92.10).
The radial artery and radial nerve are palpable.
If the tourniquet is not used, the pulsation of Step 2: Identify and Ligate the Proximal Posterior Radial Collateral
the radial artery can be detected by touch in Artery
the intermuscular septum. The radial nerve runs
beneath the artery and is also palpable. • Dissect both the anterior and posterior border of the flap and explore around the
septum to identify the posterior radial collateral vessels and radial nerve. See steps
1 to 5 of the “Free Lateral Arm Flap” procedure described earlier.
STEP 3 PITFALLS • Make a skin incision on the proximal edge of the flap. Divide and ligate the proximal
The intermuscular septum should not be incised vessels, and elevate the flap off the periosteum distally (Fig. 92.11).
until the radial nerve is located. Other vital • Identify the radial nerve in the intermuscular septum and retract the nerve down on
structures that are in the septum are the posterior
the humerus. The nerve runs beneath the posterior radial collateral artery.
radial collateral vessel and its perforators.
• Dissect the vessels toward the distal pedicle at the level of the BR muscle.
Expected course of radial collateral artery
A B
Pivot point Lateral epicondyle

FIGURE 92.10 (A–B) The pedicled reverse lateral arm flap is based on a rich anastomotic network of
small nonaxial vessels between the posterior radial collateral artery and radial recurrent artery; therefore
the flap is designed not as a propeller flap but as a peninsular flap.
Radial nerve
A B
Intermuscular septum
FIGURE 92.11 (A–B) The proximal flap dissection is done the same as for a free flap. The most important step is
dividing the posterior antebrachial cutaneous nerve and not the radial nerve; therefore the same attention to
proximal flap anatomy is crucial.
Rotated flap Rotated flap
Preserved radial nerve
FIGURE 92.12 (A–C) The reverse lateral arm flap can be islandized, but no axial vessel exists, so a wide
subcutaneous pivot point must be preserved.
STEP 4 PEARLS
After flap rotation, check the blood circulation to
Step 4: Flap Inset the flap. A twisted pedicle may disrupt feeding
vessels. Confirm the bleeding from the dermis
• Incise the skin at the distal margin of the flap. Carry the incision down through the and subcutaneous fat layer after rubbing them.
subcutaneous tissues to the fascia. Incise the fascia and attach it to the flap. If the bleeding is uncertain, put the flap back to
• Rotate the flap onto the defect without skeletonizing the pedicle (Figs. 92.12 and 92.13). the original position and recheck the bleeding. If
this improves circulation, it means the feeding
POSTOPERATIVE CARE AND EXPECTED OUTCOMES vessels are twisted. Additional mobilization of the
pedicles and dissecting the feeding vessels from
• After surgery, place the patient in a splint for immobilization for 2 weeks. the surrounding tissues is necessary.
• Keep the flap warm and avoid compression on the flap, especially around the pedicle.
FIGURE 92.13 Final inset, tension free.
EVIDENCE
Katsaros J, Schusterman M, Beppu M, Banis Jr JC, Acland RD. The lateral upper arm flap: Anatomy
and clinical applications. Ann Plast Surg. 1984;12:489–500.
The authors described the anatomy of the lateral upper arm flap based on 32 cadaver dissections. The
posterior radial collateral artery and its two venae comitantes that serve as the vascular pedicle of the
flap were found in all the cadavers. They also described the operative technique and the clinical re-
sults in 23 patients. Variations of the posterior radial collateral artery were found in three patients: the
artery arising not via the intermuscular septum but via the belly of the triceps in one patient and du-
plicate arteries in two patients. There was one flap failure, and all the patients had numbness over
the lateral aspect of the elbow postoperatively. One patient was found to have a radial nerve com-
pression syndrome after surgery because of tight donor-site closure.
Prantl L, Schreml S, Schwarze H, et al. A safe and simple technique using the distal pedicled reversed
upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg. 2008;61:546–551.
The authors retrospectively reviewed 10 patients who underwent distal pedicled reversed upper arm
flap. A lateral arm flap was performed in 8 out of 10 patients, and a medial upper arm flap was used
to cover the defect in the remaining 2 patients. Mean operation time was 1.5 hours. Flap failure did
not occur, and all patients had no restriction of elbow range of motion. This study showed that pedi-
cled reversed upper arm flap is a safe, stable, and simple technique without any critical complica-
tions (Level IV evidence).
Sauerbier M, Germann G, Giessler GA, Sedigh Salakdeh M, Döll M. The free lateral arm flap—a reliable
option for reconstruction of the forearm and hand. Hand (N Y). 2012;7:163–171.
The free lateral arm flap was used for coverage of the forearm and hand defects in 21 patients. The flap
width ranged from 3 to 8 cm. The length of the flap was 5 to 20 cm and the maximum pedicle length
was 8 cm. The mean operative time was 5 hours. All the donor-site defects were closed directly. No
patient had donor site morbidity, and only one case accepted a secondary procedure for flap thin-
ning. The authors concluded that the free lateral arm flap was a reliable option for defect coverage at
the forearm and hand for small and medium size defects (Level IV evidence).
Ulusal BG, Lin YT, Ulusal AE, Lin CH. Free lateral arm flap for 1-stage reconstruction of soft tissue and
composite defects of the hand: A retrospective analysis of 118 cases. Ann Plast Surg. 2007;58:173–178.
The authors retrospectively reported the long-term outcomes of the free lateral arm flap in 118 cases
with hand defects. One hundred and four reconstructions were fasciocutaneous, six were fascial,
and eight were composite flaps. The average flap size was 42 cm2. There were three flap failures,
and the success rate was 97.5%, without wound complications. The esthetic appearance of the flap
was satisfactory, and only 16% required a secondary thinning procedure (Level IV evidence).
Maruyama Y, Takeuchi S. The radial recurrent fasciocutaneous flap: Reverse upper arm flap. Br J Plast
Surg. 1986;39(4):458–461. http://doi.org/10.1016/0007-1226(86)90113-X. In this classic article, the
authors outline the anastomosis of the radial recurrent vessels and its anastomosis with the radial
collateral vessels at the level of the lateral epicondyle. This was the first paper to describe what we
now call the reverse flow lateral arm flap.
Tan BK, Lim BH. The lateral forearm flap as a modification of the lateral arm flap: vascular anatomy
and clinical implications. Plast Reconstr Surg. 2000;105(7):2400–2404.
The authors used latex injected specimens to demonstrate that the posterior radial collateral artery was
not axial distal to the lateral epicondyle, but branched into a finely arborized plexus that became
more superficial the further distal the branches went. This supported the extended lateral arm flap
(ELAF), incorporating skin beyond the lateral epicondyle.
Al-Kandari Q, Kalandar A, Burezq H. Versatility of lateral arm flap for hand reconstruction—A clinical
experience. Eur J Plast Surg. 2016;39:435–440.
A clinical series showing the versatility of the lateral arm flap in hand surgery, including fasciocutane-
ous, fascia, and osteocutaneous flaps.
CHAPTER 93
Venous Flap
Yu Zhou, Chun-Yu Chen, and Kevin C. Chung
INTRODUCTION
• The venous flap is a thin, pliable flap consisting of skin, subcutaneous tissue, and
veins. It differs from conventional flaps in that it is not an arterial afferent and venous
efferent flap (Fig. 93.1A). Instead, inflow and outflow occur through the venous sys-
tem of the donor tissue (see Fig. 93.1B). These flaps can be well shaped to fit differ-
ent wounds and provide great mobility, permitting wide range of motion (ROM) of the
hand for pinch and grip.
• The venous flap is a versatile reconstructive option because it can be harvested
without sacrificing the main donor artery and does not entail deep dissection. There
are many possible donor site options because the flap is not limited by the arterial
direction or the size of the vascular pedicle.
• There are two subcategories of venous flap:
• The purely venous flap (Fig. 93.2A) consists of total venous perfusion. Both the
afferent and efferent veins from the flap are anastomosed with veins at the re-
cipient site. Although this design has theoretical applications, it is seldom used
because the low oxygen concentration in the venous flow is thought to hinder
perfusion and nutrient circulation.
• The arterialized venous flap (AVF) consists of arterialized venous perfusion. The
afferent vein is anastomosed to an artery at the recipient site. The efferent vein is
A
FIGURE 93.1 (A) Traditional flap and (B) venous flap.
FIGURE 93.2 (A) Purely venos flap; (B) Arterial flow-through flap (A-A type) (C) Arterial inflow and ve-
nous outflow flap (A-V type). The arrows represent the direction of blood flow. The red color indi-
cates arterial blood flow; the blue color indicates venous blood flow.
694
anastomosed to an artery or vein. The AVF is the most commonly used venous
flap and will be discussed in this chapter.
• A-A type (arterial flow-through; see Fig. 93.2B): The A-A type is mostly used as
a vascular conduit to repair arterial defects and provide soft tissue coverage.
• A-V type (arterial inflow and venous outflow; see Fig. 93.2C): Unlike the A-A
type, the A-V type has more extensive applications because there are more
veins available for anastomosis at the recipient site.
• The AVF can be designed with antegrade or retrograde flow, meaning that blood
flows either through or against the venous valves within the afferent vein.
• In an antegrade AVF, perfusion is limited because the lack of resistance within the
afferent vessel encourages blood to travel straight through the flap instead of
entering the peripheral tissues (Fig. 93.3A). When blood does reach the periphery
of an antegrade AVF, congestion may occur as a result of the low pressure gradi-
ent across the flap and the limited number of drainage points.
• In a retrograde AVF, the IV pressure increases against the valves and theoretically
forces the blood into the peripheral circulation (see Fig. 93.3B).
• The potential limitations of the AVF must be taken into consideration when determin-
ing flap size. A retrograde AVF can be larger than an antegrade AVF because the
resistance within the flap vessels encourages more widespread perfusion. Neverthe-
less, to avoid complications, the maximum size should not exceed 50 cm2.
INDICATIONS
• The venous flap is a good option for many hand and digit repairs because it is thin
and mobile, with several potential donor sites:
• The volar forearm, dorsal foot, and the medial side of the lower leg provide good
coverage of the dorsal hand and digits, which need a thin and mobile flap to
maintain full motion.
• The thenar, hypothenar, and medial plantar regions are well suited to cover de-
fects of the fingertip and finger pulp, which is glabrous and has a thick cutaneous
layer and less flexibility.
• The venous flap can also be used to repair composite defects:
• Skin and vessel defects: The AVF is used to reconstruct soft tissue and vascular
defects simultaneously. It can be used for segmental defect in avulsion injury or
finger replantation. As a vascular conduit, the A-A type AVF can feed the distal
tissues of the digits.
• Skin and tendon defects: The AVF can be used to reconstruct skin and tendon
defects simultaneously. Common methods include forearm tendocutaneous AVF
with palmaris longus (PL) tendon or dorsalis pedis tendocutaneous AVF with
extensor digitorum longus (EDL) tendon.
B
FIGURE 93.3 Antegrade versus Retrograde Venous Flap. (A) The arterial flow through the valves
reaches the efferent vein smoothly. (B) The arterial flow against the valves, which has higher IV pres-
sure, forces the blood into peripheral circulation to achieve metabolism.
696 CHAPTER 93 Venous Flap
• Skin and nerve defects: The innervated AVF can restore both sensory function
and skin coverage of the hand or digit when a nerve graft is anastomosed with
the digital nerves. For instance, an AVF from the dorsum of the foot carries
branches of superficial peroneal nerves to the recipient site.
Contraindications
• Contraindications include infection of the recipient site, inadequate debridement
resulting in unhealthy tissue, and lack of reliable blood vessels available for anasto-
mosis at the donor site.
• Although there are cases of large venous flap survival, such as 70 to 120 cm2, sur-
vival is not reliable for defects greater than 50 cm2.
• The size and depth of the wound are assessed, and the wound is completely de-
brided. There must be sufficient blood supply over the wound bed. The healthy
wound bed should be red and shiny in appearance and bleed easily.
• Apply a tourniquet so that the veins engorge within the donor site and then assess the
venous distribution (Fig. 93.4). Mark the number and location of veins. Also determine
which veins should be afferent versus efferent based on their size and orientation. As
the size of the flap increases, the number of outflow veins should also increase to
encourage venous drainage.
• Evaluate the potential donor areas to determine whether the skin characteristics and
venous distribution are compatible with the recipient site. Options include the volar
side of the distal forearm, back of the foot, medial side of the lower limbs, and thenar
and hypothenar regions.
• Any site is suitable to repair small defects (less than 10 cm2).
• The distal forearm is ideal to repair soft tissue defects of medium size (11–24 cm2).
• The medial side of the lower extremity and the dorsal foot are used to repair large
soft tissue defects (at least 25 cm2).
• The thenar and hypothenar regions are used to repair small soft tissue defects in
the fingertips or finger pulp because of the similar skin features. The thick, gla-
brous skin from these regions can withstand high shearing forces on the palm.
IMAGING
A radiograph is used to detect the presence of fracture, joint dislocation, or bone defect
in the recipient area, which should be treated before flap transfer.
SURGICAL ANATOMY
• In antegrade flow, the venous valves function to prevent backflow and encourage
unidirectional blood flow. When arterial blood travels against the valves in retrograde
flow, the higher blood pressure can dilate the blood vessel wall and loosen the
valves, permitting blood flow.
FIGURE 93.4 Engorged vein network under pressure.

Type I. Through-valve type Type I. Through-valve type

Flow-though antegrade Y-shaped pattern
Ve1 V1
A Va Ve V A Va
Ve2 V2
Type II. Against valve type Type II. Against valve type
Reversed Y pattern H-shaped pattern
A Va A Va
V Va1
V Ve1
Type III. Mixed pattern:

through and against valves
V1 Ve1
Venous flap Va Afferent vein Anastomosis
Ve3 V3
Ligation
A Va A Recipient artery Ve Efferent vein
Arterial inflow
Ve4 V4 V Recipient vein Intra-venous valve Venous outlow
V2 Ve2
FIGURE 93.5 AVF Classification. Type I is a “through and along valve” pattern; Type II is an against-valve pattern; Type III is a
mixed pattern of through- and against-valve. (Fig. 22.36 in Chang, J, Neligan PC. Plastic Surgery: Volume 1. 4th ed. Elsevier;
2017:366–432.)
• The AVF is classified and designed based on the direction of blood flow with respect
to the venous valves (Fig. 93.5):
• Type I (antegrade): Through-valve AVFs have a straight or Y-shaped vein pattern
and may be used to cover small or long and narrow defects. This is a good option
for skin and vessel reconstruction.
• Type II (retrograde): Against-valve type AVFs contain a reversed Y- or H-shaped
venous network and may be used to reconstruct medium-sized defects.
• Type III: Mixed pattern AVFs are appropriate for larger defects.
• Type II and III AVFs are more conducive to flap survival because the blood flow
rate is better controlled in a retrograde system. The blood is forced into micro-
circulation as it oscillates back and forth against the valves, effectively perfusing
the flap.
• The proper pressure gradient between afferent and efferent parts of the flap is critical
to maintaining perfusion and microcirculation. Ideally, the flap should have resistant
inflow and more free-flowing outflow to permit drainage.
• Maintaining resistant inflow depends on the characteristics of the afferent vein,
which should be smaller in diameter than the efferent vein. A long afferent vein
pedicle is unnecessary and may even damage the flap if the vessel becomes
twisted and restricts blood flow. If several arteries are available in the recipient
site, select the smaller one for anastomosis.
• An appropriate efferent vessel is key to preventing congestion. A flap with larger,
longer, and more than one efferent vein is less likely to become swollen and ne-
crotic. Increasing the number of drainage vessels also encourages more efficient
nutrient and oxygen exchange. Drainage through a proximal vein is more efficient
because blood flows through the valves.
• Flap survival also depends on the density and distribution of flow-through veins.
• The veins in the AVF cannot be completely straight and unobstructed because
the lack of resistance would encourage the high-pressure arterial blood to travel
through the flap too quickly, without entering the peripheral tissue.
• To avoid this, the flow route is designed so that afferent and efferent veins are
both on the proximal side of the flap. If the venous design is Y- or H-shaped, then
distal veins can be ligated so that blood flow is reverted back to the proximal side
(see Fig. 93.5).
ARTERIALIZED VENOUS FLAP COVERAGE AFTER

DERMATOFASCIECTOMY
Surgical principles are illustrated in the case of Dupuytren contracture (Fig. 93.6). After
removal of the underlying cord on the middle finger, a venous flap is designed to
cover the wound. Dermatofasciectomy for Dupuytren contracture is explained further
in Chapter 98. Observations have shown that by removing the entire skin component,
recurrence of Dupuytren cord is minimized. Furthermore, the skin defect after scar
contracture release should be replaced by a well-designed flap in a one-stage proce-
dure, rather than a pedicle flap such as a cross-finger flap, that would need division at
the second stage.
Step 1: Recipient Site Assessment and Donor Site Selection

• An incision is marked over the palm and finger for removal of skin and underlying
cord (Fig. 93.7).
• An incision is made beyond the cord margin. The skin flap is then elevated and the
neurovascular bundles are carefully identified.
• The central cord and the skin are excised over the pulley system so that the fingers
can fully extend. The bilateral neurovascular bundles and flexor tendons are ex-
posed (Fig. 93.8).
• The skin defect measures 2.8 cm by 1.2 cm in size, extending distally over the meta-
carpophalangeal (MCP) joint to the proximal phalanx.
• The defect is assessed; in this case, there are no associated tendon, vessel, or nerve
defects. Moreover, the defect is small and the area is rather nonsensitive. The ipsi-
lateral volar distal forearm is a good donor site option because the skin is pliable,
permitting primary closure of the donor site.
FIGURE 93.6 Dupuytren contracture.

FIGURE 93.8 Bilateral neurovascular bundle and flexor tendons are exposed.
FIGURE 93.9 Venous network in the AVF. AVF, Arterialized venous flap. STEP 2 PEARLS
• The flap should be at least 10% larger than
the defect to ensure a tension-free closure.
Step 2: Flap Design and Harvest • Both afferent and efferent veins should be on
• The engorged venous network is easily seen by the naked eye under the pressure of the proximal side of the flap to promote drain-
age.
a tourniquet (Fig. 93.9). An H-shaped flap is designed over a dense venous network.
• The afferent pedicle should be small and short
• The flap size measures 3.0 cm by 1.5 cm, slightly larger than the defect at the re- to control (limit) blood flow velocity, avoid a high
cipient site. The long axis of the flow-through vein is designed in the center of the number of venous valves in the afferent vessel,
flap. and reduce the risk of pedicle kinking. The ef-
• The incisions parallel to the flow-through vein are made first, and then the superficial ferent pedicle should be larger and longer than
the afferent vein to encourage venous drainage
fascia layer is sharply elevated beneath the vein. The venous network and surround-
and make it easy to reach the recipient vessel.
ing fascial tissue are protected. The two distal veins are ligated and divided. The two • A ratio of one afferent vein to two efferent
proximal veins, which together make a U-shape, are selected as the afferent and veins is appropriate for small to medium-sized
efferent veins (Fig. 93.10). flaps. Larger flaps should have more efferent
• The vascular pedicle is carefully dissected to the proximal border of the flap, and the veins to increase drainage.
• A denser venous network is also needed to
flap is elevated (Fig. 93.11). The inflow vein can be kept short, but the outflow vein
perfuse a larger flap. If the number of efferent
should be as long as possible to reach the recipient vein without tension. In this vein options is limited, then the vessels should
case, it should be long enough to reach the dorsum of the finger. be anastomosed more proximally, where the
• The diameter and distance of the two vessels are measured. The afferent vein is vascular diameter is large enough for efficient
much smaller than the efferent vein, measuring 0.5 mm in diameter. The efferent vein drainage.
is 1.0 mm in diameter and 4 cm in length.
Step 3: Flap Transfer and Vessel Anastomosis STEP 2 PITFALLS
• The radial digital artery is chosen as the recipient artery to provide arterial blood to It is important to ligate the venous twigs securely
to prevent postoperative hemorrhage from high
the flap in a retrograde fashion (see Fig. 93.5). This artery is clamped to confirm that
arterial pressure.
the finger can be perfused sufficiently by the ulnar digital artery.
Efferent vein
Efferent vein
Afferent vein
Afferent vein
FIGURE 93.10 The smaller and shorter vein is the afferent vein; the
larger and longer vein is the efferent vein. FIGURE 93.11 The flow-through vein is designed as a U-shape by
ligating the two distal veins.
Radial digital A.
FIGURE 93.12 Afferent vein and recipient artery.
• The radial digital artery is cut at its proximal end. It is then anastomosed end-to-end
with the afferent vein of the AVF under a microscope (Figs. 93.12 and 93.13).
• After releasing the vessel clip, check that the AVF has immediate pulsatile flow
STEP 3 PEARLS through the valves of the efferent parallel vein (Fig. 93.14).
• The afferent vein should be close to the • The efferent vein is long enough to tunnel through the intermetacarpal space to the
recipient artery to prevent pedicle kinking. dorsal hand, where a healthy recipient vein is available (see Fig. 93.14). The vessels
• Retrograde input and antegrade output help are similar in caliber, measuring about 1 mm in diameter, and anastomosed in an
ensure the appropriate pressure gradient end-to-end manner (Fig. 93.15).
between afferent and efferent parts of the
• After the tourniquet is removed, the patient has proper dilation of the dorsal hand
flap and thus promote flap survival.
veins and the flap becomes pink (Fig. 93.16).

• The recipient site is closed with interrupted 4-0 Nylon sutures.
• The donor site is also primarily closed with 4-0 Nylon sutures (Fig. 93.17).

• The hand is dressed and fixed in a splint for 14 days before initiating ROM exercises.
• A window is cut in the dressing to expose the flap and permit direct observation.
AVF color, skin temperature, and capillary response should be monitored.
Radial digital A.
AVF
Afferent vein
FIGURE 93.13 The afferent vein is 0.5 mm in size, anastomosed end-to-end with the radial digital artery.
FIGURE 93.14 The efferent vein was tunneled through the intermetacarpal space dorsally and imme-
diate pulsatile flow was noted.
FIGURE 93.15 The efferent vein was anastomosed to a vein over the dorsal hand with the same caliber.
FIGURE 93.16 The flap was perfused well and is now pink.
FIGURE 93.17 Wound closed.
FIGURE 93.18 (A) First week after operation; swelling and mild congestion was noted. (B) After
1 month, the flap congestion subsided and healed well.
• In the first week after the operation, swelling of the flap may become apparent but
should gradually subside (Fig. 93.18A–B). If not, be vigilant. Thrombosis can be
treated by revision of the anastomosis.
• The hand should be elevated to decrease venous congestion. In this case, the pa-
tient is admitted for 3 days to receive IV heparin and aspirin.
See Video 93.1
EVIDENCE
Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized
venous free flaps having 2 parallel veins. J Hand Surg Am. 2008;33(10):1802–1806.
The authors performed 44 arterialized venous free flaps for the reconstruction of digital soft tissue
defects. The authors had satisfactory results using these flaps (Level IV evidence).
Woo SH, Kim KC, Lee GJ, et al. A retrospective analysis of 154 arterialized venous flaps for hand
reconstruction: An 11-year experience. Plast Reconstr Surg. 2007;119(6):1823–1838.
The authors presented their 11-year clinical experience of 154 AVF hand reconstruction cases. They
classified the venous flaps based on size and composition. The authors concluded that the
arterialized venous flap is a valuable and effective tool for reconstructing complex hand injuries
and may have a more comprehensive set of indications (Level IV evidence).
Lee DC, Kim JS, Roh SY, Lee KJ, Kim YW. Flap coverage of dysvascular digits including venous
flow-through flaps. Hand Clin. 2019;35(2):185–197.
The authors presented a dysvascular digit, which is defined as a threatened circulatory condition
caused by illness or trauma. A dysvascular digit always needs surgical manipulation of the vessel in
trauma cases. The revascularization of the digit is a priority, after which reconstruction of the defect
is performed. In this article, the authors present and discuss the venous free flap, thenar free flap,
toe plantar free flap, free style perforator flap, hypothenar free flap, and anconeus muscle free flap
CHAPTER 94
Revascularization and Replantation of Digits
and Hand
Kevin C. Chung
Replantation refers to the reattachment of a completely amputated part of a digit,

whereas revascularization is defined as repair of an incompletely amputated part that is
nonviable and will experience necrosis without vascular repair.
INDICATIONS
• The aim of digit replantation is not only to restore vascularity but also regain useful
function. There are many factors that influence the final decision, including the type
of injury; level of amputation; which digit was injured; and patient factors, such as
age, personal expectations, and professional needs. The surgeon should weigh
functional achievements against treatment costs when considering revision amputa-
tion versus replantation. Discuss all considerations with patients thoroughly before
a final decision is made.
• Absolute indications include thumb amputation (Fig. 94.1), multiple digit amputa-
tions (Fig. 94.2), and any amputation in a child.
• Relative indications include single finger amputation distal to the flexor digitorum
superficialis (FDS) insertion and ring finger avulsion amputation.
Contraindications
Contraindications include patients with comorbidities contraindicating microsurgery,
psychosocial factors that affect compliance with therapy, and gross damage of the
amputated part.
FIGURE 94.1 Thumb amputation. FIGURE 94.2 Multidigit amputation.
704
CHAPTER 94 Revascularization and Replantation of Digits and Hand 705
• A thorough history collection and an appropriate trauma evaluation are made first to
exclude conditions that are not suitable for replantation.
• Both the amputated part and proximal part are carefully checked. Mechanism of
injury, ischemic time, and preserving method are obtained before surgery.
• The patient’s overall health and comorbid conditions should be carefully evaluated,
which will contribute to making the final decision.
IMAGING
Plain radiographs, typically consisting of posteroanterior (PA) and lateral views, should
be taken to evaluate the extent of the bone injury of both the injured hand and the
amputated part (Fig. 94.3A–C).
SURGICAL ANATOMY
• The phalanx is located in the center of the cross section of each digit (Fig. 94.4). The
dorsal extensor apparatus, flexor digitorum profundus (FDP) tendon, and/or FDS
tendon and their sheaths embrace the phalanges and joints. There are two proper
A B C
FIGURE 94.3 (A–C) PA, oblique, and lateral films of a multidigit amputation. PA, Posteroanterior.
Dorsal veins
Extensor
tendon
Digital artery
Palmar digital Palmar digital Digital nerve
A B
nerve artery
FIGURE 94.4 (A) Cross-section illustration of digit. (B) Exposure of key anatomic structures in a digit. (From Neligan’s
Plastic Surgery. 3rd ed. Fig. 5.8.4)
706 CHAPTER 94 Revascularization and Replantation of Digits and Hand
digital arteries that provide the major blood supply in each digit. They are located at
the dorsolateral aspect of the digital nerves. Distal to the metacarpophalangeal
(MCP) joint, the bilateral neurovascular bundle travels along the lateral sides to the
flexor tendon between the volar Grayson ligament and the dorsal Cleland ligament
(Fig. 94.5). The diameter of the digital artery at the level of the proximal phalanx is
1.0 to 1.5 mm, and that of the terminal branch at the fingertip is 0.2 to 0.3 mm. The
ulnar digital arteries of the thumb, index, and middle fingers have greater diameters
than those of the parallel radial arteries. On the contrary, in the ring and little fingers,
the radial digital arteries are larger.
• The dorsal veins that are located between the skin and the extensor tendon are larger
in diameter than the volar veins, so the backflow of the amputated part is dependent
on repairing these dorsal veins in most cases. Precise vein repair, of as many veins
as possible, is critical to the success of replantation.
• In the fingertip, two digital arteries run centrally to communicate with each other and
form the distal transverse palmar arch at the level of the middle of the pulp (nail
base). The palmar arch sends off several longitudinal branches to supply the finger-
tip (Fig. 94.6A–B). The central branch is often larger than the ones in the lateral side
and is just palmar to the distal phalanx. The digital nerves turn from the palmar-
medial to the dorsolateral aspect of the arteries in the distal phalanx, which is con-
trary to the middle and proximal phalanges. Proximal to the nail base, one large
dorsal terminal vein is located at the middle of the distal digit (see Fig. 94.6C). Distal
to the nail base, there is no dorsal vein that can be anastomosed, so small and thin
veins on the volar side are often used to reconstruct venous drainage in fingertip
replantation; however, no consistent palmar vein has been described.
POSITIONING
• The patient is placed in a supine position on an operating table with the hand on a
hand desk and a tourniquet on the upper arm.
• To expose the ulnar digital artery of the thumb, the hand should be placed in a supinated
position, which can be uncomfortable. This can be avoided by using a vein graft to con-
nect the ulnar digital artery and the radial artery at the anatomic snuff box (Fig. 94.7).
• The patient’s temperature must be maintained as close to normal as possible to
avoid peripheral vasospasm.
Palmar digital
artery
Grayson A4 pulley
ligament
A3 pulley
Distal
transverse
palmar arch
A2 pulley Dorsal
terminal
vein
A B C
FIGURE 94.5 Illustration of neurovascular bundle and sur-
rounding ligaments. FIGURE 94.6 (A–C) Illustration of digital arteries and dorsal veins.
STEP 1 PEARLS
• The digital nerves are usually identified first
because they are not retracted as much and
are easier to locate. As the nerve is pulled
aside, look for the retracted artery at the
dorsolateral aspect of the nerve.
Vein graft
• A bilateral midlateral incision is helpful to
expose the volar neurovascular bundle
Radial artery (Fig. 94.9A–B).
• In the fingertip, the distal transverse palmar
arch and its branches run superficial to the
insertion of the FDP tendon. The distal ends of
the arteries may appear when compressing
FIGURE 94.7 Vein graft interposition. the pulp gently.
• In an effort to save time, especially when re-
plantation of the multiple digits is performed,
one team can prepare the amputated parts
PROCEDURE before the patient is brought to the operating
room.
Step 1: Debridement and Inspection
• Contaminated and nonviable tissues are removed (Fig. 94.8).
STEP 1 PITFALLS
• The retracted ends of the tendon are identified and debrided to a clean margin.
• It is better to identify and debride the retracted
• The digital nerves and arteries are identified and tagged with 6-0 Prolene sutures for
proximal flexor tendon at this step rather than
easier identification. after bone fixation.
• Any attached tissue of an incomplete amputa-
Step 2: Bone Shortening and Fixation tion, even if it is narrow, should be preserved
• The crushed bones in both the amputated part and the proximal part are removed with because this skin bridge contributes to venous
drainage to assure greater success (Fig. 94.10).
a rongeur. The bones should be shortened to permit ease of vessel repairs, which will
STEP 2 PEARLS
• In addition to avoiding infection, the aim of
bone shortening is to achieve primary repair of
the tendons and neurovascular structures.
There is no outcomes concern if the bone
shortening is limited to about 1.0 to 1.5 cm in
the digits, but an addition of 1 to 2 mm of ves-
sel length can provide more leeway to perform
anastomosis without tension.
• Besides K-wire, several materials, including
interosseous wiring, miniplate, and screws,
can be used to fixate the bone, but application
of these may be time-consuming and require
additional soft tissue dissection.
• If the joint cannot be preserved because
of damage or loss, primary arthrodesis is
required.
• If possible, any joints should be stabilized
in the functional position.
• One should consider spare part surgery. In
particular, a nonsalvageable digit can be used
for bone, nerve, tendon, skin, and potential
joint grafting.
FIGURE 94.8 Debridement of nonviable tissue.
Neurovascular
bundle
B
A
FIGURE 94.9 (A) Bilateral midaxial incision exposes the volar neurovascular bundle. (B) Exposure of the neurovascular bundle.
STEP 2 PITFALLS
• It is important to protect the adjacent soft
tissues from iatrogenic damage during bone Skin bridge can
shortening and fixation. provide venous
• The bone surfaces should be smooth so that drainage
good bony contact can be achieved to prevent
nonunion.
• When a single K-wire is used for bone fixation,
periosteum repair is useful to prevent finger
rotation.
STEP 3 PEARLS
• Effort should be made to balance the force
between the extensor and flexor tendons by FIGURE 94.10 Dorsal skin bridge is left intact to facilitate venous drainage.
checking normal finger cascade.
• Repair of the FDS tendon is not necessary in
proximal phalanx replantation, because repair- decrease operative time. For revascularizing injuries, the bones cannot be resected.
ing both the FDS and FDP will compromise Vein grafts from the volar wrist are needed to interpose into the arterial defect.
gliding through the A2 pulley and result in lim- • The bones are fixated with two retrograde Kirschner wires (K-wires; Fig. 94.11). K-wires
ited proximal interphalangeal (PIP) joint motion. are used to expedite the surgical conduct. The endurance of the surgeon is a limiting
In revascularization injuries, however, the FDS
tendons are repaired to provide a gliding sur-
face for the FDP tendon. If the PIP joint is in-
tact, a functioning FDS tendon enhances finger
motion.
STEP 3 PITFALLS
Make sure to repair the lateral bands of the
extensor tendon and intrinsic tendons at the
level of the proximal phalanx; otherwise, it will
result in a severe flexion deformity of the distal
interphalangeal (DIP) joint.
Fracture line
FIGURE 94.11 Kirschner wire (K-wire) fixation expedites surgical conduct.

Flexor
Extensor tenorraphy
tenorraphy Palmar digital
artery and
nerve repair
STEP 4 PEARLS
• We recommend the 180-degree vertical tech-
nique. The first suture is placed in the middle
Volar side of the back wall of the vessel (Fig. 94.15A). The
FIGURE 94.12 Extensor tenorrhaphy. needle is first placed out-to-in of the lumen of
FIGURE 94.13 Flexor tenorrhaphy and repair of palmar one end, and then placed in-to-out of the lu-
digital artery and digital nerve. men of the other end, so that the knot is placed
outside the lumen. The second suture is placed
in the middle of the front wall where it is 180
degrees from the first suture (see Fig. 94.15B).
factor. The operation must be performed expediently, particularly with multidigit replan- The long ends of the first two sutures are
pulled (see Fig. 94.15C) to rotate the vessel in
tations, because the surgical conduct may be less optimal when fatigue sets in.
either direction for placement of the remaining
sutures (see Fig. 94.15D). This technique per-
Step 3: Tendon Repair mits rotation of the vessel through only 90 de-
• The extensor tendon is repaired with the horizontal mattress suture method (Fig. 94.12). grees so that long dissection of the vessel and
• After extensor tendon repair, the flexor tendon is sutured using a four- or six-strand a turning clamp are not necessary. The vessels
are short and cannot be rotated. Thus repairing
3-0 braided suture technique (Fig. 94.13). the back wall first permits ease of repair.
• If reconstruction of the bilateral digital arteries is
Step 4: Arterial Anastomoses and Nerve Coaptation not available, the dominant artery (the one with
• The digital arteries are debrided under an operating microscope until healthy intima the larger diameter) should be repaired.
is presented (Fig. 94.14). • A small nerve gap (less than 1.5 cm) can be
bridged by vein graft rather than nerve graft.
• After a good pulsatile blood from the proximal artery is confirmed, the arterial anasto-
• We prefer to repair the dorsal veins first after
moses are performed with 9-0, 10-0, or 11-0 interrupted nylon sutures (see Fig. 94.13). bone fixation because this is the most techni-
• The digital nerves are repaired with two or three epineurial sutures after being cally difficult part of the operation. The extensor
trimmed back to healthy fascicles (see Fig. 94.13). tendon can be repaired expediently, then as
many veins are repaired as possible. The dorsal
Step 5: Venous Anastomoses skin is closed, which leaves the volar structures
to repair without having to turn the hand again.
Two or more dorsal vein anastomoses are performed to provide venous drainage (Fig. 94.18).
A B
C D
FIGURE 94.14 Debridement of digital artery to
healthy intima. FIGURE 94.15 (A–D) A 180-degree vertical technique for arterial anastomosis.
STEP 4 PITFALLS 1
4
• If there is a vessel defect after debridement, a
vein graft harvested from the volar wrist is
used to bridge the defect (Fig. 94.16A–B). The
vein graft should be reversed to retain ante-
grade flow rather than flow against the venous
valves (see Fig. 94.16C). 3
• A ribbon sign (Fig. 94.17), particularly after A
avulsion injuries, indicates torsion and stretch 2
on a vessel. In this situation, a long-injured
part of the vessel is debrided, and a vein graft
is often needed. A
B
• It is extremely important to facilitate vessel anas-
tomosis without tension. Shearing force of the
sutures because of anastomosis under excessive
tension will lead to tearing of the vascular wall,
bleeding, vasospasm, and ultimately thrombosis.
• For thumb avulsion amputations, the recom- B
mended method is to use a vein graft to con-
nect the ulnar digital artery of the thumb to a
A
branch of the radial artery in the anatomic B
snuff box (see Fig. 94.7). This is easier to per-
form than shifting a digital artery from other
fingers. The ulnar and radial arteries for the
thumb are kept over the volar skin flap via the
midaxial incision. Therefore, both arteries can
be exposed and repaired with the hand pro-
nated, rather than the awkward supinated Heparinized saline
hand, which makes the repair easier. It is un-
necessary to place the patient prone on the C
operating table to facilitate the arterial repair. FIGURE 94.16 (A–C) Vein graft harvest and reversal.
• In fingertip replantation, there is usually not enough
space to place the vessel clamps, so we perform
the anastomoses under tourniquet control.
STEP 5 PEARLS
• If it is difficult to identify the dorsal vein first, the Red-line sign
artery is connected to observe the backflow of
blood at the skin edge after restoring the arterial
blood supply and then finding its partner in the
dorsal subdermal layer at the proximal corre-
sponding site.
• Use an arm or finger tourniquet to avoid
performing venous anastomosis in the diffuse
bloody field.
STEP 5 PITFALLS
Dorsal vein
• Ideally, two veins are repaired per one artery Ribbon sign anastomosis
repaired, but it is difficult to find four or more
veins to anastomose. The anastomoses with
larger diameters can reduce the number of
veins to repair.
• In addition to dorsal vein anastomosis, the
veins on the palmar side of the pulp can be
repaired to increase venous outflow in distal
digital replantation. FIGURE 94.17 Ribbon sign. FIGURE 94.18 Dorsal vein anastomosis.
• Vein repair is frequently not available in fingertip
replantation distal to the nail base. External bleed-
ing by nail bed removal or application of leeches
can improve the venous drainage postoperatively.
Artery-only replantations can survive when the
amputated digit has a lower tissue oxygenation Step 6: Skin Closure and Dressing
requirement, such as distal amputations. Occa- • The skin is closed loosely using 4-0 chromic sutures after careful hemostasis
sionally, blood outflow can be achieved using an (Fig. 94.19A–B).
arteriovenous shunt by repairing the arteries with
a vein graft to a large dorsal vein. • The hand is placed in a soft and bulky dressing, and the tip of the replanted digit is
left exposed for postoperative monitoring (Fig. 94.20).
A B
FIGURE 94.19 (A–B) Skin closure with 4-0 chromic sutures.
Dressing leaves fingertip

exposed for post-operative
monitoring
FIGURE 94.20 Tip of replanted digit left exposed for postoperative monitoring.

• The patient should be kept in a warm room (over 70° F) with the hand elevated. To avoid tension, the midaxial incisions may be left
Postoperative monitoring of the replanted digit is performed for 5 days. The dressing partially open or a skin graft can be placed over
is not changed in these days unless excessive bleeding from the wound occurs. open wounds. Tight closure will cut off the blood
flow in the tediously repaired vessels.
Adequate pain control and broad-spectrum antibiotics should be given to the patient
postoperatively. Our standard protocol for prevention of thrombosis is to give low-
dose heparin at 800 U/h and dextran 40 at 25 mL/h for 5 days after replantation. The STEP 6 PITFALLS
patient can be discharged in 5 days after replantation, and the sutures removed in • The skin suture needle should be placed care-
10 to 14 days. fully to be sure to avoid injuring the underlying
• Postoperative monitoring of a replanted digit includes digital color, turgor, capillary anastomosed vessels.
• Dressing in a circumferential manner may
refill, and surface temperature (Table 94.1). Needle prick of the digit pulp using an result in vascular compression.
18-gauge needle to observe the speed and color of vascular flow can be used when
the previously mentioned indicators are not clear. Fast and dark bleeding suggests
TABLE
94.1 Factors in Postoperative Monitoring of a Replanted Digit
Normal Arterial Crisis Venous Crisis

Color Rosy Pale Dark red or purple
Surface temperature .32 degrees Celsius Decrease Decrease
Turgor Moderate Flaccid Firm
Capillary refill 1–2 seconds Slow or none Brisk
venous insufficiency, whereas slow or absent bleeding from the pinprick point is a
sign of arterial insufficiency.
• When vasospasm is suspected, the factors that cause the patient discomfort should
be identified and addressed first. The arterial problem often happens within 2 hours
after anastomosis, whereas venous thrombosis is usually found during the first 72
hours after replantation. Once arterial thrombosis is confirmed, an immediate return
to the operating room for exploration, thrombectomy, and revision of the anastomo-
ses is the only way to salvage the digit. When venous congestion is not severe, or
in fingertip replantation, it may be overcome by placing normal-strength heparin on
the nail bed or by using medical-grade leeches (Fig. 94.21A–B).
• Initiation of postoperative hand therapy depends on the stability of bone fixation.
K-wires are usually removed at 6 to 8 weeks.
• The survival rate of replantation varies from 70% to 93% in the large replantation
reports of more than 100 cases. The survival rates for revascularization are consid-
ered higher than those of replantation because the venous drainage is often se-
cured. The factors affecting survival rate include characteristics of injury, level of
amputation, skill of the surgeon, and patient age. Avulsion injuries have the lowest
survival rate, crush injuries have a better survival rate, and clean guillotine injuries
have the highest survival rate of replantation. More proximal replantation has a
higher survival rate because of larger vessel diameter.
• The functional outcomes of digit replantation, such as range of movement and sen-
sation, are inconsistent. In general, younger patients, guillotine trauma with a limited
injury, or more distal amputation have better recovery. Although bone shortening,
joint stiffness, and tendon adhesion may occur after replantation, a thumb that main-
tains length can restore favorable appearance and function.
• Fig. 94.22A shows a left thumb amputation that underwent replantation and
achieved favorable return to function and excellent appearance at 1 year postopera-
tively (see Fig. 94.22B–C).
• Fig. 94.23A shows an oblique crush amputation of the right hand that underwent
replantation. After 1.5 years of excellent compliance with hand therapy sessions and
A B
FIGURE 94.21 (A–B) Medical-grade leeches prevent venous congestion.

A B C
FIGURE 94.22 (A) Complete amputation of left thumb. (B–C) Favorable thumb opposition and appearance at 1-year follow-up.
A B
C D
FIGURE 94.23 (A) Complete amputation of right hand. (B) Satisfactory thumb abduction and opposition at 1.5-year follow-up visit. (C) Patient is able
to make a fist at the 1.5-year follow-up visit.
subsequent opponensplasty to improve thumb function, the patient achieved satisfac-

tory thumb abduction and opposition (see Fig. 94.23B), and is able to form a fist (see
Fig. 94.23C).
EVIDENCE
Chung KC, Yoon AP, Malay S, Shauver MJ, Wang L, Kaur S; FRANCHISE Group. Patient-reported and
functional outcomes after revision amputation and replantation of digit amputations: The FRANCHISE
multicenter international retrospective cohort study. JAMA Surg. 2019;154(7):637–646.
The authors conducted a retrospective cohort study across 19 centers in the United States and Asia to
compare patient-reported and functional outcomes after revision amputation or replantation for trau-
matic digit amputation. A total of 338 adults, aged 18 years or older, were recruited and followed for
a minimum of 1-year posttreatment. The replantation cohort demonstrated significantly better aggre-
gated patient-reported outcome scores, measured by the Michigan Hand Outcomes Questionnaire
(MHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity
module. Subgroup analyses revealed that the revision amputation cohort had significantly better
two-point discrimination for single-finger amputations distal to the PIP joint. Nevertheless, the replan-
tation cohort achieved significantly greater pinch strength in patients with two digits amputated
(excluding the thumb), better nine-hole peg test times in patients with three or more digits amputated
(including the thumb), and better Semmes-Weinstein monofilament test in patients with three or
more digits amputated (excluding the thumb). The authors conclude that replantation achieves better
patient-reported outcomes and long-term functional benefit in patients with three or more amputated
digits and in single-finger amputations (excluding the thumb) that are distal to the PIP joint (Level III
evidence).
Yoon AP, Mahajani T, Hutton DW, Chung KC, Finger Replantation and Amputation Challenges in
Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE) Group. Cost-effectiveness of
finger replantation compared with revision amputation. JAMA Netw Open. 2019;2(12):e1916509.
This cost-effectiveness analysis used data from the Finger Replantation and Amputation Challenges
in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE) study to identify the most
cost-effective treatment for traumatic digit amputation. With a willingness-to-pay threshold of
$100,000 per quality-adjusted life-years, the authors demonstrated that replantation was cost-
effective compared with revision amputation for all finger amputation patterns, including single-
finger and multidigit amputations. The highest probability for replantation to be cost-effective
was observed in multifinger replantations (excluding the thumb; Level II evidence.)
Cho HE, Kotsis SV, Chung KC. Outcomes following replantation/revascularization in the hand. Hand
Clin. 2019;35(2):207–219.
This review article discusses the numerous factors that influence outcomes for digit replantation and
revascularization and presents strategies for measuring and analyzing functional and patient-reported
outcomes in these patients. In addition, the authors teach the key concepts for evaluating initial
vascular success in replanted digits (Level V evidence).
CHAPTER 95
Toe to Thumb Transfer
INDICATIONS
• One indication is loss of the thumb because of a traumatic injury (Fig. 95.1).
• Although replantation of the amputated thumb is always considered first, there
may be instances where the amputated digit is not viable or replantation is not
possible. For these cases, toe to thumb transfer is an excellent option for replac-
ing the lost digit.
• Traumatic amputation at the level of the proximal phalanx is the optimal indication
because this preserves the carpometacarpal (CMC) and metacarpophalangeal
(MCP) joints.
• Another indication is multiple finger amputations.
• Toe transfer procedures can reconstruct the thumb and other amputated digits,
restoring the essential tripod pinch function to the hand.
• One final indication is a congenital thumb defect.
• Constriction ring syndrome (CRS), which occurs when fibrous bands of the am-
niotic sac entangle fetal structures and restrict their growth, can cause congenital
thumb defects. Unlike other congenital malformations, CRS typically presents
with healthy joints, muscles, and tendons proximal to the defect site. Therefore
CRS is an excellent indication for toe to thumb transfer.
• It is crucial that patients understand the limits of reconstruction, the morbidity and
aesthetic changes to the donor site, and the possibility that the surgery will be un-
successful. The reconstructed thumb may not restore full function and range of
motion (ROM) to the hand, and its appearance will differ from the opposite thumb.
In addition, patients may have concerns that walking and exercise will be impaired
postoperatively, despite evidence that demonstrates no significant difference in
postoperative function of the foot.
• For traumatic digit amputations, we recommend delayed transfer in all cases to
permit optimal healing of soft tissue. This also gives the patient time to psycho-
logically prepare for the procedure, recognize the functional deficit, and compre-
hend the need for the procedure. Finally, the patient must be motivated to comply
with the rigorous rehabilitation that will be necessary for a successful postoperative
outcome.
FIGURE 95.1 Traumatic thumb amputation at the level of MCP joint. MCP, Metacarpophalangeal.
715
716 CHAPTER 95 Toe to Thumb Transfer
INDICATIONS PEARLS
Contraindications
• The procedure should not be performed in children younger than 2 years old, be-
• If reconstruction of the amputated thumb is
still desired after replantation is deemed not cause the small caliber of the blood vessels will preclude microvascular anastomosis.
feasible, it is best to preserve as much length • Other contraindications include vascular disease, lack of compliance with smoking
as possible of the remaining bone, tendons, cessation and postoperative care, and any previous injuries of the foot that hinder
and neurovascular structures. This will facili- toe harvest.
tate reconstructive procedures such as toe to
thumb transfer. CLINICAL EXAMINATION
• Children with unilateral thumb malformations
can be treated as early as 2 years of age. • Examine the structures at the amputation level of the thumb and the patient’s re-
Early treatment will avoid the development of maining hand function. This assessment can inform whether the remaining tendons
adaptive behaviors, such as decreasing the can still glide and permit flexion and extension of the digit. In addition, examine the
use of the abnormal hand.
surrounding soft tissue to anticipate whether the transferred toe will face challenges
• Preoperative and postoperative photographs
that demonstrate the results of toe to thumb during healing.
transfer and the typical appearance of the do- • Assess the patient’s expectation of how the procedure will restore function and their
nor site defect (Fig. 95.2A–B) can facilitate motivation to cooperate with the rehabilitation program.
patient understanding and expectations for • The choice of the recipient vessel for anastomosis will either be the radial artery or
the procedure.
the princeps pollicis, depending on the level of the amputation. Therefore it is critical
• We advocate the use of the second toe for
thumb reconstruction because the donor site to perform the Allen test during the clinical examination to verify that the ulnar artery
deformity is minimal. Harvesting the big toe alone can provide adequate perfusion to the hand once the radial artery or princeps
will cause substantial damage to the appear- pollicis anastomosis with the donor vessel is complete.
ance of the foot, as well as problems with • The thumb amputation site should be free of infection before toe to thumb transfer.
push off, despite preservation of the big toe
• The critical consideration is whether there is enough soft tissue over the thumb to
head of the metatarsal.
support the toe. One should not harvest too much soft tissue from the foot, which
can cause wound complications. In certain situations, a groin flap is placed over the
thumb as the first stage to add soft tissue that can be used to wrap around the toe
to cover critical structures.
FIGURE 95.2 (A) A 4.5-year follow-up after transfer of the second toe to the right thumb. (B) Appearance
of the donor site.
FIGURE 95.3 Radiographs show a thumb amputation at the level of the MCP joint. MCP, Metacar-
pophalangeal.
IMAGING
• X-ray imaging can detect the remaining bone length of the thumb, the presence of
additional bone defects, and the integrity of joints such as the interphalangeal (IP)
joint and the MCP and CMC joints (Fig. 95.3).
• X-rays can also be performed on the toes that are planned for transfer. This can help
rule out any comorbid conditions that may not be visible, including degeneration of
the toe joint or bone lesions. Likewise, imaging can provide the length and diameter
of each phalanx for surgical planning before transfer.
• An angiogram is not recommended because it is often difficult to obtain high-quality im-
ages of distal tissues such as the thumb and toes. Instead, evaluation of the vessel distribu-
tion can be performed with a pencil Doppler and being familiar with the anatomic variations.
SURGICAL ANATOMY
• The thumb plays a crucial role in hand function. It permits the many advanced ma-
nipulations that human hands are capable of:
• The fine-pinch handling of small objects is produced by the ulnar aspect of thumb
and the radial pulp of index/middle fingers.
• For a stronger grasp, the thumb recruits the ring and middle fingers.
• Vasculature and nerve supply of the thumb (Fig. 95.4):
• After the radial artery crosses the radial styloid and reaches the anatomic snuff
box, it branches into the princeps pollicis artery. The princeps pollicis artery then
Ulnar digital nerve
Palmar ulnar digital artery
Princeps pollicis
artery
First metacarpal artery Palmar radial digital artery
Radial digital nerve
Superficial palmar
arch
Superficial branch
radial artery
Radial artery
FIGURE 95.4 Neurovascular supply of the thumb. Reprinted with permission from Shubinets V, Elliott
RM. Ulnar thumb pulp reconstruction using the anterograde homodigital neurovascular island flap.
J Hand Surg Am. 2018;43(1):89.e1–89.e7 (Fig. 1).
passes volarly through the first intermetacarpal space, and it branches into the
proper radial and ulnar digital arteries of the thumb. The princeps pollicis artery
then forms the deep palmar arch, which is continuous with the ulnar artery.
• The proper palmar digital nerves accompany the proper radial and ulnar digital
arteries, which distribute only to the palmar side of thumb and the nail bed. The
dorsal aspect of the thumb is innervated by branches of the superficial radial
nerve.
• Vasculature and nerve supply of the toe is described as follows:
• The dorsal first webspace of the foot serves as the anatomic foundation of toe
transfer, whether harvesting the second toe or the great toe.
• The first dorsal metatarsal artery (FDMA) branches from the dorsalis pedis artery.
It merges with the first plantar metatarsal artery (FPMA) around the intermetatar-
sal ligament and then immediately bifurcates into the proper digital arteries of the
great and second toes.
• Approximately 70% of patients have the FDMA as the dominant artery for blood
supply to the toe. The FPMA is dominant in 20% of patients, and the remaining
10% of patients have the same caliber in both arteries (Fig. 95.5A–C). Asymmet-
ric dominance between the two feet is present in 20% of the population.
POSITIONING
• The patient should be positioned supine on the table, with the affected hand out-
stretched on a radiolucent hand table.
• Apply tourniquets to the upper arm and the thigh that is ipsilateral to the donor toe.
It is preferable to harvest a toe from the nondominant foot, which is usually the left
foot.
• If possible, two operative teams should be present to simultaneously prepare the
recipient site and harvest the toe.
STEP 1 PEARLS
SECOND TOE TO THUMB TRANSFER
• Carefully strip the adventitial layer of the recip- Step 1: Preparation of Recipient Site
ient artery to minimize postoperative vaso-
spasm. • The amputated thumb stump is incised along the previous scar. The incision is ex-
• For traumatic thumb defects, previous salvage tended proximally and distally in a zigzag fashion (Fig. 95.6).
procedures and debridement may have cre- • The radial and ulnar skin flaps overlying the stump are elevated and mobilized (Fig. 95.7).
ated adhesions over the tendons. Releasing This permits identification of all the relevant structures, including the metacarpal bone,
these adhesions will enable smooth tendon flexor and extensor tendons, digital nerve, dorsal veins, and the radial artery at the ana-
gliding after transfer is complete.
tomic snuff box (Fig. 95.8).
A B C
FIGURE 95.5 (A) In 70% of cases, a dominant first dorsal metatarsal artery is present. (B) In 20% of cases, a dominant first plantar metatar-
sal artery is present. (C) In 10% of cases, both arteries have similar caliber. Reprinted with permission from Rubin JP, Neligan P. Neligan
Plastic Surgery. 4th ed. Elsevier; 2017 (Fig. 14.7B–D).
Superficial dorsal vein
FIGURE 95.6 Planning the incision. FIGURE 95.7 The radial and ulnar skin flaps overlying the stump
are elevated and retracted, respectively.
Radial artery
FIGURE 95.8 Careful dissection exposes the planned recipient artery and tendons.
• The remnant of the thumb proximal phalanx and the head of the first metacarpal are STEP 1 PITFALLS
removed and set aside for the thumb MCP joint fusion that will be performed at the
When identifying the recipient artery, some
end of the operation (Fig. 95.9). Periosteal dissection should be conservative when surgeons may choose to create a separate
exposing the bone in the recipient site. incision in the snuff box instead of extending the
• The proper or common digital nerves can be identified close to the edge of the am- primary incision. If a separate incision is made,
putation site (Fig. 95.10). Inspect the nerve for neuromas and, if present, resect until the surgeon should take care to create a wide and
healthy nerve tissue is observed under magnification. loose subcutaneous tunnel so that the pedicle of
the transferred toe can be passed through to the
• The vessels in the anatomic snuff box should be meticulously dissected. The radial recipient site without being compressed.
artery or, preferably, the princeps pollicis artery can serve as the recipient artery for
anastomosis. The surrounding venous plexus from the cephalic vein can be used as
the recipient vein.
Step 2: Harvest of Second Toe

• An elliptical incision is planned around the base of the second toe, extending proximally
in a “lazy S-shaped” curve at the dorsal and plantar foot, respectively (Fig. 95.11). The
path of the incision should cross the midpoints of the first and second webspaces of
the foot.
Flexor pollicis longus
FIGURE 95.9 Removal of the thumb metacarpal head. Proper digital nerves
The white arrow indicates the raw surface of the remain- FIGURE 95.10 The digital nerves are identified close to the palmar
ing metacarpal after removal of cartilage. edge of the amputation site.
FIGURE 95.11 An elliptical incision is planned around the second toe with proximal extension.
• The dissection begins at the dorsal foot by elevating a dorsal V-shaped flap centered
over the second ray (Fig. 95.12A). The dissection continues in the first webspace,
where the surgeon should identify the sizable dorsal metatarsal vein and the FDMA
that lies superficial to the intermetatarsal ligament (see Fig. 95.12B).
• For patients with a dorsal dominant arterial system, the transmetatarsal ligament is
transected. Next, ligate and cut the digital artery to the big toe but preserve the
digital artery to the second toe.
• The digital artery is deep to the vein. Do not mistake the more superficial vein as the
artery. Any vascular structure that goes to the big toe can be ligated with clips.
• The FDMA is dissected in a retrograde direction all the way to the dorsalis pedis
artery. The dorsal veins are also identified.
• The deep peroneal nerve lies adjacent to the FDMA and should be preserved for
harvest (see Fig. 95.12B).
• The extensor digitorum longus and brevis tendons to the toe are then transected
proximally.
• Make the plantar dissection with similar V-shaped incisions as described for the
dorsal incision. After raising the skin flaps, the medial and lateral proper digital
Deep peroneal nerve
Extensor digitorum
longus
First dorsal
metatarsal artery
Dorsal metatarsal vein
A B
FIGURE 95.12 (A) The FDMA and dorsal metatarsal veins are exposed during superficial dissection.
(B) Deep dissection to skeletalize the vessel pedicles and identify the deep peroneal nerve and the
extensor tendon. FDMA, First dorsal metatarsal artery.
STEP 2 PEARLS
• The second toe is a better candidate for har-
vest than the big toe. The MCP joint of the big
toe must be preserved to maintain normal
function of the foot, which limits the length
that can be harvested. By contrast, the second
toe can be harvested down to the metatarsal
and also leaves a subtler donor site deformity
compared with the big toe.
• For toes with a plantar-dominant blood supply,
the FDMA may either be absent or very small.
Therefore in patients with a plantar-dominant
system, dissection of the dorsal foot is only
useful for harvesting the vein; the FPMA will
be isolated later during plantar dissection. If
Flexor digitorum longus the plantar artery is dominant, a vein graft
should be used to augment its length rather
FIGURE 95.13 The black arrows indicate the proper digital nerves. than engaging in a tedious dissection deep
between the metatarsals.
• Even with a suitable dorsal artery, the surgeon
nerves that branch off from the common digital nerve are dissected proximally, then should isolate the plantar arteries and place
transected. The flexor pollicis longus (FPL) tendon is also cut proximally (Fig. 95.13). tagging sutures on the adventitia for easy
• Once these anatomic structures have been isolated and divided, the second toe is identification if the toe does not perfuse ade-
then disarticulated (Fig. 95.14) and brought to the hand table (Fig. 95.15). quately from the dorsal circulation. In this
situation, vein grafting the plantar artery will
augment the perfusion of the toe and solve a
Step 3: Inset of Second Toe tenuous situation.
• The recommended sequence of repairs is: • Before dividing the major blood vessels of the
• Bone or joint capsule, then flexor tendon, volar digital nerves, closure of volar second toe, it is best to release the tourniquet
wound, extensor tendon, dorsal sensory nerve, vein, artery, and, finally, closure for at least 20 minutes to reperfuse the digit.
One should handle the vessels gently to de-
of the dorsal wound. crease vasospasm that may be problematic.
• After removing the cartilage at the base of the second toe, a longitudinal 0.045-inch Kirsch- While the toe is being perfused and warmed,
ner wire (K-wire) is used to secure the toe in full extension at the recipient site (Fig. 95.16). the surgeon can dissect out the structures
The second toe has a natural flex posture, so the toe is pinned in extension and the exten- over the thumb to get ready for insetting the
sor tendons must be repaired in maximum tension to prevent a claw deformity. toe. The toe in its native state over the foot
must be well perfused before detaching the
• We routinely dissect out the intrinsic tendon to the toe to pair it with the thenar ten- vessels. If the toe is not perfused, a microscope
don or muscle to augment toe extension (see Fig. 95.14). must be used to evaluate the arterial system to
• The docking site for the toe is packed with an autologous bone graft harvested from the toe. Most likely, the artery has been tran-
the excised head of the thumb metacarpal to augment healing. Then, a 25- to sected inadvertently. In this situation, the proper
28-gauge interosseous wire is used to fix the proximal phalanx of the toe to the artery to the toe must be identified and a vein
graft used to bridge the vessel defect.
thumb metacarpal (see Fig. 95.16).
FIGURE 95.14 Disarticulation of the second toe. The forceps grab the intrinsic tendon to the second
toe, which will be repaired to the thenar tendon of thumb when inset.
Flexor digitorum longus
Extensor digitorum longus

Deep peroneal nerve
Vein
First dorsal
metatarsal
artery
FIGURE 95.15 The divided second toe with all the necessary anatomic structures.
FIGURE 95.16 A longitudinal 0.045-inch Kirschner wire (K-wire) and intraosseous wire are used to
secure the toe in full extension at the recipient site.
• Two parallel 1-mm drill holes are placed through both cortices of the thumb meta-
carpal and the proximal phalanx of the second toe. These drill holes should be
placed 2 mm from the contact site between the toe and the thumb. Next, carefully
pass the interosseous wire through the 1-mm drill holes in the proximal phalanx
of the toe and the thumb metacarpal. Finally, twist the ends of the wire together
to secure the two bones in place. The position of the toe is confirmed radio-
graphically. After the wire is secured in place, the previously placed K-wire is
driven into the thumb metacarpal. Be careful using the drill. It is important to re-
tract the soft tissue to avoid inadvertently wrapping the critical soft tissues
around the K-wires, which would be disastrous.
• The FPL tendon is secured to the flexor digitorum tendon in the same manner
(Fig. 95.17A). After closing the volar wound, the extensor pollicis longus (EPL)
tendon is sutured into the toe extensor digitorum tendon using a weave fashion STEP 3 PEARLS
with 2-0 Ethibond suture (see Fig. 95.17B). Interosseous wires are recommended over other
• The deep peroneal nerve is coapted to the dorsal sensory branch of the radial nerve fixators because they can be applied to a bony
within the first webspace in an end-to-end fashion under the microscope using epi- stump as short as 5 mm.
neural sutures.
• The radial artery at the snuff box is anastomosed end-to-end to the FDMA. When STEP 3 PITFALLS
the clamp is removed, the transferred toe should demonstrate good pulsatile flow Proximal interphalangeal (PIP) joint extension lag
through the artery, and adequate venous outflow of the toe should be confirmed. is a common complication of second toe transfer.
The dorsal veins are then coapted to the cephalic vein. We prefer repairing two This can be avoided by tightly repairing the
veins, which will augment outflow and provide more insurance of the venous drain- extensor tendon with all joints held in extension
and repairing the intrinsic tendons.
age from the high-flow arterial system.
Step 4: Close Wounds

• After deflating the tourniquet, assess the perfusion of the transferred toe. Carefully
cauterize any sites of bleeding.
• Close the skin with interrupted 3-0 nonabsorbable sutures.
• Do not close the wound tightly over the vessels. If the wound closure is deemed to
be too tight, a full-thickness skin graft harvested from the upper arm can be placed
over the wound to decrease tension over the vessels.
• Donor site (Fig. 95.18):
• The skin should be closed without tension.
• Repair the intermetatarsal ligament that was transected during harvest of the
second toe using 2-0 Prolene sutures.
Flexor
tendon suture
Extensor
A
tendon suture
FIGURE 95.17 (A) The flexor pollicis longus tendon is sutured into the flexor digitorum tendon. (B) The extensor pollicis longus tendon is
sutured into the toe extensor digitorum tendon.
FIGURE 95.18 Wound closure of donor site.
• It is not necessary to use a splint to protect the foot because the loss of one toe
does not produce instability.
• If the incision is well designed, the donor site wound can usually be closed without
tension. If primary closure is difficult, the surgeon can remove the distal second
metatarsal to enable skin closure with less tension. Skin grafting over the donor site
should be avoided to prevent morbidity to the foot.
• Recipient site (Fig. 95.19):
• It is crucial to avoid any compression over recipient pedicles during wound clo-
sure. If tension is present while closing the wound, it is advisable to partially close
the wound and apply skin grafts to cover the remaining defect.

• The patient’s thumb is placed in a spica splint after the operation. The hand and
wrist are loosely wrapped, leaving the transferred toe uncovered to permit continu-
ous monitoring.
• The hand and forearm are kept slightly elevated to reduce edema and ease venous
return.
FIGURE 95.19 Wound closure of recipient site.

FIGURE 95.20 Assess the transferred toe’s perfusion by continuous pulse oximetry and compare it
with the opposite thumb.
FIGURE 95.21 Appearance of the recipient site 1 week after the operation.
• The patient is monitored carefully for the first few days. The color, turgor, tempera-
ture, and capillary refill of the toe surface should be inspected. Continuous pulse
oximetry can also be placed over the transferred toe to assess perfusion (Fig. 95.20).
Vessel patency can be checked periodically by Doppler.
• Daily aspirin (325 mg/day) can be administered to the patient and continued for
2 weeks to prevent thrombosis at sites of anastomosis.
• Remove the splint and stitches about 10 days postoperatively (Figs. 95.21 and
95.22), then begin gentle passive mobilization. The K-wire may be removed after the
radiograph demonstrates adequate healing (typically at 1 month). At this time, the POSTOPERATIVE PITFALLS
patient can initiate active ROM exercises for the toe IP joint. Avoid using bulky dressings because they can
• Gradual strengthening activities can begin at 2 months (Fig. 95.23). inadvertently compress pedicles at the recipient
• Gait analyses have shown that no significant difference in foot function is observed site. Furthermore, blood clots from the wound may
after transfer of the second toe to the thumb. adhere to the dressings, and their removal can
lead to pain-induced vasospasm.
See Video 95.1
FIGURE 95.22 Appearance of the donor site 1 week after the operation.
FIGURE 95.23 Excellent function at 3 months postoperatively.
EVIDENCE
Lin P, Sebastin SJ, Ono S, Bellfi LT, Chang KW, Chung KC. A systematic review of outcomes of toe-
to-thumb transfers for isolated traumatic thumb amputation. Hand (NY). 2011;6(3):235–243.
The authors conducted a systematic review of the literature to compare functional outcomes among
different methods of toe-to-thumb transfers, including the second toe, the great toe, the
wrap-around great toe, and the trimmed great toe. Studies were included in the review if they:
(1) presented primary data, (2) reported three or more toe-to-thumb transfers for isolated complete
traumatic thumb amputation between the MCP joint and the IP joint and (3) presented functional
outcome data. Twenty-five studies were included for analysis, representing 450 toe-to-thumb trans-
fers. Overall, the study included 101 second toe transfers, 196 great toe transfers, 122 wrap-around
transfers, and 31 trimmed toe transfers. No statistically significant difference could be detected
among the four types of transfers with regards to survival, ROM, grip or pinch strength, and static
two-point discrimination. The mean survival rate was 96.4%.
Waljee JF, Chung KC. Toe-to-hand transfer: Evolving indications and relevant outcomes. J Hand Surg
Am. 2013;38(7):1431–1434.
The authors reviewed the advantages and disadvantages of various toe-to-hand transfer techniques,
including big toe transfer, second toe transfer, wrap-around toe transfer, and trimmed big toe trans-
fer. Disadvantages of big toe transfer include an excessively bulky contour, whereas transfer of the
second toe often results in an undesirable hook appearance of the digit because of the smaller,
bulbous tip of the second toe. In addition, the transferred second toe was associated with subse-
quent claw deformity. Unlike the big toe, however, harvest of the second toe can include the
metatarsal joint without impeding function of the foot, which permits increased length of the
transferred second toe. Harvest of the second toe also minimizes changes in appearance to the
donor site, compared with harvest of the big toe.
Yim KK, Wei F, Lin C. A comparison between primary and secondary toe-to-hand transplantation. Plast
Reconstr Surg. 2004;114:107–112.
The authors conducted a comparative study of 175 consecutive toe-to-hand transplantations in 122
patients. The average interval between injury and primary reconstruction was 7 days (31 patients),
and the average interval between injury and secondary reconstruction was 10.7 months (144 pa-
tients). The survival rate was 96.8% (30 of 31) for primary reconstruction and 96.5% (139 of 144) for
secondary reconstruction. Each group had one superficial infection. The infection rate was 6.5% and
0.7% in the primary and secondary groups, respectively. There was no statistically significant differ-
ence between the two groups in terms of survival, intraoperative anastomotic revision, reexploration,
future secondary procedure, infection, or complications.
Chung KC, Wei F. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand
Surg Am. 2000;25:651–658.
Twenty-one patients who had unilateral, isolated thumb amputations at the MCP joints were studied to
evaluate the outcome. Among these patients, 16 patients had toe transfer, whereas 5 patients did not
have reconstruction. Toe transfer patients demonstrated significantly better overall hand function,
ability to perform activities of daily living, work performance, aesthetics, and satisfaction. In addition,
patients with toe transfer showed comparable strength and dexterity in the affected hand to the op-
posite normal hand. Foot donor site morbidity was minimal, and no significant difference was found
between the groups.
CHAPTER 96
Sympathectomy of Radial, Ulnar, and Common
Digital Arteries for Raynaud Phenomenon
INTRODUCTION
• Raynaud phenomenon (RP) is an exaggerated vascular response to cold tempera-
ture or emotional stress, which manifests clinically as color changes in the fingers
from white to blue to red.
• Primary RP (“Raynaud disease”) occurs in the absence of associated conditions;
secondary RP (“Raynaud syndrome”) is associated with conditions such as sclero-
derma (systemic sclerosis), systemic lupus erythematosus, and an extensive list of
other conditions, medications, and vascular injuries.
• Both primary and secondary RP arise from an abnormal vascular response of digital
arteries and cutaneous arterioles. This means the defect is local to the digits, rather than
a defect in the central nervous system. Evidence suggests that increased adrenergic
responses of local vessels causes primary RP, whereas the diverse conditions associated
with secondary RP likely lead to the local dysregulation of the vasospastic response.
• For patients with either primary or secondary RP, digital sympathectomy can be
performed to remove the poor functioning sympathetic nerves.
• Professional collaboration and frequent communication with rheumatology colleagues
is critical when caring for patients with Raynaud phenomenon.
INDICATIONS
• Traditional indications for sympathectomy are persistent pain and/or tissue ischemia
(ulcers, gangrene, autoamputation; Fig. 96.1A–B) despite maximal lifestyle (avoiding
cold, wearing gloves, stress-reduction techniques) and medical optimization (calcium
channel blockers, propranolol, clonidine, and many other medications).
• Although sympathectomy can also be considered for patients who wish to stop tak-
ing medications or have less strict lifestyle modifications, various factors must be
taken into account. This consideration is valid in young patients who present with
RP and wish to avoid decades of medication and activity restriction. Additionally,
spontaneous remission may occur in patients with primary RP, obviating the need
for surgery; remission is uncommon in secondary RP.
• Botox is a nonoperative treatment option. Typically, 10 to 20 units of Botox are in-
jected around each neurovascular bundle in the distal palm. Although some patients
experience immediate relief that lasts several years, outcomes are unpredictable and
do not indicate the potential effectiveness of sympathectomy.
Cyanosis
A B
FIGURE 96.1 (A–B) Clinical indications for sympathectomy: refractory symptoms and frank necrosis
despite maximal nonsurgical interventions.
728
CHAPTER 96 Sympathectomy of Radial, Ulnar, and Common Digital Arteries for Raynaud Phenomenon 729
Contraindications
• Patients with severe pulmonary disease and other comorbid conditions should avoid
general anesthesia.
• Microsurgical expertise is critical to dissect around small vessels and nerves in the hand.
CLINICAL EXAMINATION • The thumb is often spared in primary RP; its
• Collaboration with the patient’s rheumatologist is important to diagnose primary involvement suggests a secondary cause.
versus secondary RP. Further, it is important to manage other body systems that are • An angiogram can be performed to further in-
associated with secondary RP and could make surgery dangerous. vestigate an abnormal Allen’s test or weak/
absent ulnar or radial pulse because these
• Perform a physical examination to evaluate three specific factors:
findings suggest the presence of sclerosed
• Extent of disease: Digital ulcerations, chronic wounds, and frank tissue necrosis vessels. A bypass operation can be performed
all suggest end-stage disease. End-stage disease despite optimal nonsurgical in combination with arterial sympathectomy to
management is a relatively conservative indication for surgery (see Fig. 96.1A–B). treat the sclerosis. Typically, the ulnar artery is
• Likelihood of healing after an operation: Evaluate the palm and wrist for (1) trophic more diseased than the radial artery.
changes and evidence of chronic-appearing wounds, which suggest that the
surgical incisions may not heal, and (2) presence of infection or other acute pro- CLINICAL EXAMINATION PITFALLS
cesses that need to be treated before elective surgery. RP has many clinical mimics: cold sensitivity,
• Need for arterial bypass: The inability to palpate an ulnar or radial pulse and an peripheral neuropathy, complex regional pain
abnormal Allen’s test suggest an abnormality in the arteries or palmar arches that syndrome, occlusive vascular disease (emboli,
could be treated with arterial bypass (Chapter 97) and can be further evaluated atherosclerosis, thromboangiitis obliterans),
with an angiogram. In this scenario, the arterial bypass or reconstruction should acrocyanosis, and erythromelalgia. Consultation
with an experienced rheumatologist is critical
be performed at the same time as arterial sympathectomy so that microsurgery before undertaking any operative intervention.
is not performed in a scarred wound bed.
IMAGING
IMAGING PEARLS
• An angiogram is critical to (1) confirm the diagnosis by noting vaso-occlusion (Fig. 96.2A),
It is possible that an angiogram will not match
because symptoms of RP with a normal angiogram suggest a different diagnosis, and
the clinical picture. In this scenario, does the
surgeon perform sympathectomy on vessels that
do not show angiographic evidence of disease?
For example, if the ulnar artery is diseased and
Radial A. Common digital A. 2, 3, 4
occluded, the radial artery is uninvolved, and
digital ischemia exists on the ulnar digits, should
the surgeon perform sympathectomy on the radial
artery? In our opinion, the answer is yes, but it
depends on a conversation between the patient
and surgeon, taking into account disease stage,
the limited understanding of the disease process,
and the potential outcomes of surgical intervention.
A
Superficial palmar arch
Ulnar A.
Anterior interosseous artery

Radial artery
B Ulnar artery (difficult to see)
FIGURE 96.2 (A–B) Profound vaso-occlusion of ulnar artery, palmar arch, and common digital arter-
ies to index, long, ring, and small fingers on angiogram.
730 CHAPTER 96 Sympathectomy of Radial, Ulnar, and Common Digital Arteries for Raynaud Phenomenon
(2) determine whether arterial bypass is required based on whether the arteries at the
wrist and hand are completely occluded and whether proximal and distal targets exist for
arterial bypass (see Fig. 96.2B). Typically, the ulnar artery is more severely occluded.
• Doppler sonography is used in the preoperative holding bay to mark where signals
of the radial and ulnar artery are lost because these points indicate the proximal
extent of arterial sympathectomy, and to identify a saphenous vein graft. It is also
used in the operating room to assess immediate changes in arterial signals after
sympathectomy.
SURGICAL ANATOMY
Hand Anatomy
• There are three common digital arteries in the hand, supplying the second, third, and
fourth webspaces (Fig. 96.3). All arise from the superficial palmar arch, formed
mainly by the ulnar artery. The ulnar digital artery to the small finger and radial digital
artery to the index finger branch off much more ulnarly and radially, respectively.
Therefore incisions approaching the ulnar and radial borders of the hand, respec-
tively, are required to access these vessels.
• The common digital nerves and common digital arteries lie between the flexor tendons.
It is crucial to protect the nerves during the procedure.
Forearm Anatomy
• It is important to understand where the vessels are within the forearm, especially
when tracing them proximally. Consult cross-sectional anatomy references.
Common
digital arteries
Berrettini connection
Area of sympathectomy
Superficial
palmar arch
Deep palmar
arch
Radial artery
Ulnar artery
FIGURE 96.3 Note the branching of common digital arteries into proper digital arteries.
Ulnar Artery
• Distally at the wrist, the ulnar nerve is exposed immediately deep and radial to the
flexor carpi ulnaris (FCU) tendon and ulnar to the artery. From ulnar to radial, or
superficial to deep, the structures are FCU, ulnar nerve, ulnar artery. The nerve and
artery can be traced proximally by retracting the FCU tendon; as the dissection
proceeds proximally, the artery will move radially and under the FDS muscle belly as
it approaches the brachial artery origin, whereas the ulnar nerve will remain ulnar
toward the cubital tunnel, eventually traveling between the two heads of the FCU.
The dorsal cutaneous ulnar nerve comes off the ulnar nerve proper 8 to 10 cm
proximal to the wrist crease (see Chapter 61, Fig. 61.1); however, this does not need
to be specifically identified because the artery of interest is on the opposite side.
Radial Artery
• The radial artery is easily found between the flexor carpi radialis (FCR) and brachio-
radialis (BR) tendons at the wrist and stays between these two muscles more
proximally.
• It is also important to protect the ulnar nerve and radial sensory nerve during the
dissection. The ulnar nerve is near the ulnar artery for its entire course, as seen in
the operative dissection. The radial sensory nerve enters the operative field more
proximally than the ulnar nerve; it pierces the deep fascia roughly 7 to 8 cm proximal
to the wrist joint (10 cm from the radial styloid). It will generally not be in the opera-
tive field.
Arterial Sympathectomy
• Arterial sympathectomy strips the adventitial tissues off the radial and ulnar arteries
supplying the hand and the common digital arteries supplying the digits. Removing
the adventitia (1) removes sympathetic vasoconstriction signals to the arteries, and
(2) removes compressive fibrous tissue that accumulates around vessels in this dis-
ease (Fig. 96.4A–B).
• Arterial sympathectomy interrupts the distal sympathetic activity but does not
change the sympathetic response proximal to the operative site.
B
FIGURE 96.4 (A) Stripping of the arterial adventitia. (B) (From Fox P, Chung L, Chang J. Management
of the hand in systemic sclerosis. J Hand Surg. 2013;38(5):1012–1016. Fig. 4B)
POSITIONING
STEP 1 PEARLS
• Administer general or regional anesthetic and position the patient supine on the
• Alternatively, zigzag Bruner incisions can be operating room table with a tourniquet. Regional block anesthesia is preferred be-
made to expose only one common digital artery
(see Fig. 96.5B), or transverse incisions can cause it has a vasodilatory effect to enhance flow to the digits.
be made to expose the radial artery and first • Administer prophylactic antibiotics.
dorsal interosseous artery (see Fig. 96.5C).
• The common digital arteries bifurcate approxi- PROCEDURE
mately one fingerbreadth proximal to the web-
space border/proximal digital crease; in other Step 1: Incision Design
words, the bifurcation is not just before the
digits start. Therefore optimal incision place- • Transverse incisions are made over the palmar creases to perform digital artery
ment is at the distal palmar crease, and no sympathectomy (Fig. 96.5A). Ensure that the incision is as radial and ulnar as re-
further distal (see Fig. 96.3). quired to reach the radial digital artery to the index finger and the ulnar digital artery
to the small finger, respectively.
• Two parallel longitudinal incisions are marked for the sympathectomy of radial
STEP 1 PITFALLS
and ulnar arteries over the distal forearm (see Fig. 96.5A). The incision length
Sympathectomy can only be performed with direct depends on the length of the diseased vessel. Typically, sympathectomy is per-
access to the artery, so larger incisions may be
formed over the entire ulnar artery that is diseased and over a 3 to 5 cm segment
necessary to ensure excellent exposure.
of radial artery.
FIGURE 96.5 (A) Standard incisions for sympathectomy of the radial artery, ulnar artery, and common
digital arteries. (B) Alternative Bruner incision for single digit sympathectomy. (C) Transverse incisions
to expose radial artery and first dorsal intersseous artery.
Step 2: Exposing the Ulnar Artery STEP 2 PEARLS

• Incise through skin and subcutaneous fat down to the deep fascia with a knife. The
• Use retractors to pull the incision corners
only superficial structures are subcutaneous veins; no major nerves exist in this area. proximal and distal, permitting full exposure
• Incise the FCU fascia with a knife along its entire length. of the deep fascia.
• Carefully retract the FCU ulnarly, using scissors to identify the ulnar artery and nerve. • Handle the ulnar nerve with care to avoid
The nerve is found between the FCU and artery. neuropraxia.
• Excellent assistance is necessary to provide
• Separate the ulnar artery and nerve along the entire diseased segment. Jeweler’s
gentle retraction when the artery and nerve
forceps are helpful to ensure that only the epineurium is grasped. Microclips or mi- are separated. Self-retaining retractors are
crobipolars are required to take down arterial branches to the surrounding muscles. critical for gentle handling of the nerve.
• Exposing the deep fascia and neurovascular
Step 3: Exposing the Radial Artery bundle should be the fast part of this opera-
tion. Separating the nerve from the artery
• Incise through skin and subcutaneous fat down to the deep fascia with a knife.
carefully takes time.
• Incise the FCR fascia with a knife along its entire length.
• Carefully retract the FCR ulnarly and the BR radially; the artery will be in this interval.
• Expose the entire length of the diseased artery. If it appears healthy on an angiogram, STEP 3 PEARLS
expose 3 to 5 cm. The radial sensory nerve exits the deep fascia
between the BR and extensor carpi radialis longus
Step 4: Exposing Common Digital Nerves (ECRL), which is more posterior and should not be
in the field of dissection.
• Incise through skin, subcutaneous tissue, and palmar fascia with a knife.
• Identify the superficial palmar arch, three common digital arteries, and the radial
digital artery to index finger and ulnar digital artery to little finger. STEP 4 PEARLS
• Thick palmar fascia exists between the skin
Step 5: Sympathectomy and common digital bundles; the bundles exist
• Digital sympathectomy is ideally performed using the operating room microscope immediately beneath this fascia, so great care
(Fig. 96.6); radial and ulnar sympathectomy can be performed with 3.5x loupes. must be taken when dividing the fascia (see
• Jeweler’s forceps and microscissors are used to strip the adventitia using blunt and Chapter 61, Fig. 61.1).
• It is helpful to use small self-retaining retrac-
sharp techniques (Fig. 96.7).
tors or to have an assistant retract the skin to
put tension on the palmar fascia.
Step 6: Hemostasis • It is difficult to visualize diseased vessels under
• Take down the tourniquet and check the fingers for return of blood flow. tourniquet control; first identify the flexor ten-
• Cauterize pulsatile vessels. dons and then identify the bundles in between.
Step 7: Closure and Dressing STEP 4 PITFALLS

• Palm incisions are closed with 4-0 nylon horizontal mattress sutures. Forearm inci- Great care must be taken to avoid harming the
sions are closed with 3-0 dermal and 4-0 running subcuticular sutures (Fig. 96.8). neurovascular structures, which lie immediately
• A sterile soft dressing is applied; do not apply a splint. deep to the palmar fascia.
Common digital artery of 2nd, 3rd, and 4th webspace. STEP 5 PEARLS
• Toothed micro forceps are slightly sturdier and
may be used to hold the adventitia during
stripping.
• Be sure to strip the adventitia along the entire
length of the exposed vessels.
3
4
FIGURE 96.6 Sympathectomy completed on second, third, and fourth common digital arteries,
viewed through the microscope.
STEP 6 PEARLS Ulnar A before vena comitantes stripped

• When tourniquet times exceed 60 to 90 minutes,
tissue hyperemia is best treated with gentle pres-
sure rather than vigorous cautery.
• If no injury is suspected, ischemic fingers are
best treated with warm saline, papaverine, and
patience.
Radial A.
FIGURE 96.7 Sympathectomy completed on radial artery and in progress on ulnar artery. VC, vena
comitantes.
STEP 8 PITFALLS
Debridement should be conservative if at all and may
not reach the bleeding tissue until increased tissue
perfusion is achieved after sympathectomy. It is
hard to predict when improved blood flow will return
after sympathectomy; repeat debridement may be
needed, but debridement should be conservative to FIGURE 96.8 Closure.
preserve as much tissue as possible.
Step 8: Wound Debridement

POSTOPERATIVE PEARLS Debridement of any wounds can be performed conservatively after sympathectomy.
Ulnar nerve neuropraxia can be seen postoperatively,
with weakened intrinsic muscles and decreased
sensation. Unless there is concern for sharp • The hand is placed in a soft dressing.
transection injury, the patient should be reassured • The patient can start range-of-motion exercises and scar massages once the sutures
and followed weekly until symptoms improve. are removed about 10 days postoperatively (Fig. 96.9). Wound healing improves by
1 month postoperatively (Fig. 96.10).
FIGURE 96.9 One-week postoperative, with ulnar nerve sensory and motor neuropraxia.
FIGURE 96.10 One-month postoperative, with return of normal ulnar nerve function. Patient endorses
tremendous improvement in symptoms and is interested in having the right side done.
• Palm incisions are painful, and the patient may notice increased pain in the fingers
that is often described as throbbing, worse with dependency and at the end of the
day, relieved with elevation and rest, and more common in warmer digits.
See Video 96.1
EVIDENCE
Leyden J, Burn MB, Wong V, et al. Upper extremity angiographic patterns in systemic sclerosis:
implications for surgical treatment. J Hand Surg Am. 2019;44(11):990.e1–990.e7.
The authors reviewed 110 upper extremity angiograms in patients with systemic sclerosis between
1996 and 2017 and devised a classification system that had high interrater reliability. The proposed
classification system can help refine research in this field.
Chiou G, Crowe C, Suarez P, Chung L, Curtin C, Chang J. Digital sympathectomy in patients with
scleroderma: An overview of the practice and referral patterns and perceptions of rheumatologists.
Ann Plast Surg. 2015;75(6):637–643.
The authors surveyed 500 rheumatologists to elicit their practice patterns and perceptions of digital
sympathectomy, and found that only 50% of rheumatologists routinely counseled, whereas 67%
expressed the desire to refer. This paper identifies an opportunity for hand surgeons to have
better dialogue on surgical options with referring rheumatologists.
Neumeister MW. Botulinum toxin type A in the treatment of Raynaud’s phenomenon. J Hand Surg Am.
2010;35(12):2085–2092.
The author presents his positive experience with Botox for the treatment of RP. A total of 24 patients
with RP were injected with onabotulinumtoxinA. All but 5 patients experienced improved vascularity
and relief of pain. Laser Doppler scans illustrated notable improvement in perfusion. Five patients
had repeat injections for recurrent pain.
CHAPTER 97
Ulnar Artery to Superficial Arch Bypass
with a Vein Graft
INDICATIONS
• The ulnar artery bypass procedure with a vein graft is used to reconstruct an ulnar
artery damaged from occlusion caused by Raynaud phenomenon or repetitive
trauma to the hand known as hypothenar hammer syndrome.
• For Raynaud phenomenon, the indications are similar to those in Chapter 96, but
there must be proximal and distal targets amenable to microsurgical anastomosis for
this procedure to be indicated.
• For hypothenar hammer syndrome, front-line therapies include behavior modifica-
tions such as smoking cessation and cold avoidance. Medications include aspirin
and calcium channel blockers to help manage symptoms and prevent distal embo-
lism of ulnar artery thrombus. In the presence of persistent symptoms or frank tissue
loss, surgical reconstruction is indicated.
• Similar to Chapter 96, the hand should be evaluated for the presence of ischemic
changes such as cyanosis, cold skin temperature, ulcerations, and frank necrosis
and tissue loss (Fig. 97.1).
• An Allen’s test is performed to assess patency of the palmar arch. This can be done
clinically by looking for capillary refill or using a Doppler probe to identify a signal on
the thumb while the radial artery is occluded.
IMAGING
• Various noninvasive examinations, such as Doppler imaging, computed tomographic
(CT) angiography, and magnetic resonance angiography, are useful to evaluate the
vascular lesions. Nevertheless, angiogram is still the standard and remains necessary
for preoperative evaluation.
• The angiogram is inspected to confirm the presence and define the extent of ulnar
artery occlusion and plan for surgical bypass. Look for proximal and distal targets
amenable to microsurgical anastomosis. Typically, the proximal target is readily
Cyanosis
FIGURE 97.1 Physical examination findings in ulnar artery occlusion can range from normal to subtle
color and temperature changes (pictured here) to ulcerations and frank tissue loss.
736
CHAPTER 97 Ulnar Artery to Superficial Arch Bypass with a Vein Graft 737
Distal target
amenable to
anastomosis
Patent radial artery
Patent ulnar artery
Occluded ulnar artery
FIGURE 97.2 Two angiograms exhibiting ulnar artery occlusion, with no clear distal target on left, and a
clear distal target on right.
available given the long course of the proximal ulnar artery. The distal target can be
more difficult to identify if the occlusion is at a bifurcation of the superficial arch and
common digital artery (Fig. 97.2).
• Occluded common digital arteries can be anastomosed using side branches of the
vein graft or end-to-side repair.
• Preoperative vein mapping can be used if the patient’s habitus precludes vein iden-
tification. This can often be done in the preoperative holding bay using the ultra-
sound machine (see “Positioning”). However, this is typically not necessary. The
architecture of the vein graft can be determined during dissection, and select side
branches should be preserved for anastomosis.
SURGICAL ANATOMY
• The ulnar artery arises just distal to the elbow where the brachial artery bifurcates
into the radial and ulnar arteries, but some patients have a high bifurcation in the
proximal brachium. Immediately after forming, the ulnar artery gives off two recurrent
arteries and the common interosseous artery and then continues distally and ulnarly
between the superficial and deep finger flexors until it reaches the ulnar forearm,
where it remains underneath the flexor carpi ulnaris (FCU) for most of its course. The
diameter of the ulnar artery is about 2 mm, and the diameter of its two accompany-
ing veins is about 1 mm.
• The ulnar artery joins the ulnar nerve in the proximal forearm. It is important to pro-
tect this structure during the procedure.
• In the wrist, the artery lies in the Guyon canal, radial to the pisiform and ulnar to the hook
of hamate, where it is covered by the volar carpal ligament. After giving off the deep
branches, the ulnar artery continues as the superficial palmar arch in the palm (Fig. 97.3).
• The superficial arch gives rise to the finger’s digital arteries. The ulnar artery gives
off the ulnar digital artery to the little finger and three common digital arteries at the
level of the metacarpophalangeal joint (Fig. 97.4; see also Fig. 97.3).
• The superficial arch lies deep to the palmar aponeurosis and palmaris brevis and
superficial to the flexor brevis minimi digiti muscle, flexor tendons, and lumbrical
muscles (see Fig. 97.4). The superficial palmar arch is considered complete when it
has the communicating branches from the deep palmar arch, radial artery, or median
artery in about three-quarters of cases. An incomplete superficial palmar arch oc-
curs in the remaining cases.
738 CHAPTER 97 Ulnar Artery to Superficial Arch Bypass with a Vein Graft
Common digital
arteries
Ulnar digital artery

of the little finger
Deep palmar arch
Radial artery
Deep branch of
ulnar artery Pisiform
Ulnar artery
FCU tendon
FIGURE 97.3 The superficial arch, and therefore the ulnar artery, gives rise to the finger’s digital
arteries. The ulnar artery gives off the ulnar digital artery to the little finger and three common digital
arteries at the level of the metacarpophalangeal joint.
Flexor tendon
Common digital
nerve to the
Proper digital 3rd webspace
artery
Common digital
artery to the
4th webspace
Superficial
palmar arch
Ulnar a. & n.
Hook of TCL
hamate
FIGURE 97.4 The superficial arch lies deep to the palmar aponeurosis and palmaris brevis and
superficial to the flexor brevis minimi digiti muscle, flexor tendons, and lumbrical muscles. TCL,
Transverse carpal ligament.
POSITIONING
• The procedure is done under general anesthesia. A preoperative block can be a useful
adjunct for pain control, although saphenous vein harvest requires general anesthesia.
• The patient is placed supine with an arm table and tourniquet. The saphenous vein
graft donor leg is also prepped and a tourniquet is used.
• The procedure is performed under loupe and microscope magnification.
PROCEDURE
The distal bypass target is identified first to ensure that a bypass can be performed.
Once this is confirmed, the proximal ulnar artery target is identified, and the saphenous
vein graft is harvested.
STEP 1 PEARLS
Step 1: Markings
The entire incision is planned at the start, using a curvilinear design from the hypothenar The incision can be extended proximally to expose
healthier ulnar artery.
area to the palm, a zigzag incision across the wrist, and a straight line over the ulnar
artery extending as proximal as is necessary (Fig. 97.5).
Step 2: Expose Ulnar Artery STEP 2 PEARLS
• A standard Guyon canal decompression is performed first by preserving the various • Rubber loops are used to tag and retract the
nerve branches and the vessels to the digits (Fig. 97.6). accompanying ulnar nerve. Great care should be
taken to protect this nerve and its superficial
• This exposure is extended distally until the distal bypass target is identified.
branches.
• A suitable distal target is one with which a tech-
nically perfect microvascular anastamosis can be
performed. It should have a suitable size match
and be free of thrombus and intimal injury with
no kinking.
FIGURE 97.5 The entire incision is planned at the start, using a curvilinear design from the hypothe-
nar area to the palm, Brunner steps across the wrist, and a straight line over the ulnar artery,
extending as proximal as required (arrow head at right).
Superficial
palmar arch
Thrombosed
segment of
Ulnar digital artery the ulnar artery
of the little finger
Tied small
A deep branch branch of
forming the deep ulnar artery
palmar arch
Sensory branch
of the ulnar
nerve
FIGURE 97.6 A standard Guyon canal decompression is performed first, establishing familiar anatomy
for the surgeon. This exposure is extended distally until the distal bypass target is identified. This is a
healthy-appearing vessel in both cases of hypothenar hammer and Raynaud reconstruction. In this
case, the ulnar artery thrombosis included the deep branch of the ulnar artery, which contributes to
the deep palmar arch. This necessitated a branch vein graft to reconstruct two distal targets.
Proximal
Basilic vein harvest
STEP 3 PEARLS
• A branched graft can be harvested as needed, Elbow
though multiple donor sites may need to be Distal
examined to find a suitable branched graft
B
(Fig. 97.8). If a branched graft is used, the
branching must be proximal in situ because FIGURE 97.7 (A) A saphenous vein graft is harvested from the lower part of the leg through a longi-
reversing the graft to compensate for valves tudinal incision directly over the vein graft. A branched graft can be harvested as needed, but multi-
will mean the branching is now appropriately ple donor sites may need to be examined to find a suitable branched graft. If a branched graft is
distal (see Fig. 97.7). used, the branching must be proximal in situ because reversing the graft to compensate for valves
• The distal cephalic or basilic vein within the will mean the branching is now appropriately distal. (B) Alternatively, a basilic vein may be harvested.
forearm is also suitable for grafting.
• Even though the vein graft can be harvested
through multiple transverse incisions, it is
much safer and easier to harvest it under a • Once a suitable distal target is identified, the proximal ulnar artery is then exposed.
longitudinal exposure. The artery is found underneath the FCU tendon, and the exposure is done proximal
• The incision can be made adjacent to the vein enough to expose healthy-appearing artery suitable for the proximal bypass target.
graft to avoid injuring it during harvest.
Step 3: Saphenous Vein Graft Harvest
STEP 3 PITFALLS • The leg is exsanguinated and the tourniquet is inflated.
• The vein graft should be 10% to 30% longer • A saphenous vein graft is harvested from the lower part of the leg through a longi-
than the arterial defect to achieve a tension- tudinal incision directly over the vein graft (Fig. 97.7A).
free repair. This is measured in situ, before the • Alternatively, a basilic vein may be harvested (see Fig. 97.7B).
vein graft is harvested, because the graft will
naturally contract once divided. Step 4: Excision of Diseased Ulnar Artery
• The saphenous nerve that runs with the vein
at the lower part of the leg should be pre- • The diseased segment of the distal ulnar artery is excised after clamps are placed
served during harvesting of the vein graft. (Fig. 97.9).
• Once harvested, we mark one end of the graft
with blue ink to establish the direction of blood
flow (see Fig. 97.8).
Marked proximal
end of vein graft
STEP 4 PEARLS
A side branch of the
The bleeding from the small branches of the artery distal end of vein graft
is stopped by ligation, vascular clips, or bipolar
cauterization.
STEP 4 PITFALLS
All of the damaged arterial segments should be
excised because damage of the arterial intima will
FIGURE 97.8 In this case, the thrombosed ulnar artery involved the deep branch of the ulnar artery,
increase the risk for future thrombosis.
contributing to the deep palmar arch. Therefore a branched vein graft was obtained to reconstruct
both the superficial arch and the ulnar artery’s contribution to the deep arch.
FIGURE 97.9 The diseased segment of the distal ulnar artery is excised after clamps are placed.
STEP 5 PEARLS
When multiple common digital arteries are involved
• After the tourniquet and clamps are released, good pulsatile flow through both ends of the in the reconstruction, the proximal ones need to be
artery is confirmed to be sure that there is no unexpected occlusion of the arterial segments. anastomosed to the vein graft in an end-to-side
fashion (Fig. 97.12).
Step 5: Microvascular Anastomosis
• The vessels are irrigated with heparinized saline, and the reversed vein graft is
brought to the field. STEP 5 PITFALLS
• The deep branch of the ulnar artery is anastomosed end-to-end to the side branch • The vein graft must be used in a reversed
of the vein graft first. Then the main trunk of the artery is bridged by the graft in end- direction to prevent venous valves from
to-end anastomoses (Fig. 97.10). Alternatively, venous couplers can be used to stopping arterial flow.
• Check the course of the vein graft to avoid
coapt the ulnar artery stump to the vein graft, but this can be difficult to achieve with
kinking and twisting before each anastomosis.
thick-walled arteries (see Fig. 97.10).
Anastomosis
site
Vein graft
FIGURE 97.10 (A) The deep branch of the ulnar artery is anastomosed end-to-end to the side
branch of the vein graft first. Then the main trunk of the artery is bridged by the graft in end-to-end
anastomoses. (B) Alternatively, venous couplers can be used to coapt the ulnar artery stump to the
vein graft, although this is technically hard with venous couplers and thick-walled arteries.
End-to-side
anastomosis
Superficial
palmar arch
Vein graft
FIGURE 97.11 Good pulsatile flow through the vein graft after FIGURE 97.12 When multiple common digital arteries are involved in the
clamps are removed is confirmed by reconstruction, the proximal ones need to be anastomosed to the vein graft
observation and by Doppler signal. in an end-to-side fashion.
• There is a good pulsatile flow through the vein graft after clamps are removed, which
is confirmed by observation and by Doppler signal (Fig. 97.11).
Step 6: Closure
• All bleeding points are cauterized and the wound is closed using 4-0 nylon sutures
(Fig. 97.13).

• After the operation, the patient is placed in a dorsal wrist splint, with the wrist in a
neutral position and fingers in a functional position. Sutures are removed in 2 weeks.
• If the microsurgery is performed technically perfectly, then only daily aspirin is
needed for anticoagulation. We use ASA 81mg PO QD.
• High patency rates after vein graft bypass procedure in a short term are expected.
Additional blood flow can alleviate the symptoms and increase function of the isch-
emic hand simultaneously (Fig. 97.14).
See Video 97.1
FIGURE 97.14 Increased blood flow from the ul-

nar artery reconstruction can alleviate symptoms
FIGURE 97.13 The wound is closed in a standard fashion. and reverse ischemic changes.
EVIDENCE
Dethmers RS, Houpt P. Surgical management of hypothenar and thenar hammer syndromes: A retro-
spective study of 31 instances in 28 patients. J Hand Surg Br. 2005;30:419–423.
The authors reported the outcomes of surgical treatment of 29 cases of hypothenar hammer syndrome
and two cases of thenar hammer syndrome. After the involved arterial segment of the artery was
resected, arterial reconstruction was done in 29 of 31 cases; the arteries were ligated in two cases.
Three hands were symptom free, 15 were improved, 11 were unchanged, and 2 were worse at a
mean follow-up of 43 months. Twenty-seven revascularizations were examined by Duplex sonogra-
phy. The results showed 48% were patent and 52% were occluded, partially thrombosed, and had
aneurysmal dilatations in the grafts. Longer grafts (7 cm or longer) had a worse patency rate.
Ferris BL, Taylor Jr LM, Oyama K, et al. Hypothenar hammer syndrome: Proposed etiology. J Vasc
Surg. 2000;31:104–113.
This retrospective study reported one large series of cases with hypothenar hammer syndrome, including
surgical treatment of 21 hands in 19 patients. Surgical treatment consisted of thrombosed segment
resection and the saphenous vein graft interposition. The average follow-up period was 22 months
(1 to 66 months). Sixteen grafts were patent, and the patients had no recurrence of symptoms. Two of
three patients whose graft had late occlusion had no symptoms of finger ischemia, and one had mild,
chronic digital ischemia.
Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interposition vein grafting: Patency with
microsurgical technique. J Hand Surg Am. 1991;16:274–278.
In this study, the authors reported eight cases of chronic distal ulnar artery thrombosis treated with
microsurgical interposition vein grafting. Long-term patency and clinical symptoms were evaluated
at a minimum of 1-year follow-up. Seven of eight vein grafts (88%) were patent, and one graft was
occluded. For the seven patent grafts, overall results were excellent in four cases and improved in
three cases. There was no improvement in the nonpatent graft case. The authors concluded
interpositional vein grafting procedures could be indicated for symptomatic chronic ulnar artery
thrombosis.
Jones NF, Raynor SC, Medsger TA. Microsurgical revascularisation of the hand in scleroderma. Br J
Plast Surg. 1987;40(3):264–269.
An early case report of two patients with severe Raynaud phenomenon treated successfully by
reconstructing the ulnar and radial arteries with branched vein grafts.
ddsf
SECTION XI
Contractures and
Spastic Conditions
CHAPTER 98 Surgical and Nonsurgical Treatment
of Dupuytren Contracture 745
CHAPTER 99 Biceps and Brachialis Lengthening 757
CHAPTER 100 Step-Cut Fractional Lengthening of Flexor
Tendons and Flexor Digitorum Superficialis
to Flexor Digitorum Profundus Transfer 764
CHAPTER 101 Flexor-Pronator Slide 770
CHAPTER 102 Thumb Adductor Release 774
CHAPTER 103 Capsulotomy for Proximal Interphalangeal
Contracture 779
CHAPTER 104 Capsulotomy for Metacarpophalangeal
Contracture 780
744
CHAPTER 98
Surgical and Nonsurgical Treatment of Dupuytren
Contracture
Shepard P. Johnson and Kevin C. Chung
INDICATIONS
• It is important to take a patient-centered approach and implement shared decision-
making when treating patients with Dupuytren disease because indications for inter-
vention vary widely based on patients’ subjective functional limitations and needs.
• Intervention for Dupuytren disease is most successful in instances when a cord
develops and causes metacarpophalangeal (MCP) or proximal interphalangeal (PIP)
joint contractures with functional consequences, including:
• Difficulty grasping objects.
• Difficulty performing fine motor tasks.
• Catching of flexed finger (e.g., placing hand in pocket).
• Inability to perform proper hygienic care of palmar tissue.
• Objectively, intervention is indicated when the MCP joint has a greater than 30-degree
contracture or the PIP joint has any degree of contracture.
• Indications for the five main treatment options are as follows:
• Enzymatic treatment with collagenase clostridium histolyticum (CCH) injection
• This treatment is indicated when there is a distinct and easily palpable cord
(Fig. 98.1A). This includes pretendinous, central, spiral, natatory, or adductor digiti
minimi (ADM) cords leading to contractures of the MCP or PIP joint (see Fig. 98.1B).
• Up to two injections of CCH may be performed at once, either in two different
cords in the same hand or at two sites along a single cord that hinders two
separate joints.
• Repeat CCH injections for recurrence are permissible.
• Percutaneous needle aponeurotomy for Dupuytren contracture
• This treatment is preferable for patients who seek a less invasive, less time-
intensive, and less costly treatment and for frail patients who would not toler-
ate extensive surgical treatments.
A B
FIGURE 98.1 Distinct visible and palpable pre-tendinous cord in the palm resulting in an MCP joint contrac-
ture is an excellent candidate for CCH or needle aponeurotomy.
745
746 CHAPTER 98 Surgical and Nonsurgical Treatment of Dupuytren Contracture
• Patients should have a distinct and easily palpable cord. This includes preten-
dinous or ADM cords causing MCP or PIP contracture.
• We caution use of this procedure for recurrence after previous surgery be-
cause of the high risk for complications.
• Partial open fasciectomy
• This treatment is ideal for patients who desire a longer disease-free period
(compared with CCH or needle aponeurotomy).
• Patients typically have recurrent or recalcitrant contractures. They may also
require concomitant joint capsulotomy or release of checkrein ligaments.
• Partial open fasciectomy is also indicated if Dupuytren disease causes con-
tractures in multiple digits (Fig. 98.2) or if there is significant disease burden
FIGURE 98.2 Dupuytren disease with coales- distal to the MCP joint crease; at this level, the neurovascular bundles are at
cence of scar tissue affecting multiple adjacent greater risk for injury during CCH injection or needle aponeurotomy.
digits resulting in flexion contractures at the MCP • Dermatofasciectomy
and PIP joints is suitable for open fasciectomy. • This procedure is indicated to treat Dupuytren cords with extensive involvement
of overlying skin, or recurrent Dupuytren cords that were previously excised.
• Digit amputation
• Digit amputation is reserved for end-stage disease with severely contracted
digit (typically the small finger), immobile joints, and loss of soft tissue.
Contraindications
• One contraindication is the absence of a functionally limiting contracture or soft-
tissue complication (i.e., wound).
• CCH is not indicated for isolate nodules or pits.
• Another contraindication is the inability to comply with postprocedural splint protocol.
• Contractures may recur rapidly without extension splinting in the early postinter-
ventional period.
• Visualize and palpate the hand to identify distinct cords that correlate with specific
joint flexion deformities.
• Identify nodules and explain to patients that the nodules will persist after CCH
injection or needle aponeurotomy.
• Identify confluence of cords interfering with function of multiple joints (e.g., nata-
tory cords within the webspace adherent to pretendinous cords of adjacent digits).
• Identify spiral cords because they displace neurovascular bundles superficially
and centrally, placing the bundles at greater risk during interventions.
• Evaluate joint flexion deformity:
• For the tabletop test, have the patient place the palm of their hand on a table
and identify cords that prevent contact with the table (Fig. 98.3).
• Use a goniometer to document joint flexion (helpful for monitoring progression
of disease and outcomes after intervention).
• Evaluate skin quality, depth of Dupuytren disease, and contracted tissue.
• Thin, contracted skin adherent to the Dupuytren cord is at higher risk for
wound complications after release.
• Document baseline sensory examination of each finger.
A B
FIGURE 98.3 Table top test demonstrates the inability to place the small finger flush with table
due to a PIP joint contracture.
CHAPTER 98 Surgical and Nonsurgical Treatment of Dupuytren Contracture 747
SURGICAL ANATOMY
• Dupuytren disease affects the superficial palmodigital fascia (Table 98.1 and
Fig. 98.4A):
• Normal fascial or palmar aponeurotic (PA) elements consist of fibers in multiple
directions that split into bands for each digit.
• Normal elements are referred to as bands, and the correlating diseased elements
are termed cords.
• Cords are generally within 4 mm beneath the palmar skin.
• Bands
• Longitudinal PA fibers are in three layers. The middle layer passes under the nata-
tory ligament and neurovascular (NV) bundle, forming the spiral band. In the fingers,
this becomes the lateral digital sheet (lateral to the NV bundle; see Fig. 98.4B).
• Transverse PA fibers contribute to the superficial transverse palmar ligament (not
affected by Dupuytren disease) and to the natatory ligament that contributes to
webspace shape and digital fascia.
• In the fingers, the Grayson ligament is volar to the NV bundle, and the Cleland
ligament is dorsal to the NV bundle (see Fig. 98.4C).
• Cords
• Central cords are generally close in proximity to the palmar skin (and furthest
from the flexor tendons) and most prominent between the distal palmar crease
and palmodigital crease.
• CCH injection and needle aponeurotomy are performed where the cord is identi-
fiable.
• MCP contracture: Proximal to palmodigital crease
• PIP contracture: Distal to palmodigital crease
• Spiral cords put the NV bundles at risk by pushing the NV bundles to the midline,
whereas retrovascular cords can displace and/or compress the NV bundles by
flexing the distal interphalangeal joint.
TABLE
98.1 Types of Cords Involved in Dupuytren Contracture
Cord Location Causes
Pretendinous (most frequent) Palm MCP flexion does not displace
NV bundle
Vertical (uncommon—branches Palm Painful triggering
off pretendinous cord)
Spiral (pretendinous/lateral/spiral Palm/digit Displaces NV bundle to midline
bands and Grayson ligament) and palm
Natatory Webspace/digit Webspace contraction; limits
finger abduction
Central extension of pretendinous Digit Usually does not displace NV
cord bundle
Retrovascular Digit DIP contracture and prevents full
correction of PIP contracture
Lateral (present with pretendi- Digit DIP and PIP contracture; dis-
nous and natatory cord and places NV bundle
Grayson ligament)
Abductor digiti minimi (ADM) ADM tendon PIP contracture
Proximal/distal commissural Proximal/distal First webspace contracture
commissural
ligament
DIP, Distal interphalangeal; MCP, metacarpophalangeal; NV, neurovascular; PIP, proximal interphalangeal.
Portion of the natatory ligament
Natatory ligament
Longitudinal fibers
of palmar aponeurosis
Transverse fibers of
palmar ligament First layer
Pretendinous band
Second layer
Third layer
Palmar aponeurosis
Superficial transverse
Spiral band palmar ligament
A B Vertical fibers of palmar aponeurosis
Lateral digital
sheath
Grayson ligament
Cleland
ligament
Spiral band
Transverse fibers
Pretendinous
C band
FIGURE 98.4 (A) The pretendinous bands are the most common fascial element involved in Dupuytren, whereas the transverse ligament is not involved.
(B) The sagittal view of the hand demonstrates how multiple cords can (1) coalesce together, (2) adhere to the overlying skin, and (3) adhere to deep
structures. (C) In the digit, the Grayson ligament is volar to the NV bundle, and the Cleland ligament is dorsal (not involved in Dupuytren).
POSITIONING
• For CCH injection and needle aponeurotomy, surgeons should sit across from the
patient while the affected extremity is laid supinated on a hand table.
• Patients with procedural or needle phobia should be placed in a semirecumbent
or recumbent supine position.
• The surgeon can use the ulnar border of their nondominant hand to place gentle
pressure to extend the affected finger, while still allowing their nondominant fingers
to remain free to aid the dominant hand with cord localization and needle control.
ENZYMATIC TREATMENT WITH COLLAGENASE

CLOSTRIDIUM HISTOLYTICUM INJECTION
Step 1: Prepare CCH for Injection
• CCH powder is reconstituted in a sterile diluent of 0.3 mg/mL calcium chloride dihy- STEP 1 PEARLS
drate and 0.9% sodium chloride. • Once reconstituted, CCH can be kept at room
• Each vial contains 0.9 mg of powdered CCH, but 0.58 mg is the recommended injec- temperature for 1 hour or refrigerated for up to
tion amount. 4 hours.
• A short 27-gauge needle, ideally 0.5 in. long,
• For MCP cord injections, use 0.39 mL of sterile diluent and plan to inject 0.25 mL of
should be used for injection.
the solution. • Use a 1-mL tuberculin syringe with a nonde-
• For PIP cord injections, use 0.31 mL of sterile diluent and plan to inject 0.20 mL of tachable needle.
the solution.
Step 2: Identify Target Cord(s) and Mark Location to Be Injected

• When extending the MCP or PIP (individually) of the affected digit, the cords that are
drawn superficial and taut are likely responsible for tethering of the joint. STEP 2 PEARLS
• Palpate the target cord and mark the injection area (approximately a 5-mm area to If a Y-shaped cord (e.g., the juncture of a central
permit three equally spaced aliquots). cord and natatory cord) is identified, consider
injecting at the junction point of the Y—this may
• MCP cords: Midpoint area between the distal palmar crease and the palmodigital
reach both cords from the one injection (Fig. 98.5).
crease.
• PIP cords: Area just distal to the palmodigital crease (no more than 4 mm from
the crease). STEP 2 PITFALLS
• Inject 1 to 2 mL of local anesthetic subcutaneously at the target location but avoid If possible, avoid injection in thin skin that is
overfilling and obscuring the palpable cord. adherent to the underlying cord because these
areas have a higher incidence of skin tears during
manipulation.
Step 3: Inject
Inject three small aliquots into target area of cord (Fig. 98.6).
• Cleanse the skin with alcohol. STEP 3 PEARLS
• Insert needle perpendicular to the skin, approximately 3 mm deep, and into the cord. • The surgeon can use their nondominant hand
• Inject one-third of the total injection volume. Expect to feel resistance to fluid flow to identify the borders of the target cord and
because of the tight fibrous cord. pinch the area to be injected to facilitate
appropriate injection location (Fig. 98.7).
• Remove needle and inject an additional one-third of volume 2 to 3 mm proximally
• After inserting the needle, passively flex and
and then distally from the initial injection into the same target cord. extend the finger to confirm the needle is not
• Gently wrap the hand in a soft dressing. Patients may use the hand for regular tasks in or abutting the flexor tendon.
the same evening.
STEP 3 PITFALLS
Step 4: Cord Manipulation and Rupture 1 to 7 Days Later
• Evaluate the cord and determine whether there is already partial or complete cord rupture. • The injection should be difficult and have re-
sistance to CCH flow; if it flows too easily, stop
• Relocalize the target cord and anesthetize the area (use local or intermetacarpal block). injecting immediately because the needle has
likely passed through the cord and is near the
flexor tendon.
• Patients should be counseled about potential
side effects: edema, hyperemia, pain, ecchy-
mosis, and even lymphangitis/axillary lymph-
adenopathy.
Skin
Subcutaneous fat
Dupuytren cord
Deep fat
Flexor tendon
Metacarpal
Collagenase and diluent
FIGURE 98.5 Coalescence of adjacent cords often occur at the MCP level due to involvement of the
natatory ligaments. Consider injection at these Y-shaped cords to address contractures of multiple digits.
Skin
Subcutaneous fat
Dupuytren cord
Deep fat
Flexor tendon
FIGURE 98.7 Use the non-dominant hand fingers to
Metacarpal
pinch the target cord area to be injected to facilitate
Collagenase appropriate injection location.
FIGURE 98.6 Inject CCH into the target cord at three consecutive points approximately
2-3mm away. This can be performed with through a single skin hole (left) or three sep-
arate skin holes (right).
• Rupture the MCP cord by gently flexing the wrist and then use gentle, steady force
to extend the finger with firm passive extension. Hold for 10 to 20 seconds.
• Flex the PIP joint and push against the flexed finger to lever against the MCP cord
(Fig. 98.8).
• For PIP cords, flex at the MCP joint before forceful passive extension of the PIP joint.
• After feeling the major “pop” of cord rupture, one can press along the cord with the
fingertip and break up any additional residual fibrous bands.
Step 5: Multiple Cords

• In patients with multiple cords, inject up to two cords in the same hand during a
FIGURE 98.8 Flexing the PIP joint and levering it single treatment visit.
while extending the MCP joint can assist in cord • Injections and finger extension procedures may be administered up to three times
rupture.
per cord at approximately 4-week intervals.
STEP 4 PEARLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES

If no rupture is achieved with the first attempt, one • Routine local wound care should be used to treat any skin tears.
can attempt extension two additional times until • Most patients can return to normal function within the week, once bruising and ten-
the cord ruptures. derness are resolved.
• Nighttime extension splinting is recommended for 3 months post-procedure to help
STEP 4 PITFALLS
maintain the improvement.
• MCP and PIP cords usually have an adequate response to one injection. Even in pa-
• In fingers with substantial, long-standing PIP
tients who do not have complete resolution, the improvement is usually substantial.
flexion deformity, underlying joint contracture
may prevent full extension, even with success- • Recurrence of contractures (PIP before MCP) is common after 1 to 2 years and re-
ful cord rupture. peat injections can be offered at this time.
• Furthermore, attenuation of the extensor
mechanism may lead to persistent extensor
lag in some cases.
• Skin tears can occur with cord rupture. Even
large tears heal with routine wound care in our
experience (Fig. 98.9A–B).
A B
FIGURE 98.9 (A) Skin tears (red arrow) can occur after cord rupture (yellow arrow), (B) but will heal
well with local wound care (blue arrow).
• There is no significant difference in outcomes (correction of contracture) between POSTOPERATIVE PEARLS

CCH and needle aponeurotomy at 1 to 2 years.
• Most complications are short term and self-
limited, such as edema, pain, blisters, and skin
PERCUTANEOUS NEEDLE APONEUROTOMY tears.
• The rare complication of tendon rupture has
Step 1: Identify Target Cord(s) and Mark Location to Be Injected been reported, although mostly after multiple
injections into PIP cords. Nevertheless, be vigi-
• When extending the MCP of the affected digit, the cords that are drawn superficial
lant in identifying this potential complication
and taut are likely responsible for tethering of the joint. should it occur because treatment is required.
• Mark the target cord(s) in the palm where it is prominent and furthest from the deep
tendons and NV bundles.
• Have an assistant hold the finger in extension because this will help displace the STEP 1 PEARLS
pathologic cord volarly, making the cord more palpable and decreasing the likeli- • Well-defined pretendinous cords causing con-
hood of injury to surrounding/deeper structures. tractures are most easily and safely treated
with needle aponeurotomy.
• Inject 1 to 2 mL of local anesthetic subcutaneously at the target location but avoid
• Avoid deep injection so that the digital nerves
overfilling and obscuring the palpable cord. are not anesthetized.
• Counsel patient to communicate during the
Step 2: Identify Characteristics of Target Cord procedure and report any pain or paresthesia
• Hold the finger in passive extension. (Tinel sign) when the surgeon is manipulating
the needle subcutaneously.
• At the marked location(s), through a single skin entry point, perform multiple volar
perforations in multiple directions and in multiple planes. Make mental notes of cord
characteristics, including tactile feedback, thickness, width, and depth. STEP 1 PITFALLS
• After determining the spatial and tactile characteristics of the cord, obtain a fresh
• Needle aponeurotomy of PIP cord contractures is
needle for cord transection. feasible but carries a higher risk for NV bundle
injury (given close proximity at the proximal pha-
Step 3: Perforate and Transect Target Cord langeal level). Therefore greater experience is
• Introduce the sharp bevel of the needle perpendicularly into the target cord. recommended before attempting this procedure.
• Use slow, deliberate sweeping motions to sequentially transect the cord layer by • Similarly, ADM cords require greater care given
the proximity of the ulnar NV bundle of the
layer from superficial to deep (Fig. 98.10). small finger.
• The surgeon should feel (and hear) distinct feedback when cutting the robust Dupuy-
tren scar tissue.
• Maintain extension during the procedure to keep the target cord under tension. STEP 2 PEARLS
• Use a 25-gauge needle for small, distal cords
Step 4: Rupture the Cord and up to 20-gauge (rarely, 18-gauge) needles
• Gentle but firm passive extension should pop the cord. for thick, robust, proximal cords.
• Do not pass the needle entirely through the
• With the finger extended, palpate along the cord and confirm that no residual cord
cord because this increases the risk for
is appreciable (Fig. 98.11). damaging other structures.
• Repeat steps 2 and 3 as needed. • Change needles frequently because they can
become dull quickly.
Beveled needle • If the patient complains of any nerve symp-
used as scalpel
toms or sharp pains, do not advance further.
Adjust the needle placement away from that
location.
• If there is concern that the tendon has been
entered, have the patient flex and see if the
needle moves with the tendon.
STEP 2 PITFALLS
• Using a larger needle may result in more skin
tears.
• Use caution when placing the finger in extreme
extension when treating MCP cords, because
this may also serve to tighten the flexor tendon
and put it at additional risk.
• Gentle flexion at the wrist may help relieve
flexor tendon tension.
FIGURE 98.10 Needle aponeurotomy is performed with a gentle sweeping motion of a needle to
allow the bevel to sequentially rupture the cord layer by layer. The surgeon will hear and feel distinct
feedback as the bevel contacts the thick, diseased fascial cords.
STEP 3 PEARLS
• With experience, surgeons will easily recognize
the distinct feel and sound of a needle apo-
neurotomy, which is akin to scraping the hook
side of a Velcro strap.
• For skin pitting, the needle can be used to
sweep under the dermis and release tethering
to the diseased fascia.
A B
STEP 3 PEARLS FIGURE 98.11 (A) Pretendinous cords causing MCP flexion of the ring and small finger are marked with
a purple dotted line. Target location for needle aponeurotomy (red arrow) in the mid to distal palm area
• If targeting multiple joints or cords, the treat-
is safe as the NV bundles are deep at this location. (B) Excellent resolution of contracture can be
ment progresses from distal to proximal. The
attained.
PIP joint is released first, followed by the MCP
joint.
• If the patient experiences pain during passive
extension, a formal digital block can be per- POSTOPERATIVE CARE AND EXPECTED OUTCOMES
formed before stretching. • A small adhesive bandage is placed after the procedure.
• If a skin tear occurs, local wound care with regular dressing changes is needed
STEP 3 PITFALLS until it heals. Be sure the patient is warned of the possibility of a skin tear before
• Do not insert the needle back into any area treatment to avoid an unhappy patient.
where the cord is no longer easily palpable. • There are no specific activity restrictions; permit range of motion (ROM) and use as tolerated.
• Avoid using excessive force, especially in • There is no significant difference in outcomes (correction of contracture) between
elderly patients, who are more susceptible CCH injection and needle aponeurotomy at 1 to 2 years, but patients experience
to fracture with forceful manipulation. less pain and recover more quickly after needle aponeurotomy.
• Needle aponeurotomy is less expensive than CCH injection.
Major complications of nerve injury, vessel injury, or Limited Open Fasciectomy
tendon rupture have been reported. Risk increases
when procedures are performed more distally in EXPOSURES
the fingers (i.e., distal to the palmodigital crease).
• For exposure in the palm, a transverse incision along the distal palmar crease is used.
• For exposure in a digit, a longitudinal incision is used over the midline of the digit
with optional Z-plasties. This incision is ended in a V (point facing proximally) near
EXPOSURES PEARLS the PIP joint or distal interphalangeal (DIP) joint (Fig. 98.12).
• Incisions should be superficial so that they do
not inadvertently injure critical structures that PROCEDURE
may have been pulled toward the skin.
• Bruner incisions are equally suitable but do not Step 1: Skin Incision and Exposure of Involved Structures
permit skin lengthening and introduce a risk
for ischemia of the skin flaps. • Incisions should be superficial enough to begin dissection of skin flaps but not so
deep that they risk injuring the pathologic cords that may contain the NV bundle.
• Use a knife to sharply elevate the skin flaps at the dermal level, leaving the fat down
EXPOSURES PITFALLS and off the flap.
When raising skin flaps to expose diseased cords • Retract the flaps with sutures.
and aid in identifying NV bundles, avoid elevating
the soft tissue between the digits (white arrow)
because this risks damage to the perforating
vessels keeping the digital skin flaps viable (see
Fig. 98.12).
STEP 1 PEARLS
• Use small skin hooks to provide tension when
creating skin flaps. This enables the surgeon to
take down the adherent segments of the skin.
• Use a pushing technique with the knife, rather
than a sawing technique. Sawing can cut NV
structures, but pushing with the knife is less
likely to do so in case they are inadvertently
encountered. Diseased tissue will feel gritty, FIGURE 98.12 (A) Surgical incisions provide access to palm and digital disease. Z-plasty incisions
whereas NV bundles will be soft. Constantly facilitate closure when the midline longitudinal incisions are used in the digits (red arrow). A V-Y
using fresh blades facilitates precise dissection. advancement flap is used at the distal end of the incision (white arrow). The blue area indicates the
soft tissue area that should be preserved (i.e., not elevated) during dissection to protect blood
supply to the skin flaps.
A B C
FIGURE 98.13 Identify NV bundles in areas with less disease burden first. Distally, it can be found in the soft area lateral and superficial
(red arrow). At the palmodigital area, the nerve can be wrapped in a spiral cord (blue arrow indicates spiral cord and nerve can be
visualized between the tenotomy scissors). After removal of disease, the NV bundles should be easily identified (green arrows).
Step 2: Identify Neurovascular Bundles and Separate Them

From Cords
STEP 1 PITFALLS
• Use gentle longitudinal spreading as needed to define the NV bundles. Identify areas
with less disease burden and trace proximally and distally to visualize the path of the Avoid making holes/perforations in the skin flaps
NV bundles (Fig. 98.13). during elevation. We prefer to leave a sliver of
diseased tissue adherent to the overlying skin.
• Proximally, the NV bundles are deep and may only be visualized after cord eleva-
tion has begun. In the palm, the transverse palmar aponeurosis is superficial to
the NV bundles. Resect the diseased cords superficial to the transverse fibers to STEP 2 PEARLS
keep the bundle safe and protected (Fig. 98.14). • Transverse fibers of the palmar aponeurosis
• At the palmodigital area, the cord may be wrapped in a spiral cord (Fig. 98.15). are not easily identified on the ulnar side of
• Distally at the PIP joint, the NV bundles may be found in a soft area between the the small finger; there is no protection for NV
cords. bundles there.
• Maintain visualization of the NV bundles at all
• Unroof diseased tissue over the NV bundles so that their path is clear. Fasciectomy times during dissection.
can proceed once the surgeon has defined the NV bundles’ trajectory.
FIGURE 98.14 The transverse palmar aponeurosis has transverse running fibers (shown above the
tenotomy scissors) that are uninvolved in the Dupuytren disease. These fibers are seen lateral to the
central cords (red arrow shows the ring finger central cords and the blue arrow shows the location
of the removed small finger central cord). The NV bundles are deep to this healthy tissue.
A B
FIGURE 98.15 (A) At the palmodigital junction, several diseased cords may be present. The tenot-
omy scissors are elevating a lateral band (red arrow) that connects to the pretendinous cord of the
ring finger (blue arrow). (B) The forceps are holding the ulnar digital nerve of the ring finger which
has been displaced superficial and central by the spiral cord (green arrow).
Step 3: Dissect Diseased Fascia

• For disease that is predominantly in the palm (and causes MCP contracture), perform
the dissection in a proximal to distal fashion, starting in the palm.
• Identify and mobilize the principal cord to facilitate the dissection.
• Dissect all extensions from the cord to the skin.
• Transversely transect the proximal-most portion of the cord, place a hemostat on
the end, and circumferentially elevate from proximal to distal.
• Leave the transverse fascia deep to the cord intact but remove longitudinal cords
that extend deep to attach to the underlying pulleys.
• For disease that is predominantly in the digit (and causing PIP contracture), perform
the dissection in a distal to proximal fashion.
• After both digital NV bundles are visualized, transect the central cord and pro-
FIGURE 98.16 In the small finger, there may be ceed proximally.
cords arising from or adherent to the adductor • After the central diseased fascia is completely mobilized, extend the digit to evaluate
digiti minimi (red arrow). contracture resolution.
• Remove any tethering lateral and spiral cords when maintaining protection of the NV
STEP 3 PEARLS bundles (Fig. 98.16; see also Fig. 98.15)
• Lastly, remove any retrovascular cords that run deep to the neurovascular bundles.
• Blunt dissection deep to the cords is useful in
elevating diseased tissue from underlying
structures, but spreading in the soft tissues Step 4: Joint Correction
should be done longitudinally and gently to • If the PIP joint still remains in a fixed flexed position after cord release, then release
minimize risk for injury to the NV bundles that the volar plate and perform a volar capsulotomy.
could occur with a transverse spread. • Incise the A3 pulley, retract the flexor tendons, and identify the volar plate.
• Find the NV bundle in the soft spot at the level
of the PIP joint. The NV is superficial and can be • Transect the proximal margin of the volar plate (checkrein ligaments), and gently,
identified more readily starting at the PIP joint. passively extend.
• Release a portion of the volar collateral ligament to prevent snapping of the collateral
ligaments over the proximal phalanx head.
STEP 3 PITFALLS
Use caution when manipulating the digital vessels. Step 5: Wound Closure
Aggressive handling can cause thrombosis, potentially • Deflate the tourniquet, obtain hemostasis, and ensure that digits are well perfused.
requiring repair.
• Evaluate skin flaps and wounds. With removal of the diseased cords, some wounds
may be able to be closed primarily.
STEP 4 PEARLS • In areas of flexion over the digits, a 60-degree Z-plasty is designed into the closure
Central slip attenuation may contribute to to break up the straight-line scars (Fig. 98.17).
persistent flexion of the PIP. Use a tenodesis • Once all wounds are closed, confirm adequate perfusion. A tightly closed skin envelope
test intraoperatively to help identify this potential can compress digital vessels.
issue, and, if identified, consider longer extension
• Use a series of interrupted nylon sutures and place dressing of antibiotic ointment
splinting and therapy postoperatively.
and Vaseline gauze, followed by a volar resting splint.
STEP 4 PITFALLS
• We caution against aggressive correction of a
fixed flexion deformity, because this risks injury
to the NV bundles.
• NV bundle(s) may be overly stretched after
release of contracture to full extension. If the
finger remains pale after extension, one may
need to keep the finger in some degree of
flexion to take tension off of the vessel and
permit adequate inflow.
STEP 5 PEARLS
Inspect vascular sufficiency with the digit in full
FIGURE 98.17 V-Y advancement and Z-plasty closures have added skin length in the longitudinal plane. extension, because straightening of a severely
contracted finger may lead to vascular impairment
and digital ischemia.
• Place hand in postoperative splint with digits fully extended for 1 week.
• After 1 week, remove splint for ROM exercises, including passive extension of the
PIP joint. Continue aggressive scar massage and ROM exercises/stretching through-
out the day to maintain contracture release.
• Patients may take off the splint during the day and continue nighttime splinting for 3
to 6 months postoperatively to prevent early recurrence of flexion contractures.
• If central slip attenuation is identified, consider a multiweek extension splinting regimen.
• Surgery has a lower recurrence rate (i.e., less recurrence at 5 years) than needle
aponeurotomy and CCH injection.
Dermatofasciectomy
PROCEDURE
Step 1: Mark the Diseased Area and the Excision Area
• The skin involved in the cord will be removed. Incisions should be made in the healthy
skin at the margins of the diseased area to completely excise the diseased tissues
and to more easily identify critical structures in safer tissue planes (Fig. 98.18).
• If flexion contracture obstructs the volar skin over the PIP, start with the proximal
area and identify and transect the cord there to open the digit more.
Step 2: Identify Neurovascular Bundles and Separate From Cords

Refer to step 2 of “Limited Open Fasciectomy.”
Step 3: Dissect Diseased Fascia

Dissect diseased fascia (Fig. 98.19). To do so, refer to step 3 of “Limited Open Fas-
ciectomy.”
FIGURE 98.19 Diseased dermatofascial cord has been resected

FIGURE 98.18 (A) Incisions should be designed (blue arrow) in healthy tissue (yellow arrow) and the neurovascular bundles (blue arrows) have
at the borders of the diseased tissue so that all the skin adherent to the been isolated during dissection. The red arrow demonstrate the
underlying diseased fascia is removed. pulley system which has been preserved to prevent bow stringing.
A B
FIGURE 98.20 Secure the skin graft with sutures. Ensure there is adequate graft to allow digit extension without
excess tension on the skin graft (B).
Step 4: Full-Thickness Skin Graft to Wound Bed

• Harvest a graft from an area without hair, such as the volar forearm or lateral inguinal
region.
• The graft should be thinned, leaving no fat to interpose between the wound bed and
dermal layer.
POSTOPERATIVE PITFALLS • Spread the graft out over the wound bed with minimal overhang of graft and residual
Any areas of poor graft take or graft failure will native skin.
require wound care and monitoring. This wound • Secure the graft with interrupted or running chromic gut suture around the pe-
care should focus on keeping any eschar moist riphery (Fig. 98.20) and with interrupted silk sutures that can be used to secure
to prevent additional scarring and contracture as the bolster.
it heals.
• Place a bolster of petroleum jelly gauze and cotton and secure with silk sutures.
Splint with finger in extension.

• Place extension splint.
• Remove operative splint and bolster approximately 1 week postoperatively.
• Apply petroleum jelly gauze daily to the skin graft, with additional wound care as
needed for any areas of poor healing.
• Conduct ROM and therapy with extension splinting for up to 6 weeks and use night
splinting for 6 months.
• Early improvements are often reported, but in the long term, the disease process is
FIGURE 98.21 Ten-year follow up demonstrates likely to recur. Ten-year follow-up is shown in Fig. 98.21.
well incorporated skin graft, softening of scars, See Video 98.1
and persistence of mild PIP joint contracture.
EVIDENCE
Binhammer P. Comparative outcomes of Dupuytren disease treatment. Hand Clin. 2018;34(3):377–386.
This review article summarizes the literature comparing outcomes of treatment options. Despite a large
number of publications, there is a lack of consensus on how to measure outcomes and define recur-
rence. The author concludes that (1) surgery has the lowest recurrence rate, (2) recurrence is lower in
older patients, (3) patients experience less pain and quicker recovery with needle aponeurotomy
compared with CCH compared with surgery, and (4) outcomes between needle aponeurotomy and
CCH injection are no different.
Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy,
and collagenase injection for Dupuytren contracture. J Hand Surg Am. 2011;36:1826–1834.e32.
Needle aponeurotomy is cost-effective if the success rate is high, whereas open partial fasciectomy is
not cost-effective for many patients. Collagenase is cost-effective if the price can be kept under $950.
Roush TF, Stern PJ. Results following surgery for recurrent Dupuytren’s disease. J Hand Surg Am.
2000;25:291–296.
Nineteen patients (28 fingers) were treated for recurrent contracture. Dermatofasciectomy and full-
thickness skin grafting had better postoperative total active motion (TAM) than limited fasciectomy
but did not prevent recurrence and did not have as good of TAM outcomes as fasciectomy and local
flap reconstruction.
CHAPTER 99
Biceps and Brachialis Lengthening
INDICATIONS
• One indication is a spastic elbow contracture from upper motor neuron injuries
(which are frequently the result of cerebral palsy, stroke, or traumatic brain injury).
• Any neurologic injury should be stable.
• In patients with volitional control, flexion contractures of 40 degrees may benefit
from surgical lengthening.
• Without volitional control, surgery is reserved for contractures over 100 degrees,
principally to facilitate hygiene care.
• The goals of surgery are to help with activities of daily living, allow adequate hygiene,
and improve appearance. Improvement of function after surgery in spastic limbs can
be difficult to predict.
Contraindications
• Contracture surgery should be delayed in any patient with ongoing, progressive
neurologic injury.
• Patients should undergo a thorough course of conservative treatment, including
therapy, serial splinting, oral spasmolytics (e.g., baclofen, dantrolene), and perhaps
botulism injections before being considered for surgery.
• Patient cooperation, spasticity, and inconsistent volitional control may make clinical
examination difficult.
• The level of cerebral or spinal cord involvement dictates how much of the extremity
is functional and which muscles become spastic.
• A common presentation of upper extremity spasticity combines shoulder adduction
and internal rotation, elbow flexion, wrist flexion, forearm pronation, finger flexion,
and thumb adduction (Fig. 99.1).
• Voluntary motor control and sensibility of the extremity must be determined. Patient
intelligence and any global athetoses must also be taken into account.
<
FIGURE 99.1 Common presentation of elbow spasticity consisting of elbow flexion (*), wrist flexion,
forearm pronation (^), finger flexion, and thumb adduction (1).
757
758 CHAPTER 99 Biceps and Brachialis Lengthening
• The examiner must differentiate between extrinsic muscle spasticity or contracture

and intrinsic joint contracture.
• Pure muscle spasticity will reveal full joint range of motion (ROM) when the sur-
rounding muscles relax (if able) or are fatigued. Administration of a local nerve
block may relax spasticity and permit more passive motion.
• Muscle and joint contractures will limit passive ROM. These can be difficult to
distinguish around the elbow. If contracted muscles cross two joints (e.g., biceps
brachii, extensor carpi radialis longus [ECRL], extensor carpi radialis brevis
[ECRB]), relaxation at the adjacent joint will yield a slight increase in elbow motion.
• Observation of routine tasks is invaluable when evaluating a patient’s current function
and needs.
• Having a patient perform a task with both hands indicates whether the patient
understands directions and will highlight functional deficits.
Specific Conditions
• Cerebral palsy is a static, nonprogressive central nervous system injury that affects
children from birth or shortly after and can manifest as a wide range of functional
and cognitive deficits. These children often do not have joint contractures beneath
their spastic muscles. Surgery is usually delayed until after the child has developed
functional use of the extremity (usually after 6 years of age), which should be evalu-
ated over multiple visits. Video recording the child can be helpful. Reconstruction in
older patients should proceed with great care, because these patients are frequently
able to compensate or adapt to their available level of function.
• After a stroke, neurologic recovery occurs throughout the first 6 months and any sur-
gery should be delayed for at least a year after injury. Stroke patients are frequently
older with weaker muscles that have had fewer years of abnormal tone. Thus spasticity
occurs to a lesser degree than in cerebral palsy. The recovery of motor function can be
poor in older people, but surgery may aid with positional and contracture correction.
• After a traumatic brain injury, spontaneous recovery can occur for up to 18 months,
and surgery should not be attempted during this time. Patients are frequently
younger. There is often quadriplegic involvement and concomitant peripheral nerve
injuries or fractures, which can cause deformity. Heterotopic ossification, particularly
around the elbow, can cause joint contractures. Depending on the injury, patient
cognition and cooperation is variable.
IMAGING
• Elbow x-rays are essential before any planned operation to evaluate for joint integrity
and the presence of heterotopic ossification.
• Computed tomography (CT) or magnetic resonance imaging (MRI) may be required if the
joint structure cannot be elucidated on radiographs (e.g., from prohibitive positioning).
• Dynamic electromyography helps to identify spastic and flaccid muscles, as well as
the patient’s phasic activity, if the examination is unreliable. Evaluation in the elbow
should include the biceps, brachialis, and brachioradialis.
SURGICAL ANATOMY
• The biceps brachii, brachialis, and brachioradialis are the main contributors to spastic
elbow flexion contracture (Fig. 99.2).
• Numerous neurovascular structures are at risk in the surgical field, so detailed
knowledge of anatomy is essential.
• The anterior elbow, or cubital fossa, is bound by the brachioradialis laterally and the
pronator teres medially.
• The lacertus fibrosus, or bicipital aponeurosis, extends from the prominent distal
biceps tendon to cover the cubital fossa.
• Immediately medial to the bicep tendon is the brachial artery, and the median nerve
courses medial to the artery.
• The lateral antebrachial cutaneous nerve (LABCN) runs lateral to the biceps tendon
between it and the brachioradialis.
• The radial nerve runs deep to the brachioradialis, lateral to the brachialis muscle.
Biceps brachii
Median nerve
Lateral cutaneous Brachial artery

nerve of forearm
Brachialis
Brachioradialis
Pronator teres
Bicipital aponeurosis
FIGURE 99.2 Antecubital anatomy showing biceps, brachialis, and brachioradialis.

• The patient should be supine with a hand table on the operative side. • In cases of severe contracture, Z-plasties can be
• A sterile tourniquet is placed as high on the brachium as possible. incorporated in the incision design (Fig. 99.5).
• Preservation of the bicipital aponeurosis is not
EXPOSURES necessary, and it should be fully released.
• A 15-cm lazy-S incision is centered over the antecubital fossa, beginning on the
medial arm and crossing to the lateral proximal forearm (Fig. 99.3) The S incision EXPOSURES PITFALLS
gives wide exposure and when the elbow is straightened, the S incision is length- There are numerous large and small veins that
ened in a straight line by recruiting lateral skin to facilitate closure. cross within the cubital fossa. Large veins should be
• Subcutaneous dissection is carried down to the fascia, taking care to protect the preserved and protected, if possible, whereas small
LABCN. veins can be ligated or coagulated. Meticulous
hemostasis prevents a postoperative hematoma.
• The lacertus fibrosis is incised to reveal the cubital fossa.

Biceps brachii
Bicipital aponeurosis
A B
FIGURE 99.4 (A–B) Biceps tendon.
• Beginning medially, the median nerve and brachial artery are identified adjacent to
the biceps tendon and protected (Fig. 99.4).
PROCEDURE
Step 1
• The biceps tendon is exposed to its insertion on the bicipital tuberosity of the radius. Place
retractors medial and lateral to protect the median nerve, brachial artery, and LABCN.
• Depending on the degree of contracture, perform either a fractional lengthening (for
mild contracture) or a step-cut lengthening (for severe contracture).
FIGURE 99.5 Z-plasty incision design. • For a fractional lengthening, the musculotendinous junction is identified proximally
and two transverse cuts are made in the tendinous portion 1 to 2 cm apart. Each cut
STEP 1 PEARLS is made halfway through the tendinous section, one medially and one laterally. Pas-
sively extend the elbow to separate the tendinous sections, leaving the underlying
Test elbow extension with the forearm supinated
before biceps release. In supination, the biceps muscle fibers in continuity.
tendon is under less tension. • For step-cut tendon lengthening, identify as much of the distal biceps tendon as
possible. Make a longitudinal cut in the middle of the tendon in line with its fibers.
STEP 1 PITFALLS Transverse cuts are made proximally and distally, exiting on opposite sides of the
Be sure to leave underlying muscle fibers intact longitudinal cut (Fig. 99.6). As much of the tendon is used as possible to provide
during fractional lengthening (Fig. 99.7). more tendon surface for repair.
**
A
B
FIGURE 99.7 Brachialis fractional lengthening.
FIGURE 99.6 (A–B) Biceps tendon step-cut lengthening with planned longitudinal (*) and opposite- Reprinted with permission from Canale ST,
exiting transverse cuts (**). Reprinted with permission from Gohritz A, Friden J. Management of Beaty JH, eds. Campbell’s Operative Orthopae-
SCI-induced upper extremity spasticity. Hand Clin. 2018;34(4):555–565. dics. 12th ed. Mosby; 2012.

• Once the biceps tendon is released, it can be retracted to reveal the brachialis
Two fractional lengthening incisions give more
muscle. release than one. The proximal incision should be
• Myotomy of the brachialis is performed because there is not much tendon that can made first, then the distal. If the order is reversed,
be lengthened. then the proximal musculotendinous surface may
• During a myotomy, in patients without volitional control, the entire brachialis can be retract under the biceps muscle.
transected down to the anterior joint capsule. Watch out for and preserve the mus-
culocutaneous nerve that lies on the surface of the brachialis muscle. STEP 2 PITFALLS
Frequently, the neurovascular structures (brachial
Step 3 artery or median nerve) limit how much extension
• Elbow motion is assessed for residual brachioradialis contracture. correction can be achieved (Fig. 99.8).
• If needed, a partial or complete brachioradialis release can be performed.
• For a partial release, use blunt dissection or cautery to release the origin off the STEP 3 PEARLS
distal humerus and allow it to slide forward. Using a needle-point electrocautery (Bovie) to
• For complete release, identify the radial nerve. Using electrocautery, directly cut divide muscle fibers will help with hemostasis and
through the entire muscle belly, taking care to protect the radial nerve (Fig. 99.9). minimize bleeding.

If a step-cut lengthening of the biceps tendon is performed, the two ends are con- The LABCN is superficial and medial to the
nected with a Pulvertaft weave and sutured with 2-0 braided, nonabsorbable suture brachioradialis. The radial nerve runs on the underside
(Fig. 99.11). of the brachioradialis muscle belly (Fig. 99.10). Both
need to be identified before dividing any muscle.
Brachialis muscle
Brachioradialis
muscle
FIGURE 99.8 Tension on median nerve limiting the extent of

contracture release. Proximal end of biceps tendon
Distal end of
biceps tendon
Flexor-pronator
Radial muscle group
nerve
FIGURE 99.9 Complete release of the brachioradialis.
Brachioradialis Biceps
muscle tendon
Deep
branch
Superficial
branch
FIGURE 99.10 Image of brachioradialis with or without radial

nerve crossing elbow. Artwork © 2020 John W. Karapelou.
From Yurgil JL, Hulsopple CD, Leggit JC. Nerve Blocks: Part I.
Upper Extremity. Am Fam Physician. 2020 Jun 1;101(11):
654-664. FIGURE 99.11 Ends connected with a Pulvertaft weave and sutures.
FIGURE 99.12 Resting posture after step-cut and brachialis lengthenings.
STEP 4 PEARLS
The tendon is repaired under minimal tension in Step 5
the position of maximal extension. • The tourniquet is released, and the field meticulously inspected for bleeding vessels.
• A drain should be placed if there is continued oozing from the wound, but meticu-
STEP 5 PEARLS lous hemostasis either with cautery or ligating the vessels is preferable.
• The skin is closed with deep and superficial sutures. No fascial closure is necessary.
As the goal of surgery is improvement of resting
posture, correction to full extension (to 0 degrees) • The arm is splinted in 30 degrees of flexion.
is rarely necessary. It is preferable to achieve 30 • The fingers are checked for perfusion. If there is any vascular compromise (without
degrees of resting flexion posture (Fig. 99.12). a vessel injury), the arm should be flexed to relax the brachial artery.

STEP 5 PITFALLS
• The splint is removed, and the incision is examined at 10 to 14 days.
Tension on neurovascular structures may limit the • If a biceps step-cut and repair was performed, the arm is splinted full-time for 4
amount of correction.
weeks and then night splinting is continued for 3 more weeks thereafter.
• Patients only undergoing fractional lengthening may begin ROM exercises at the first
postoperative visit.
Careful application of the bandage is essential to • Patients with volitional control should expect to lose some flexion strength, particu-
prevent either premature removal (especially if the
larly if significant muscle is released.
patient is a child) or a constricting bandage.
See Video 99.1
EVIDENCE
Carlson M, Hearns K, Inkellis E, Leach ME. Early results of surgical intervention for elbow deformity in
cerebral palsy based on degree of contracture. J Hand Surg Am. 2012;37:1665–1671.
This retrospective evaluation of 71 returning patients (74 elbows) treated with surgical release of con-
tracture of the elbow secondary to cerebral palsy divided patients into two groups based on the de-
gree of contracture. Those less than 45 degrees (n = 74) received partial lengthening of the biceps
and brachialis and proximal release of the brachioradialis. The group with greater than 45 degrees of
contracture (n = 14) underwent more extensive full elbow release, with biceps z-lengthening, partial
brachialis myotomy, and brachioradialis proximal release. Mean follow-up was 22 months and
18 months for each group, respectively. Both groups had significant improvements in elbow flexion
posture angle at ambulation (over 50 degrees in both). Active extension increased 17 degrees in the
partial lengthening group, with a 4-degree loss of active flexion. In the full elbow release group,
active extension improved 38 degrees, but there was an average 19-degree loss of active flexion.
Surgical intervention can effectively treat the deformity, but with greater contracture there is more
active flexion loss (Level IV evidence).
Dy C, Pean C, Hearns K, Swanstrom MM, Janowski LC, Carlson MG. Long-term results following
surgical treatment of elbow deformity in patients with cerebral palsy. J Hand Surg Am. 2013;38:
2432–2436.
This study examines long-term (>5 years) outcomes of the same cohort as the previous review. Twenty-
three patients (23 elbows) met inclusion criteria. The mean age of surgery was 9 years old and the
mean time of follow-up was 9 years. At long-term follow-up, active extension had maintained a
12-degree improvement with 8 degrees lost in active flexion. The average flexion posture during
ambulation was improved by 63 degrees. Correction results in their small cohort seem durable over
the long term (Level IV evidence).
Gong H, Cho H, Chung C, Park MS, Lee HJ, Baek GH. Early results of anterior elbow release with and
without biceps lengthening in patients with cerebral palsy. J Hand Surg Am. 2014;39:902–909.
The authors reviewed 29 patients with cerebral palsy who had anterior elbow release. The first 14 patients
had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous
adventitia off the biceps tendon. The later 15 patients had partial biceps tendon lengthening
in addition to the procedures in the first cohort. Mean follow-up was 72 months for group 1 and
31 months for group 2. The patients with biceps lengthening had more improvement in flexion
posture (53 vs. 44 degrees) and active extension (23 vs. 15 degrees) but had a mean decrease of
7 degrees in active elbow flexion (vs no change). Anterior elbow release can provide good elbow
positioning (Level III evidence).
Gschwind CR, Yeomans JL, Smith BJ. Upper limb surgery for severe spasticity after acquired brain
injury improves ease of care. J Hand Surg Eur. 2019;44(9):898–904.
The study presents the benefits of surgery for caregivers of patients with upper extremity spasticity.
The authors performed a heterogeneous mix of procedures in 45 spastic arms and hands in 38
noncommunicative patients with stroke, traumatic brain injury, neurodegenerative disorders, hypoxic
brain injury, and encephalitis. An average of 12 surgeries were performed on each limb, including
lengthening in every elbow. At an average follow-up of 6 months, there was significant improvement
in the reported Carer Burden Scores, including improvements in cleaning and dressing the limb
CHAPTER 100
Step-Cut Fractional Lengthening of Flexor Tendons
and Flexor Digitorum Superficialis to Flexor
Digitorum Profundus Transfer
TABLE House Functional INDICATIONS

100.1 Classification System
• An indication is patients with spastic wrist and finger flexion contractures resulting
House in functional limitations in activities of daily living, poor hygiene, and undesirable
Classification hand appearance.
0 Does not use • Patients should have exhausted nonoperative treatments, including splinting, oc-
cupational therapy, serial casting, and pharmacologic agents (e.g., botulinum toxin
1 Poor passive assist
A, baclofen).
2 Fair passive assist • Indications may vary based on the patient’s cognitive ability and baseline function.
3 Good passive assist • For patients with little voluntary control and minimal sensibility, hand hygiene is
the primary indication.
4 Poor active assist
• With more control, surgery must be tailored to the specific functional limitations
5 Fair active assist of each patient.
6 Good active assist • Hand function may be evaluated using the House Classification (Table 100.1).
• Fractional lengthening permits correction of mild deformities (Fig. 100.1A–B) and
7 Spontaneous use,
partial also maintains function; this should be the primary surgical option in patients with
volitional motion (House grade 2 or greater).
8 Spontaneous use,
• Flexor digitorum superficialis (FDS) to flexor digitorum profundus (FDP; superficialis-
complete
to-profundus transfer, STP) transfer is reserved for significant contracture (i.e., in-
Adapted from House JH, Gwathmey FW, Fidler ability to extend the fingers even when the wrist is flexed; Fig. 100.2). The procedure
MO. A dynamic approach to the thumb-in-palm
greatly reduces the ability to flex the fingers and should be performed in patients
deformity in cerebral palsy: evaluation and results
in fifty-six patients. J Bone Joint Surg Am. who do not use finger flexion for function (House 0 or 1).
1981;63:216–225.
Contraindications
STP transfer is contraindicated in patients with functional voluntary finger flexion and
grasp.
A B
FIGURE 100.1 (A–B) Mild flexion contracture with active finger extension preserved.
764
CHAPTER 100 Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor 765
FIGURE 100.2 Severe flexion contracture, unable to extend fingers.
• Clinical examination of spasticity is frequently challenging because of limitations in
patient cognition, cooperation, and function.
• Multiple separate examinations and even video recordings can be helpful to charac-
terize the patient’s upper extremity function.
• Involved spastic muscles, weak antagonist muscles, and underlying joint contrac-
tures must all be identified and documented.
• Selective peripheral nerve blocks can relax spastic muscles to permit complete
joint motion examination.
• Wrist flexion also takes tension off the spastic finger flexors to permit evaluation
of any metacarpophalangeal (MCP) or interphalangeal (IP) joint contracture.
• Wrist flexion contractures are frequently caused by a spastic flexor carpi ulnaris
(FCU), with occasional contribution from the flexor carpi radialis (FCR) and palmaris
longus (PL).
• Perform Volkmann’s test for digital flexor tightness by first extending the digits fully
with the wrist flexed. Then the wrist is slowly extended while maintaining full finger
extension. Surgery may be indicated if the wrist cannot be extended beyond neutral
(0 degrees; Fig. 100.3A–B).
• Sensation, including stereognosis, two-point discrimination, and proprioception,
should be assessed.
IMAGING
X-rays of the hand and wrist should be obtained preoperatively to rule out arthrosis or
bony blocks to motion.
SURGICAL ANATOMY
• A thorough knowledge of forearm anatomy is a mandatory prerequisite for this op-
eration (Fig. 100.4).
• Volarly, the FCR, PL, and FCU are encountered most superficially. Proximally, the
pronator teres (PT) may be seen too.
• The FDS is immediately deep to the superficial muscles.
• The deep volar forearm contains the flexor digitorum profundus (FDP), flexor pollicis
longus (FPL), and pronator quadratus (PQ).
• The median nerve travels between the FDS and FDP proximally and between the
FDS and FPL distally.
766 CHAPTER 100 Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor
Palmaris
Volkmann
angle
Median
nerve
B
FIGURE 100.3 (A–B) Volkmann’s test. (Fig. 32.4, from Kozin SH,
Lightdale-Miric NL. Spasticity: cerebral palsy and traumatic brain FCR FDS
injury. In Wolfe S, Pederson W, Kozin SH, Cohen M, eds. Green’s
Operative Hand Surgery. 7th ed. Elsevier; 2017:1080–1121.) FIGURE 100.4 Key anatomic structures in the forearm.
• The palmar cutaneous branch of the median nerve emerges volarly 5 cm proximal
to the wrist crease and runs just ulnar to FCR.
• The ulnar neurovascular bundle travels deep underneath the FCU muscle.
POSITIONING
Supine positioning with a hand table and an upper arm tourniquet are used.
EXPOSURES PEARLS
• A longer incision may be needed for STP EXPOSURES
transfer. • A longitudinal incision is made on the volar forearm (Fig. 100.5).
• The incision should curve radially in the distal • Incise the volar fascia to access the forearm musculature (Fig. 100.6).
half and cross the wrist at an angle if a simul-
• The PL is frequently divided distally to be used in concomitant tendon transfer or to
taneous carpal tunnel release is planned.
help treat a wrist flexion contracture.
FIGURE 100.5 Planning the incision. FIGURE 100.6 Exposure of the forearm musculature.
Fractional Lengthening of Flexor Tendons STEP 1 PITFALLS

The median nerve may appear similar to the tendon
PROCEDURE when the tourniquet is inflated. It must be identified
and protected before tendon incision (Fig. 100.7).
Step 1
Identify the musculotendinous junction of each tendon to be lengthened. FDS and FDP
should be lengthened for mild finger contractures. STEP 2 PEARLS
Making the distal tenotomy 2 cm proximal to the
Step 2 distal aspect of the musculotendinous junction
• Two transverse tenotomy incisions are planned in the musculotendinous junction, 1 ensures that muscle fibers remain attached on
cm apart from each other. both ends.
• The distal tenotomy cut is made, leaving the underlying muscle fibers in continuity
(Fig. 100.8).
STEP 2 PITFALLS
• Gently extend the wrist and fingers to separate the tenotomy ends.
Avoid hyperextending the wrist and fingers. This
• Perform the second incision 1 cm proximal to the first and extend again to achieve
may damage the underlying muscle.
the full lengthening (see Fig. 100.8).
Step 3
The skin is closed with interrupted deep dermal absorbable suture and then interrupted
nylon or running subcuticular sutures.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE PITFALLS

• The arm is immobilized in a plaster splint with the fingers and wrist in extension for Careful application of the bandage is essential to
2 weeks until dressing and suture removal in the office. prevent either premature removal (especially if the
• Therapy for motion is started at this time, and for the next 4 weeks a removable brace patient is a child) or a constricting bandage.
holding the fingers extended is worn when not performing active motion exercises.
Median nerve
FIGURE 100.7 Identifying the median nerve.
2nd incision
1st incision
FIGURE 100.8 Distal and proximal tenotomy.

768 CHAPTER 100 Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor
• Fractional lengthening can typically provide a 15% to 20% length increase and also
maintain volitional flexor control.
STEP 1 PEARLS
Superficialis to Profundus (STP) Transfer
The tendons to each individual finger should be
labeled separately before division to facilitate final
PROCEDURE
tenorrhaphy to the correct corresponding FDP
tendon. Step 1: Identification of Tendons and Division of FDS
• After exposure, the FDS and FDP tendons are identified and labeled with whip stitch
sutures and sterile labels (Fig. 100.9).
STEP 1 PITFALLS • Flex the wrist and fingers and sharply transect the FDS tendons as distally as
Protect the median nerve throughout the procedure possible.
to ensure that it is not inadvertently transected. • Once cut, the FDS tendons can be retracted proximally to expose the FDP muscle
belly (Fig. 100.10).
STEP 2 PITFALLS Step 2: Division of FDP Tendons

Hands with severe contractures may need to be • Each FDP tendon is labeled and transected just proximal to the musculotendinous
prepped a second time after the contractures junction.
are released, if the palmar skin was not easily
accessible preoperatively. • Extend the fingers to ensure release and position them in an acceptable resting posture.
• The overlap of the remaining proximal FDS and distal FDP tendon stumps deter-
mines the amount of contracture correction achievable. This overlap will reduce as
the fingers are extended.
STEP 3 PEARLS
• The four distal (FDP) or proximal (FDS) tendons Step 3: Superficialis to Profundus Tenorrhaphy
may be sewn together to create a single large
tendon for transfer. • The proximal FDS tendon of each finger is attached to the corresponding distal FDP
• We prefer individual tendon transfer so that tendon using a Pulvertaft weave (Fig. 100.11). The first pass of the weave is secured
the finger posture and cascade may be fine- with 3-0 braided nonabsorbable suture and the position of the finger is checked. If ac-
tuned as needed. ceptable, the remaining passes of the weave are completed and secured with sutures.
• With the wrist neutral, the patient should be • Tension should be set so that the MCP and IP joints are flexed to about 45 degrees
able to fully passively extend the fingers.
with the wrist in neutral. Starting from the index finger and moving ulnarly, the fingers
may be set in gradually increasing tension to recreate a normal finger cascade.
Step 4
The skin is closed with interrupted deep dermal absorbable suture and then interrupted
nylon or running subcuticular sutures.
POSTOPERATIVE PEARLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES
Active motion therapy is not routinely pursued after • The arm is immobilized in a plaster splint with the wrist in extension, MCP joints
STP transfer.
flexed to 60 degrees, and the IP joints extended for 2 weeks until dressing and su-
ture removal in the office.
FDP musculotendinous
junction
FDS
FIGURE 100.10 Exposure of the FDP muscle belly.

FIGURE 100.9 Labeling the FDS and FDP tendons. FDP, Flexor digi-
torum profundus; FDS, flexor digitorum superficialis.
FIGURE 100.11 Superficialis to profundus tenorrhaphy.
• Therapy for passive motion is started at this time, and for the next 4 weeks, a remov-
able brace is worn, holding the wrist at 20 degrees of extension and the fingers
flexed 20 degrees at the MCP joints.
• After 4 weeks, the splint is worn at night as long as it is tolerated.
• Patients and families should expect significantly easier postoperative access to the
palm for hand hygiene.
See Videos 100.1, 100.2, and 64.1
EVIDENCE
Peraut E, Taïeb L, Jourdan C, et al. Results and complications of superficialis-to-profundus tendon
transfer in brain-damaged patients, a series of 26 patients. Orthop Traumatol Surg Res. 2018;104(1):
121–126. doi:10.1016/j.otsr.2017.08.019.
The authors review results and complications of STP transfers for spasticity secondary to stroke or
traumatic brain injury in 26 patients with a mean age of 57 years (range 36–79) and mean follow-up
of almost 4 years. All hands improved from the initial positioning, except one hand, which developed
a claw deformity. Wrist stabilization was simultaneously performed in 20 hands. Reported complica-
tions included development of supination posture (15%), spontaneous MCP flexion (38%), swan neck
deformities (23%), and a thumb-in-palm contracture (30%).
Heijnen C, Franken R, Bevaart B, Meijer J. Long-term outcome of superficialis-to-profundus tendon
transfer in patients with clenched fist due to spastic hemiplegia. Disabil Rehabil. 2008;30:675–678.
This is a retrospective review of six patients (mean age 54 years) who underwent STP transfer with
spastic hemiplegia at an average of 10 years after stroke. The surgical indication was hygienic
problems in all patients and 3 patients also reported pain. Mean follow-up was 19 months.
Postoperatively, all hands could be passively opened and mean resting position of the MCP was
60 to 90 degrees. Pain was improved in 2 of 3 patients. All patients were satisfied with their choice
to have surgery.
Keenan M, Korchek J, Botte M, Smith C, Garland D. Results of transfer of the flexor digitorum
superficialis tendons to the flexor digitorum profundus tendons in adults with acquired spasticity
of the hand. J Bone Joint Surg Am. 1987;69:1127–1132.
This is a retrospective review of 31 patients (34 hands) treated with STP transfer. Patients were exam-
ined at a mean of 50 months postoperatively. The transfer was performed en mass from FDS to
FDP. All of the patients had a clenched-fist deformity preoperatively, with severe hygienic problems
of the palmar skin and no active function of the hand. Postoperatively, all of the hands were in an
open position, which enabled good hygiene of the palmar surface. Complications included minor
wound infections in three patients. An ulnar nerve neurectomy was performed distal to Guyon’s
canal in 25 hands, and intrinsic plus deformities developed in 7 of the 9 hands without neurectomy.
Keenan M, Abrams R, Garland D, Waters R. Results of fractional lengthening of the finger flexors in
adults with upper extremity spasticity. J Hand Surg Am. 1987;12:575–581.
This is a retrospective review of the results of fractional lengthening of the finger flexors in 27 patients
with upper extremity flexor spasticity with a mean follow-up time of 33 months. Patients were divided
preoperatively into those with potentially functional hands (n = 22) and those who were nonfunctional
(n = 5) based on the presence of motor control and hand sensibility. Postoperatively, all five nonfunc-
tional hands, which lacked any motor control, improved in posture and the hygiene problems
resolved. Twenty of the 22 patients with potentially functional hands (91%) improved their spastic
hand function score, with a mean of 3.7 points. Two patients (9%) decreased their spastic hand
function score as a result of overlengthening of the finger flexors, with loss of grip strength.
CHAPTER 101
Flexor-Pronator Slide
INDICATIONS
• Indications include established Volkmann ischemic contracture of the flexor-pronator
muscles of moderate severity and a sustained functional impairment of the spastic
upper extremity (resulting from central nervous system disorders such as cerebral
palsy, traumatic brain injury [TBI], or cerebrovascular accident [CVA]) with fixed fore-
arm pronation, wrist flexion, and finger flexion deformities.
Contraindications
Contraindications include complete absence of voluntary motor control of forearm
supination, wrist extension, and finger extension or family or parental reluctance to
proceed with surgery.
• It is important to ensure that the neurologic and orthopedic statuses are stable. For
example, after CVA or TBI, there is a period of time (12–18 months) when there may
be spontaneous functional improvement.
• Preoperative examination of the upper limb often reveals a fixed contracture of the
forearm in pronation and a flexion contracture of the wrist and digits. In more severe
digital flexion contractures, there may also be palmar skin breakdown. Grasp and
release motions of the hand are severely impaired because of the wrist position.
• In Volkmann contractures, there are volar deep soft-tissue adhesions and fibrosis
with or without peripheral nerve involvement. There is often some level of retained
finger and thumb flexion.
IMAGING
Radiographs of the forearm, wrist, and digits have limited use for preoperative planning
before flexor-pronator slide.
SURGICAL ANATOMY
• Regardless of the indication for surgery, a thorough understanding of the fore-
arm anatomy is essential. Understanding the relationships of the volar forearm
musculature, ulnar nerve, median nerve, brachial artery, and neurovascular
structures adjacent to the interosseous membrane is mandatory prior to em-
barking on surgery.
• In patients with spasticity, the forearm anatomy will be normal.
• In patients with a Volkmann contracture, the forearm anatomy may be distorted by
EXPOSURES PEARLS scarred musculature and scar-entrapped median and ulnar nerves.
• During superficial dissection, the medial
antebrachial cutaneous nerve is identified POSITIONING
and protected (Fig. 101.3). The operation is performed under general anesthesia with the patient placed supine on
• The plane between the flexor-pronator fascia the operating table. A tourniquet is placed high on the upper arm and the entire extrem-
and the overlying subcutaneous tissue may be
ity is prepared and draped.
difficult to develop. There are multiple perforat-
ing vessels to the dermal layer that will require
coagulation (Fig. 101.4). EXPOSURES
• The dissection extends radially to the median • An extensile anteromedial longitudinal incision is made, extending from just proximal
nerve as it enters the interval between the to the medial epicondyle to the midforearm along the axis of the ulna (Fig. 101.1).
deep and superficial heads of the pronator
• Wide subcutaneous flaps are elevated from the cubital tunnel region to the anterior
teres (Fig. 101.5).
forearm (Fig. 101.2).
770
FIGURE 101.1 Resting posture of the contracted upper extremity. FIGURE 101.2 Wide subcutaneous flaps are elevated.
*
MABC nerve
branch
Medial
epicondyle
Median
nerve
FIGURE 101.4 Black star on cutaneous perforator traversing
FIGURE 101.3 MABC (medial antebrachial cutaneous) nerve the surgical site.
branch identified by Freer elevator.
FIGURE 101.5 Median nerve before full neurolysis. The Freer elevator points to the median nerve.
PROCEDURE
Step 1
The ulnar nerve is identified proximal to the medial epicondyle and the ligament of
Osbourne is released. An ulnar nerve decompression is completed distal to the deep
flexor carpi ulnaris muscle fibers (Fig. 101.6).
772 CHAPTER 101 Flexor-Pronator Slide
Ulnar nerve
Median nerve
FIGURE 101.6 Forceps with gentle traction on the ulnar nerve. FIGURE 101.7 After extensive median neurolysis.

The flexor digitorum superficialis (FDS), palmaris Through the anterior dissection plane, the median nerve is identified as it enters the
longus (PL), and flexor carpi radialis (FCR) muscles flexor musculature. A complete median neurolysis is ensured so that the flexor-pronator
are carefully elevated from the interosseous
membrane to ensure that they can easily slide muscles can ultimately slide distally without tension on the nerve (Fig. 101.7).
distally. The median nerve has terminal motor
branches in this region and requires protection. Step 3
• The posterior and anterior exposures are connected in a plane just anterior to the
STEP 2 PITFALLS elbow capsule and the anterior band of the medial collateral ligament (Fig. 101.8).
• The entire flexor-pronator mass is then elevated from the medial epicondyle origin,
The median nerve motor branches are directly
within the deep exposure of the pronator. The distal the anterior elbow capsule, and the proximal portion of the interosseous membrane
motor branches are at risk during the more anterior using bipolar electrocautery (Fig. 101.9).
exposure.
Step 4
With gentle wrist and digital extension, the entire flexor-pronator muscle is translated
STEP 4 PEARLS
distally (Fig. 101.10).
A submuscular transposition of the ulnar nerve is
usually necessary to avoid tension on the nerve.
After transposition, the ulnar nerve will be adjacent
Step 5
to the median nerve in the anterior forearm. The tourniquet is released and hemostasis ensured. A subcuticular skin closure is per-
formed (Fig. 101.11).
Flexor -pronator
mass
Ulnar
nerve
FIGURE 101.8 Instrument around entire flexor-pronator mass before

release. FIGURE 101.9 After release of flexor-pronator mass.
FIGURE 101.10 With gentle wrist and digital extension, the entire
flexor-pronator muscle is translated distally.
FIGURE 101.11 Skin closure.

• A long-arm splint is designed to maintain the fingers and wrist in near full extension,
with concomitant elbow extension and forearm supination.
• After 2 weeks, the surgical splint is removed and a long arm cast is applied.
• At 1 month postoperatively, the long arm cast is converted to a forearm-based or-
thosis that maintains the wrist and digits in full extension. The splint is removed for
hygiene purposes and for daily occupational therapy exercises.
• At 2 months, use of a nighttime-only splint is initiated.
• Unrestricted activities resume at 3 to 4 months postoperatively.
See Video 101.1
EVIDENCE
Sharma P, Swamy MKS. Results of the Max Page muscle sliding operation for the treatment of
Volkmann’s ischemic contracture of the forearm. J Orthop Traumatol. 2012;13(4):189–196.
The authors present their experience with the flexor-pronator (Max-Page) muscle slide procedure in
patients with Volkmann contracture. They present functional outcomes in 19 patients treated over a
10-year period. They analyzed dexterity scores, hand grip strength, sensibility, and appearance and
graded final results as good, fair, or poor. Fifteen patients achieved good functional results. Three
had fair and one had poor results. All three variables showed significant improvements postopera-
tively. Wound dehiscence was the most common complication. One patient underwent revision
surgery to restore good hand function. The authors conclude that the procedure gives good
functional results and is technically straightforward to perform (Level IV evidence).
Thevenin-Lemoine C, Denormandie P, Schnitzler A, Lautridou C, Allieu Y, Genêt F. Flexor origin slide
for contracture of spastic finger flexor muscles: a retrospective study. J Bone Joint Surg Am. 2013;
95(5):446–453.
The authors sought to assess the increase in wrist and digital extension after a Page-Scaglietti flexor-
pronator release for spasticity of the upper extremity. Data from 54 hands and 50 patients (35 men
and 15 women) were evaluated. The Zancolli and House classifications were used to evaluate
improvements. The mean duration of follow-up was 26 ± 21 months. The mean gain in wrist exten-
sion with fingers extended was 67 ± 25 (range, 210–110). Preoperatively, no hands were classified
as Zancolli Group 1, whereas 25 hands were classified as Zancolli Group 1 at the latest follow-up
review. Ten nonfunctional hands (rated as House Group 0 or Group 1) became functional as a
supporting hand postoperatively. Zancolli and House classifications increased significantly
(p < 0.01) postoperatively. Partial recurrence of deformity occurred in 12 patients. In 7 cases,
surgery unmasked spasticity or contracture of the intrinsic muscles, which required further
intervention. The authors conclude that the Page-Scaglietti release improves range of motion
and function in people with wrist and finger contractures because of central nervous system
disorders (Level IV evidence).
CHAPTER 102
Thumb Adductor Release
INDICATIONS
• Cerebral palsy patients may develop spastic contracture of thumb adduction and
flexion muscles, which causes a characteristic thumb-in-palm deformity (Fig. 102.1).
• House described four types of thumb-in-palm deformity:
• Type 1: First ray adduction across the palm from contracture of the adductor pol-
licis (AdP).
• Type 2: First ray adduction with flexion of the metacarpophalangeal joint (MCP)
from contracture of flexor pollicis brevis (FPB).
• Type 3: First ray adduction with volar plate laxity leading to MCP hyperextension.
• Type 4: First ray adduction with MCP flexion and interphalangeal (IP) joint flexion
from contracture of the flexor pollicis longus (FPL).
• Surgical correction is indicated if:
• A patient is functionally unable to grasp and pinch objects because of the malposi-
tioned thumb, and conservative measurements have been exhausted (such as ag-
gressive hand therapy, thumb abduction splinting, and botulinum toxin injections).
• To facilitate hygiene using a nonfunctional hand.
• Surgical correction of thumb-in-palm deformity requires (1) release of contracted
intrinsic and/or extrinsic muscles, (2) augmentation of weak muscles, and (3) stabi-
lization of joints. For Type 1, release of the AdP from the metacarpal origin may also
be necessary. Various adjunct procedures may also be indicated (Table 102.1).
FIGURE 102.1 Thumb-in-palm deformity resulting Contraindications

from spastic contraction of the thenar musculature, • Patients without sufficient voluntary muscle control, cognitive ability, or motivation
predominantly the adductor pollicis.
to rehabilitate after surgery should not undergo thumb adductor release (unless it is
for hygienic issues).
• Patients must have adequate shoulder, elbow, forearm, and wrist function to posi-
tion the hand in a posture that permits use of thumb grip and pinch.
TABLE Surgical Options to Address Deformities or Deficits Associated

102.1 With Thumb-In-Palm Deformity
Deformity Surgery
Thumb contracture (with Release of FPB, APB, FDI
MCP flexion)
Thumb contracture (with Release of FPB, APB, FDI, and FPL lengthening
MCP and IP flexion)
Soft tissue deficit in first Thumb webspace z-plasty or locoregional flap
webspace
Weak thumb extension and EPL rerouting
abduction Augmentation of EPL, EPB, or APL with tendon
transfers (e.g. brachioradialis, palmaris longus,
extensor carpi radialis longus)
Joint instability CMC, MCP, or IP arthrodesis.
MCP volar plate capsulodesis.
APB, Abductor pollicis brevis; APL, abductor pollicis longus; CMC, carpometacarpal joint; EPB, extensor
pollicis brevis; EPL, extensor pollicis longus; FDI, first dorsal interosseous; IP, interphalangeal joint;
MCP, metacarpophalangeal joint.
774
• For patients with cerebral palsy, a complete examination of the upper extremity is
needed to understand the potential function and posture of each muscle and joint.
• Spastic contracture often manifests as shoulder internal rotation, elbow flexion,
forearm pronation, wrist flexion, wrist ulnar deviation, and thumb-in-palm deformity.
• Proximal procedures are necessary first if the hand cannot be placed in a favor-
able manner for utilization of thumb grip and pinch.
• Hand and thumb examination:
• Visually inspect the position of the first ray in relation to palm. Determine whether there
is adequate first webspace soft tissue to permit abduction and extension of the thumb.
• Palpate the thenar eminence to assess for contractures of involved muscles.
Note which muscles need release.
• Passively and actively assess range of motion (ROM) at the thumb CMC, MCP,
and IP joints. Evaluate for hyperextension and volar plate laxity of MCP. Deter-
mine whether any joints need stabilization.
• Assess strength of flexion, extension, adduction, abduction, and opposition of the
thumb. Consider whether muscles require augmentation with tendon transfers.
• Observe hand function. Determine whether the thumb-in-palm deformity inhibits
the patient’s ability to grasp objects and oppose the thumb against the fingers.
First dorsal
SURGICAL ANATOMY interosseous
Adductor pollicis
• The following intrinsic muscles may have contractures (Fig. 102.2):
Flexor pollicis
• Adductor pollicis (AdP): Consists of an oblique head and a transverse head, longus
which originate from the capitate, the base of the second and third metacarpals, Flexor pollicis
the volar intercarpal ligament, and the sheath of the flexor carpi radialis (FCR) brevis
tendon. The AdP inserts on the ulnar base of the thumb proximal phalanx. Abductor pollicis
• Flexor pollicis brevis (FPB): Consists of a superficial head and a deep head, which DBUN brevis
originate from the trapezium and transverse carpal ligament and trapezoid, capi-
RBMN
tate, and the distal carpal row volar ligaments, respectively. The FPB heads both
insert on the radial base of the thumb proximal phalanx. FIGURE 102.2 The contracted thenar muscula-
• Opponens pollicis (OP): Lies deep to the APB, originates from the trapezium and ture involved in thumb-in-palm deformity. When
releasing the adductor pollicis muscle and the
transverse carpal ligament, and inserts onto the volar radial side of the thumb
flexor pollicis brevis, the DBUN and RBMN
metacarpal. should be protected, respectively. DBUN, Deep
• Abductor pollicis brevis (APB): Lies radial to the FPB on the superficial (proximo- branch of the ulnar nerve; RBMN, recurrent
lateral) aspect of the thenar eminence. The APB arises from the transverse carpal branch of the median nerve. (From Fig. 72.11,
ligament, trapezium, and scaphoid and inserts onto the radial base of the thumb Azar F, Canale ST, Beaty JH, eds. Campbell’s
Operative Orthopaedics, 14th ed. Elsevier;
proximal phalanx.
2020).
• First dorsal interosseous (FDI): Originates on the radial side of the second meta-
carpal and the ulnar side of the first metacarpal. The FDI inserts on the radial side
of the base of the second proximal phalanx and the extensor apparatus. The FDI
muscle lays on the dorsum of the AdP, and together these muscles make up the
EXPOSURES PEARLS
mass of the first webspace.
• Nerves at risk during thenar myotomy: Protect the RBMN as it travels radially just distal to
the transverse carpal ligament.
• Deep branch of the ulnar nerve (DBUN): Enters the hand via the Guyon canal, travels
with the deep palmar arterial arch, and terminates between the two heads of the AdP.
The DBUN is at risk for injury during release of the AdP from its metacarpal origins.
• Recurrent branch of the median nerve (RBMN): The RBMN is most commonly
extraligamentous, with a takeoff immediately distal to the TCL. The nerve then
travels radially, crosses over the FBP, and terminates in the thenar musculature.
The RBMN is at risk for injury during release of the FBP, OP, and APB.
• Common digital nerves to the long and index fingers: These nerves lie on the
lumbricals and run longitudinally toward the digits.
Thumb Intrinsic Muscle Release

EXPOSURES
• A midpalmar incision is designed along the border of the thenar eminence (Fig. 102.3).
• Sharp dissection is carried through subcutaneous tissue and palmar fascia.
776 CHAPTER 102 Thumb Adductor Release
STEP 1 PEARLS
• Protect the DBUN, which is encountered be-
tween the oblique and transverse heads of
the AdP.
• Protect the deep palmar arch, which is
encountered during release of the proximal FIGURE 102.3 A palmar incision along the thenar eminence is used to access the AdP and thenar
origin of the AdP. musculature. The incision can be extended proximally (purple dotted line) if more access is needed
to release the abductor pollicis brevis. AdP, Adductor pollicis.
STEP 1 PITFALLS
Aggressive retraction to expose the deep thenar • The most distal portion of the transverse carpal ligament (TCL) is incised to expose
musculature may cause nerve traction injuries. the median nerve and flexor tendons.
Step 1: Thumb Adductor Pollicis Origin Release

STEP 2 PEARLS
• The AdP muscle origin on the third metacarpal is exposed after retracting the com-
• Extend the proximal portion of the palmar mon digital branches of the median nerve and the long finger flexor digitorum super-
incision to provide adequate exposure of the ficialis (FDS) ulnarly (Fig. 102.4).
thenar muscles.
• Apply a thumb abduction force to maintain • Using a bipolar cautery to control bleeding, release the AdP muscle (oblique and
tension on the thenar musculature as it is transverse head) from the radial side of the third metacarpal.
released.
• As the muscles are released, they will retract Step 2: Thenar Muscle Origin Release
distally toward the thumb insertions. Retraction • If adequate thumb abduction is not achieved with the AdP myotomy, then release
will reveal unreleased, taut structures.
the remaining thenar musculature.
• Incise and completely release the origin of the FPB and OP from the transverse
carpal ligament.
• Continue proximally and release the distal two-thirds of the origin of the APB (Fig. 102.5).
Median nerve
and flexor digitorum Adductor
superficialis muscle pollicis muscle, Adductor
retracted oblique and pollicis
transverse Flexor
heads pollicis
brevis
Abductor
pollicis
brevis
Recurrent Superficial head of Proximal extent

branch of flexor pollicis brevis
of APB origin
median nerve muscle and abductor
pollicis brevis muscle release
Transverse
cut and retracted FIGURE 102.5 During thenar muscles release,
A B carpal
ligament the thumb should be held in an abducted and
FIGURE 102.4 The common digital nerve and flexor digitorum superficialis to the long finger are re- extended position to permit visualization of unre-
tracted ulnarly to expose the third metacarpal. The adductor pollicis can then be released completely. leased, taught structures that may be causing
The red line shows where the transverse carpal ligament can be incised to provide better residual contracture. (From Fig. 72.11, Azar F,
exposure.(Fig. 102.4B from Disorders of the brain. In Karol LA, ed. Tachdjian’s Pediatric Orthopaedics. Canale ST, Beaty JH, eds. Campbell’s Operative
Elsevier; 2022: 1419–1529.e19.) Orthopaedics, 14th ed. Elsevier; 2020).
Step 3: First Dorsal Interosseous Release

STEP 3 PEARLS
Release the FDI from its origin on the first metacarpal.
• Protect the princeps pollicis vessel at the base
of the metacarpal during FDI release.
Extensor Pollicis Longus Rerouting to Enhance Thumb • If visualization of the FDI is poor from the volar
Abduction approach, perform the release with (1) a sepa-
rate longitudinal incision over the dorsal aspect
of the thumb metacarpal or (2) during a con-
EXPOSURES comitant first webspace contracture release.
Make a longitudinal incision at Lister tubercle to facilitate visualization of the first three
extensor compartments.
STEP 2 PEARLS
PROCEDURE Release subcutaneous tissue septae that may
interfere with EPL tendon gliding.
Step 1: Elevate the Extensor Pollicis Longus
Open the third extensor compartment and elevate the EPL superficially.
STEP 3 PEARLS
Step 2: Transpose the Extensor Pollicis Longus • Evaluate tenodesis by passively flexing and
• Transpose the EPL into the subcutaneous space and displace it radially. extending the wrist and observing the resultant
• Mobilize the EPL tendon from its musculotendinous junction to a point distal to the thumb motion.
• The final trajectory of pull from the transposed
extensor retinaculum.
EPL should simulate the APL.
Step 3: Create the Abductor Pollicis Longus Sling
Create the APL sling (Fig. 102.6).
• Open the first extensor compartment.
• Harvest a slip of APL (proximally based).
• Loop the APL sling around the EPL to prevent ulnar subluxation.
• Suture the APL sling to the volar periosteum of the radius (or volar first dorsal com-
partment).

• Immobilize the thumb metacarpal in wide abduction and opposition for 4 weeks.
• After 4 weeks, continue nighttime splinting with a custom orthoplastic splint to prevent
deformity recurrence.
• Initiate hand therapy and guided rehabilitation at 4 weeks if tendon transfers were
performed.
• Surgical reconstruction of thumb-in-palm deformity appears to improve hand func-
tion, hygiene, and the appearance and quality of life of patients.
• Restoration of hand posture, position, and gross motor function are expected after
thumb-in-palm releases, but complete restoration of fine motor function and dexter-
ity is unrealistic in the setting of patients with spastic conditions.
See Video 102.1
EPL
APL
sling
FIGURE 102.6 Extensor pollicis longus (EPL) rerouting from the third extensor compartment to the
first dorsal compartment using a slip of the abductor pollicis longus (APL). Placing the EPL in a more
radial position permits greater abduction of the thumb. (From Kozin SH, Lightdale-Miric N. Spastic-
ity: Cerebral palsy and traumatic brain injury. In Wolfe S, Pederson W, Kozin SH, Cohen M. Greens
Operative Hand Surgery. 7th ed. Elsevier; 2017:1080–1121.)
778 CHAPTER 102 Thumb Adductor Release
EVIDENCE
Smeulders M, Coester A, Kreulen M. Surgical treatment for the thumb-in-palm deformity in patients
with cerebral palsy. Cochrane Database Syst Rev. 2005;(4):CD004093. doi:10.1002/14651858.
CD004093.
This Cochrane Review evaluated the efficacy of surgical interventions for thumb-in-palm deformity,
including surgical indications and outcomes. Only nine studies were included, all of low quality.
Reliable judgment on the role of surgery could not be determined, but surgery appeared to improve
hand function, facilitate hygiene, and improve patient quality of life.
Alewijnse JV, Smeulders MJ, Kreulen M. Short-term and long-term clinical results of the surgical correction
of thumb-in-palm deformity in patients with cerebral palsy. J Pediatr Orthop. 2015;35(8):825–830.
This retrospective study on surgical outcomes for thumb-in-palm deformity identified 39 patients. The
success rate was 87% and 80% for short-term and long-term follow-up, respectively, and 87% of
patients would undergo surgery again. The authors concluded that surgical correction of thumb-in-
palm deformity has a high clinical success rate and patient satisfaction in the long term.
CHAPTER 103
Capsulotomy for Proximal Interphalangeal
Contracture

This chapter includes the following video: Video 103.1 – Proximal Interphalangeal
Volar Capsulotomy.
KEY CONCEPTS
• Proximal interphalangeal (PIP) joint capsulotomy is indicated for patients with de-
creased range of motion (ROM) and functional limitations who do not experience
relief after nonoperative management (active joint mobilization, dynamic and/or
static splinting, and passive stretching). Patients must understand that recurrence is
common and postoperative therapy is mandatory.
• A no. 15 blade is used to incise the membranous volar plate over the head of the
proximal phalanx. The blade is gently curved, separating the volar plate from the
accessory collateral ligaments. This maneuver divides the checkrein ligaments, pre-
serves the transverse digital artery, and releases the accessory collateral ligaments.
• A Freer is used to elevate the volar plate in a proximal-to-distal direction. The finger
is passively extended at the PIP joint to identify any other tight areas. Additional
release is performed as necessary. The incisions are closed with 5-0 nylon and the
patient is placed in a volar splint with full PIP extension and metacarpophalangeal
(MCP) flexion.
• Aggressive active ROM is started within 48 hours of surgery. Patients are placed in
a static extension splint at night and when not performing ROM exercises.
Extensor
Middle Collateral Accessory Volar plate Proximal

phalanx ligament collateral phalanx
ligament
FIGURE 103.2 The collateral ligaments and accessory collateral ligaments lie adjacent to the retinac-
ular ligament and provide lateral stability to the PIP joint. PIP, Proximal interphalangeal.
779
CHAPTER 103
Capsulotomy for Proximal Interphalangeal
Contracture
INDICATIONS
• Proximal interphalangeal (PIP) joint capsulotomy is indicated for patients with de-
creased range of motion (ROM) and functional limitations who have failed nonop-
erative management (active joint mobilization, dynamic and/or static splinting, and
passive stretching).
• Patients must understand that recurrence is common and postoperative therapy is
mandatory.
• In rheumatoid arthritis, synovitis within the joint stretches the extensor mechanism
and causes a boutonniere deformity.
• In osteoarthritis and posttraumatic arthritis, edema causes expansion of the synovial
spaces. A swollen metacarpophalangeal (MCP) joint assumes an extended posture,
which increases the relative flexion force on the PIP joint. The collateral ligaments
contract and limit motion over time.
• The fingers are examined for swelling, scars, and deformity.
• Passive and active ROM at the PIP joint is tested with the MCP flexed and extended.
Increased PIP motion with MCP flexion may indicate intrinsic tightness. If passive
motion exceeds active motion, then tendon adhesions may be present. If passive and
active motion are equal and PIP motion is the same in all MCP positions, then the
pathology is within the PIP joint.
• The joint is tested for stability in all directions.
IMAGING
• Standard, three-view radiographs are performed to evaluate the bony anatomy and
assess for articular congruity (Fig. 103.1).
FIGURE 103.1
779.e1
779.e2 CHAPTER 103 Capsulotomy for Proximal Interphalangeal Contracture
• Magnetic resonance imaging (MRI) and computed tomography (CT) are rarely needed
but offer a more detailed assessment of the articular surface and bony anatomy in
posttraumatic situations.
SURGICAL ANATOMY
• The PIP joint has a large arc of motion but is constrained by the anatomy of the
articular surfaces and the surrounding soft tissue attachments.
• The PIP joint is covered laterally by a superficial layer made of transverse and
oblique fibers of the retinacular ligament of Landsmeer. The oblique retinacular liga-
ment links the motion of the PIP and distal interphalangeal (DIP) joints. With PIP
flexion, the ligament relaxes the DIP joint to allow flexion. During PIP extension, the
ligament tightens to extend the DIP.
• The collateral ligaments and accessory collateral ligaments are stout structures ad-
jacent to the retinacular ligament and provide lateral joint stability (Fig. 103.2).
• Paired checkrein ligaments extend proximally from the volar plate and insert onto the
proximal phalanx; their primary function is to limit extension. An anatomic landmark
that delineates the checkrein ligaments is the transverse digital artery, which passes
3 mm proximal to the PIP joint (Fig. 103.3).
Extensor
Middle Collateral Accessory Volar plate Proximal

phalanx ligament collateral phalanx
ligament
FIGURE 103.2
Middle phalanx
Volar plate
Nutrient branch
of digital artery
Checkreins
FIGURE 103.3
CHAPTER 103 Capsulotomy for Proximal Interphalangeal Contracture 779.e3

• The patient is placed supine with the arm extended on a hand table.
• The use of local anesthetic with or without IV sedation allows the patient to partici-
pate intraoperatively. Assessment of active ROM helps ensure that all limiting pa-
thology has been addressed.
• No special equipment is required.
Midlateral Approach Design the midaxial incision on the side of the

digit opposite a pinch or resting surface (the ulnar
• An incision is designed at the junction of the glabrous and dorsal skin extending side of the index finger and radial side of the small
from the midshaft of the proximal phalanx to the midshaft of the middle phalanx finger).
(Fig. 103.4).
• The skin and subcutaneous tissue are incised using a no. 15 blade. The digital
EXPOSURES PITFALLS
bundles are visualized and retracted volarly.
• The lateral aspect of the flexor tendon sheath is incised, and the transverse reti- Avoid an excessive sheath excision and violation of
the A2 and A4 pulleys.
nacular ligament is divided to visualize the flexor tendons (arrow; Fig. 103.5). After
division of the transverse retinacular ligament, synovitis is usually visible.
• The flexor tendons are retracted to expose the volar plate (arrow) and collateral liga-
ments (Fig. 103.6).
Volar Approach
• A V-shaped incision is designed, centered at the PIP skin crease.
• The skin and subcutaneous tissue are incised, and a flap is raised at the level of the
flexor tendon sheath. The neurovascular (NV) bundles are identified and protected.
FIGURE 103.4
FIGURE 103.5
FIGURE 103.6
779.e4 CHAPTER 103 Capsulotomy for Proximal Interphalangeal Contracture
• The A3 pulley is divided on its lateral edge to expose the flexor tendons. The A2 and
A4 pulleys are preserved.
• The tendons are retracted to expose the volar plate and checkrein ligaments.

This maneuver divides the checkrein ligaments, Step 1
preserves the transverse digital artery, and
releases the accessory collateral ligaments. A no. 15 blade is used to incise the membranous volar plate over the head of the
proximal phalanx. The blade is gently curved, separating the volar plate from the ac-
cessory collateral ligaments (Fig. 103.7).
STEP 1 PITFALLS
Careful retraction is necessary to avoid injury to the Step 2
nearby flexor tendons and neurovascular bundles. A Freer is used to elevate the volar plate in a proximal-to-distal direction (Fig. 103.8).
Step 3
• The finger is passively extended at the PIP joint to identify any other tight areas
(Fig. 103.9). Additional release is performed as necessary.
Middle phalanx
Incision
Collateral ligament
Volar plate
Proximal phalanx
FIGURE 103.7
Accessory
Middle Collateral collateral Proximal
phalanx ligament ligament Volar plate phalanx
Extensor
FIGURE 103.8
CHAPTER 103 Capsulotomy for Proximal Interphalangeal Contracture 779.e5
FIGURE 103.9
• The incisions are closed with 5-0 nylon and the patient is placed in a volar splint with
full PIP extension and MCP flexion.

• Aggressive active ROM is started within 48 hours of surgery.
• Patients are placed in a static extension splint at night and when not performing
ROM exercises.
• Sutures are removed at 2 weeks.
See Video 103.1
EVIDENCE
Yang G, McGlinn EP, Chung KC. Management of the stiff finger: evidence and outcomes. Clin Plast
Surg. 2014;41(3):501–512.
This article reviews the anatomy, classification, and treatment options for MCP, PIP, and DIP joint
contractures.
Ghidella SD, Segalman K, Murphey M. Long-term results of surgical management of proximal
interphalangeal joint contracture. J Hand Surg Am. 2002;27:799–805.
This article retrospectively reviews outcomes for 68 PIP joints that underwent contracture release. The
mean improvement was 7.5 degrees of motion. Factors that that affected ROM outcomes were age,
number of prior procedures, preoperative flexion, removal of an exostosis, number of structures
released, and preoperative arc of motion. A second surgery was performed in 35% of cases overall.
The authors state that an ideal candidate is a patient younger than 28 years who has preoperative
maximum flexion measurement of less than 43 degrees. The study did not address the postoperative
rehabilitation or compliance of patients and was focused on operative intervention and long-term
outcome.
Bruser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures:
Midlateral versus palmar incision. J Hand Surg Am. 1999;24:288–294.
This is a retrospective review comparing 45 fingers treated for PIP contracture. A palmar incision was
used in 19 fingers and a midlateral incision was used in 26 fingers. The groups had comparable de-
mographics and preoperative function. In follow-up at 1.5 years, the midlateral incision group had a
mean arc of motion of 0 to 90 degrees in comparison to the palmar incision group, which was 30 to
90 degrees.
Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C. The treatment of chronic flexion contractures
of the proximal interphalangeal joint. J Hand Surg Br. 1995;20:385–389.
This is a retrospective review of 19 patients treated for chronic flexion contractures. The preoperative
extension deficit ranged from 70 to 90 degrees. The treatment protocol included surgical release fol-
lowed by static and/or dynamic splinting. Surgery was performed using a midlateral approach. Oper-
ative release included release of the accessory collateral ligament, volar plate, and checkrein liga-
ments. Complete extension of the finger was achieved in 11 cases (57.9%); in the remaining 8 cases
(42.1%) the residual extension deficit ranges from 10 to 15 degrees. The authors conclude that surgi-
cal release of the PIP joint with postoperative therapy has good results with minimal complications.
CHAPTER 104
Capsulotomy for Metacarpophalangeal
Contracture
INDICATIONS
• Metacarpophalangeal (MCP) joint stiffness can usually be prevented or corrected
with nonoperative management, such as edema control, splinting, and early joint
mobilization. About 90% of patients with MCP contractures are successfully treated
nonoperatively. MCP capsulotomy is indicated in motivated patients with persistent
contracture and hand dysfunction after several months of therapy.
• Surgery is one part of the treatment plan for MCP contracture. Postoperative hand
therapy is critical to maximize joint motion and treat scars, hypersensitivity, and
edema. Patients and therapists should meet before surgery to discuss expectations.
Patients must understand and commit to the plan.
Contraindications
• One contraindication for the procedure is an inability to attend postoperative hand
therapy. The patient must have access to a capable hand therapist and be willing to
attend therapy several times per week.
• It is also essential to ensure that the patient and therapist will be permitted to work
together; preoperative payor (insurance) authorization should be confirmed when
necessary.
• The goal of the examination is to identify the source of stiffness. Pathology in the
soft tissue, capsuloligamentous structures, muscles, tendons, or bone can contrib-
ute to MCP contracture. See Table 104.1 for additional details.
• Examine the quality and compliance of the skin. An injured MCP joint typically assumes
an extended posture. Scar contracture or dorsal skin deficiency sometimes contribute.
• Passive and active range of motion (ROM) are carefully evaluated. Passive motion
that exceeds active motion suggests pathology in the muscle or tendon. When ac-
tive and passive motion are equal, the cause of stiffness is likely capsuloligamentous
scarring or a bone block. When the joint does not move at all, it is impossible to
localize the problem. Joint releases can be done first to get the joints mobile before
tackling the tendon etiology.
TABLE
104.1 Etiology and Treatment of Metacarpophalangeal Contracture
Category Involved Structures Operative Treatment Options
Soft tissue Skin, subcutaneous tissue, Scar release, skin graft, flap
fascia
Capsule/ligament Joint capsule, collateral Capsulotomy or capsulectomy,
ligaments, volar plate collateral ligament release, re-
lease of volar plate adhesions
Muscle/tendon Extensor or flexor tendons, in- Tenolysis, tendon lengthening, in-
trinsic tendons, tenosynovium trinsic release, tenosynovectomy
Bone Articular incongruity, bone Arthroplasty, arthrodesis
block
780
CHAPTER 104 Capsulotomy for Metacarpophalangeal Contracture 781
IMAGING
Standard, three-view radiographs of the hand are mandatory to evaluate the joint sur-
faces and rule out bony blockade or exostoses.
SURGICAL ANATOMY
• The MCP joint is an asymmetric condylar joint with motion permitted in two axes:
flexion-extension and radioulnar deviation. The normal arc of motion is slight hyper-
extension (0 to 45 degrees) to 90 degrees of flexion.
• The joint is stabilized by the volar plate, paired proper and accessory collateral liga-
ments, and the extensor tendon (Fig. 104.1).
• The volar plate is a thick, fibrocartilaginous structure that originates from the head
of metacarpal and inserts onto the base of the proximal phalanx. Its primary function
is to limit hyperextension.
• The radial and ulnar proper collateral ligaments originate from the dorsal metacarpal
head and run diagonally to the volar base of the proximal phalanx. These ligaments
are substantial: 1.5- to 3-mm thick, 4- to 8-mm wide, and 12- to 14-mm long. The
accessory collateral ligaments originate proximal and volar to the proper collateral
ligaments and fan out to insert onto the proximal phalanx, volar plate, and flexor
tendon sheath.
• The dorsal joint capsule is closely associated with the extensor mechanism. The
sagittal bands originate from the volar plate, then wrap around the joint capsule and
insert onto the extensor hood. They centralize the extensor tendon over the MCP
joint and prevent bowstringing during hyperextension. The intrinsic tendons insert
onto the lateral bands, which are volar to the axis of rotation of the MCP joint and
act as flexors (Fig. 41.5).
• In extension, the dorsal capsule and collateral ligaments are redundant and permit
motion of the proximal phalanx on the metacarpal head. As the proximal phalanx is
flexed, the collateral ligaments become taut; maximum tension occurs at about
70 degrees of MCP flexion. In postinjury swelling without splinting, the MCP joint
assumes an extended posture. The dorsal capsule and collateral ligaments shorten
and scar, resulting in joint stiffness (Fig. 104.2).

• The patient is positioned supine on the operating room table with the arm extended
on a hand table.
Extensor tendon
Dorsal capsule Metacarpal head

Base of proximal phalanx
Flexor tendon
Collateral ligament Volar plate ACL
FIGURE 104.1 Metacarpophalangeal (MCP) anatomy. (From Yang, G. Management of the stiff finger.
Clin Plast Surg, 2014;41[3]:501–512.)
782 CHAPTER 104 Capsulotomy for Metacarpophalangeal Contracture
Accessory
collateral Capsule Collateral ligament is lax
ligament
A B
FIGURE 104.2 (A–B) Metacarpophalangeal (MCP) joint flexion versus extension. (From Watt, AJ. Functional
reconstruction of the hand: The stiff joint. Clin Plast Surg. 2011;38[4]:577–589.)
• The procedure is performed under axillary block or local anesthesia with sedation.
EXPOSURES PITFALLS Improvement in active ROM is assessed by lightening the sedation and asking the
A single, transverse incision provides access to patient to flex and extend the joint.
multiple MCP joints but may gap under the stress
of postoperative therapy. There is often dorsal skin EXPOSURES
laxity that can accommodate the stretch of the skin A dorsal transverse incision (for all four joints, provides a better aesthetic result) or lazy-
during therapy. The wound must be closed tightly S incision (for one or two joints) centered at the joint is used to access each MCP joint
to avoid dehiscence with stress.
(Fig. 104.3).
PROCEDURE
Step 1: Metacarpophalangeal Joint Exposure and Dorsal
Capsulotomy
• The skin is incised, and dissection proceeds rapidly to the extensor mechanism.
• The radial and ulnar sagittal bands are partially incised longitudinally to gain access
to release the dorsal capsule and the collateral ligaments and avoid ulnar sublux-
ation of the extensor tendons. If the radial sagittal band is detached entirely, the
extensor tendons will sublux ulnarly, which is difficult to correct. The partially re-
leased sagittal bands do not need to be repaired—the extensor tendon is sharply
elevated off the dorsal capsule, then retracted laterally to expose the joint.
• A transverse incision is made in the dorsal capsule in continuity with release of the
dorsal collateral ligaments, which will be taut and contracted. Take care to preserve
the underlying articular cartilage (Fig. 104.4). Alternatively, a portion of the dorsal
capsule is excised.

CHAPTER 104 Capsulotomy for Metacarpophalangeal Contracture 783
FIGURE 104.4 Metacarpophalangeal (MCP) capsulotomy performed.
• The MCP joint is flexed to assess motion. If additional release is needed, proceed to
step 2.
STEP 2 PEARLS
Step 2: Collateral Ligament Release, Volar Capsule Release, Extensor • MCP joint flexion during surgery can help to
Tenolysis identify tight portions of the collateral ligaments.
• The radial and ulnar collateral ligaments are sequentially released from their origin • MCP motion should be smooth. The proximal
on the dorsal metacarpal head (Fig. 104.5A). Release is performed from dorsal to phalanx should glide around the metacarpal
head. If the dorsal joint gaps open with attempted
volar until adequate MCP flexion is achieved.
flexion (i.e., opens like a book), additional release
• If the joint cannot flex beyond 60 degrees, there are two possible scenarios: is needed at the volar aspect of the metacarpal
(1) Part of the collateral ligament remains intact and additional release is required head. Pass an elevator between the bone and the
(see Fig. 104.5B), or (2) the volar plate has adhered to the capsule. Adhesions volar plate to free adhesions.
between the volar plate and capsule are released with a Freer elevator. • Rarely, the MCP joint will jump or trigger as it
reaches full extension. If this occurs, any remain-
• Extensor tendon excursion is checked by flexing and extending the MCP joint. If the
ing accessory collateral ligament is divided.
tendons do not glide freely, tenolysis is performed.

• MCP joint motion is checked again to ensure that there are no additional tight struc- Take care to release the ulnar and radial collateral
tures and that motion is smooth. ligaments equally. Deviation of the digit can occur
• The sagittal band is repaired with 4-0 nonabsorbable suture. if there is imbalance.
• The skin is closed with 4-0 nonabsorbable suture.
Collateral ligament
divided from origin
on metacarpal head
Dorsal capsule
Flex to identify tight

collateral ligament
A Volar plate
FIGURE 104.5 (A) Collateral ligament divided from metacarpal head. (B) Flexion to identify tight collateral ligament. (From Yang, G.
Management of the stiff finger. Clin Plast Surg, 2014;41[3]:501–512.)
784 CHAPTER 104 Capsulotomy for Metacarpophalangeal Contracture

• The patient is placed in a soft dressing or a splint with the MCP joints flexed at 70 degrees
according to surgeon preference. Strict elevation is immediately initiated.
• The patient is seen in the office in 3 to 5 days to begin motion. Early, intensive hand
therapy is critical to success. Aggressive active and passive motion exercises and
nighttime splinting are continued for 6 to 8 weeks.
• Most patients can be passively flexed to 90 degrees on the operating room table but
will lose motion in the immediate postoperative period because of swelling, pain,
and scarring. Patients can expect to gain about 30 degrees of flexion if they are
compliant with therapy.
EVIDENCE
Buch VI. Clinical and functional assessment of the hand after metacarpophalangeal capsulotomy. Plast
Reconstr Surg. 1974;53(4):452–457.
The author describes the operative technique and discusses postoperative results for 27 hands treated
with MCP capsulotomy. MCP contractures were caused by burns, crush injuries, and peripheral
nerve injuries. Fourteen patients had capsulectomy alone; 10 patients had capsulotomy and split
thickness skin grafting; and 3 patients had capsulotomy with an abdominal flap for soft tissue cover-
age of the dorsal hand. Most MCP joints gained about 30 degrees of flexion. Early, active postopera-
tive therapy was critical for success. Patients who required skin grafts or flaps had worse outcomes
because of the need for immobilization.
Gould JS, Nicholson BG. Capsulectomy of the metacarpophalangeal and proximal interphalangeal
joints. J Hand Surg Am. 1979;4(5):482–486.
MCP capsulectomy was performed on 105 joints in 37 patients over 3 years. A dorsal approach was
used for 100 joints. Patient ages ranged from 10 to 70 years and follow-up time was 3 to 32 months.
Overall, patients gained 21 degrees of active motion and 29 degrees of passive motion. Fracture and
crush injury patients had the least gain in motion (18 degrees active; 20 degrees passive). Nerve
injury (35 degrees active, 37 degrees passive), burn (36 degrees active, 42 degrees passive), and
stroke (52 degrees passive) patients had greater gains in motion after surgery.
Weeks PM, Young VL, Wray Jr RC. Operative mobilization of stiff metacarpophalangeal joints: dorsal
versus volar approach. Ann Plast Surg. 1980;5(3):178–185.
The authors compare outcomes after volar or dorsal approach for MCP capsulotomy in 61 joints. In the
volar approach group, 76% of patients gained greater than 50 degrees of passive motion and 44%
gained greater than 50 degrees of active motion. In the dorsal approach group, 29% of patients
gained more than 50 degrees of passive motion and 16% gained more than 50 degrees of active
motion. The authors conclude that the dorsal approach provides better operative exposure, but the
volar approach is advantageous in the postoperative period.
ddsf
SECTION XII
Congenital Hand Disorders

CHAPTER 105 Pediatric Trigger Digits 786
CHAPTER 106 Release of Finger Syndactyly Using Dorsal
Rectangular Flap 794
CHAPTER 107 Duplicated Thumb and Finger Treatment 802
CHAPTER 108 Index Pollicization for Hypoplastic Thumb 814
CHAPTER 109 Pediatric Opponensplasty 825
CHAPTER 110 Camptodactyly Correction 833
CHAPTER 111 Macrodactyly Correction 842
CHAPTER 112 Release of Constriction Ring Syndrome 849
CHAPTER 113 Centralization for Radial Longitudinal
Deficiency 857
CHAPTER 114 Cleft Hand Reconstruction 865
CHAPTER 115 Arthrogryposis Reconstruction 873
785
CHAPTER 105
Pediatric Trigger Digits
There are two types of pediatric trigger digit procedures: trigger thumb release and
trigger finger release.
Pediatric Trigger Thumb Release

INDICATIONS
• Trigger thumbs are one of the most common hand conditions affecting the pediatric
population. They typically present in children between 1 to 4 years of age.
• Timing for surgical intervention is debated because symptoms will resolve in an
uncertain percentage of children. A period of observation is therefore recommended
in children younger than 3 years of age, regardless of symptoms.
• Surgery is indicated for children older than 3 years with a thumb interphalangeal (IP)
joint locked in flexion or for those with painful, intermittent locking and clicking.
Contraindications
Contraindications include age less than 3 years, parental reluctance to proceed with
surgery, medical comorbidities that would preclude safe surgery, and symptoms resolv-
ing with splinting alone.
• Pediatric trigger thumbs are often locked in flexion at the IP joint (Fig. 105.1). The IP
joint may be passively extended with a painful and palpable click in early stages of
the condition.
• A palpable Notta node (focal nodular thickening of the flexor pollicis longus [FPL]
tendon) is noted about the volar aspect of the metacarpophalangeal joint (Fig. 105.2).
• Trigger thumbs may occur bilaterally and both thumbs should be examined.
FIGURE 105.1 Trigger thumb with IP joint flexion. IP,

Interphalangeal. FIGURE 105.2 Notta node, indicated on the image by a black asterisk.
786
IMAGING
Although imaging is unnecessary for treatment planning in confirmed cases of trigger
digits, many patients undergo plain radiographs before surgical evaluation to rule out a
fracture or dislocation.
SURGICAL ANATOMY
• The thumb flexor tendon sheath is made up of two annular pulleys and one oblique
pulley and contains the FPL tendon (Fig. 105.3).
• The radial digital nerve to the thumb crosses obliquely over the A1 pulley and is at
risk of injury during pulley release (Fig. 105.4).
• The etiology of a trigger thumb is thought to be related to a size mismatch between EXPOSURES PEARLS
the FPL tendon and the flexor tendon sheath. Avoid infiltrating local anesthetic directly into
the surgical site because this may obscure
POSITIONING visualization. The principle in hand surgery is to
The patient is placed in the supine position on the operating table with the entire upper block the nerves proximal to the operative field.
arm prepared in the surgical area. A nonsterile tourniquet is applied on the upper arm.
EXPOSURES PITFALLS
EXPOSURES
• Care is taken to make the initial incision only
• The operation is performed under general anesthesia. through the dermis to avoid injury to the radial
• After exsanguination of the arm, a 1-cm transverse or chevron marking is made digital nerve lying in the subcutaneous fat.
overlying the thumb metacarpophalangeal (MCP) joint flexion crease (Fig. 105.5). We • The radial digital nerve is also at risk if the in-
apply the chevron incision for wider exposure. The incision in the palm often heals cision is designed too radially along the axis of
the thumb.
without residual scarring.
A2
A1
Oblique
pulley
FIGURE 105.3 Anatomy of the thumb flexor tendon sheath.

788 CHAPTER 105 Pediatric Trigger Digits
A1 pulley
Radial digital
nerve of thumb
Thenar muscle
FIGURE 105.4 Close relationship of the A1 pulley and radial digital nerve of the thumb.
FIGURE 105.5 A 1-cm marking over the flexion crease at the thumb MCP joint. MCP, Metacarpo-
phalangeal.
PROCEDURE
Step 1
• The tendon sheath and A1 pulley are exposed using scissors and a gentle spreading
technique.
STEP 2 PEARLS • Small blunt retractors are used to retract the subcutaneous tissues and the neuro-
Occasionally, triggering persists after complete A1 vascular bundles on the radial and ulnar aspects of the thumb.
pulley release. This can be managed by partially
releasing the proximal leading edge of the oblique Step 2
pulley.
The A1 pulley is released with a knife or scissors (Fig. 105.6A–B).
A B
FIGURE 105.6 (A) A1 pulley exposure. (B) After A1 pulley release. The black arrow points to the FPL
tendon. FPL, Flexor pollicis longus.
FIGURE 105.7 Incision closure. FIGURE 105.8 Soft bandage applied.
Step 3 POSTOPERATIVE PITFALLS

• The tourniquet is deflated and hemostasis is ensured. The bandage should be tight enough to prevent
• The incision is closed with absorbable interrupted sutures (Fig. 105.7). premature removal by the child but not so tight
• A soft bandage is applied (Fig. 105.8). that it causes constriction.

• The dressing is kept on for 7 to 10 days.
• After dressing removal, the caretakers are instructed on daily wound care and a
bandage is applied to the surgical site.
• Rehabilitation is unnecessary, except in patients with a preoperative IP joint contracture.
• Outcomes after A1 pulley release for pediatric trigger thumbs are excellent and risk
for recurrence is negligible.
Pediatric Trigger Finger Release

INDICATIONS
• Triggering in digits other than the thumb is less common and may be associated with
tendon abnormalities, metabolic derangements, or inflammatory etiologies.
• Timing for surgical intervention is debated because symptoms will resolve in an
uncertain percentage of children. A period of observation is therefore recommended
in children younger than 3 years of age, regardless of symptoms.
• Although pediatric trigger thumbs are treated with a simple A1 pulley release, trigger
digits often require additional surgical maneuvers through a versatile incision that
can be extended distally, if needed.
Contraindications
Contraindications include age less than 3 years, parental reluctance to proceed with
surgery, medical comorbidities that would preclude safe surgery, and trigger digit mani-
festations resolving with splinting alone.
• The presentation and underlying pathology of pediatric trigger finger are distinct
from adult trigger finger. Pediatric trigger finger is associated with mucopolysac-
charidosis, juvenile rheumatoid arthritis, Ehlers-Danlos syndrome, Down syndrome,
and central nervous system disorders.
• The middle finger is the most commonly affected non-thumb trigger digit and typi-
cally presents with the classic findings of clicking or jumping with active extension
of the digit (Fig. 105.9).
IMAGING
Although imaging is unnecessary for treatment planning in confirmed cases of trigger
digits, many patients undergo plain radiographs before surgical evaluation to rule out a
fracture or dislocation.
SURGICAL ANATOMY
• The digital flexor tendon sheath is made up of five annular pulleys and three cruciate
pulleys and contains the flexor digitorum superficialis (FDS) and flexor digitorum
profundus (FDP) tendons (Fig. 105.10).
• Multiple anatomic abnormalities have been implicated as a cause of pediatric trigger
finger, including:
• Abnormally proximal decussation of the FDS tendon
• Aberrant lumbrical muscle insertion into the FDS tendon
• Abnormal relationship of the FDS and FDP tendons
• Thickening of the A2 and A3 pulleys
• Tendon nodule
• We advocate incision of the A1 pulley, followed by release of the decussation of the
FDS tendon by splitting it to permit unchecked excursion of the FDP. Occasionally,
the proximal A2 pulley needs to be incised. We do not routinely remove a slip of the
FDS tendon as advocated by some authors.
POSITIONING
The patient is placed in the supine position on the operating table with the entire upper
arm prepared in the surgical area. A nonsterile tourniquet is applied on the upper arm.
FIGURE 105.9 The middle finger is the most common non-thumb trigger digit in the pediatric population.
A5
C3
A4
C2
A3
C1
A2
A1
FIGURE 105.11 Bruner-style zigzag incision over

FIGURE 105.10 Anatomy of the digital flexor tendon sheath. the A1 pulley.
EXPOSURES PEARLS
EXPOSURES Dissection is kept along the axis of the digit to
• The operation is performed under general anesthesia. prevent inadvertent injury to the radial or ulnar
neurovascular bundles.
• After exsanguination of the arm, a chevron or Bruner-style zigzag incision is made
overlying the A1 pulley and extended distally, as needed (Fig. 105.11).
EXPOSURES PITFALLS
PROCEDURE A transverse incision for trigger digit release is

not recommended because it cannot be easily
Step 1 extended for additional pulley or tendon release.
• The tendon sheath and A1 pulley are exposed using scissors and a gentle spreading
technique (Fig. 105.12). STEP 2 PEARLS
• Nodular thickening of the FDS tendon is common (Fig. 105.13).
• The patient is usually under general anesthesia
• Small blunt retractors are used to retract the subcutaneous tissues and the neuro- and smooth gliding of the tendons with active
vascular bundles. ROM cannot be assessed. Each tendon can be
individually pulled with a retractor to ensure
Step 2 smooth independent gliding.
• The A1 pulley is released with a knife or scissors (Fig. 105.14). • Partial release of the leading edge of the A2
pulley is generally required.
• After A1 pulley release, passive manipulation of the digit is performed to ensure
smooth gliding of the FDS and FDP tendons.
STEP 3 PEARLS
Step 3 • Nodular thickening of the FDS or FDP tendons
• If persistent triggering is noted with passive digital motion, the decussation of the is not excised.
• The incision may be extended distally if neces-
FDS tendon around the FDP tendon (i.e., Camper’s chiasm) is released using scis-
sary for greater exposure.
sors (Fig. 105.15).
FIGURE 105.12 A1 pulley exposure. FIGURE 105.13 Nodular thickening of FDS tendon. FDS, Flexor digitorum superficialis.
FIGURE 105.15 Release of decussation of the FDS

FIGURE 105.14 A1 pulley release. tendon around the FDP tendon. FDP, Flexor digitorum
profundus; FDS, flexor digitorum superficialis.
• Despite these maneuvers, residual bulk of the flexor tendons can prevent normal active
flexion of the digit even with pulley and Camper’s chiasm release. In rare cases, resec-
tion of a slip of the FDS tendon may be necessary to achieve unrestricted motion.
Step 4
• The incision is closed with absorbable interrupted sutures (Fig. 105.16).
• A soft bandage is applied.
POSTOPERATIVE PITFALLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES

The bandage should be tight enough to prevent • The dressing is kept on for 7 to 10 days.
premature removal by the child but not so tight • After dressing removal, the caretakers are instructed on daily wound care and a
that it causes constriction.
bandage is applied to the surgical site.
FIGURE 105.16 Incision closure.
• Rehabilitation is unnecessary except in patients with a preoperative joint contracture.

• Recurrence can occur after release of a pediatric trigger finger and is usually related
to incomplete pulley release or residual flexor tendon bulk.
EVIDENCE
Dittmer AJ, Grothaus O, Muchow R, Riley S. Pulling the trigger: Recommendations for surgical care of
the pediatric trigger thumb. J Pediatr Orthop. 2020;40:300–303.
The authors retrospectively reviewed 149 patients with 193 pediatric trigger thumbs over a 10-year
period. All children were classified according to the Sugimoto classification; 16.5% of patients had
stage II (triggering with active extension of thumb IP joint), 10.3% of patients had stage III (triggering
without active extension of thumb IP joint), and 73% of patients had stage IV (rigid deformity without
passive extension of thumb IP joint) thumbs. Stage IV thumbs were 4.6 times more likely to fail con-
servative treatment than stage II or III thumbs (P = .006). Older children with bilateral stage 3 thumbs
were the most likely to go straight to surgery. There were four postsurgical complications for a rate of
3.4% with a recurrence rate of 1.7%. Based on these data, the authors recommend that stage IV
thumbs undergo surgery without an observational period and stage II and stage III thumbs can be
safely observed for at least 1 year before surgery (Level III evidence).
Farr S, Grill F, Granger R, Girsch W. Open surgery versus non operative treatments for paediatric
trigger thumb: a systematic review. J Hand Surg Eur Vol. 2014;39(7):719–726.
The authors performed a systematic review of 17 retrospective studies and 1 prospective study of
trigger thumb treatments. The mean follow-up periods were 59 (surgery), 23 (splinting), and 76
months (exercising), respectively. They reported full IP joint motion in 95% of patients treated surgi-
cally, 67% treated with splinting, and 55% treated with passive exercising. The authors conclude
that A1 pulley release yields the most reliable and rapid outcomes (Level II evidence).
Marek DJ, Fitoussi F, Bohn DC, Van Heest AE. Surgical release of the pediatric trigger thumb. J Hand
Surg Am. 2011;36(4):647–652.
The authors present a review of 173 consecutive patients with 217 thumbs treated surgically. They
report a 36 degree loss of extension preoperatively and an average of 1 degree postoperative loss of
extension. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major
complications or identified recurrences. Five thumbs developed minor skin complications that healed
with conservative management. There were no secondary surgeries (Level II evidence).
Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger
thumb. J Bone Joint Surg Am. 2008;90(5):980–985.
The authors prospectively evaluated rates of spontaneous resolution of trigger thumb symptoms in
53 patients (71 thumbs) over a 10-year period. Forty-five (63%) resolved spontaneously. Median time
to resolution of symptoms was 48 months. The authors conclude that pediatric trigger thumb can be
expected to resolve without treatment in at least 60% of patients (Level II evidence).
Bae DS, Sodha S, Waters PM. Surgical treatment of the pediatric trigger finger. J Hand Surg Am.
2007;32(7):1043–1047.
This retrospective study evaluated 23 pediatric trigger fingers treated over a 10-year period with divi-
sion of the A1 pulley and resection of a single slip of the FDS. Ninety-one percent of fingers had
complete resolution of the triggering; two patients required revision surgery to address the remnant
FDS tendon slip or an aberrant FDS muscle belly in the palm. There were no complications using the
described treatment (Level IV evidence).
CHAPTER 106
Release of Finger Syndactyly Using Dorsal
Rectangular Flap
• The newly created webspace should be designed more proximal than normal to ac-
count for web creep (i.e., distal extension of the webspace scar).
• A flap, rather than skin grafts, should always be used to resurface the webspace to
ensure pliability and normal finger movement.
• When possible, the digits should be covered by interdigitating flaps. If primary clo-
sure is tight, however, placement of full-thickness skin grafts is recommended. It is
unusual to be able to completely cover both digits entirely with skin flaps alone.
INDICATIONS
• Syndactyly release is indicated to improve appearance, address functional limita-
tions, and prevent progressive finger deformity during growth.
• Syndactyly release is typically performed between 12 and 18 months of age, when
the anatomic structures are larger and when anesthesia is safer compared with
younger ages.
• Ideally, all surgery should be completed before the child reaches school age. For
syndactyly of the first and fourth webspaces, earlier release at approximately
6 months of age is recommended to prevent angulatory and rotational deformities
resulting from the differences in length of the thumb/index and ring/small fingers
(i.e., border digits).
• If adjacent web spaces are affected, it may be safer to release them at separate
stages at least 3 months apart to avoid digital ischemia.
Contraindications
There are a few contraindications for the procedure:
• Minor incomplete syndactyly that does not impair digital flexion, extension, and
abduction.
• Complicated syndactyly cases that may result in worse postoperative function be-
cause of joint instability.
• Parental reluctance to proceed with surgery.
• Medical comorbidities that would preclude safe surgery.
• Syndactyly is classified by the extent of fusion and the elements that are fused.
• Complete syndactyly refers to fusion of fingers from the web to the tip (Fig. 106.1),
whereas incomplete syndactyly refers to fusion that does not span the entire finger
(Fig. 106.2).
• Simple syndactyly refers to fusion of the skin only, whereas complex syndactyly refers
to fusion of the phalanges.
• Complicated syndactyly refers to fusion of multiple digits and multiple elements.
This type of syndactyly is associated with other congenital anomalies including
Apert syndrome (Fig. 106.3) and Poland syndrome (Fig. 106.4). Border digit angular
deformities are common in complicated syndactyly (Fig. 106.5).
IMAGING
Preoperative radiographs can assist with classification of syndactyly and to evaluate
skeletal elements. The radiograph in Fig. 106.6 shows complex syndactyly, whereas
Fig. 106.7 is consistent with complicated syndactyly.
794
CHAPTER 106 Release of Finger Syndactyly Using Dorsal Rectangular Flap 795
FIGURE 106.1 Complete syndactyly. FIGURE 106.2 Incomplete syndactyly.
FIGURE 106.3 Apert hand. FIGURE 106.4 Poland syndrome.
SURGICAL ANATOMY
• The webspace is hourglass-shaped and slopes 45 degrees from the dorsal metacar-
pal head to the volar midproximal phalanx (Fig. 106.8). The third webspace is the
most distal, followed by the second and fourth webspaces (Fig. 106.9).
• On occasion, the digital artery bifurcates more distal than normal. One artery may
need to be ligated to permit digital separation.
POSITIONING
The patient is placed in the supine position on the operating table with the arm ex-
tended on a hand table. A nonsterile tourniquet is applied on the upper arm. When a
full-thickness skin graft is anticipated (most cases), the groin should also be prepared
and draped into the field.
796 CHAPTER 106 Release of Finger Syndactyly Using Dorsal Rectangular Flap
FIGURE 106.6 Radiograph of complex syndactyly.

FIGURE 106.5 Border digit angular deformities in compli-
cated syndactyly.
45°
FIGURE 106.7 Radiograph of complicated FIGURE 106.8 (A–B) Shape and angle of webspace. Reprinted with per-
syndactyly. mission from Ni F, Mao H, Yang X, Zhou S, Jiang Y, Wang B. The Use of
an Hourglass Dorsal Advancement Flap Without Skin Graft for Congeni-
tal Syndactyly. J Hand Surg. 2015;40(9):1748-1754.e1.
EXPOSURES
• A proximally based dorsal rectangular flap is used for webspace reconstruction. It is
designed by marking the midpoint of the metacarpal head to the midpoint of each
EXPOSURES PEARLS proximal phalanx.
For syndactyly release of the long and ring fingers, • The points are connected by lines that form a proximally based flap with its base at
a rectangular flap can be designed so that the the level of metacarpal heads (Fig. 106.10). The dorsal flap is designed wider at the
radial side of the ring finger is covered by the volar base and narrower at the distal aspect of the flap.
skin (Fig. 106.12A-C). This may make it more • The interdigitating flaps are designed using two Z-shape lines, one dorsal and the
comfortable for the patient to wear a ring.
other on the volar aspect of the hand such that they form mirror images (Fig. 106.11).
D
C
FIGURE 106.9 The third webspace is the most

distal. Reprinted with permission from Ni F, Mao
H, Yang X, Zhou S, Jiang Y, Wang B. The Use
of an Hourglass Dorsal Advancement Flap With- FIGURE 106.10 The dorsal rectangular flap is designed by marking the midpoint of metacarpal head
out Skin Graft for Congenital Syndactyly. J Hand to the midpoint of each proximal phalanx.
Surg. 2015;40(9):1748-1754.e1.
The dorsal Z is drawn first by connecting the following four points: A and C are on
one digit, whereas B and D are the adjacent digit (see Fig. 106.10).
A: The distal corner of the dorsal rectangular flap
B: The midpoint of the dorsal crease at the proximal interphalangeal (PIP) joint
C: The midpoint of the middle phalanx
D: The midpoint of the dorsal crease at the distal interphalangeal (DIP) joint
• The Z-shape line should be the same level on the dorsal side and the volar side (see
Fig. 106.10).
PROCEDURE
Step 1: Flap Elevation
• The skin markings are incised and the skin flaps are elevated.
• The interdigitating dorsal and volar flaps are elevated only to the edge of each finger
to prevent unnecessary tendon exposure.
FIGURE 106.11 Interdigitating flaps are de-
Step 2: Separation of Digits signed using two Z-shaped lines that form a
• The distal fingertip containing the nail plate is cut sharply using scissors. mirror image; one volar and one dorsal.
• Longitudinal neurovascular structures are identified and preserved.
• Tenotomy scissors are used to spread transversely between the fused digits. Trans- EXPOSURES PITFALLS
verse fascial bands are identified and sharply divided in a distal to proximal direc-
Although data suggest higher rates of hypertrophic
tion. The digits should be completely released to the level of the transverse inter- scarring with techniques using a skin graft, we
metacarpal ligament, which is spared (Fig. 106.14). avoid the use of a dorsal metacarpal advancement
flap (Fig. 106.13) because it inevitably leads to
Step 3: Skin Flap Inset scarring of the dorsal hand.
• The proximally based dorsal rectangular flap is advanced into the newly created
webspace and secured using 4-0 or 5-0 chromic suture. The flap should easily STEP 1 PEARLS
advance into the new webspace without tension. Although opposing Buck-Gramcko flaps (i.e., thin
• Preliminary inset of the digital flaps with a few tacking stitches provides the oppor- skin flaps used to cover the sides of the separated
tunity to assess how best to proceed with definitive inset. nail folds) are an option for fingertip reconstruction,
• Plan to inset the digital flaps with the goal of leaving a larger recipient skin defect simply suturing the skin graft to the nail plate leads
to acceptable results and avoids the risk for partial
rather than multiple defects that will require more time for inset of multiple smaller
loss of small skin flaps.
grafts.
STEP 1 PITFALLS
To avoid flap necrosis, care is taken to elevate the
skin flaps with a small amount of subcutaneous fat.
STEP 2 PEARLS
• The bifurcation of the neurovascular bundle
commonly lies distal to the predicted web-
space (Fig. 106.15). Both should be retained;
however, ligation of one branch can be per-
formed if the other digital artery is normal.
• Bone exposure during digital separation may
occur. Despite this concern, we have not had
poor wound healing after skin grafting over
exposed bone in children with syndactyly.
STEP 3 PEARLS
• The interdigitating flaps should not be sutured
under tension. Judicious flap defatting may be
performed to decrease tension on the skin A B
flaps during closure.
• Small open areas may be left open to heal
Full-thickness skin graft Volar skin flap
secondarily, but diligent wound care must be
performed to prevent synechiae of adjacent
open wounds. Larger skin-deficient areas will
require a full-thickness skin graft.
STEP 3 PITFALLS
Deflating the tourniquet after definitive flap and C Dorsal skin flap
skin graft inset may result in the need for suture
removal if there is any compromise of digital FIGURE 106.12 (A–C) Syndactyly release of the long and ring fingers.
circulation.
FIGURE 106.13 Scarring after dorsal metacarpal advancement flap.

FIGURE 106.14 Digits released to the level of the transverse intermeta-

carpal ligament.
FIGURE 106.15 Bifurcation of the neurovascular bundle.
• Tight flap closure will impair digital circulation and requires removing previously
placed sutures. Tack the flaps down securely and without tension, instead of ad-
vancing them too tightly.
• The tourniquet is then deflated and hemostasis is ensured.
• The interdigitating flaps are completely inset across the digits.
Step 4: Harvest of Full-Thickness Skin Graft

• If the skin defect is not sufficiently covered using the interdigitating flaps, a full-
thickness skin graft from the groin is used. The donor site is infiltrated with 0.5%
lidocaine with epinephrine early in the case to enable graft elevation in a hemostatic
and efficient manner (Fig. 106.16).
• An elliptical skin graft is harvested along the groin crease using a No. 15 scalpel. The
graft is taken along the lateral groin to minimize future hair growth at the recipient
site. The skin and dermis are elevated sharply with a scalpel and any additional
subcutaneous fat is removed with scissors.
FIGURE 106.16 Preparing to harvest a full-thickness skin graft from the groin, after infiltrating with
0.5% lidocaine with epinephrine. The vasoconstrictive effect facilitates harvest and minimize blood
loss.
FIGURE 106.17 The skin graft donor site dermis is reapproximated

using absorbable sutures. FIGURE 106.18 Full-thickness skin graft fills defects on the fingers.
POSTOPERATIVE PEARLS • The skin graft donor site dermis is reapproximated using absorbable suture and the
• Web creep can occur with normal hand growth skin is reapproximated with either interrupted chromic sutures or a subcuticular
and can be prevented by early release of the Monocryl suture (Fig. 106.17).
fingers and exaggerating the webspace depth • The skin graft is then cut to fill defects on the fingers. It is technically easier to cover
during surgery. For complicated cases that have fewer, larger skin defects than many small skin defects (Fig. 106.18).
joint instability or skeletal deformity, arthrodesis
may be considered after skeletal maturity.
• It is common that the affected digits deviate to-
ward each other after separation, and the fam- • Dressings are applied to provide gentle compression on the skin grafts.
ily should be reassured that this is expected. • The wound should be protected using a long arm cast for 2 to 3 weeks to prevent
shear injury to the skin grafts and to promote healing; it is imperative that the elbow
be flexed at least 90 degrees to prevent cast removal (Fig. 106.19). The olecranon
should be well-padded to prevent skin breakdown, whereas the antecubital fossa
• Short-term complications after syndactyly should have limited padding to facilitate adequate molding of the splint.
release may include skin necrosis, skin graft • If the webspace is not fully healed, the parents must be taught to put Xeroform
failure, or neurovascular injury.
• Long-term complications may include web gauze between the fingers to prevent open wounds from healing to each other.
creep or scar contracture. Revision scar • Hand therapy may be useful to educate the parents regarding scar massage to im-
release with or without a skin graft is prove scar thickness. Additionally, postoperative splints with elastomer inserts may
occasionally required. be helpful to prevent hypertrophic scarring and web creep.
• Keloid scarring has been reported in 1% to • Ten-year follow-up photos of a bilateral fourth webspace syndactyly reconstruction
2% of patients.
are shown in Figs. 106.20 and 106.21.
See Video 106.1
FIGURE 106.20 Ten-year follow-up of bilateral fourth webspace

FIGURE 106.19 Flexing the elbow prevents removal of long arm cast. syndactyly reconstruction (dorsal view).
FIGURE 106.21 Ten-year follow-up of bilateral fourth webspace syndactyly reconstruction (volar
view).
EVIDENCE
Hsu VM, Smartt Jr JM, Chang B. The modified V-Y dorsal metacarpal flap for repair of syndactyly
without skin graft. Plast Reconstr Surg. 2010;125:225–232.
This is a retrospective report of 28 syndactyly releases without using a skin graft. Only two patients
(7.1%) experienced postoperative complications. The authors suggest that skin grafting can be
omitted for simple syndactyly if there is sufficient skin to cover the middle and distal phalanges with
local flaps (Level V evidence).
Goldfarb CA, Steffen JA, Stutz CM. Complex syndactyly: Aesthetic and objective outcomes. J Hand
Surg Am. 2012;37(10):2068–2073.
The authors analyzed the results of 25 complex syndactyly webspace reconstructions using a dorsal
commissural flap and full thickness skin grafts. Patients returned for clinical examination and subjec-
tive assessment at an average of 9 years after the most recent surgery. Angular and rotations defor-
mities were common and there was a notable nail wall deformity in most fingers. Surgeon visual
analog scale (VAS) scores (range, 0–10) averaged 2.8, whereas patient VAS scores were 0.4 for pain,
1.9 for appearance, and 1.1 for function. The authors conclude that complex syndactyly reconstruc-
tion is challenging, and common postsurgical findings include rotational and angular deformity and
nail deformity (Level III evidence).
Barabás AG, Pickford MA. Results of syndactyly release using a modification of the Flatt technique.
J Hand Surg Eur. 2014;39:984–988.
The authors analyzed the results of 144 congenital syndactyly releases using a modified Flatt technique
(dorsal hourglass flap, interdigitating zigzag flaps, and full-thickness skin grafts) with a mean follow-
up of 5 years. Web creep occurred in 4.2% of web releases. They suggest that avoiding longitudinal
straight-line scars across the webspace may be an important factor in avoiding web creep (Level V
evidence).
Sullivan MA, Adkinson JM. A systematic review and comparison of outcomes following simple
syndactyly reconstruction with skin grafts or a dorsal metacarpal advancement flap. J Hand Surg
Am. 2017;42:34–40.
This systematic review compared the outcomes of simple syndactyly reconstruction with skin grafts
versus techniques using only a dorsal metacarpal advancement flap. Overall, skin grafting procedures
were associated with more complications (e.g., flap necrosis/graft failure, contracture, web creep,
hypertrophic scarring) and a greater need for revision. When stratified by subtype, patients with
simple, complete syndactyly who underwent skin grafting had a significantly higher rate of hypertro-
phic scarring than those who underwent dorsal metacarpal advancement flap reconstruction (Level II
evidence).
Yuan F, Zhong L, Chung KC. Aesthetic Comparison of two different types of web-space reconstruction
for finger syndactyly. Plast Reconstr Surg. 2018;142(4):963–971.
The authors compared the long-term aesthetic outcomes of techniques using skin grafts (29 patients)
versus the dorsal pentagonal advancement flap technique without skin grafting (16 patients). They
found that the dorsally based rectangular flaps with skin grafting had statistically significantly better
visual analog scale scores and a greater odds of receiving an “excellent” rating compared with dorsal
pentagonal advancement flaps. The authors conclude that dorsal rectangular flaps may offer better
overall aesthetic outcomes for patients despite the use of a skin graft (Level II evidence).
CHAPTER 107
Duplicated Thumb and Finger Treatment
Polydactyly Reconstruction
1. Radial polydactyly (i.e., thumb duplication)
a. Type II thumb duplication
b. Type IV thumb duplication
2. Ulnar polydactyly
a. Type B ulnar polydactyly
Reconstruction of Type II and Type IV Thumb Duplication

INDICATIONS
• Thumb polydactyly is among the most common congenital hand conditions, with an
incidence of 1 in 10,000 live births. Reconstruction is generally recommended to
improve the size and shape of the thumb. Although children with a duplicated thumb
may function well without reconstruction, the stigma of an uncorrected congenital
deformity may not be acceptable for the child or the family.
• Thumb reconstruction should be considered around 12 months of age, before the
development of substantial deviation of the duplicated elements and because gen-
eral anesthesia is safer at this age. Additionally, dissection of anatomic structures is
technically easier compared with surgery at younger ages. This surgical timing also
permits recovery before development of integrated thumb-index tip-to-tip pinch,
which occurs between 12 to 15 months of age.
Contraindications
Contraindications include:
• Parental reluctance to proceed with surgery
• Medical comorbidities that would preclude safe surgery
• Classification of the duplicated thumb is based on the level of the duplicated
elements, which ranges from type I (bifid distal phalanx) to type VII (triphalangeal
thumb). Type IV is the most common (40%–50%) and represents a complete
duplication of the proximal and distal phalanges (Table 107.1).
• The duplicated elements are abnormal in size and shape. Therefore some surgeons
prefer to call it a “split” thumb rather than a “duplicated” thumb. Generally, the dupli-
cated radial digit is smaller in length and width. The surgeon should examine the thumb
for the level of duplication, the degree of hypoplasia of each component, stability of the
involved joints, and position of the thumb with respect to the bony axis and first web-
space (Fig. 107.1A–B).
• Genetic counseling is typically only indicated in type VII thumbs because this condition
is inherited in an autosomal dominant pattern and is associated with other hematologic,
cardiovascular, and musculoskeletal anomalies (Fig. 107.2).
IMAGING
Pre-operative radiographs are useful to identify the anatomy of duplicated elements.
The osseous anatomy is always abnormal, with varying degrees of bony hyperplasia,
widening, and/or angulation of the articular surfaces. Fig. 107.3 shows radiographs
of type IV.
802
TABLE
107.1 Classification of Thumb Duplication
Type Anatomic Description %
I Bifid distal phalanx 4
II Duplicated distal phalanx sharing common distal inter- 16

phalangeal joint articulation
III Bifid proximal phalanx 11
IV Duplicated proximal phalanx sharing common metacarpal 40

articulation
V Bifid metacarpal 10
VI Duplicated metacarpal sharing common carpal 4

articulation
A
VII Triphalangeal thumb 20
SURGICAL ANATOMY
• The flexor and extensor tendons split and insert eccentrically into the base of the
distal phalanges. The intrinsic musculature is aberrant. In proximal duplications, the
opponens pollicis (OP) inserts on the radial duplicate metacarpal and the abductor
pollicis brevis (APB) and flexor pollicis brevis (FPB) insert on the proximal phalanx of
the radial duplicate. A divergent-convergent configuration of the duplicated ele-
ments may also occur. This results from the net effect of the split flexor pollicis
longus (FPL) pulling the distal phalanges into convergence, whereas the thenar in-
trinsic muscles pull the proximal phalanges into divergence (Fig. 107.4). A pollex
B
abductus (i.e., abnormal ligamentous connection between the FPL and extensor
pollicis longus [EPL]) is present in up to 20% of duplicated thumbs and may contrib- FIGURE 107.1 (A) Type II thumb. (B) Type IV
ute to thumb interphalangeal (IP) joint stiffness and abduction. thumb.
804 CHAPTER 107 Duplicated Thumb and Finger Treatment
FIGURE 107.2 Triphalangeal thumb. FIGURE 107.3 Type IV thumb radiograph.
Divergent tendons
of flexor pollicis
longus
Divergent tendons
Abductor of extensor
pollicis brevis pollicis longus
Flexor Extensor
pollicis brevis pollicis longus
Extensor
pollicis brevis
FIGURE 107.4 Forces crossing the thumb MCP joint leading to a divergent-convergent configuration
of the duplicated elements. MCP, Metacarpophalangeal.
• The ulnar collateral ligament is necessary for thumb stability during pinch. This
structure is typically preserved because the ulnar duplicate is retained.
• The arterial supply of the duplicated digits most commonly arises from a single
digital artery on the ulnar side of the ulnar and radial duplicate (74%). Twelve percent
of patients have three digital arteries; an ulnar and radial digital artery for the ulnar
duplicate and an ulnar digital artery for the radial duplicate. Ten percent of dupli-
cated thumbs will have four digital arteries, whereas 5% of duplicated thumbs will
have a single ulnar digital artery supplying the ulnar duplicate.
POSITIONING
• The operation is performed under general anesthesia with the patient supine on the
operating table. A tourniquet is placed on the upper arm and the entire extremity is
prepared and draped.
• Intraoperative fluoroscopy is often required to confirm anatomy, thumb alignment, or
in planning and performing osteotomies and placement of Kirschner wires (K-wires).
The operative table should be positioned to provide easy access to the C-arm.
EXPOSURES PEARLS
EXPOSURES
The Bilhaut-Cloquet procedure was developed
When ablating the radial thumb, one must retain a periosteal flap from the radial col- in an effort to combine elements of both thumbs
lateral ligament of the resected thumb to reconstruct the radial collateral ligament of the into a single thumb (Fig. 107.5A–B). Although
retained thumb. The EPL of the resected thumb can be transferred to the ulnar side of conceptually appealing, it is exceedingly difficult to
the retained thumb to augment and rebalance thumb IP joint extension. create an aesthetically pleasing thumb by unifying
the distal phalanges and soft tissue envelope of
the duplicated elements. The technique is difficult
RECONSTRUCTION OF TYPE II THUMB DUPLICATION to perform and often leads to nail deformity and
IP joint stiffness. As such, many surgeons have
Step 1 abandoned this technique. It is preferable to accept
• The radial thumb duplicate is selected for removal. A racquet-shaped incision is a smaller, more aesthetically appealing thumb
by using soft tissue from the resected thumb to
designed on the radial thumb (Fig. 107.6A–B).
augment the retained thumb.
• The skin flaps and soft tissues are elevated, and the radial aspect of the IP joint is
identified.
• The distal insertion of the flexor tendon, extensor tendon, and radial collateral ligament STEP 1 PEARLS
are carefully elevated off of the base of the radial duplicate distal phalanx (Fig. 107.7). The radial duplicate is selected for ablation
because removal of the ulnar duplicate may
compromise IP joint ulnar collateral ligament (UCL)
stability with pinch and leave a painful scar on the
contact-bearing aspect of the thumb.
A B
FIGURE 107.5 The Bilhaut-Cloquet procedure, combining elements of both thumbs into a single
thumb.
Ulnar side Radial side
Collateral
ligament
A B FIGURE 107.7 The RCL is carefully elevated

from the radial duplicate distal phalanx
FIGURE 107.6 (A–B) Type II thumb preoperative thumb markings. base. RCL, Radial collateral ligament.
FIGURE 107.8 The redundant head of the proximal phalanx is FIGURE 107.9 The RCL (black star on flap) is attached to the radial
removed with a knife. base of the retained thumb distal phalanx. RCL, Radial collateral
ligament.
Step 2
The radial duplicated thumb is removed at the level of the IP joint.
Step 3
The proximal attachment of the radial collateral ligament is protected, and the redun-
dant head of the proximal phalanx is removed with a knife (in young children where the
bone is soft) or osteotome (in older children/adults with ossified bone; Fig. 107.8).
STEP 5 PITFALLS
Care is taken to follow the curve of the needle Step 4
when placing transosseous sutures to prevent The retained distal phalanx is centralized over the proximal phalanx. The centralized
pulling through the soft bone.
position is maintained using a single longitudinal 0.035-inch K-wire passed retrograde
through the distal phalanx into the proximal phalanx.
STEP 6 PEARLS
Step 5
Reattaching the radial duplicate FPL into the
central volar base of the retained ulnar duplicate is The radial collateral ligament is reattached to the radial base of the retained thumb
technically difficult because of the need to dissect distal phalanx using 4-0 nonabsorbable sutures (Fig. 107.9). It is easy to pass the suture
the pulp of the digit to expose the FPL insertion needle through metaphyseal bone in young patients because the bone is primarily
site. As such, we often only perform extensor cartilaginous and soft.
tendon transfer.
Step 6
Residual minor malalignment of the digit can be addressed by reattaching the elevated
extensor and flexor tendon insertions into the central base of the retained distal phalanx
(Fig. 107.10).
Step 7
• The tourniquet is released and hemostasis ensured. Skin closure is performed using
absorbable suture. The redundant skin may be inset using a W-plasty style closure
to prevent future scar contracture (Figs. 107.11 and 107.12).
• A long-arm thumb spica cast is applied, with the elbow in at least 90 degrees of
flexion to prevent premature removal (see Fig. 106.19 in the chapter 106 “Release of
Finger Syndactyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to
prevent skin breakdown, but limited padding is placed over the antecubital fossa
to facilitate adequate molding of the splint.
RECONSTRUCTION OF TYPE IV THUMB DUPLICATION

FIGURE 107.10 Reattaching the elevated Step 1
extensor tendon insertions into the base of
the retained distal phalanx to balance forces • The radial duplicate is selected for removal because it is usually smaller and removal
across the IP joint. IP, Interphalangeal. does not disturb the ulnar collateral ligament of the retained thumb (Fig. 107.13). A
racquet-shaped incision is designed as previously described (Fig. 107.14). The skin
Collateral
ligament Z-plasty
FIGURE 107.11 The redundant skin may be resected and FIGURE 107.12 Definitive closure of the
inset using a Z-plasty to prevent future scar contracture. incision.
FIGURE 107.13 Type IV thumb. FIGURE 107.14 Type IV thumb preoperative markings.
flaps are elevated to expose the radial aspect of the metacarpophalangeal (MCP)
joint and the extensor mechanism.
• The insertion of the thenar intrinsics into the radial aspect of the thumb is detached,
and the radial collateral ligament (RCL) is elevated with an extended periosteal flap
to enable reinsertion into the retained thumb proximal phalanx (Fig. 107.15A–B).
• The extensor and flexor tendons to the duplicated thumb are transected at the level
of the IP joint.
STEP 2 PITFALLS
Step 2 A persistent pollex abductus can contribute to
progressive angular deformity after surgery. If
The soft tissue connections between the duplicated elements are divided sharply and
present, this should be divided with a knife.
the radial duplicate is removed.
A B
FIGURE 107.15 (A) RCL/APB flap marked for elevation. (B) RCL/APB flap (black star) held in forceps. APB, Abduc-
tor pollicis brevis; RCL, radial collateral ligament.
Collateral
ligament
Proximal phalanx base Metacarpal head

FIGURE 107.16 The RCL is carefully elevated from
FIGURE 107.17 The redundant head of the metacarpal is removed
the radial duplicate proximal phalanx base. RCL,
with a knife.
Radial collateral ligament.

With the goal of a straight thumb at the conclusion If bifid or wide, a resection of the metacarpal head is performed to reduce its sagittal
of the procedure, an osteotomy may be necessary plane prominence. In younger children, this may be performed using a scalpel with a
to correct any phalangeal angular deformity. The sawing motion over the unossified metacarpal. Extreme care should be used when
osteotomy can be performed using a Rongeur or
performing this maneuver to prevent transection of the elevated radial collateral liga-
bone cutter, taking care to protect the tendons and
neurovascular (NV) structures. Because growth ment (Figs. 107.16 and 107.17).
in children is unpredictable, we do not always
perform corrective osteotomy at the time of the Step 4
initial procedure but await correction when the The thumb is aligned and secured in place using a retrograde longitudinal or oblique
needs arise at a later age.
0.035-inch K-wire traversing the MCP joint (Fig. 107.18).
Step 5
The periosteal flap carrying the radial collateral ligament and the thenar intrinsic inser-
tion is sutured to the radial base of the ulnar thumb proximal phalanx using 4-0 nonab-
sorbable suture. If necessary, additional sutures may be placed to reinforce the origin
of the radial collateral ligament at the metacarpal head (Fig. 107.19).
FIGURE 107.18 Pin fixation of the thumb MCP joint. FIGURE 107.19 The RCL/APB flap (black star) reattached to
MCP, Metacarpophalangeal. the radial base of the retained thumb proximal phalanx. APB,
Abductor pollicis brevis; RCL, radial collateral ligament.
Step 6
If necessary, the duplicated EPL of the resected thumb can be sutured to the ulnar aspect
of the retained thumb distal phalanx to balance the deforming forces acting across the
thumb IP joint. This may be performed through the radial incision or passed subcutane-
ously to an additional incision over the ulnar aspect of the distal phalanx (Fig. 107.20).
Step 7
• The tourniquet is released and hemostasis ensured. Skin closure is performed using
absorbable suture after excision of redundant skin (Fig. 107.21).
Radial Ulnar
Extensor
tendon
FIGURE 107.20 The duplicated extensor tendon

transferred to the ulnar aspect of the retained
thumb distal phalanx to balance the deforming
forces acting across the thumb MCP and IP
joints. IP, Interphalangeal; MCP, metacarpopha-
langeal. FIGURE 107.21 Definitive closure of the incision.
flexion to prevent premature removal (see Fig. 106.19 in the chapter 106 “Release of
Finger Syndactyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to
prevent skin breakdown, but limited padding is placed over the antecubital fossa
to allow for adequate molding of the splint.

• The K-wire is removed between 4 and 6 weeks postoperatively.
• The development of an angular deformity is not uncommon during growth. As such,
patients should be reevaluated annually. If a progressive deformity occurs, a correc-
tive osteotomy may be performed to straighten the thumb. Fig. 107.22A–B shows
preoperative and postoperative x-rays of an opening wedge osteotomy of the
proximal phalanx.
• Fig. 107.23A–B shows 1-year postoperative photos of a Wassel II. Fig. 107.24A–B
shows preoperative and 2-week postoperative photos.
A B
FIGURE 107.22 (A) Type IV thumb preoperative x-ray. (B) Type IV thumb postoperative x-ray after
opening wedge osteotomy of proximal phalanx.
A B
FIGURE 107.23 (A–B) Right thumb type II reconstruction, 4 years postoperatively.

A B
FIGURE 107.24 (A–B) Right thumb type IV reconstruction, 2 weeks postoperatively.
Ulnar Polydactyly
INDICATIONS
• The classification of postaxial polydactyly according to Temtamy and McKusick is
as follows:
• Type A: An extra digit is fully formed and articulates with the fifth or a sixth meta-
carpal (Fig. 107.25A).
• Type B: A rudimentary digit exists as ulnar duplication attached only by a soft
tissue stalk (see Fig. 107.25B).
• A type B digit on the ulnar side of the hand, termed a nubbin, is poorly formed and
attached via a neurovascular stalk.
Contraindications
One contraindication is parental reluctance to proceed with removal.
• Children with polydactyly are born with one or more extra digits.
• Although bone and nail structures may be present in a type B polydactylous digit, Ulnar polydactyly may be one feature of a genetic
there are no osseous and ligamentous structures connecting the digit to the hand. condition or syndrome, such as Down syndrome or
Meckel syndrome.
• Hand function is rarely affected by ulnar polydactyly.
A B
FIGURE 107.25 (A) An extra digit is fully formed and articulates with the fifth or a sixth metacarpal.
(B): A rudimentary developed digit exists as ulnar duplication attached only by a soft tissue stalk.
Type B Ulnar Polydactyly

TYPE B ULNAR POLYDACTYLY
Step 1
Treatment is performed with either suture ligation or surgical resection.
Suture Ligation
• Suture ligation is performed in the newborn nursery or during a clinic visit.
• Ligation interrupts the blood supply to the duplicated digit. This results in dry gan-
grene and subsequent auto-amputation.
• Nevertheless, suture ligation often leaves a residual stump in up to 40% of cases
that may require a formal excision in the operating room, because it is difficult to
ligate precisely at the base of the digit.
Surgical Resection
Option 1: Vascular Clipping and Excision for Neonates
• This can be performed in the operating room or in the clinic.
• An effective approach is to clip the digit in the clinic when the baby is feeding.
• A vascular clip is placed at the base of the duplicated digit.
• Local anesthetic is not necessary. The soft tissue stalk is cut using scissors just
distal to the clip (Fig. 107.26).
• By clipping and cutting at the very base of the digit, a residual stump can be pre-
vented, whereas suture ligation tends to slip off the base to the narrowest point of
the pedicle.
• This procedure is preferred because it does not require general anesthesia and can
be done rapidly with minimal risk. This is convenient for the parents and obviates the
risk and cost of general anesthesia in an operating room.
Option 2: Surgical Resection in the Operating Room in Older Infants Who

Cannot Tolerate Clipping
• Under general anesthesia, the hand is prepared and draped.
• Local anesthetic can be used for pain control.
FIGURE 107.26 Vascular clip applied to • An ellipse is marked around the junction of the neurovascular stalk of the type B
polydactyly stalk. polydactyly and the adjacent small finger (Fig. 107.27A).
• The stalk and polydactylous digit are excised under tension to permit the digital nerve
STEP 1 PEARLS stump to settle within the soft tissues of the unaffected digit (see Fig. 107.27B).
• After obtaining hemostasis, the skin is closed with absorbable suture.
In bilateral polydactyly cases, both digits can be
addressed in the same surgical session.
Step 2
After completing the procedure, a soft bandage is placed on a hand.
STEP 1 PITFALLS
Ligation alone may fail or result in the development POSTOPERATIVE CARE AND EXPECTED OUTCOMES
of a digital neuroma stump. The residual stump • If the surgical clip remains intact, it should be removed 2 weeks after the procedure.
can be excised later, if desired by the patient or
• Although revision for residual tissue or scarring may be needed later in some cases,
family.
a good clinical and cosmetic outcome is typically achieved.
A B
FIGURE 107.27 (A) Markings for postaxial polydactyly excision. (B) Closure after excision of polydac-
tyly and transection of the neurovascular stalk.
EVIDENCE
Mullick S, Borschel GH. A selective approach to treatment of ulnar polydactyly: preventing painful
neuroma and incomplete excision. Pediatr Dermatol. 2010;27(1):39–42.
The authors present treatment options for ulnar polydactyly and review a series of 10 patients
(13 hands) in whom previous suture ligation was performed, resulting in a residual neuroma stump.
The authors report that all 10 patients were successfully treated with completion amputation of the
residual stump combined with proximal ligation of the supernumerary digital nerves. The authors
recommend an individualized treatment approach rather than performing suture ligation for all
patients with Type B ulnar polydactyly (Level IV evidence).
Dijkman R, Selles R, van Rosmalen J, et al. A clinically weighted approach to outcome assessment in
radial polydactyly. J Hand Surg Eur Vol. 2016;41(3):265–274.
In this study, the authors sought to develop an outcome assessment system based on clinical data.
They performed linear regression analysis on data from a multicenter study of 121 patients with radial
polydactyly types II, IV, and VII to develop a clinically weighted outcome assessment system. Active
flexion, scar appearance, and prominence at amputation site were the main items influencing overall
functional and aesthetic outcome. Palmar abduction, MCP joint deviation, and nail appearance
influenced overall functional and aesthetic outcome the least. The authors conclude that their
assessment system accurately reflects clinician impressions of outcomes and helps guide treatment
and evaluation of outcome (Level III evidence).
Gholson JJ, Shah AS, Buckwalter JA, Buckwalter JA. Long-term clinical and radiographic follow-up
of preaxial polydactyly reconstruction. J Hand Surg Am. 2019;44(3):244.
The authors sought to determine the long-term results of preaxial polydactyly reconstruction by
evaluating strength, range of motion, pain, arthritis, and functional outcomes. Patients having preaxial
polydactyly reconstruction 15 to 60 years ago (median 36 years) completed the Disabilities of the
Arm, Shoulder, and Hand (DASH) and Patient-Reported Outcomes Measurement Information
Systems (PROMIS) surveys. Patients completed a clinical evaluation comprising grip strength, pinch
strength, side pinch strength, and range of motion and underwent radiographs of the reconstructed
thumb to evaluate for arthritis. The mean DASH score was 3.7, similar to the general population
mean of 10.1 (standard deviation [SD], 14.5). The mean PROMIS score was 51.5, similar to the
general population mean of 50 (SD, 10.0). The mean pinch strength, side pinch strength, and grip
strength did not differ significantly from the contralateral extremity. There was significantly decreased
range of motion at the IP joint. No patient had pain in the thumb or hand on clinical evaluation;
15.4% of patients developed radiographic evidence of IP joint arthritis; and 46.2% had an angular
deformity. The authors conclude that thumb polydactyly patients have functional outcomes similar to
the general population, despite decreased range of motion at the IP joint. None of the patients with
radiographic arthritis had associated pain. Given the risk for late angular deformity, the authors
recommend close follow-up until skeletal maturity (Level IV evidence).
CHAPTER 108
Index Pollicization for Hypoplastic Thumb
INDICATIONS
• Indications include hypoplastic thumbs with an inadequate carpometacarpal (CMC)
joint (Blauth types IIIB and IV) or complete absence of the thumb (Blauth type V).
• Pollicization is generally offered at 12 to 18 months of age because general anesthe-
sia is safer and structures are larger, facilitating dissection. Surgery at this age also
permits time for preliminary correction of any associated radial deficiencies (typically
addressed between 3–6 months of age). Finally, cortical representation of the thumb
has not yet solidified at this age.
Contraindications
Contraindications include:
• Hypoplastic thumbs with a functional CMC joint (Blauth types I, II, and IIIA)
• Parental reluctance to proceed with surgery
• Medical comorbidities that would preclude safe surgery
• A poorly developed, stiff index finger (a relative contraindication)
• The Blauth classification system is useful because it correlates with surgical treat-
ment (Table 108.1).
• Types IV (floating thumb; Fig. 108.1) and V (absent thumb; Fig. 108.2) are straight-
forward to identify clinically. It can be difficult, however, to distinguish type IIIA
(stable CMC joint) from type IIIB (unstable CMC joint) thumbs. Because the trape-
zium and trapezoid ossify around 5 to 6 years of age, radiographs cannot be relied
on to assist in diagnosis.
• Serial examination of the child is required to differentiate a type IIIA from a type IIIB
thumb. A newborn uses digital grasp, whereas infants begin using the thumb in
FIGURE 108.1 Type IV (floating thumb).
TABLE
108.1 Blauth Classification of Thumb Hypoplasia and Treatment Options
Type Features Treatment Options
I Mild hypoplasia with all elements present No treatment
II Narrow first web, ulnar collateral ligament No treatment
insufficiency, and absence of thenar Z-plasty of first web, UCL
intrinsic muscles strengthening/reconstructions,
and opponensplasty
III Type II plus extrinsic tendon deficiencies
and/or skeletal deficiency
IIIA Stable CMC joint Same as type II
IIIB Unstable CMC joint Pollicization
IV Absent metacarpal and rudimentary Pollicization
phalanges “Pouce flottant”
V Total absence Pollicization
CMC, Carpometacarpal; UCL, ulnar collateral ligament.

FIGURE 108.2 Type V (absent thumb).
814
grasp at about 1 year of age. If the child uses the thumb when manipulating objects,
this suggests that the CMC joint is stable. If the child prefers to grasp objects be-
tween the index and long finger (i.e., scissor pinch), the web will appear wider and
the index finger will begin to pronate; these findings suggest an unstable CMC joint
(type IIIB thumb hypoplasia).
• Children with types IV and V hypoplasia may exhibit varying degrees of index finger
stiffness and hypoplasia, which can adversely affect results after pollicization.
• Because many other anomalies are associated with thumb hypoplasia, the child
should be thoroughly examined. The hand surgeon may be the first medical care
provider to evaluate the patient. Specifically, children should be evaluated for VAC-
TERL association (i.e., vertebral abnormalities, anal atresia, cardiac abnormalities,
tracheoesophageal fistula and/or esophageal atresia, renal agenesis and dysplasia,
and limb defects), Fanconi anemia, TAR (thrombocytopenia-absent radius) syn-
drome, and Holt-Oram syndrome.
IMAGING
• Radiographs of the hands are useful in determining the degree of metacarpal and
phalangeal hypoplasia. Because the patient is often evaluated in infancy, the osse-
ous anatomy may not be readily apparent on imaging. Radiographs of the forearms
and wrists can also identify other associated upper extremity anomalies, such as
radial deficiency (Fig. 108.3A) or radial head dislocation (see Fig. 108.3B).
• The age of the child can be estimated based on the number of carpal bones seen
on the radiograph (Fig. 108.4A). The order of ossification of carpal bones is detailed
in Fig. 108.4B. In general, approximately one ossification center appears per year
from the ages of 1 year to 7 years.
• Type IIIA hypoplasia is associated with full length of the metacarpal (Fig. 108.5),
whereas a tapered metacarpal without a base reflects a type IIIB hypoplastic thumb.
SURGICAL ANATOMY
After pollicization of an index finger, the common digital artery to the index long web-
space becomes the primary arterial supply to the transposed digit. The radial digital
artery to the index finger is often attenuated or absent, but this finding should not affect
the ability to proceed with pollicization.
A B
FIGURE 108.3 (A) Radial longitudinal deficiency. (B) Radial head dislocation.
816 CHAPTER 108 Index Pollicization for Hypoplastic Thumb
2 years
1 year
12 years
3 years
7 years
Hamate
Trapezoid Pisi-
6 years Trapezium Capitate form
Triquetrum
Scaphoid
Lunate
B 5 years 4 years
A
FIGURE 108.4 (A) Type IV hypoplastic thumb with 2 visible carpal bones (indicating patient is 2 years of age). (B) Order of ossification of carpal bones.
A B
FIGURE 108.5 Type IIIA hypoplasia with full FIGURE 108.6 (A) Volar markings for type IIIB thumb. (B) Volar markings for type IV thumb.
length of the metacarpal.
EXPOSURES PEARLS
Pollicization is a complex procedure that requires POSITIONING
meticulous attention to detail. We recommend a
stepwise approach to conceptually organize and • The procedure is conducted under general anesthesia with the patient supine on the
simplify the reconstruction (Table 108.2). operating room table. A well-padded tourniquet is placed on the upper arm and the
limb is prepared and draped in the usual fashion.
• Although some surgeons prefer gentle exsanguination to identify vascular struc-
EXPOSURES PITFALLS
tures, we prefer full exsanguination because this prevents blood staining from ob-
There are many modifications of skin flap design; scuring important neurovascular structures.
it is substantially more important to adhere to basic
principles of pollicization than to select the “best”
incision design. Poorly planned skin incisions can result
EXPOSURES
in inadequate soft tissue coverage of the first webspace, A longitudinal curvilinear incision is marked over the palmar aspect of the index finger
leading to difficulty with full thumb abduction and the metacarpal (Fig. 108.7A–B). A V-shaped incision is marked over the dorsum of the in-
need for skin grafting for coverage. Ideally, the first dex finger metacarpal such that the apex is at the level of the neck of the metacarpal
webspace should have supple soft tissue coverage
without scars to optimize thumb opposition. (Fig. 108.6A–B). The dorsal and palmar incisions are then connected at the base of the
index finger.
A B
FIGURE 108.7 (A) Dorsal markings for type IIIB thumb. (B) Dorsal markings for type IV thumb.
TABLE
108.2 Twenty-Step Approach to Pollicization
Step 1 Skin markings.

Step 2 Complete exsanguination.
Step 3 Skin flap elevation and exposure of neurovascular bundles.
Step 4 Ligation of the proper digital artery to the radial side of the long finger.
Step 5 Intraneural dissection and separation of common digital nerve to the second
webspace (to prevent tension on proper digital nerve to index finger during
later recession).
Step 6 Index finger first annular pulley release.
Step 7 Division of the second webspace transverse metacarpal ligament.
Step 8 Elevation of the dorsal skin flap with preservation of the dorsal veins.
Step 9 Index extensor tendons freed from adjacent extensor tendon/juncturae tendineae.
Step 10 Elevation of the first dorsal and first palmar interosseous muscles from the
index metacarpal shaft and MCP joint.
Step 11 Complete release of the interosseous muscles from the MCP joint with a strip
of extensor hood.
Step 12 Suture tagging of the index finger lateral bands (ensure that traction on these
structures causes PIP joint extension).
Step 13 Osteotomy through the index metacarpal physis and metacarpal base.
Step 14 Suture fixation of the index MCP joint in hyperextension.
Step 15 Recession of the index finger (with or without temporary K-wire fixation) into thumb
position (approximately 100 degrees of pronation and 45 degrees of abduction).
Step 16 Suture approximation of the epiphysis and metacarpal base.
Step 17 Intrinsic function restoration (first dorsal interosseous transferred to radial lateral
band and first palmar interosseous transferred to ulnar lateral band).
Step 18 Loose skin flap inset.
Step 19 Tourniquet deflation, provision of hemostasis, and complete skin closure.
Step 20 Application of bulky, nonconstricting hand dressing and long arm cast with
thumb exposed.
K-wire, Kirschner wire; MCP, metacarpophalangeal; PIP, proximal interphalangeal.


• Dissection of these small neurovascular struc- Step 1
tures will require the use of loupes with 3.5
or greater magnification. • The palmar skin is incised and thick skin flaps are raised.
• The radial neurovascular bundle to the index • The index finger radial digital neurovascular bundle is identified and isolated. If the
finger may be hypoplastic or absent, but polli- child does not have this radial vessel or even if it is diminutive, the procedure can
cization can still be performed because the proceed because the major blood supply emanates from the common digital artery
ulnar common digital artery becomes the pri-
between the index and long fingers. The common digital artery to the second web-
mary blood supply to the transposed digit.
• The common digital arteries may arise from space is then identified. The dissection continues distally to isolate the ulnar digital
the deep arch and require more extensive artery to the index finger and the radial digital artery to the middle finger (Fig. 108.8).
dissection. • The radial digital artery to the long finger is ligated using 6-0 Prolene suture imme-
diately distal to the bifurcation. After this structure is divided, the index finger is
entirely based on the common digital artery to the second webspace and the index
finger radial digital artery, if present. The vessels are mobilized proximally to the level
of the superficial arch to prevent tethering of the vessels with proximal transposition
of the index finger.
• Intraneural dissection of the common digital nerve may be required to separate the
fibers of the ulnar digital nerve to the index finger from the fibers of the radial digital
nerve to the middle finger. This dissection is carried proximally to the level of the
superficial arch.

Transverse venous connections between the index • The A1 pulley of the index finger is divided longitudinally (Fig. 108.9).
and long fingers should be ligated, taking care to • The ulnar neurovascular bundle of the index finger is retracted radially, and the trans-
protect the outflow from the index finger. verse metacarpal ligament between the index and long finger metacarpals is sharply
divided at the neck of the metacarpal (Fig. 108.10). This maneuver results in substan-
STEP 3 PITFALLS tial mobility of the index metacarpal, facilitating subsequent steps in the procedure.
The radial and ulnar neurovascular (NV) bundles Step 3

and dorsal veins must be protected during
elevation of the interosseous muscles. • The dorsal skin is incised and flaps are raised at the dermal layer. It is critical to keep
the dorsal veins within the subdermal layer to maintain venous outflow from the in-
dex finger (Fig. 108.11).
• The juncturae tendineae between the index and long finger extensor tendons are
identified and divided.
• The first dorsal and palmar interossei are elevated off the radial and ulnar aspects of
the metacarpal shaft, respectively. Only the proximal portion of these muscles origi-
nating from the base of the metacarpal are left undisturbed in preparation for future
*
*
FIGURE 108.8 Volar exposure with black star indicating radial digital
artery to the middle finger. FIGURE 108.9 Volar exposure with black star indicating divided A1 pulley.
FIGURE 108.11 Dorsal skin flap elevation with black star indicating
veins within subdermal fat.
FIGURE 108.10 Exposure of the transverse metacarpal ligament
before division.
First dorsal interosseous muscle

FIGURE 108.12 Elevation of the first dorsal interosseous muscle before elevation.
insertion into the lateral bands. The tendons of these two muscles are carefully
separated from the metacarpophalangeal (MCP) joint capsule and divided distally
along with a small portion of the extensor hood (Fig. 108.12).
Step 4
While protecting the dorsal veins, the skin is elevated over the proximal phalanx and
the extensor hood is identified. The radial and ulnar lateral bands are identified on either
side of the midproximal phalanx. The location of these structures can be confirmed by
placing them on traction and noting extension of the index finger proximal interphalan-
geal (PIP) joint (Fig. 108.13). The lateral bands are tagged with 6-0 Prolene suture for
STEP 5 PEARLS
ease of future identification.
• Although the metacarpal shaft is removed, the
Step 5 insertion of the flexor carpi radialis (FCR) and
extensor carpi radialis longus (ECRL) proximally
• Distal and proximal osteotomies of the index finger metacarpal shaft are performed and the origin of the collateral ligaments dis-
to shorten the finger and enable proximal recession. tally must be spared.
• The distal osteotomy is created beyond the neck of the metacarpal through the • After rotation and proximal transposition, the
physis (Fig. 108.14A–B). In young patients, the physis is soft and a blade can be tip of the index finger should reach the PIP
joint of the middle finger.
used for this osteotomy. The metacarpal epiphysis is now the new thumb trapezium.
FIGURE 108.13 Dorsal dissection of the radial and ulnar lateral bands. Traction on the lateral bands
results in PIP joint extension. PIP, proximal interphalangeal.
Distal osteotomy
First dorsal
interosseous
muscle
B
A
FIGURE 108.14 (A–B) Proximal and distal index finger metacarpal osteotomy locations.
STEP 6 PEARLS • The proximal osteotomy is done at the base of the metacarpal using a bone cutter
A normal index finger MCP joint can hyperextend and the metacarpal segment is removed (Fig. 108.15).
20 to 30 degrees beyond neutral. Hyperextension • The index finger is now mobile and attached only by the dorsal veins, radial and
of a thumb CMC joint, however, is not desirable. ulnar NV bundles, and flexor and extensor tendons.
STEP 7 PEARLS
Step 6
To prevent hyperextension of the index finger MCP joint (the new thumb CMC joint), the
• The position should be such that the pulp of
the index finger is in contact with the radial dorsal capsule is sutured to the physis with 4-0 nonabsorbable suture when the joint is
aspect of the PIP joint and the proximal in maximal hyperextension.
phalanx of the middle finger.
• An oblique osteotomy of the metacarpal base Step 7
can be created to improve the position of the
• The index finger is placed over the base of the index metacarpal. The index MCP
thumb.
joint will now function as the new thumb CMC joint. It is positioned in 45 degrees of
Palmar
Dorsal
Side view
FIGURE 108.16 Positioning of the thumb before definitive inset.
FIGURE 108.15 Excised index finger metacarpal segment.
palmar abduction and 100 to 120 degrees of pronation to recreate the position of STEP 7 PITFALLS
the thumb (Fig. 108.16). • One must ensure that the palmar incision pro-
• Additional 4-0 nonabsorbable sutures are placed between the epiphysis and the vides adequate exposure of the base of the
metacarpal base and surrounding soft tissues to stabilize the fixation. metacarpal. An excessively long pollicized
thumb is most often the result of not seating the
index finger well proximally. It is almost impossi-
Step 8 ble to make the thumb too short, but frequently
• Intrinsic function of the pollicized digit is restored via two tendon transfers. The first the newly created thumb will be too long and
dorsal interosseous tendon is attached to the radial lateral band at the level of the have the appearance of a finger. Be sure to re-
midproximal phalanx to provide abduction of the pollicized index finger. The first sect the index metacarpal as proximally as pos-
sible but also maintain the insertion of the ECRL
palmar interosseus tendon is attached to the ulnar lateral band and functions as the
tendon if present. Seat the index finger deeply
thumb adductor (Fig. 108.17). These structures may be interwoven and secured us- within the wound to create an aesthetically
ing nonabsorbable suture. appealing thumb.
• The extensor and flexor tendons are left undisturbed and dynamically rebalance over • Care should be taken to ensure that NV struc-
time. The new anatomic functions of the index finger joints and muscle units are tures and tendons are not entrapped in the
interface between the metacarpal base and
detailed in Table 108.3.
the proximally transposed index finger.
DP → DP
DIPJ → IPJ STEP 8 PEARLS
MP → PP • Interosseous muscle transfer to the lateral

bands is conceptually the most difficult step in
pollicization.
PIPJ → MPJ
• Proximal transposition of the index finger leads
PP → M to redundancy in the extrinsic flexor and exten-
sor tendons. To address this, some surgeons opt
to shorten the extensor and flexor tendons dur-
MCPJ → CMCJ ing pollicization. We do not find this necessary
because experience has shown that children
M (head) → Trapez. regain active motion within months of surgery.
1st PI → AddP
1st Pl 1st DI → AbPB

(Abl)
EIP → EPL
AbPB
EDC → AbPL
FIGURE 108.17 Diagram of tendon transfers and new muscle functions. AbPB, Abductor pollicis
brevis; AbPL, abductor pollicis longus; AddP, adductor pollicis; CMCJ, carpometacarpal joint; DI,
dorsal interosseous; DIPJ, dorsal interphalangeal joint; DP, distal phalanx; EDC, extensor digitorum
communis; EIP, extensor indicis proprius; EPL, extensor pollicis longus; IPJ, interphalangeal joint;
M, metacarpal; MCPJ, metacarpophalangeal joint; MP, middle phalanx; PI, palmar interosseous;
PIPJ, proximal interphalangeal joint; PP, proximal phalanx.
TABLE
108.3 Functional Units of Pollicized Thumb
Unit New Function
Skeletal Units
Distal interphalangeal joint Interphalangeal joint
Proximal interphalangeal joint Metacarpophalangeal joint
Musculotendinous Units
Extensor indicis proprius Extensor pollicis longus
Extensor digitorum communis (index) Abductor pollicis longus
First palmar interosseous Abductor pollicis
First dorsal interosseous Abductor pollicis brevis
Step 9
STEP 10 PITFALLS
• The skin flaps are transposed and provisionally secured in position with widely
On rare occasions, the pollicized finger may appear placed 5-0 chromic sutures.
pale after closure. The cause is usually vasospasm,
• Fig. 108.18 illustrates the flap movement and index finger transposition.
which can be alleviated with warm soaks. If the
perfusion does not improve within 15 minutes,
any constricting skin sutures should be removed Step 10
and the vascular inflow and outflow inspected. The The tourniquet is deflated and the “thumb” is inspected for capillary refill and any evi-
most common cause of vascular insufficiency is dence of vascular compromise. Taking care to protect the NV structures, meticulous
a tight closure, which can be treated with a skin
hemostasis is ensured with bipolar electrocautery. The skin flaps are fully inset using
graft.
5-0 chromic suture (Fig. 108.19).
B
C
C
C
FIGURE 108.18 Flap movement and index finger transposition.

FIGURE 108.19 Skin flap inset and definitive closure.

• A long-arm thumb spica cast is applied with the elbow in 90 to 100 degrees of flex-
ion to prevent premature removal (Fig. 108.20). The arm is kept elevated to promote
venous drainage.
• The cast is removed 4 weeks postoperatively and hand therapy is initiated to address
thumb mobility, pinch, and grasp. The patient is transitioned to a short-arm thumb
spica orthosis for protection and stability; this is removed only for therapy and clean-
ing/scar management. The orthosis is discontinued 3 months postoperatively.
• In general, outcomes after pollicization are directly related to the mobility of the index
finger. A strong, mobile index finger functions well as a thumb, whereas a stiff, weak
index finger makes a poor thumb. After pollicization, one can expect about 30% of grip
and pinch strength compared with the contralateral unaffected thumb. Although some
children with thumb hypoplasia may be candidates for a free toe transfer, pollicization
remains the preferred procedure. Fig, 108.21 shows the 2-year postoperative result.
See Video 108.1
FIGURE 108.20 Long arm cast application. FIGURE 108.21 Two-year postoperative result.
EVIDENCE
Buck-Gramcko D. Pollicization of the index finger: Methods and results in aplasia and hypoplasia of
the thumb. J Bone Joint Surg. 1971;53:1605–1617.
This classic article details the techniques and outcomes for index finger pollicization in 114 patients
(100 congenital), with long-term follow-up of up to 12 years. The author details his technique and
subsequent modifications (Level V evidence).
Tonkin MA, Boyce DE, Fleming PP, Filan SL, Vigna N. The results of pollicization for congenital thumb
hypoplasia. J Hand Surg Eur Vol. 2015;40:620–624.
This study reviewed the results of index pollicization in patients with and without forearm/wrist involve-
ment. CMC joint motion was near normal in both groups (decreased retropulsion in patients with
forearm/involvement). MCP and IP joint flexion, grip, thumb lateral and tip pinch strengths, and
Jebsen timed test were superior in patients without forearm/wrist involvement. Subjective assess-
ment by patients/parents found 72% excellent/good results for function and 94% for appearance.
Doctor excellent/good assessments were 60% and 70%, respectively. The authors conclude that
forearm/wrist anomalies significantly compromise results but are not a contraindication for
pollicization (Level IV evidence).
Kollitz KM, Tomhave W, Van Heest AE, Moran SL. Change in hand function and dexterity with age after
index pollicization for congenital thumb hypoplasia. Plast Reconstr Surg. 2018;141(3):691–700.
The authors reviewed the range of motion, strength, and dexterity in 29 patients who underwent pollici-
zation at an average follow up of 3.9 years. Distal grasp span increased 0.17 inch and Kapandji
opposition improved 0.26 point with each year of age; however, proximal webspace size did not
increase over time. Grip strength improved an average of 2.69 kg/year, and tripod and key pinch
improved 0.58 kg and 0.67 kg with each year of age. Box and Block Test scores improved an aver-
age of 4.11 blocks/year. Scores on the Nine Hole Peg Test improved 3.83 seconds/year, and scores
on the Functional Dexterity Test improved 0.026 peg/second each year. These data suggest that
children with pollicized thumbs improve in dexterity and strength with growth, but the webspace
size did not change with age (Level IV evidence).
Canizares MF, Feldman L, Miller PE, Waters PM, Bae DS. Pollicization of the index finger in the United
States: Early readmission and complications. J Hand Surg Am. 2019;44(9):795.
In this study, the authors investigated early postoperative complications after pollicization in the United
States. A total of 459 pollicization procedures performed in 408 patients at 38 US pediatric hospitals
from 2003 to 2014 were identified using the Pediatric Health Information System database. Sixty-one
patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%),
most commonly vascular in nature. The authors concluded that baseline data are informative be-
cause they identify opportunities for future preventative measures and quality improvement (Level IV
evidence).
Hellevuo C, Leppänen OV, Kapanen S, Vilkki SK. Long-term outcomes after pollicization: A mean
11-year follow-up study. J Hand Surg Eur Vol. 2020;45(2):173–180.
The authors evaluated the long-term results of pollicization for a congenitally absent or severely hypo-
plastic thumb. Twenty-nine patients with 34 pollicizations were divided into two groups: those with
simple thumb hypoplasia (22 pollicizations) and those with radial longitudinal dysplasia (12 polliciza-
tions). Patients were followed from 1.3 to 32 years, with a mean follow-up time of 11 years. The
patients were examined clinically and radiologically, and they completed a questionnaire concerning
satisfaction with appearance, function, and social interaction. In both groups, grip and pinch
strengths of the operated hands were inferior to the normative age-related values. The authors found
better patient satisfaction in the simple hypoplasia group than in the radial longitudinal dysplasia
group. The functional outcomes and patients’ satisfaction did not correlate with the age of patients
at operation (Level IV evidence).
CHAPTER 109
Pediatric Opponensplasty
INDICATIONS
• One indication for this procedure is a hypoplastic thumb with a functional carpo-
metacarpal joint (Blauth types II and IIIA).
• Opponensplasty is typically offered at 12 to 18 months of age, because general
anesthesia is safer and structures are larger, facilitating dissection. Surgery at this
age also permits time for preliminary correction of any associated radial deficiencies
(typically addressed between 3 to 6 months of age). Finally, cortical representation
of the thumb has not yet become solidified at this age.
• Transfer of the abductor digiti minimi (ADM), otherwise known as the Huber
transfer, is commonly used to restore opposition among pediatric patients with
thumb hypoplasia and an otherwise reconstructible thumb. This procedure can
also improve appearance by increasing the bulk of the thenar eminence. Further-
more, the ADM is always present, even in severe cases of radial longitudinal
deficiency.
• Transfer of the flexor digitorum superficialis (FDS) of the middle or ring finger is an
alternative option for opponensplasty. The FDS transfer does not increase thenar
eminence bulk, but it does provide additional tendon length for ulnar collateral liga-
ment (UCL) reconstruction, if necessary. The details of this transfer can be found in
Chapter 63.
Contraindications
Contraindications include hypoplastic thumbs with an inadequate carpometacarpal
joint (Blauth types IIIB and IV) or complete absence of the thumb (Blauth type V), pa-
rental reluctance to proceed with surgery, and medical comorbidities that would pre-
clude safe surgery.
• See Chapter 108 for details regarding the Blauth classification system, examination
details, and associated anomalies.
• There are five clinical features of thumb hypoplasia that should be considered when
assessing a type II or IIIA hypoplastic thumb (Fig. 109.1):
• The thumb is shorter and smaller.
• There is thumb interphalangeal (IP) joint stiffness.
• Intrinsic atrophy is present in type II thumbs, whereas type IIIA thumbs have both
intrinsic and extrinsic muscle atrophy.
• The first webspace may be narrowed (less than 50 degrees of radial thumb ab-
duction) and require widening.
• The thumb metacarpophalangeal (MCP) joint UCL may be attenuated (a greater
than 20-degree difference in UCL laxity compared with the normal side) or absent
and should be reconstructed for stable pinch and grasp.
IMAGING
See Chapter 108 for details regarding preoperative imaging.
SURGICAL ANATOMY
• The intrinsic muscles of the thumb (abductor pollicis brevis [APB], opponens pollicis
[OP], flexor pollicis brevis [FPB], and adductor pollicis [AP]) are deficient in types II
and III, and absent in types IV and V (Fig. 109.2).
825
826 CHAPTER 109 Pediatric Opponensplasty
A B
FIGURE 109.1 (A-B) Clinical examination of hypoplastic thumb.
• The flexor pollicis longus (FPL) and extensor pollicis longus (EPL) are hypoplastic in
type III thumbs. There may be an anomalous connection (i.e., pollex abductus) be-
EXPOSURES PEARLS
tween the FPL and the EPL at the level of the MCP joint. This may exacerbate the
Most patients, but not all, will need Z-plasty and angular deformity of the thumb.
stabilization of the MCP joint, so the incisions are
planned on a case-by-case basis. • The three elements of types II and IIIa hypoplastic thumbs that require correction include:
• Intrinsic muscle atrophy
• A narrowed first webspace
EXPOSURES PITFALLS • An unstable thumb MCP joint UCL
Avoid an incision that is too ulnar or dorsal on the • Extrinsic muscle attenuation/absence may need to be addressed on a case-by-case
hand because this limits exposure of the origin of basis (e.g., FDS or extensor indicis proprius tendon transfers for thumb IP joint flex-
the ADM muscle and ulnar neurovascular bundle. ion or extension, respectively).
• Thumb IP joint stiffness and the small caliber of the thumb will not improve even with
successful reconstruction.
POSITIONING
The procedure is conducted under general anesthesia, with the patient placed supine
on the operating room table. A well-padded tourniquet is placed on the upper arm and
the limb is prepared and draped in the usual fashion.
EXPOSURES
A longitudinal curvilinear incision is marked over the ulnar border of the hand along the
axis of the hypothenar musculature (Fig. 109.3).
PROCEDURE
• More proximally, the palmaris brevis overlies • The arm is exsanguinated and the tourniquet is inflated.
the ADM. The palmaris brevis can be differen- • The palmar skin is incised and thick skin flaps are raised.
tiated by the transverse orientation of its fibers.
• The ulnar digital nerve to the small finger • The ADM muscle is skeletonized with spreading scissor dissection, with care taken
should be visualized throughout the dissection to protect adjacent neurovascular structures. The pedicle does not need to be visu-
to prevent inadvertent injury. alized during muscle exposure.
• The ADM has two insertions: one to the ulnar aspect of the base of the proximal
phalanx and the other to the extensor expansion. These are divided with scissors at
STEP 1 PITFALLS
the level of the MCP joint of the small finger.
Excessive proximal dissection may put the • The ADM muscle is mobilized completely to its origin from the pisiform in prepara-
neurovascular pedicle of the ADM muscle at risk.
tion for transfer to the thumb (Fig. 109.4).
Adducted posture
Slight decrease
in thumb size
MCPJ UCL instability

Slender phalanges
Underdeveloped or
and metacarpals
absent thenar muscles
Normal carpal bones
Normal distal radius

I II
Adducted posture Adducted posture

Underdeveloped or
Underdeveloped or absent thenar muscles
absent thenar muscles and thumb extrinsics
and thumb extrinsics
Absence of proximal
Full-length metacarpal portion of metacarpal
Variable absence of Variable absence of
trapezium and scaphoid trapezium and scaphoid
Variable absence Variable absence

IIIA of radial styloid IIIB of radial styloid
Distal midaxial origin

of floating thumb
Absent first dorsal
Absent thenar and interosseous in 50%
extrinsic thumb muscles of patients
Fully developed
neurovascular pedicle Absent radial
Variable absence of carpal bones
trapezium and scaphoid Absent
radial styloid
Variable absence Hypoplasia of
IV of radial styloid V distal radius
FIGURE 109.2 Intrinsic and extrinsic muscle aberrations in the hypoplastic thumb. MCPJ, Metacarpophalangeal joint; UCL, ulnar collateral
ligament.
FIGURE 109.3 Marking the axis of the hypothe- FIGURE 109.4 ADM muscle is mobilized in preparation
nar musculature. for transfer to the thumb. ADM, Abductor digiti minimi.

The palmar skin elevation should be done • A chevron-style incision, is made over the radial aspect of the thumb MCP joint at
superficially to avoid injury to the contents of the the level of the APB insertion.
carpal tunnel. • Any pollex abductus is identified and divided (Fig. 109.5).
• The palmar skin between the thumb incision and ADM dissection is widely under-
mined using a blunt clamp.

• The radial limb of the four-flap Z-plasty should • When the first webspace is narrow and/or the thumb MCP joint is unstable, one
be designed dorsally, and the ulnar limb should must plan for an incision in the first webspace.
be designed extending in a palmar direction.
This permits exposure of the thumb MCP joint
and UCL through the radial limb incision.
• We recommend closing the first webspace
incision before insetting the ADM muscle
transfer because visualization becomes
difficult after inset. The Z-plasty flaps are
transposed as shown in Fig. 109.7.
STEP 3 PITFALLS
The radial digital nerve to the index finger and the
dorsal radial sensory branches of the radial nerve
are at risk of injury during elevation of the Z-plasty
skin flaps and should be identified and protected.
Anomalous connection
to extensor pollicis
longus
Flexor pollicis
longus
Extensor pollicis
longus
FIGURE 109.5 The pollex abductus is identified and divided.

FIGURE 109.6 Marking a four-flap, 120-degree Z-plasty on the first webspace.
• A four-flap, 120-degree Z-plasty is marked on the first webspace and the skin is
STEP 4 PEARLS
incised with a no. 15 scalpel (Fig. 109.6).
If the structures around the ulnar aspect of the thumb
• Full-thickness flaps are elevated, taking care to protect the underlying neurovascular
MCP joint are not sufficient to impart stability to the
structures. joint even after imbrication, a UCL reconstruction
• The fascia overlying the intrinsic muscles is carefully released with scissors. using free tendon graft may be necessary.
Step 4
STEP 4 PITFALLS
• If the UCL is attenuated or unstable, the adductor pollicis tendon is divided at its
insertion into the extensor expansion and reflected ulnarly to expose the thumb UCL. • The K-wire should not exit through the radial
• A single 0.045-inch Kirschner wire (K-wire) is passed obliquely from radial to ulnar aspect of the metacarpal head, where it may
impinge on the insertion of the ADM tendon
through the MCP joint to maintain the MCP joint in neutral position (Fig. 109.8). after opponensplasty.
• The thumb MCP joint capsule and UCL are imbricated using 4-0 nonabsorbable • Global instability of the thumb MCP joint may
sutures to provide stability with pinch. not be adequately corrected with UCL recon-
• If the capsule and UCL are not sufficient to restore stability, the adductor pollicis struction alone. These rare situations will
tendon is mobilized, advanced, and sutured to the ulnar base of the proximal pha- require chondrodesis (cartilage fusion) of the
thumb MCP joint.
lanx and extensor mechanism using 4-0 nonabsorbable sutures.
60°
D
60° 60°
C B 120°
60° 120°
A
D
C B
B
A D B
B D
D
C A
A A C
C
FIGURE 109.7 Depiction of Z-plasty flap transposition.

A B
FIGURE 109.8 The Kirschner wire (K-wire) is FIGURE 109.9 (A) ADM being transferred to thumb. (B) After ADM muscle transfer inset. ADM,
passed obliquely from radial to ulnar through the Abductor digiti minimi.
MCP joint. MCP, Metacarpophalangeal.

• The ADM muscle is turned 180 degrees like The ADM is transferred radially across the palm and woven through the APB tendon
the page of a book, rather than 90 degrees, to
insertion and joint capsule at the level of the radial thumb MCP joint using 4-0 nonab-
avoid twisting of the neurovascular pedicle
(Fig. 109.10). sorbable sutures (Fig. 109.9A–B).
• Because the ADM has minimal excursion, inset
of the transfer requires placement of the Step 6
thumb ray in an unnatural amount of opposi- • The tourniquet is deflated and hemostasis is ensured.
tion. This exaggerated posture will stretch over
• The ulnar palm and radial thumb incisions are closed using absorbable suture
time.
(Fig. 109.11).

STEP 5 PITFALLS
• A long-arm thumb spica cast is applied with the elbow in 90 to 100 degrees of flex-
• A narrow subcutaneous tunnel may limit the
ability to easily transfer the ADM muscle to the ion to prevent premature removal (Fig. 109.12). The arm is kept elevated to promote
thumb or limit excursion of the muscle. venous drainage.
• Careful insertion of the ADM into the soft tis-
sues about the thumb MCP joint will prevent
rupture of the transfer with subsequent use.
Abductor digiti
minimi m.
FCU
Pisiform
PM ligament
Flexor digiti
minimi brevis m.
FIGURE 109.10 ADM muscle is turned 180 degrees rather than 90 degrees. ADM, Abductor digiti
minimi; FCU, flexor carpi ulnaris; PM, Pisometacarpal.
FIGURE 109.11 Ulnar palm and radial thumb incisions FIGURE 109.12 Long-arm thumb spica cast applied with elbow
are closed using absorbable sutures. flexed 90 to 100 degrees.
A B
FIGURE 109.13 (A) The 2-month postoperative result, palmar view. (B) The 2-month postoperative result, dorsal view.
• The cast is removed 4 weeks postoperatively and the patient is transitioned to a

short-arm thumb spica orthosis for protection and stability for another 2 to 4 weeks;
this is removed only for therapy and cleaning/scar management.
• Therapy begins at 6 to 8 weeks, with a focus on gentle range-of-motion (ROM) exercises.
• The orthosis is discontinued at 3 months postoperatively.
• With adherence to the aforementioned principles and meticulous technique, good to
excellent outcomes may be achieved. One can expect a marked improvement in
hand function, thumb stability, and opposition strength.
• Fig. 109.13A–B shows the 2-month postoperative result.
See Video 109.1
EVIDENCE
Wall LB, Goldfarb CA. Tendon transfers for the hypoplastic. Thumb Hand Clin. 2016;32(3):417–421.
In this study, the authors provide a thorough review of thumb hypoplasia and the indications for
reconstruction. They also describe in detail the most common options for restoring thumb
opposition: the Huber ADM muscle transfer and the FDS opposition transfer. They emphasize
that both transfers use ulnar-sided structures to augment the thenar musculature. Further, they
state that although the Huber opposition transfer increases thenar bulk, it does not provide
additional tissue for metacarpophalangeal stability (Level V evidence).
McDonald TJ, James MA, McCarroll Jr HR, Redlin H. Reconstruction of the type IIIA hypoplastic
thumb. Tech Hand Up Extrem Surg. 2008;12(2):79–84.
In this review, the authors outline the common findings in children with type IIIa thumb hypoplasia. The
differences between types IIIa and IIIb thumbs are also highlighted. Although many techniques are
available for management of the type IIIa thumbs, the authors focus on the critical details of their
preferred approach to management with a discussion of expected outcomes. The benefits of the
ADM versus FDS opponensplasty are also described (Level V evidence).
Abdel-Ghani H, Amro S. Characteristics of patients with hypoplastic thumb: A prospective study of
51 patients with the results of surgical treatment. J Pediatr Orthop B. 2004;13(2):127–138.
The authors present outcomes of 51 patients (82 hypoplastic thumbs), of whom 18 patients underwent
surgical reconstruction with 3-year follow-up. In this series, type V thumb hypoplasia was most
common, and the majority (86%) suffered from associated anomalies. Among patients who under-
went opponensplasty and UCL reconstruction, the majority achieved stability (70%) at the MCP
joint and the ability to oppose the finger to the small finger (89%; Level IV evidence).
CHAPTER 110
Camptodactyly Correction
INDICATIONS
Indications include functional impairment, a flexion deformity greater than 30 to 60 degrees,
and a deformity that persists after 6 to 12 months of stretching and splinting.
Contraindications
Contraindications include no functional impairment, improvement of the deformity with
splinting alone, flexion contracture of less than 30 degrees, and family or parental re-
luctance to proceed with surgery.
• Camptodactyly is a flexion deformity or contracture of the proximal interphalangeal
(PIP) joint that most often manifests in the small finger. It is frequently bilateral with
asymmetric involvement and is classified into three different types (Table 110.1).
Camptodactyly often presents during periods of rapid growth, such as in the first
year of life and during adolescence.
• Conditions associated with camptodactyly include arthrogryposis, skeletal dyspla-
sias, Beal syndrome, and Marfan syndrome.
• The PIP joint is checked for extension lag and flexion contracture with the wrist in
neutral position. Extension lag is the maximum extension measurement when per-
forming active motion testing. Flexion contracture is the maximum extension mea-
surement when performing passive motion testing. A perfectly straight PIP joint is
considered to have 0 degrees of lag or contracture. Extension lag and flexion con-
tracture measurements may be quite different. For example, a joint may have an
extension lag of 60 degrees, but a passive extension force across the PIP joint may
reveal a joint correctable to a 30-degree flexion contracture.
• Assessing the affected digit with the metacarpophalangeal (MCP) joint in flexion and
extension is performed next. For patients with camptodactyly, when the MCP joint
is in extension, the finger assumes a flexed posture at the PIP joint. Passive exten-
sion of the PIP joint may produce blanching of the skin, which implies a skin defi-
ciency (Fig. 110.1). Additionally, if passive flexion of the MCP joint improves PIP joint
extension, the etiology of the contracture is outside the PIP joint (e.g. skin deficiency,
subcutaneous fibrous bands, or tightness of the extrinsic finger flexors, such as the
flexor digitorum superficialis [FDS]). If passive extension is not improved with MCP
TABLE
110.1 Types of Camptodactyly
Type Description
1 A newborn presents with a flexion deformity of the fifth and/or fourth finger.
This is the most common type and affects males and females equally.
2 Physical changes similar to type 1, but it develops between 7 and 11 years of
age. Females are affected more often than males. The flexion deformity will
not improve over time and may develop into a severe flexion contracture.
3 Present from the time of birth. It affects several fingers, is bilateral, and often
has an accentuated flexion deformity. It is associated with a variety of syn-
dromes and other malformations.
833
834 CHAPTER 110 Camptodactyly Correction
Skin contracture
FIGURE 110.1 Skin contracture associated with camptodactyly.
joint flexion, there is some component of primary joint contracture that will need to
be surgically corrected.
• A compensatory hyperextension deformity of the MCP joint is frequently found with
a PIP joint flexion deformity. With the Bouvier maneuver, the examiner corrects the
hyperextension by passively placing the MCP joint in neutral or slight flexion. If this
restores full PIP joint active extension, then MCP joint hyperextension is the cause of
the PIP joint flexion deformity; this may be secondary to an intrinsic muscle abnor-
mality. An FDS transfer to the lateral band may be indicated in this situation. Concep-
tually, this transfer would increase MCP joint flexion and PIP joint extension forces.
• For patients with passively correctable PIP joint flexion deformities, the extensor
tenodesis effect is used to assess extrinsic extensor integrity. The wrist and MCP
joints are placed in full flexion. In an unaffected digit, this maneuver should produce
full PIP joint extension through passive stretch on extensor digitorum communis
(EDC). If it does not, this implies a laxity or hypoplasia of the central slip.
IMAGING
Three-view standard hand radiographs are obtained. The configuration of the proximal
phalanx and middle phalanx at the PIP joint is evaluated. The lateral film will be the
most informative view. The head of the proximal phalanx loses its rounded articular
convex contour, and there is flattening at the base of the middle phalanx articulation.
The base of the middle phalanx is volarly subluxated and the flexed middle phalanx
creates an indentation in the palmar neck of the proximal phalanx (i.e., the “parrot
beak” deformity; Fig. 110.2).
SURGICAL ANATOMY
• The development of camptodactyly has been attributed to anomalous joint archi-
tecture, laxity of the extensor mechanism at the PIP level, anomalous fascial
bands from the annular one pulley, abnormal flexor tendons, abnormal lumbrical
muscles, and/or anomalous intrinsic muscles. The most commonly identified
anomalies include an anomalous lumbrical muscle or an absence/anomaly of the
FDS tendon.
• The FDS tendon has been described as contracted, underdeveloped, or devoid of a
functional muscle. The abnormal tendon may originate from the palmar fascia or
transverse carpal ligament instead of a muscle belly. This anomalous musculotendi-
nous architecture cannot elongate during periods of rapid growth, which can lead to
a PIP joint flexion deformity.
• The lumbrical may have an abnormal origin or insertion; an origin from the trans-
verse carpal ligament or the ring flexor tendons have been described. Abnormal
insertions are more common and include an attachment directly into the MCP joint
capsule, onto the FDS, into the ring finger extensor apparatus, or within the lumbri-
cal canal. The lack of intrinsic contribution to PIP extension creates an intrinsic
minus deformity.
Proximal phalanx
head loses convex
articular contour
Volar subluxation
of the middle Indentation at
phalanx neck of proximal
phalanx
FIGURE 110.2 Radiographic findings of camptodactyly.
POSITIONING EXPOSURE PEARLS

The procedure is performed under general anesthesia with or without a brachial plexus • In flexible camptodactyly without a fixed PIP
block. A well-padded tourniquet is placed on the upper arm. joint flexion contracture and with mild-to-mod-
erate contracture of skin, a palmar longitudinal
EXPOSURES approach with Z-plasty lengthening or Bruner
incision may be used. When there is a sub-
A transverse volar PIP joint flexion crease incision is designed (Fig. 110.3). This incision
stantial skin contracture and a Z-plasty or dor-
is used to release contracted structures on the volar side of the PIP joint. A proximally solateral flap are insufficient for closure, skin
based dorsolateral transposition flap is designed to cover the volar defect after con- grafts will be needed.
tracture release. The posterior border of the flap is on the midlateral line, and the ante- • Some surgeons advocate for a cross-finger
rior border of the flap will depend on the estimated size of the defect after contracture flap for volar skin coverage, but this is not
necessary if a transposition flap and skin graft
release. The length of the flap is designed to reach beyond the distal interphalangeal
are adequately employed.
(DIP) joint crease (Fig. 110.4).
Transverse volar
PIP joint flexion
crease incision
FIGURE 110.3 Volar skin markings. PIP, Proximal interphalangeal.

Transposition
flap
FIGURE 110.4 Transposition flap design.
PROCEDURE
Step 1: Skin and Fascial Contracture Release and Dorsolateral Flap
Elevation
• The transverse volar PIP joint flexion crease incision is made with a scalpel.
• The dorsolateral flap is raised along the deep fascial plane, leaving only areolar
tissue over the extensor expansion. A volar digital neurovascular bundle is identi-
fied and protected. The neurovascular bundles are at risk when making the trans-
verse incision because they are superficial. One should incise through the skin,
then use scissors to dissect and isolate the digital nerves. The flap is elevated from
distal to proximal to the base of the flap at the level of the head of the proximal
phalanx (Fig. 110.5A–B).
• Fascia and soft tissue volar to the flexor tendon are released. Any abnormal fascia
and linear fibrous bands are released during exposure of deeper structures. The
radial and ulnar digital neurovascular bundles are identified and protected.
• The flexor tendon sheath is exposed at the PIP joint, and the sheath is opened at
the level of the A3 pulley. The flexor digitorum profundus (FDP) tendon is retracted
to expose the Camper’s chiasm and insertion of the FDS tendon.
A B
Flap margins Neurovascular Flap elevated from

incised bundle neurovascular bundle
FIGURE 110.5 (A–B) Flap elevation.
Cut end of FDS
Pulleys A5C3 A4 C2 A3 C1 A2 A1 PA
Cut end of FDS
Retracted FDP
Camper’s chiasm
A B
FIGURE 110.6 FDS tenotomy. FDS, Flexor digitorum superficialis.
Step 2: Flexor Digitorum Superficialis Tendon Release STEP 2 PEARLS

• The Camper’s chiasm is divided longitudinally. Both slips of FDS are divided trans- It is rare for FDS division alone to correct the
versely and cut at a level distal to the chiasm (Fig. 110.6). contracture. The volar plate and collateral ligaments
• PIP joint passive range of motion (ROM) is tested. If there is no residual flexion con- typically require release.
tracture, the release is complete. If a flexion contracture remains, then the PIP joint
volar plate and collateral ligaments are released. STEP 3 PEARLS
• In severe camptodactyly, the joint may “click”
Step 3: Volar Plate and Collateral Ligament Release in and out of alignment because of incongruity
• With the FDP tendon retracted, a transverse incision is made at the level of the of the PIP joint. If there is a tendency toward
membranous PIP joint volar plate. The location is just distal to the checkrein liga- flexion even after complete soft tissue release,
a temporary Kirschner wire (K-wire) can be
ment attachment. The incision is curved distally on each side, separating the volar
driven across the joint to hold it in full or near-
plate from the accessory collateral ligaments. full extension (Fig. 110.9).
• A Freer elevator is used to gently lift the volar plate. The plate should slide distally • If correction of the PIP joint flexion contracture
as the joint is released (Fig. 110.7A–B). results in a DIP joint flexion deformity, the FDP
• If additional restrictions remain, the accessory collaterals and collateral ligaments tendon may require lengthening at the musculo-
tendinous juncture (this can be done through a
are partially divided.
separate incision in the forearm; Fig. 110.10).
• After release of all restrictive structures, full passive PIP extension is confirmed (Fig. 110.8).
Step 4: Flexor Digitorum Superficialis Transfer to Ulnar Lateral Band STEP 3 PITFALLS
(Treating Proximal Interphalangeal Joint Extension Lag) • Avoid dividing the entire radial and ulnar col-
• FDS transfer can be used to augment active extension of the PIP joint if preoperative lateral ligaments. The middle and dorsal as-
assessment confirms inability to actively extend the PIP joint with the MCP joint in pects of the ligaments should be preserved to
retain the stability of the PIP joint.
maximal flexion. • Full correction of a severe flexion contracture
may put undue tension on the neurovascular
structures. In these cases, one may be forced
to accept less than full correction.
Volar
A3 plate
C1
Checkrein
ligaments
Accessory
A2 collateral
ligament
Proper
collateral
Divide the volar ligament
plate as proximally
as possible
MCPJ
PIP joint volar
plate divided as
proximally as
A B
possible
FIGURE 110.7 (A) Illustration of volar plate release. MCPJ, Metacarpophalangeal joint. (B) Photo of
volar plate release. PIP, Proximal interphalangeal.
Full passive PIP

joint extension
FIGURE 110.8 Demonstration of full passive extension of digit after con-

tracture release. PIP, Proximal interphalangeal. FIGURE 110.9 Temporary pinning of PIP joint. PIP, Proximal interphalangeal.
STEP 4 PEARLS
• An essential component of this transfer is to FDP tendon fractional lengthening
maintain the FDS volar to the central axis of
the MCP joint by passing the tendon through FIGURE 110.10 FDP lengthening in the forearm. FDP, Flexor digitorum profundus.
the lumbrical canal. This keeps the tendon
palmar to the deep transverse metacarpal
ligament and ensures MCP flexion after the
tendon is secured to the lateral band.
• The cut end of one slip of the FDS is transferred from the volar side to the dorsal
• An interconnection between the FDS of the
little finger and ring finger is occasionally lateral side of the finger via the lumbrical canal. The end of the FDS slip is woven
encountered and is released to facilitate into the ipsilateral lateral band with 4-0 braided nonabsorbable suture (Fig. 110.11).
individual movement of each finger. Tension is set with the MCP joint positioned in 30 degrees of flexion and the PIP joint
held in full extension.
STEP 4 PITFALLS
Step 5: Dorsolateral Flap Inset and Incision Closure
FDS transfer can result in swan-neck posturing • The dorsolateral flap is transposed 90 degrees to cover the volar skin defect
and loss of PIP joint flexion. These risks must be
discussed with the patient and family preoperatively. (Fig. 110.12).
• A full-thickness skin graft is harvested from the hypothenar area, antecubital fossa,
or groin.
STEP 5 PEARLS • The tourniquet is deflated and hemostasis is performed.
• The flap inset should be without tension to • The flap is inset, and all of the incisions are closed and sutured with 4-0 absorbable
avoid partial flap loss. suture. The donor site of the full-thickness skin graft is closed primarily (Fig. 110.13).
• Meticulous hemostasis is necessary to ensure • The skin graft is inset in the donor site defect and secured with 4-0 absorbable
complete skin graft survival.
suture (Fig. 110.14A–B).
Weaving FDS slip with

ipsilateral lateral band
FIGURE 110.11 FDS tendon transfer. FDS, Flexor digitorum superficialis.
Flap transposed
FIGURE 110.12 Flap transposition before inset.

• The hand and wrist are immobilized in a short-arm splint for 2 to 3 weeks.
• Gentle active motion exercise is encouraged at 4 weeks postoperatively. If a K-wire
was placed, it is removed at this time. Therapy is also directed toward scar manage-
ment and tendon transfer training (if performed).
• Six weeks after surgery, light resistance exercises are initiated. The splint is removed
during the day except for strenuous activity.
• The splint is discontinued for all activities 12 weeks postoperatively, and unrestricted
activity is allowed. If recurrence is noted, nighttime splinting may be employed.
• A variety of operations have been proposed and surgical results have been variable.
Patient/parent compliance with splinting and therapy are just as important as the surgery.
FIGURE 110.13 Definitive closure.
A B
Full-thickness skin Full passive extension

grafts after inset demonstrated after closure
FIGURE 110.14 (A–B) Full-thickness skin graft inset.
A B
FIGURE 110.15 (A–B) Long-term outcome.
• Complications can include infection, incomplete PIP extension, decreased active

flexion, recurrence of contracture, stiffness, and pain.
• The functional status for severe flexion deformity patients is improved with the im-
proved posture of the finger (Fig. 110.15A–B).
See Video 110.1
EVIDENCE
Evans BT, Waters PM, Bae DS. Early results of surgical management of camptodactyly. J Pediatr
Orthop. 2017;37(5):e317–e320.
The authors reviewed outcomes in 22 patients (31 digits) after surgery for moderate-to-severe campto-
dactyly (>50 degrees). There were 13 males; average age at surgery was 9.6 years. All patients
underwent sequential release of contracted structures until maximal extension without compromising
vascularity or joint stability was obtained. Z-plasty of the volar skin was performed in 68% of digits,
FDS tenotomy in 77%, volar plate release in 58%, and collateral ligament release in 48%. All patients
were casted postoperatively and 71% of digits had temporary transarticular pin fixation. At initial
presentation, mean total passive motion (TPM) and total active motion (TAM) were 34 and 24 de-
grees, respectively. TPM and TAM were 35 and 25 degrees at the final follow-up. Furthermore, the
position of PIP arc of motion was in a more extended position postoperatively. Average TPM arc of
motion was from 50 to 82 degrees preoperatively and 28 to 63 degrees at final follow-up; average
TAM arc of motion was 62 to 81 degrees preoperatively and 30 to 55 degrees at final follow-up. The
authors conclude that, for patients with functionally limiting flexion contractures, surgical release
may be beneficial by providing a more extended position for improved digital release, hygiene, and
aesthetics (Level IV evidence).
Netscher DT, Hamilton KL, Paz L. Soft-tissue surgery for camptodactyly corrects skeletal changes.
Plast Reconstr Surg. 2015;136(5):1028–1035.
The authors assessed 18 consecutively operated fingers in nine skeletally immature patients in whom
advanced radiographic articular changes had occurred. Mean preoperative flexion contracture was
63 degrees (range, 35–105 degrees). The average age of the patients was 11 years (range, 4–15
years) at the time of surgery. Each patient demonstrated the classic preoperative radiographic joint
changes of the PIP or DIP joint. Two digits had extensive radiographic damage, requiring proximal
interphalangeal joint arthrodesis. Fifteen of the remaining 16 digits (94%) had substantial improve-
ment or full restoration of radiographic articular congruency at average follow-up of 9 months
(range, 3–18 months). The authors conclude that even in patients with severe radiographic changes
from camptodactyly, surgery can effectively improve ROM. Surgery before skeletal maturity can
also reverse radiographic changes (Level IV evidence).
Hamilton KL, Netscher DT. Evaluation of a stepwise surgical approach to camptodactyly. Plast Recon-
str Surg. 2015;135(3):568e–576e.
In this retrospective study, the authors reviewed surgical outcomes in 12 patients (18 digits) treated
for camptodactyly. All operated digits did not respond to splinting and had greater than a 30-degree
flexion contracture. The patients were treated with a stepwise surgical approach to release tethering
structures about the joint. Fifteen digits achieved full active extension with a range of 0 to 25 degrees.
Mean PIP flexion was 88 degrees with a range of 50 to 100. The authors believe surgery is indicated
to prevent a long-term, irreversible articular deformity. The authors also recommend that the patient’s
caregivers postoperatively must be motivated to regularly stretch the operated digit after surgery or
risk a recurrence of the flexion contracture secondary to scar tissue formation (Level V evidence).
CHAPTER 111
Macrodactyly Correction
INDICATIONS
• Macrodactyly, or enlargement of one or more digits, is an extremely rare, nonhe-
reditary condition constituting less than 1% of all congenital hand anomalies.
• Improved function is the primary reason for reconstruction. Managing parental ex-
pectations is essential for this difficult problem.
• The surgeon should determine whether the patient has static (i.e., growth propor-
tional to unaffected fingers) or progressive (i.e., increase in size at a rate faster
than unaffected fingers) macrodactyly, because progressive macrodactyly may
require earlier surgery, more frequent surgery, and lead to the development of joint
arthrosis.
• Digital size compared with the same-sex parent is a major determinant of the type
and timing of surgery. If the digit is smaller than that of the same-sex parent, no
surgery is indicated. If the digit is the same size or larger than that of the same-sex
parent, size-limiting or reducing procedures (e.g., soft tissue debulking, bone reduc-
tion, osteotomy, physeal arrest procedures) or amputation may be indicated.
• Amputation is the procedure of choice for immobile, nonthumb digits. This should
not be considered a failure of management.
Contraindications
• Digital enlargement alone is not an indication for surgery, although the appearance
TABLE Flatt Classification may lead to considerable stress for the family and patient.
111.1 of Macrodactyly • Gross overgrowth and limited function of the digit or digits should be managed with
Type I Lipofibromatosis amputation rather than reconstruction.
Type II Neurofibromatosis • Another contraindication is parental reluctance to proceed with surgery.
Type III Polyostotic CLINICAL EXAMINATION

Type IV Hemihypertrophy • The Flatt classification of macrodactyly is based on etiology and the structures in-
volved (Table 111.1).
• The index finger is most commonly affected (Fig. 111.1), followed by the middle
finger or thumb. Macrodactyly tends to affect multiple adjacent digits (Fig. 111.2)
rather than a single digit.
FIGURE 111.1 Isolated index finger macrodactyly.
842
FIGURE 111.2 Combined index and middle finger macrodactyly.
• Digital enlargement may occur secondary to lipofibromatous peripheral nerves, neurofi-

bromatosis, arteriovenous fistula, vascular malformation, Klippel-Trenaunay syndrome,
lymphatic malformation, hemihypertrophy, proteus syndrome, and CLOVES (congenital
lipomatous overgrowth, vascular malformation, epidermal nevi, and skeletal anomalies)
syndrome. The term macrodactyly, however, is more accurately reserved for isolated,
nonsyndromic congenital enlargement of a digit.
• Serial examinations with digital length and diameter measurements should be
recorded annually.
• Electrodiagnostic studies may be indicated if there is concern for peripheral nerve
compression, which is a common complication of macrodactyly. Children with car-
pal tunnel syndrome are too young to describe their symptoms. Instead, the parents
may report that the child frequently scratches and shakes the hand or bites fingers
on the affected hand.
• Children with macrodactyly and the phosphatidylinositol-4,5-bisphosphate 3-kinase
catalytic subunit alpha (PIK3CA) mutation may be a candidate for immunosuppres-
sive (e.g., rapamycin) treatment directed at the involved cellular pathways leading to
macrodactyly.
IMAGING
• Preoperative radiographs are useful to identify the bone length and deformity.
• Magnetic resonance imaging (MRI) and computed tomography (CT) scans provide
additional information regarding fatty infiltration of peripheral nerves, vascular mal-
formations, or anomalous muscles.
SURGICAL ANATOMY
• Asymmetric growth of the affected digit is very common; hyperextension and radial
deviation are typical. This may lead to digital overlap with attempted flexion (Fig. 111.3).
• Enlargement of the median nerve is predictable in patients with Type I macrodactyly.
The enlargement begins in the forearm and extends through the carpal tunnel
into the digital nerve branches.
• The involved nerves are fibrotic with fatty infiltration.
• There may be substantial overgrowth of the palmar soft tissues, muscles, and
nerves. Resection of all involved structures may lead to significant morbidity.
POSITIONING
• The operation is performed under general anesthesia, with the patient placed supine
on the operating table. A tourniquet is placed on the upper arm and the entire ex-
tremity is prepared and draped.
• If osteotomies are planned, intraoperative fluoroscopy is mandatory. In these cases,
the operative table should be positioned to provide easy access to the C-arm.
EXPOSURES PEARLS
EXPOSURES Incisions on the glabrous skin should be designed
In cases of marked digital overgrowth and limited function, amputation is performed via in such a way (e.g., zigzag or Z-plasty) to prevent
future motion-restricting scar contractures.
a combined dorsal and volar approach.
844 CHAPTER 111 Macrodactyly Correction
FIGURE 111.3 Rotational malalignment of a macrodactylous index finger.
STEP 1 PEARLS
PROCEDURE
• The proper digital nerves to the digit planned
for amputation are carefully separated from Step 1
the digital nerves to the adjacent unaffected
digits. This may require releasing the epineu- • The grossly enlarged, nonfunctional digit is marked for amputation, with incisions
rium to ensure preservation of the adjacent in the webspace extending onto the dorsal hand and distal palm (Fig. 111.4).
digital nerves. • The skin flaps are elevated and the radial and ulnar digital neurovascular bundles are
• Venous drainage to the adjacent digits should isolated.
be preserved during dorsal skin flap elevation.
• The digital nerves are dissected into the distal palm (Fig. 111.5).
Step 2
• The A1 pulley is divided.
• The flexor tendons are placed on traction and divided with scissors or a knife.
STEP 3 PEARLS
The digital nerves may be buried within adjacent Step 3
intrinsic musculature to provide padding over a The extrinsic extensor tendon is isolated and the juncturae tendinae are divided. The
future digital end neuroma.
tendon is then divided at the level of the mid- or distal metacarpal shaft (Fig. 111.6).
FIGURE 111.4 Dorsal and palmar skin markings before ray amputation.
FIGURE 111.5 Isolation of the radial digital nerve to the index finger. FIGURE 111.6 Division of the extensor mechanism before disarticula-
tion at the MCP joint. MCP, Metacarpophalangeal.
Step 4
• The digital nerves to the affected digit are placed on traction and divided with cau-
tery or are suture ligated.
• The digital arteries are ligated distal to the common digital bifurcation.
Step 5
The intermetacarpal ligament is divided with scissors, with care taken to protect the
intrinsic muscles and tendons to adjacent digits.
Step 6
The digit may be disarticulated at the metacarpophalangeal (MCP; Fig. 111.7) or car-
pometacarpal (CMC) joint. Alternatively, an osteotomy can performed at the midshaft STEP 7 PITFALLS
metacarpal level with a bone cutter. Poorly placed intermetacarpal sutures can impart
a rotational or angular deformity to the preserved
Step 7 digits. Rotation should be checked via tenodesis
For central digital amputation, the gap between the adjacent digits is closed by reap- of the wrist and MCP joints after provisional
placement of these sutures.
proximating the intermetacarpal ligament and metacarpal periosteum.
Step 8
Redundant skin and subcutaneous tissue are excised, taking care to preserve a well-
vascularized skin flap to resurface the webspace (Fig. 111.8).
Step 9
• The tourniquet is released and hemostasis is ensured. Tension-free skin closure is
performed using absorbable suture (Fig. 111.9).
FIGURE 111.7 Disarticulation of the index finger through the MCP joint. MCP, Metacarpophalangeal.
FIGURE 111.8 Skin flap contouring before definitive closure.
FIGURE 111.9 Definitive closure after skin recontouring.
flexion to prevent premature removal (see Fig. 106.19 in “Release of Finger Syndac-
tyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to prevent skin
breakdown, but limited padding is placed over the antecubital fossa to allow for
adequate molding of the splint.

• The cast is removed 4 weeks postoperatively and range-of-motion exercises are initiated.
• With a ray resection, normal range of motion, strength, and alignment of the unaf-
fected digits are typical. This typically results in a very positive aesthetic and func-
tional outcome.
• Conversely, soft tissue debulking, bone reduction, osteotomies, and physeal arrest
procedures have variable outcomes.
• Although amputation is a definitive solution for an overgrown, nonfunctional digit, mac-
rodactyly may occur in adjacent areas of the hand and continue proximally into the arm.
• Figs. 111.10 and 111.11 show 3-month postoperative photos of a right index finger
ray amputation for macrodactyly.
See Video 111.1
FIGURE 111.10 The 3-month follow-up, dorsal view of bilateral hands.
FIGURE 111.11 The 3-month follow up, palmar view of bilateral hands.
EVIDENCE
Cerrato F, Eberlin KR, Waters P, Upton J, Taghinia A, Labow BI. Presentation and treatment of macro-
dactyly in children. J Hand Surg Am. 2013;38(11):2112–2123.
The authors performed a review of treatment and outcomes of all isolated hand macrodactyly cases over
a 15-year period. There were 21 patients: 8 boys and 13 girls. A mean of 1.8 digits per child were
affected. The middle finger was most commonly affected (67%). Most patients had progressive over-
growth (n = 13; 67%). Twelve patients (57%) had nerve territory–oriented macrodactyly, whereas
9 (43%) presented with lipomatous type. There were no differences between the types of macrodac-
tyly in sex, affected side, rate of growth, digits affected, or number of procedures. Patients underwent
a mean of 3.2 staged corrective operations. No major complications were reported (Level IV
evidence).
Hardwicke J, Khan MA, Richards H, Warner RM, Lester R. Macrodactyly - options and outcomes.
In this review, the authors reported the outcomes of 32 patients diagnosed with macrodactyly. The
average age at presentation was 46 months and there was an equal distribution across the sexes,
although there was a male predominance in the upper limb and female predominance in the lower
limb. There were 20 cases of upper limb macrodactyly and 13 cases affecting the lower limb. Multi-
ple digits were more commonly affected than isolated digits, with an average of 2.5 digits affected.
Static disease required significantly fewer operations than progressive disease. The authors noted
that repeated procedures must be highlighted in cases of progressive macrodactyly. They conclude
that the functional and cosmetic outcome is good in the vast majority of cases, with good patient
acceptance (Level IV evidence).
Gluck JS, Ezaki M. Surgical Treatment of Macrodactyly. J Hand Surg Am. 2015;40(7):1461–1488.
The authors provide an exceptional overview of macrodactyly and options for treatment. They note
that, because of the relative scarcity of patients with this complex condition, treatment can be a
formidable task often left exclusively to those trained in congenital hand deformity. They provide
an algorithm and described surgical techniques for dealing with children with macrodactyly
(Level V evidence).
Ezaki M, Beckwith T, Oishi SN. Macrodactyly: Decision-making and surgery timing. J Hand Surg Eur
Vol. 2019;44(1):32–42.
In this review, the authors provide an up-to-date review of decision-making for macrodactyly recon-
struction. They also emphasize the importance of physical examination and the psychological impact
of the condition on patients. They describe common surgical procedures, including epiphysiodeses,
osteotomies, debulking procedures, carpal tunnel releases, toe transfers, and amputations. The
authors state that careful selection and timing of these surgeries is essential because poorly per-
formed and inappropriately timed surgery may lead to delayed healing and excessive scarring
(Level V evidence).
CHAPTER 112
Release of Constriction Ring Syndrome
INDICATIONS
• Constriction rings may be classified as mild, moderate, or severe.
• Mild: Only skin and a portion of subcutaneous fat are involved, without distal
lymphedema.
• Moderate: The lymphatic channels are interrupted, but the vascular system is
intact. Lymphedema of the distal portion is present.
• Severe: The constriction ring is such that the distal blood supply is compromised
and the part distal to the ring is at risk for gangrene. On occasion, a digit or por-
tion of the extremity is completely absent at birth.
• Severe constriction rings will need urgent surgical release soon after birth. Moderate
rings can be corrected at a later age (6–9 months), when anesthesia is safer and the
structures are larger. The correction of mild rings is performed mainly for aesthetic
considerations and should be done before the child goes to school (3–4 years of
age). One should not underestimate the psychological impact of a constriction ring
on the growing child.
Contraindications
Contraindications include superficial, nonconstricting rings and family or parental reluc-
tance to proceed with surgery.
• Constriction rings affect approximately 1 in 10,000 live births and occur sporadically.
• Other associated abnormalities may include clubfoot, leg length discrepancies, cleft
lip/palate, body wall defects, and visceral anomalies.
• Constriction rings most commonly affect the digits, rather than the more proximal
extremity, and more frequently affect the central digits rather than border digits. In
addition to vascular compromise, tight proximal constriction rings may lead to distal
nerve dysfunction (motor and sensory deficits), which is difficult to assess in the
newborn.
• Partial or complete circumferential constriction may be noted with acrosyndactyly
(distal fusion), absence of distal parts, or soft tissue protuberances (Fig. 112.1).
Acrosyndactyly is commonly associated with a sinus tract at the level of the web-
space (Fig. 112.2). On occasion, the fusion of adjacent digits is complicated
enough to make it difficult to discern which digit is associated with each digital tip
(Fig. 112.3).
• The presence of distal lymphedema indicates insufficient subcutaneous tissues to
facilitate adequate lymphatic fluid return. Most lymphedema will subside after cor-
rection of the constriction ring.
• In children with bilateral constriction ring syndrome, the severity of the deformity of
one limb is independent of the other.
• Constriction rings may be confused with symbrachydactyly (a group of deformities
ranging from digital hypoplasia to aplasia or deficiency of the hand or forearm).
Symbrachydactyly is frequently unilateral and is characterized by the presence of
nubbins with fingernails even in a foreshortened digit, whereas constriction rings
more commonly manifest as a congenital amputation.
• Although classification systems exist, they do not guide treatment, and most sur-
geons opt to describe the lesions by their clinical appearance.
849
850 CHAPTER 112 Release of Constriction Ring Syndrome
Overriding
small and
ring fingers
Soft tissue
prominence
FIGURE 112.2 Acrosyndactyly with a sinus tract (indicated by

FIGURE 112.1 Acrosyndactyly of a hand with constriction band. the black star) at the level of the webspace.
FIGURE 112.3 Complicated fusion in a patient FIGURE 112.4 AP x-ray in a patient with constriction band syndrome. AP, Anteroposterior.
with acrosyndactyly.
IMAGING
• Plain radiographs of the affected extremity are useful to identify any associated bony
anomalies, particularly when the constriction ring is associated with acrosyndactyly
(Fig. 112.4).
SURGICAL ANATOMY
• A constriction ring may extend from skin down to bone. As such, affected structures
may involve lymphatics, nerves, and arteries/veins. Furthermore, the constriction ring
can result in lymphedema, neurologic symptoms (palsies), and amputation. Fig. 112.5
shows a photograph of a patient with a proximal constriction band and a wrist drop
from associated radial nerve palsy.
• The soft tissue and skeletal structures that are proximal to the constriction ring are
usually normal, but the soft tissue distal to the ring can present with a variable
amount of edema (Fig. 112.6A). The physis distal and just proximal to the constric-
tion may be injured, and this can result in growth impairment of the affected part.
• The arterial inflow to the part distal to the ring arises from perforators that originate from
the main axial artery located in the deeper layers. This blood supply can be maintained
because of the intact proper digital artery and its venae comitantes (see Fig. 112.6B).
FIGURE 112.5 Proximal extremity constriction band with wrist drop secondary to associated radial
nerve palsy.
Perforator
Digital artery
Hourglass
constriction Constriction ring
A B
FIGURE 112.6 (A) Hourglass configuration of a digit with constriction band. (B) Digital perfusion through digital artery.
EXPOSURE PEARLS
POSITIONING • Staged correction of constriction rings of the
The procedure is performed under general anesthesia with a well-padded tourniquet digits is generally safer than a one-stage ap-
placed on the upper arm. In proximal rings, one may not be able to apply a tourniquet proach. One-stage correction of digital rings has
because the surgical site will be obstructed. The patient is positioned supine with the a greater chance of injuring the digital vessels
and compromising the distal circulation. In con-
affected upper extremity on a hand table.
trast, one-stage correction with circumferential
excision of a constriction ring can be performed
EXPOSURES in the proximal limbs because deeper arteries
The principles of surgical correction include constriction ring excision, excision and/or and veins are much less likely to be injured.
transposition of excessive fat proximal and distal to the ring, and single or multiple Z- • We prefer 60-degree Z-plasty flaps because of
the broader base for flap vascular inflow com-
plasty rearrangement of the skin adjacent to the ring. The tissue rearrangement pre-
pared with flaps designed with more acute angles.
vents a circular scar contracture.
STEP 1 PEARLS Correction of Finger Constriction Rings

For circumferential digital rings, it is better to treat
the dorsal portion first because this substantially PROCEDURE
improves the appearance of the finger. This may
prevent the need for a second-stage procedure Step 1: Design of Skin Flaps
directed at any remaining volar constriction. A single Z-plasty is typically sufficient for correction of a digital constriction ring, par-
ticularly when a second-stage procedure for the volar aspect of the digit is not necessary
STEP 2 PITFALLS or desired. This may be designed on the dorsum (Fig. 112.7A), or, alternatively, two
• It is unnecessary to excise all skin involved in the single Z-plasties can be designed on both midlateral lines of the finger (see Fig. 112.7B).
constriction ring; instead, incorporate the skin
into the dorsal closure to avoid a skin deficiency. Step 2: Excision of Constriction Ring and Elevation of Skin Flaps
In many cases, no skin is excised. The deepest aspect of the constriction ring is incised, and skin flaps are raised along
• The neurovascular structures will be immediately with a thin layer of fat. Preservation of a small amount of fat ensures inclusion of the
deep to the skin on the palmar aspect of the
digit. As such, dissection must be meticulous to subdermal plexus and maintains viability of the skin flaps (Fig. 112.8).
avoid injuring these structures.
Step 3: Excision of Excess Subcutaneous Fat
• The subcutaneous fat is elevated proximally and distally as a distinct layer, separate
from the skin. This adipofascial flap should be raised superficial to the extensor
paratenon or the flexor tendon sheath (Fig. 112.9A–B).
A B
FIGURE 112.7 (A) Z-plasty release of a digit with constriction band syndrome. (B) Illustration of Z-plasty release
of a digit with constriction band syndrome.
Adipofascial
layer
Skin flap
FIGURE 112.8 Z-plasty flaps elevated with a thin layer of fat.

Excision of Excision of excessive

constriction ring subcutaneous fat
Adipofascial
flaps Extensor tendon
A B
FIGURE 112.9 (A) Adipofascial flaps elevated as a separate layer from the skin. (B) Illustration of excised structures for a
digit with constriction band syndrome.
Adipofascial flap
Skin flap
Adipofascial flap closure
A B
FIGURE 112.10 (A) Adipofascial flaps transposed and reapproximated across the area of original banding. (B) Illustration of
adipofascial flap closure.
• The adipofascial flaps are approximated using absorbable suture to correct the con-
tour deformity (Fig. 112.10A–B). When necessary, dermofat flaps may be created by
de-epithelialization of the ring margins and approximated below the overlying skin
closure to prevent an hourglass deformity.
• Excessive dorsal fat, usually on the distal side, should be removed to adequately
treat any existing contour deformity.
Step 4: Transposition and Suture of Z-Plasty Skin Flaps

The Z-plasty flaps are transposed and inset using 4-0/5-0 chromic suture (Fig. 112.11A–B).
Correction of Proximal Limb Constriction Rings

PROCEDURE
Step 1: Design of Skin Flaps STEP 1 PEARLS
A multiple Z-plasty design is used for correction of proximal limb constriction rings be- Proximal limb vascularity is subfascial and not at
risk with circumferential flap elevation above the
cause they can be safely corrected in a single stage without jeopardizing distal circulation
fascia.
(Fig. 112.12).
Adipofascial
flap closure Skin closure
FIGURE 112.11 (A–B) Skin closure over the transposed adipofascial flap.
FIGURE 112.12 Proximal extremity band and markings for release.
Step 2: Excision of Constriction Ring and Elevation of Skin Flaps

• The constriction ring is incised and thick skin flaps are elevated.
• Unlike correction of finger constriction rings, the skin flaps are elevated just super-
ficial to the deep fascia, with the goal of including all subcutaneous fat in the flap
(Fig. 112.13).
Step 3: Transposition and Suture of Z-Plasty Skin Flaps

Z-plasty flaps are transposed and inset using 4-0/5-0 chromic suture (Fig. 112.14).

• The arm is dressed with a soft, bulky dressing. In young children, short-term immo-
bilization in a cast may be required for protection of the incision.
• Lymphedema of the distal part of the affected extremity or finger will improve sig-
nificantly after a few weeks. Any standing cutaneous deformities resulting from Z-
plasty inset will improve over time.
• Fig. 112.15 shows the long-term result of a constriction ring of the left thumb.
See Video 112.1
Deep fascia
FIGURE 112.13 Full-thickness skin flaps elevated just above the deep fascia.
FIGURE 112.14 Z-plasty flaps transposed and inset.
FIGURE 112.15 Long-term outcome after digital Z-plasty release of constriction band.
EVIDENCE
Drury BT, Rayan GM. Amniotic constriction bands: secondary deformities and their treatments. Hand
(N Y). 2019;14(3):346–351.
In this study, the authors report surgical treatment experience with amniotic constriction bands (ACB)
over a 35-year period. They included all notable limb deformities and the type of reconstruction.
Fifty-one patients were identified; 26 were males and 25 females. The total number of operations
was 117, and total number of procedures was 341. More procedures were performed on the upper
extremity (85%) than the lower extremity (15%). Including ACB, 16 different hand deformities were
encountered. Sixteen different surgical methods for the upper extremity were used, including a pri-
mary procedure for ACB and secondary reconstructions for all secondary deformities. Average age
at the time of the first procedure was 9.3 months. The most common procedures performed, in order
of frequency, were excision of ACB plus Z-plasty, release of partial syndactyly, release of fenestrated
syndactyly, full-thickness skin grafts, resection of digital bony overgrowth from amputation stumps,
and deepening of first and other digital webspaces. The authors conclude that many hand and upper
extremity deformities secondary to ACB are encountered and children with ACB may require more
than one operation (Level IV evidence).
Greene WB. One-stage release of congenital circumferential constriction bands. J Bone Joint Surg Am.
1993;75:650–655.
In this study, three patients underwent single-stage release of a circumferential constriction ring. No
wound problems occurred, even when there had been marked swelling of the extremity distal to the
band. The single-stage release facilitated postoperative care, and there was no need for additional
periods of anesthesia or for additional operations (Level V evidence).
Upton J, Tan C. Correction of constriction rings. J Hand Surg Am. 1991;16:947–953.
The authors present a retrospective study of 116 constriction rings in 58 patients who underwent
correction of both deep and shallow constriction rings. All excellent results occurred in patients
with shallow deformities. Improvement of contour was seen; 64% were graded as excellent, 31%
as good, and 5% as poor (Level IV evidence).
Visuthikosol V, Hompuem T. Constriction band syndrome. Ann Plast Surg. 1988;21:489–495.
A retrospective chart review of 30 cases of constriction band syndrome diagnosed and treated during
1973 to 1986 was conducted. All 30 cases were treated with single-stage Z-plasty surgery. Good
results were achieved in 16 of 20 patients with constriction alone. No compromised circulation of
the distal limb or total flap loss was encountered in this study (Level IV evidence).
CHAPTER 113
Centralization for Radial Longitudinal Deficiency
INDICATIONS
• Radial longitudinal deficiency (RLD) occurs in 1 out of 30,000 live births and is a
spectrum of deformity affecting the forearm, wrist, and hand (Fig. 113.1). Between
50% and 60% of patients have bilateral involvement.
• RLD is classified into four grades, depending on the degree of hypoplasia of the
radius (Table 113.1).
• Centralization of the wrist is recommended between 9 and 12 months of age be-
cause anesthesia is safer, preliminary soft tissue distraction can be carried out, and
subsequent thumb reconstruction can be done before the child develops a mal-
adaptive pattern of pinch (approximately 6 months after wrist realignment).
FIGURE 113.1 Right wrist radial longitudinal deficiency.
TABLE
113.1 Classification of Radial Longitudinal Deficiency
Type Distal Radius Proximal Radius
N Normal Normal
0 Normal Normal, radioulnar synostosis, congenital radial head
dislocation
1 .2 mm shorter Normal, radioulnar synostosis, congenital radial head
than ulna dislocation
2 Hypoplasia Hypoplasia
3 Physis absent Variable hypoplasia
4 Absent Absent
857
858 CHAPTER 113 Centralization for Radial Longitudinal Deficiency
• Most children will benefit from stretching and static progressive splints or serial cast-
ing beginning shortly after birth. Although centralization alone may be performed, if
needed, for children with type 0 or 1 deficiencies, children with type 2 or greater
deficiencies may need preliminary serial casting or soft tissue distraction using an
external fixator.
Contraindications
• Mild cases of RLD responsive to stretching and splinting alone.
• Centralization should be avoided in children with a stiff elbow (,90 degrees of flex-
ion), because this will limit hand-to-mouth and hand-to-head activities.
• Another contraindication may be family or parental reluctance to proceed with surgery.
• Many children with RLD have associated cardiac, hematologic, musculoskeletal, renal,
gastrointestinal, and craniofacial abnormalities. Therefore all children with RLD should
undergo a thorough preoperative musculoskeletal and systemic examination, including
spine radiographs, an echocardiogram, a renal ultrasound, and a complete blood count
(to evaluate for thrombocytopenia or anemia that may be associated with RLD).
• Evaluation of elbow range of motion (ROM) is essential. For children who are unable to
flex the elbow, the radial deviation deformity enables them to get the hand to the mouth.
IMAGING
Plain radiographs of both hands, wrist, and forearms (Fig. 113.2) should be obtained.
SURGICAL ANATOMY
Skeletal Anomalies
The radius is hypoplastic, partially absent, or totally absent. The ulna is bowed poste-
riorly and may be shortened to 60% to 75% of normal length. The articulation between
the carpus and ulna does not form a normal joint. It is usually fibrous but can be lined
by hyaline cartilage. Digital involvement (i.e., hypoplasia and/or stiffness) decreases in
severity from the radial aspect of the hand to the ulnar aspect.
Muscle Anomalies
The extensor carpi radialis longus (ECRL) and brevis (ECRB) muscles may be absent or
fused to the extensor digitorum communis (EDC). The presence of the extensor pollicis
FIGURE 113.2 X-ray of right wrist radial longitudinal deficiency.

CHAPTER 113 Centralization for Radial Longitudinal Deficiency 859
longus (EPL), extensor pollicis brevis (EPB), and abductor pollicis longus (APL) can be
predicted by the presence of a thumb metacarpal. The supinator, pronator quadratus,
and palmaris longus (PL) are usually absent. The pronator teres (PT) is absent if the radius
is absent. The flexor carpi radialis (FCR) is frequently absent. The extensor carpi ulnaris
(ECU), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) are usually pres-
ent and normal. The flexor pollicis longus (FPL) is present only if the thumb metacarpal is
present. If the thumb is present, the thenar muscles are usually present. The hypothenar,
interosseous, and lumbrical muscles are usually normal.
Vascular Anomalies
Although the brachial and ulnar arteries are usually present and normal, the radial artery
and palmar arch are either absent or attenuated. The interosseous arteries are usually
well developed.
Nerve Anomalies
The median and ulnar nerves are always present. The median nerve is the most prom-
inent structure on the radial aspect of the wrist and can be mistaken for a tendon dur-
ing reconstruction. The median nerve supplies sensation to the radial side of the arm
because the radial nerve typically ends at the elbow.
POSITIONING
The procedure is performed under general anesthesia. The affected arm is placed on a
hand table, with a tourniquet placed high on the arm.

• The four key steps of centralization are: • Alternative approaches to the wrist include
• Conducting preliminary soft tissue distraction using an external fixator device. radial Z-plasty combined with an ulnar trans-
• Designing a bilobed skin flap to transfer the redundant skin on the ulnar side to verse ellipse and a dorsal wrist and forearm
make up for the skin deficiency on the radial side. S-type incisions.
• Centralizing the carpus over the ulna. • When designing the bilobed flap, ensure that it
permits adequate exposure of the distal ulna.
• Balancing the tendons to counteract recurrent radial deviation.
PROCEDURE
Step 1: Preliminary Soft Tissue Distraction
• A uniplanar external fixator device is applied on the ulnar side of the affected limb
(pins traverse the small finger metacarpal and the ulna; Fig. 113.3A–B). It is best to STEP 1 PEARLS
perform this between 6 and 9 months of age. Ensure that the pin size is appropriate Preliminary distraction can lengthen taut radial
for the size of the metacarpal to prevent iatrogenic fracture. structures and prevent the need for ulna resection
• The parents begin distraction at a rate of 1 mm/day a week after device placement. during centralization. This may decrease the risk
for ulnar growth arrest.
The patient is observed with a weekly clinic visit and radiographs.
A B
FIGURE 113.3 (A–B) Intraoperative images of distractor application.

FIGURE 113.4 Image of right wrist after successful distraction.
STEP 2 PITFALLS
• Care should be taken to preserve the superfi- • Distraction is continued until the hand is situated slightly beyond neutral. Normally,
cial cutaneous nerves and longitudinal veins. it takes about 2 months of distraction to achieve this position (Fig. 113.4).
• Flaps should be kept as thick as possible to • The external fixator device can be removed at the same time as centralization.
avoid devascularizing the wound edges.
• Beware of the large dorsal branch of the me-
dian nerve, which replaces the absent superfi-
Step 2: Elevation of Bilobed Flap
cial radial nerve that supplies sensation to the The skin incision should start at the point of greatest tension on the radial side of the
radial aspect of the hand. This branch is posi- wrist. The first flap can be marked on the dorsum of the wrist, based proximally (A), with
tioned in the subcutaneous fold between the another corresponding flap at 90 degrees that lies on the area of greatest skin redun-
wrist and forearm.
dancy on the ulnar side (B). The flaps are raised in a plane superficial to the extensor
retinaculum (Fig. 113.5A–B).
STEP 3 PEARLS
Step 3: Dissection of Nerve and Tendons
Centralization indicates aligning the third metacarpal
over the distal ulna, whereas radialization means • The median nerve is identified first during the exposure. It is the most superficial
aligning the second metacarpal with the distal structure on the radial aspect of the distal forearm and can easily be confused with
ulna. The concept behind radialization compared a tendon (Fig. 113.6).
with centralization is that translating the wrist more • The ECU is identified distal to the retinaculum. The ECR is divided at its insertion to
ulnarly may lead to a decreased risk of recurrence facilitate later transfer to the distal stump of ECU tendon (Fig. 113.7).
of the deformity.
• The dorsal ulnar sensory nerve is identified and retracted to prevent inadvertent injury.
B B
A
A B
FIGURE 113.5 (A–B) Bilobed flap design and transposition (flaps labeled A and B for reference).
Median nerve
Hypoplastic
extensor
tendons
FIGURE 113.6 Median nerve and hypoplastic extensor tendons after flap elevation.
ECU stump EDC tendons
ECR tendon
STEP 4 PEARLS
• If there is difficulty with reduction of the carpus
onto the ulna, the radial side of the wrist
FIGURE 113.7 Transection of ECU distal stump before tendon transfer. ECU, Extensor carpi ulnaris.
should be reevaluated. Any remaining fibrous
bands should be divided to facilitate centraliza-
tion. The volar radial wrist capsule may require
Step 4: Ulnocarpal Joint Reduction and Centralization additional release.
• Occasionally, centralization is only possible af-
• The wrist capsulotomy is created distal to the ulnar physis.
ter partial carpectomy or limited shaving of the
• A progressive soft tissue release is carried out until the carpus can be aligned over the distal ulna. One should remember that the dis-
distal ulna. This requires the carpus to be carefully mobilized off of the palmar capsule. tal ulna epiphysis is only resected if reduction
is impossible because excessive removal will
Step 5: Fixation cause growth arrest.
The ulnocarpal reduction is maintained by 0.062-inch Kirschner wire (K-wire) placed
antegrade through the carpus and then retrograde into the ulnar shaft under fluoro- STEP 5 PEARLS
scopic guidance (Fig. 113.8A–B).
If the ulna has an angular deformity greater than
30 degrees, a diaphyseal closing wedge osteotomy
Step 6: Wrist Stabilization is performed at the apex of the deformity and
• The ECR tendon is transferred to the distal stump of the ECU, passing below the the same K-wire from centralization is driven
EDC (Fig. 113.10). The proximal end of the previously divided ECU is advanced and retrograde across the osteotomy site (Fig. 113.9).
sutured to the dorsal wrist capsule using nonabsorbable suture. We prefer to delay ulnar osteotomy until a later
stage, when necessary.
• The ulnocarpal capsule is reefed to impart additional static stability.
Ulnar
30°
Radial
A B
FIGURE 113.8 (A–B) X-rays of right wrist after centralization and pin placement.
FIGURE 113.9 Osteotomy of ulna for defor-

mity greater than 30 degrees.
ECR to ECU
tendon transfer
FIGURE 113.10 ECR to ECU tendon transfer routed deep to the digital extensors. ECR, extensor
carpi radialis; ECU, extensor carpi ulnaris.
Step 7: Closure
• The extensor retinaculum is repaired using 4-0 Vicryl, and the skin is closed with 5-0
Chromic sutures (Fig. 113.11A–B).

• The patient is placed in a well-padded long-arm cast with the elbow in at least 90
degrees of flexion. The extremity is immobilized for at least 8 weeks, and the K-wire
is maintained as long as possible. A long-arm orthosis to maintain the centralized
wrist position is worn continuously for 3 to 6 months and then at night until skeletal
maturity. Prolonged pin fixation followed by long-term splinting is necessary to
minimize recurrence. Ten-year follow-up shown in Fig. 113.12.
• Recurrence or persistence of deformity is common and is multifactorial. Intraoperative
etiologies include lack of complete correction during surgery, inadequate radial soft
tissue release, and failure to adequately balance forces acting across the wrist. Post-
operative etiologies include early pin removal, poor compliance with the postoperative
orthosis, and soft tissue memory. Although distraction facilitates centralization, it does
not decrease the risk of recurrence of the deformity.
A B
FIGURE 113.11 (A–B) Immediate postoperative view of the wrist after centralization.
FIGURE 113.12 Ten-year postoperative images.
• Foreshortening of the ulna (60% of normal) is common, even after a successful

centralization. The short forearm is both a cosmetic and functional problem for the
adolescent with RLD. Although the arm may be lengthened by uniplanar or multipla-
nar shaft-distraction devices in adolescence, it is imperative that the patient has
realistic expectations and the ability to tolerate the potentially protracted duration of
distraction required for satisfactory lengthening. Importantly, the functional outcome
of surgery will be mostly determined by the status of the thumb and fingers. Digital
function may worsen with distraction and centralization.
EVIDENCE
Mittal S, Garg B, Mehta N, Kumar V, Kotwal P. Randomized trial comparing preliminary results of radial-
ization and centralization procedures in Bayne types 3 and 4 radial longitudinal deficiency. J Pediatr
Orthop. 2020;40(9):509–514.
In this study, the authors randomized 14 patients with types 3 and 4 radial longitudinal deficiency (RLD),
a total of 17 limbs, to either radialization or centralization. Centralization was performed in nine limbs
and radialization was performed in eight. Nine affected limbs had type 4 RLD, and eight affected
limbs had type 3 RLD. There was no significant difference in the hand-forearm angle in the immedi-
ate postoperative period. At 3 months, the radiologic hand-forearm angle increased to 19 degrees in
the centralization group, whereas the radialization group showed an average increase to 4 degrees.
This increase in the hand-forearm angle continued at 6-, 12-, and 24-month follow-up assessments.
Worsening of the deformity was greater in the centralization group, compared with the radialization
group. The forearm length also significantly differed in the two groups at 6-, 12-, and 24-month fol-
low-up; however, when adjusted for preoperative lengths, the difference was significant only at 12-
and 24-month follow-up. At a short-to-intermediate term follow-up, radialization fares better than
centralization in terms of recurrence of deformity and in terms of affecting the forearm length
(Level I evidence).
Bhat AK, Narayanakurup JK, Acharya AM, Kumar B. Outcomes of radialization for radial longitudinal
deficiency: 20 limbs with minimum 5-year follow-up. J Hand Surg Eur. 2019;44(3):304–309.
The authors reported functional and cosmetic outcomes in 14 patients (6 bilateral and 8 unilateral) with
type 4 radial longitudinal deficiency who underwent radialization. Follow-up ranged from 5 to 19
years. At final follow-up, the length of the affected ulna was 56% of the length of the normal ulna.
The distal ulna hypertrophied to 97% of the opposite distal radius and a median loss of correction of
hand-forearm angle was 9 degrees. All hands improved on Vilkki severity grade and on the Cattaneo
functional and aesthetic grading. We conclude that radialization is an effective procedure, but
secondary procedures may be required for the long-term maintenance of wrist alignment and hand
function (Level IV evidence).
Manske MC, Wall LB, Steffen JA, Goldfarb CA. The effect of soft tissue distraction on deformity
recurrence after centralization for radial longitudinal deficiency. J Hand Surg Am. 2014;39:895–901.
Thirteen upper extremities treated with centralization alone were compared with 13 treated with ring
fixator distraction followed by centralization. The clinical resting wrist position was improved signifi-
cantly after surgery and at final follow-up in both groups, but recurrence was worse at final follow-up
in the distraction group patients. Radiographically, in the centralization alone group, the hand-
forearm angle improved from 53 degrees before surgery to 13 degrees at midterm but worsened to
27 degrees at final follow-up. In the distraction group, the hand-forearm angle improved from
53 degrees before surgery to 21 degrees at midterm but worsened to 36 degrees at final follow-up.
The hand-forearm position improved between preoperative and final assessment in both groups, but
at final follow-up, the centralization-alone group had a significantly better position. Volar subluxation
was 4 mm improved in the centralization alone group and 2 mm worse in the distraction group at
final follow-up. The authors conclude that centralization, with or without distraction with an external
fixator, resulted in improved alignment of the wrist. Distraction facilitated centralization, but it did
not prevent deformity recurrence and was associated with a worse final radial deviation and volar
subluxation position compared with wrists treated with centralization alone (Level III evidence).
Vuillermin C, Wall L, Mills J, et al. Soft tissue release and bilobed flap for severe radial longitudinal
deficiency. J Hand Surg Am. 2015;40:894–899.
The authors reviewed their experience with soft tissue release and bilobed flap reconstruction in 18
wrists with at least 3-year follow up. At a mean of 9.2 years follow-up, the average final resting wrist
radial deviation angle was 64 degrees compared with 88 degrees preoperatively. The average active
wrist flexion-extension arc was 73 degrees. Average Disabilities of the Arm, Shoulder, and Hand
(DASH) score was 27 (range, 5–54). Pediatrics Outcome Data Collection Instrument (PODCI) global
was 88 (range, 75–97), PODCI happiness was 86 (range, 70–100), and Visual Analog scale (VAS)
overall satisfaction (range, 0–10) was 1.2 (range, 0–8). At final follow-up, no physeal growth arrests
were noted on radiographs, and no patients to date required ulnocarpal arthrodesis. They conclude
that soft tissue release and coverage with a bilobed flap should be considered in the treatment algo-
rithm for patients with radial longitudinal deficiency, although some recurrence of radial deviation was
noted (Level IV evidence).
CHAPTER 114
Cleft Hand Reconstruction
INDICATIONS
Indications for this procedure include the presence of a transverse bone in which
growth leads to a progressive deformity (widening of the cleft), syndactyly affecting
border rays with progressive deviation of the longer ray, a constricted first webspace,
and closure of the cleft for aesthetic improvement.
Contraindications
Contraindications include simple, minor clefts, where surgery might impact function,
and family or parental reluctance to proceed with surgery.
• A cleft hand is considered a longitudinal central deficiency affecting the central digits
and occurs in 1 out of 10,000 to 1 out of 90,000 live births. It is commonly inherited
as an autosomal dominant trait with variable penetrance and is associated with a
number of syndromes. The condition may be bilateral and affect the feet (i.e., split-
hand, split-foot syndrome). The Manske and Halikis system classifies the level of in-
volvement of the first webspace and is useful for planning reconstruction (Table 114.1).
For example, cleft closure must be undertaken with an appreciation for the extent of
first webspace and thumb involvement; first webspace deepening is often combined
with cleft closure.
• The diagnosis of a cleft hand is straightforward; patients with a typical cleft hand
present with a V-shaped cleft in the center of the hand. The cleft severity varies
widely among patients. Additional findings include digit/ray absence, polydactyly,
and/or syndactyly of one or more digits adjacent to the cleft. Because of the
strong genetic component associated with a cleft hand, genetic counseling may
be indicated.
• Figs. 114.1 and 114.2 show a 2-year-old boy with a cleft right hand with syndactyly
between the little finger and ring finger.
IMAGING
• Radiographs of the hand and upper limb are helpful to characterize the underlying
osseous abnormalities.
TABLE
114.1 The Manske and Halikis Classification System for Cleft Hand
Type Description Characteristics
I Normal web Thumb webspace is not narrow
IIA Mildly narrowed web Thumb webspace is mildly narrowed
IIB Severely narrowed web Thumb webspace is severely narrowed
III Syndactylized web Thumb and index rays syndactylized, webspace
obliterated
IV Merged web Index ray suppressed, thumb webspace merged
with the cleft
V Absent web Thumb elements suppressed, ulnar rays remain,
thumb webspace no longer present
865
866 CHAPTER 114 Cleft Hand Reconstruction
FIGURE 114.2 AP x-ray images of cleft hand. AP, Anteroposterior.

FIGURE 114.1 Cleft hand.
• Skeletal anomalies are common. These include absence or hypoplasia of metacar-

pals within the cleft, transverse tubular bones that will widen the cleft with growth,
bifid metacarpals supporting one finger (i.e., superdigit), and duplicated metacar-
pals. Possible phalangeal anomalies include a longitudinally bracketed epiphyses or
double phalanges (Fig. 114.3).
SURGICAL ANATOMY
• Surgical anatomy will vary depending on the degree of involvement of the first web-
space, central hand, and remaining digits.
• Proximal muscle tendon units and nerves may be variably absent. This can affect
function and the technical aspects of thumb reconstruction, if needed.
POSITIONING
The procedure is performed under general anesthesia. The affected arm is placed on a
hand table, with a well-padded tourniquet placed high on the arm.
FIGURE 114.3 Marked skeletal anomalies in a cleft hand.

EXPOSURES
• In children who have a central cleft with narrow thumb and index finger web, the skin
over the dorsum of the cleft is raised as a palmarly based flap (i.e., Snow-Littler flap).
This flap is transposed radially and used to resurface the first webspace after re-
lease. Elevating the flap from the dorsal hand is easier because of a lack of adhering
palmar fascia. Additionally, this permits access to the metacarpal heads that can be
reapproximated during cleft closure.
• A distally based rectangular flap is designed over the midproximal phalanx on one
of the fingers adjoining the cleft. This flap will be used to create the webspace
formed after closure of the central cleft. Care is taken to create a smooth slope in
the reconstructed webspace.
• The fourth webspace may have an incomplete syndactyly that warrants deepening
with flaps with or without full-thickness skin grafts at a separate stage of reconstruc-
tion (Fig. 114.4).
FIGURE 114.4 Fourth webspace incomplete
syndactyly.
PROCEDURE
Step 1: Elevation of Palmarly Based Flap STEP 1 PEARLS
• The flap is designed to extend to the dorsum of the hand by parallel incisions • The flap should be mobilized sufficiently for
(Figs. 114.5A–B and 114.6A–B). easy transposition to the thumb and index
finger webspace.
• The parallel incisions are connected on the dorsum, and the dorsal flap is elevated • The viability of this flap depends on preserva-
superficial to the extensor tendon paratenon. tion of the blood supply, and dissection must
• The neurovascular bundles are identified on the palmar aspect of the hand and pro- maintain the subdermal plexus.
tected, and the flap is mobilized by dividing any tethering fascial bands (Fig. 114.7).
STEP 2 PEARLS
Step 2: Release of Thumb and Index Finger Webspace
• If the first webspace syndactyly is minimal,
A releasing incision is made between the thumb and index finger to treat the webspace local flaps (e.g., Z-plasty) alone may be
contracture (Fig. 114.8). sufficient for deepening.
• If there is substantial thumb and index finger
Step 3: Closure of Cleft webspace narrowing, one may need to divide
• The head and neck of the metacarpals adjoining the cleft are exposed during flap the fascia, the adductor pollicis, and the first
dorsal interosseous muscle. Rarely, an osteot-
elevation (Fig. 114.9). omy of the thumb metacarpal may be required
• Nonabsorbable sutures are placed to approximate the metacarpal heads and close to realign the thumb.
the cleft (Figs. 114.10A–B and 114.11). All sutures are placed before tying, taking
care to ensure adequate purchase of the periosteum, intermetacarpal ligament, and
STEP 3 PEARLS
bone (if the patient is young and the bone is soft).
Alternative options for cleft closure and soft tissue
stabilization include using the adjacent annular flexor
tendon sheath pulleys, periosteal flaps, or free grafts.
A
B
FIGURE 114.5 (A) Dorsal hand markings. (B) Illustration of dorsal hand markings.
A B
FIGURE 114.6 (A) Volar hand markings. (B) Illustration of volar hand markings.
First web space

Palmar-based flap released
FIGURE 114.7 Snow-Littler flap elevated. FIGURE 114.8 First webspace released before flap inset.
Metacarpal
heads of index
and ring
fingers
FIGURE 114.9 Cleft release with exposure of metacarpal heads.

A
B
FIGURE 114.10 (A) Intermetacarpal sutures prior to closure of cleft. (B) Illustration of intermetacarpal sutures
before closure of cleft.
FIGURE 114.11 Provisional cleft closure.

FIGURE 114.12 Flap inset into first webspace.
Step 4: Transfer of Cleft Flap to Resurface Thumb and Index Finger

Web
The previously elevated flap is transposed into the defect created by release of the
thumb and index finger web (Fig. 114.12).
Step 5: Creation of New Webspace in Cleft

• A distally based rectangular flap is designed over the ring finger at the level of the STEP 4 PEARLS
midproximal phalanx. This will be sutured to the index finger after cleft closure to The palmar skin proximal to the index finger
re-create the webspace (Fig. 114.13). (between the flap and the first webspace) must be
• The flap is elevated and sutured to the opposite incision to create the desired gentle incised and elevated to ensure that the cleft flap
can be transposed to the first webspace.
slope of the webspace (Figs. 114.14 and 114.15A–B).
Rectangular flap
Rectangular and
FIGURE 114.13 Distally based rectangular flap along the ring finger. palmar-based flaps
after elevation
FIGURE 114.14 Elevation of rectangular flap used for webspace creation.
A B
Rectangular flap
after inset
FIGURE 114.15 (A–B) Inset of rectangular flap.
STEP 5 PEARLS
Step 6
• Care should be taken to resurface the interdig-
All skin incisions are closed with absorbable sutures (Fig. 114.16A–D).
ital space with a flap, rather than a straight-
line incision.
• We recommend elevating the webspace flap POSTOPERATIVE CARE AND EXPECTED OUTCOMES
only after approximating the metacarpal heads. • A long-arm cast is applied and maintained for 4 weeks to permit healing of the in-
This permits adjustments to the flap design termetacarpal closure and soft tissues. If a metacarpal transposition is performed,
based on final location of the webspace.
Kirschner wires (K-wires) are removed 6 weeks after surgery.
• Orthotic use after 4 to 6 weeks may be used at nighttime to maintain alignment.
Formal occupational therapy may be performed with the goal of maximizing active
and passive range of motion (ROM) and function.
• The child is followed yearly until skeletal maturity to evaluate hand growth and function.
Untreated rotational deformities may worsen with growth and subsequently require
osteotomies, joint stabilization, or muscle rebalancing. Creeping of the webspace is not
A B
C D
FIGURE 114.16 (A–B) Appearance after cleft closure and flap reconstruction of first webspace. (C–D) Appearance
after cleft closure and flap reconstruction of first webspace.
FIGURE 114.17 Long-term results after cleft hand reconstruction.
uncommon with any cleft surgery. Future webspace releases may be needed to enhance
the functional and aesthetic results for the hand. The overall outcome depends on the
degree of preoperative deformity, and good function can be achieved in children with a
preserved thumb (Fig. 114.17).
See Video 114.1
EVIDENCE
Aleem AW, Wall LB, Manske MC, et al. The transverse bone in cleft hand: A case cohort analysis of
outcome after surgical reconstruction. J Hand Surg Am. 2014;39:226–236.
The authors sought to evaluate the implications of the transverse bone in cleft hand by assessing
outcomes after reconstruction in comparison with a control group. They reviewed 23 hands in 18
patients after surgical reconstruction of the cleft hand. Eleven hands had a transverse bone
component, and 12 hands (control group) did not. There was no difference in aesthetic or functional
subjective outcomes or objective outcomes measure between the two groups. The use of the cleft
for pinch was more dependent on the status of the index finger and the preoperative thumb-index
webspace rather than the presence of a transverse bone. Eleven (4 transverse and 7 control) hands
required additional surgery to treat abnormal function or posture of the index and ring fingers. Preop-
erative radiographic divergence angles were larger in the transverse bone group than in the control
group, whereas postoperative divergence angles were nearly equivalent. The authors conclude that
the presence of a transverse bone in cleft hand was not associated with worse outcomes after cleft
reconstruction. Preoperative narrowing of the thumb webspace and postoperative index finger meta-
carpophalangeal joint abnormality are associated with worse functional outcomes (Level III evidence).
Al-Qattan MM. Central and ulnar cleft hands: A review of concurrent deformities in a series of 47 patients
and their pathogenesis. J Hand Surg. 2014;39(5):510–519.
The author reviews the clinical findings of both ulnar cleft hands and central cleft hands. A review of
34 syndromic and 10 nonsyndromic central cleft hand patients was then performed in order to
report concurrent deformities. Nonsyndromic cases involved only one hand, whereas 25 out of
34 syndromic patients had bilateral hand involvement. Syndactyly, hypoplasia, transverse phalanges,
and synostosis of the carpus, metacarpals, and phalanges were common. The author then provides
an excellent review of hand embryology and pathophysiology that leads to clefting (Level IV
evidence).
Upton J, Taghinia AH. Correction of the Typical Cleft Hand. J Hand Surg Am. 2010;35:480–485.
In this review, the authors describe a technique for correction and transposition of the index ray through a
simple incision, which separates the glabrous from the dorsal skin surfaces. They note that the correc-
tion of type II and III typical cleft hands can be complicated because each hand can contain a variation
of congenital problems including syndactyly, camptodactyly, thumb hypoplasia, deficiency of the first
webspace, abnormal phalanges, maligned joints, and abnormal intrinsic muscles and extrinsic tendons.
The importance of skeletal alignment precision and preservation of the adductor pollicis muscle is
emphasized (Level V evidence).
Rider MA, Grinder SI, Tomkin MA, Wood VE. An experience of the Snow-Littler procedure. J Hand Surg
Br. 2000;25:376–381.
The authors reviewed 12 cases using the Snow-Littler procedure to close hand clefts. The procedure
described is similar to the techniques illustrated in this chapter. They concluded that this technique
improved the appearance and function for children with hand clefts (Level IV evidence).
CHAPTER 115
Arthrogryposis Reconstruction
INDICATIONS
• Elbow extension contracture with minimal passive flexion after maximizing therapy
and splinting/casting (Fig. 115.1).
• Wrist flexion contracture with or without fixed bony changes in patients with active
finger extension (Fig. 115.2).
Contraindications
Contraindications for this procedure include the improvement of deformity with splitting
alone and family or parental reluctance to proceed with surgery. The procedure should also
be avoided if the patient has adapted well to deformity and surgery would predictably
decrease function.
• The term arthrogryposis describes a host of conditions that lead to multiple con-
genital joint contractures. The most common is amyoplasia or classic arthrogryposis,
which affects 1 in 3000 live births. A subtype called “distal” arthrogryposis affects the
hands and feet with proximal limb sparing.
• Arthrogryposis is associated with a number of other conditions, including Freeman-
Sheldon syndrome.
• A thorough preoperative examination of the upper extremity should be performed.
• The upper extremity is typically adducted and internally rotated. Passive and active
range of motion (ROM) of the elbow should be well documented.
• The functional status of the triceps should be determined. If the triceps is strong, the
long head can be considered as a transfer for elbow flexion (i.e., triceps-to-biceps
transfer) after achieving acceptable passive ROM.
FIGURE 115.1 Elbow extension contracture in a FIGURE 115.2 Wrist flexion deformity in a patient with arthrogryposis
patient with arthrogryposis multiplex congenita. multiplex congenita.
873
874 CHAPTER 115 Arthrogryposis Reconstruction
A B
FIGURE 115.3 (A–B) Passive finger extension with wrist flexion.
• If the child is unable to actively extend the fingers and relies on wrist flexion for finger
release, surgery to place the wrist in neutral will compromise the ability to passively
extend the fingers through a tenodesis effect (Fig. 115.3A–B).
• Even if passive wrist extension is achieved through splinting and stretching, active wrist
extension is limited or absent. If possible, the extensor carpi ulnaris (ECU) function should
be assessed. A transfer of the ECU to the radial wrist extensors (extensor carpi radialis
longus and brevis) may improve wrist extension and address the ulnar deviation deformity.
• A preoperative occupational therapy evaluation is important to evaluate the func-
tional status of the wrist. Information gleaned from this assessment will help deter-
mine the optimal wrist position in children who need surgery and help avoid surgery
in children who have adapted to the wrist flexion contracture.
IMAGING
Plain radiographs of the wrist may assist in planning for carpal wedge resection.
SURGICAL ANATOMY
• Muscles acting across the elbow may be atrophic, but elbow anatomy in children
affected by arthrogryposis is normal.
• The wrist extensor tendons are small. The radial wrist extensors are usually adherent
to the dorsal capsule and the proximal musculature is attenuated or absent. The
ECU is often the largest extensor tendon.
Posterior Elbow Release and Tricepsplasty

POSITIONING
• The patient is placed in the supine position with the extremity on a hand table.
A well-padded tourniquet is placed high on the affected arm.
EXPOSURES PEARLS • Intraoperative fluoroscopy may be helpful to discern the medial epicondyle from the
If the ulnar nerve is at risk during dissection, it may olecranon in patients with stiff, internally rotated arms.
be transposed anterior to the medial epicondyle
and secured in a subcutaneous pocket. We do not EXPOSURES
find this routinely necessary. • A curvilinear 10-cm incision is made from the olecranon to the musculotendinous
junction of the triceps muscle. The medial and lateral skin flaps are elevated sharply
EXPOSURES PITFALLS (Fig. 115.4).
Avoid incising the triceps fascia during exposure • The ulnar nerve is then identified proximally at the medial intermuscular septum and
because this can compromise the integrity of the traced distally into the cubital tunnel. The cubital tunnel is released with scissors
tendon during subsequent reconstruction. (Fig. 115.5) and the ulnar nerve is protected.

Greater triceps tendon lengthening can be Step 1
achieved if the apex of the V is extended further A distally based V-shaped incision is marked on the triceps tendon and incised with a
proximally on the triceps.
scalpel. The apex of the V should be at the musculotendinous junction (Fig. 115.6).
FIGURE 115.4 Markings for posterior elbow FIGURE 115.5 Ulnar nerve dissection.
exposure.
Release of
capsule
STEP 2 PEARLS
• There is usually very little improvement in pas-
sive elbow flexion with triceps release alone.
• A Freer elevator can be used to identify the
Distally-based
flap of triceps posterior aspects of the medial and lateral col-
lateral ligaments of the elbow.
FIGURE 115.7 Distally based flap of STEP 2 PITFALLS

FIGURE 115.6 Marking of distally based flap of triceps retracted and posterior elbow • Aggressive and uncontrolled passive flexion of
triceps. capsule released. the elbow before soft tissue release can lead
to fracture of potentially osteopenic bone.
• Do not incise the medial and lateral collateral
ligaments of the elbow when releasing the
Step 2 posterior capsule.
• Care is required to avoid damaging the distal
• The distally based flap of tendon is elevated from the underlying muscle and the joint humeral physis.
capsule is exposed (Fig. 115.7).
• The joint capsule is released sharply by applying a gentle flexion force to the elbow.
STEP 3 PEARLS
Step 3 The elbow should be flexed and extended in the
The distally based flap of triceps tendon is then repaired in a V-to-Y fashion with non- operating room to ensure that the ulnar nerve does
not kink or subluxate (Fig. 115.10).
absorbable suture (Figs. 115.8A–B and 115.9).
Elbow extended
Elbow flexed
Olecranon
Ulnar nerve
Distally based
V–Y
flap
advancement
Triceps tendon
Lateral head
of triceps
Long head
or triceps
A B
FIGURE 115.8 Diagram of movement of distally based triceps flap after release and passive elbow
flexion.
FIGURE 115.10 Demonstration of passive flexion after triceps advance-

FIGURE 115.9 V-Y advancement and inset of triceps flap. ment and elbow capsule release.
Step 4
• The tourniquet is deflated and hemostasis is ensured with bipolar electrocautery.
• The skin is closed using 4-0 absorbable suture.
• A well-padded cast is applied with the elbow in at least 90 degrees of flexion.

• The limb is immobilized in an above-elbow cast for 4 weeks and then active and
passive ROM exercises are initiated.
• A removable orthosis is used continuously for an additional 4 weeks, followed by
nighttime-only use for a final 4 weeks. Self-feeding is encouraged throughout the
postoperative course and is guided by a hand therapist. Initial passive flexion is
limited to 90 degrees, with the goal of full passive flexion by 3 months.
• Elbow capsulotomy combined with triceps lengthening reliably increases passive
elbow ROM and enables hand-to-mouth activities if active elbow flexion is present.
Additional procedures to provide active elbow flexion may be necessary (e.g.,
triceps-to-biceps, pectoralis major, latissimus dorsi, and free functional gracilis
muscle transfers).
• Children who undergo elbow release before the age of 2 have better postoperative
flexion and overall passive arc of elbow motion compared with older children.
Carpal Wedge Osteotomy

POSITIONING
• The patient is placed in the supine position with the extremity on a hand table.
A well-padded tourniquet is placed high on the affected arm.
• Intraoperative fluoroscopy will be required to plan the midcarpal wedge resection
osteotomies and to confirm the position of the Kirschner wires (K-wires) that will be EXPOSURES PEARLS
used for fixation. Fig. 115.11 shows a preoperative lateral x-ray of a patient with • The sensory branches of the radial and ulnar
amyoplasia. nerve are elevated along with the skin flaps.
• The entire midcarpal joint must be visualized
EXPOSURES and the extensor compartments mobilized
sufficiently for full exposure.
• A single 5-cm longitudinal incision is made over the center of the dorsal wrist (Fig. 115.12).
Radial and ulnar skin flaps are raised superficial to the extensor retinaculum.
• The Lister tubercle is identified and the third compartment is opened by obliquely EXPOSURES PITFALLS
incising just ulnar to the tubercle. The extensor pollicis longus (EPL) tendon is • The EPL is small and must be handled carefully.
brought out of the third compartment (i.e., radialized). • The wrist and digital extensors are frequently
• The wrist capsule is incised and the second and fourth compartments are carefully adherent to the underlying wrist capsule
because of a lack of excursion.
elevated extraperiosteally with a scalpel to expose the carpus.
FIGURE 115.11 Lateral wrist x-ray in a patient with amyoplasia. FIGURE 115.12 Longitudinal incision marking for carpal wedge osteotomy.

• Intraoperative fluoroscopy is helpful to confirm Step 1
the position of the osteotomy in the older child.
• A V-shaped wedge of bone that tapers from dorsal to volar is removed from the
In the younger child with an incompletely
ossified carpus, the osteotomy position is midcarpal joint using an osteotome or knife (Fig. 115.13). The amount of bone re-
confirmed visually. sected is based on the extent of preoperative wrist flexion and ulnar deviation.
• A scalpel can be used in the younger child • The proximal cut is made perpendicular to the long axis of the radius and the distal
because the carpus is soft. An osteotome will cut is made perpendicular to the metacarpals. The radial side of the wedge is made
be required in the older child because of a
wider if correction of an ulnar deviation deformity is also required (Fig. 115.14).
partially ossified carpus. A saw is generally
avoided because the cut is less precise and
the bone is soft. Step 2
• The purpose of the wedge osteotomy is to achieve a posture of slight wrist exten-
STEP 1 PITFALLS
sion (Fig. 115.15). If the wrist cannot be passively brought into this position, wrist
flexor tendons will need to be released or lengthened.
• Ensure that the wedge resection is over the
midcarpal joint and not the radiocarpal joint.
• Prevent injury to the volar wrist capsule during
the osteotomy.
A B
C D
FIGURE 115.13 (A) Anteroposterior and (B) lateral views of location of the osteotomy, (C) anteropos-
terior and (D) lateral views after wedge osteotomy. (From Fig. 34.55A–D, Azar F, Canale ST, Beaty
JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020:1369–1458).
Osteotomy permits passive

wrist extension
Wedge osteotomy
FIGURE 115.14 Carpal wedge osteotomy after removal of bone wedge. FIGURE 115.15 Osteotomy permits passive wrist extension.
STEP 3 PEARLS
• Flexor lengthening is performed via a 5-cm volar longitudinal incision that is made
proximal to the wrist crease and ulnar to the palmaris longus (PL) tendon. It is technically straightforward to pass the K-wires
in an antegrade fashion through the osteotomy site.
• A tight PL tendon can be transected. Fractional lengthening of the wrist flexor ten-
The K-wires are oriented so that they exit the skin
dons can result in 2 cm of lengthening. The wrist is then passively extended to the distally between the metacarpals. The osteotomy is
desired position. closed and the K-wires are passed retrograde across
the osteotomy and the radiocarpal joint into the
Step 3 distal radius. In young children, the fusion site can
be reinforced with transosseous sutures, if desired.
Two 0.062-inch (1.57-mm) K-wires are used to maintain the corrected position of the wrist
after wedge excision of the carpus and release of any tight volar structures (Fig. 115.16).
STEP 3 PITFALLS
Step 4
• The position of the K-wires should be confirmed
The dorsal capsule is repaired using 3-0 Vicryl sutures. by intraoperative fluoroscopy (Fig. 115.17). The
wires should pass through both midcarpal and
Step 5 radiocarpal joints to ensure stable fixation.
• A good quality ECU tendon can be divided distally and transferred subcutaneously • To maintain the K-wires in the distal radius, one
should accept a neutral alignment of the wrist,
to reach the radial wrist extensors to provide a limited amount of balanced wrist rather than a more desirable position of slight
extension. extension. If the wrist is extended as the K-wires
• The skin is closed with absorbable sutures. are driven retrograde, the K-wires may impinge
on the soft tissues of the volar forearm.
FIGURE 115.17 Fluoroscopy confirms wrist Kirschner wire

FIGURE 115.16 Wrist Kirschner wire (K-wire) placement. (K-wire) placement.
FIGURE 115.18 Improvement in wrist extension at 6 months postoperatively.

• The limb is immobilized in an above-elbow cast for 4 to 6 weeks to allow the osteot- Because the ECU tendon may have minimal
omy site to heal. Unrestricted finger motion is encouraged immediately after surgery. excursion after transfer, it may act as a tenodesis,
• The K-wires are removed at the time of cast removal. rather than contributing to active wrist extension.
• The osteotomy site is protected with the use of an orthosis for 3 months.
• Formal therapy is usually not required in younger children because they typically
adjust well to the repositioned wrist.
• Surgery reliably repositions the wrist, which improves grasp. Fig. 115.18 demon-
strates improvement in wrist extension at 6 months postoperatively.
• Children older than age 7 do better than younger patients. Combining carpal wedge
osteotomy with ECU transfer leads to improved wrist extension.
• Arthrogryposis patients score lower on upper extremity function compared with age-
matched controls, but they have emotional states that are consistent with population
norms.
EVIDENCE
Elbow Release
Richards C, Ramirez R, Kozin S, Zlotolow D. The effects of age on the outcomes of elbow release in
arthrogryposis. J Hand Surg Am. 2019;44(10):898.e1–898.e6.
The authors reviewed patients with arthrogryposis who underwent a posterior elbow release for elbow
extension contracture between 2007 and 2014. They included 13 patients (18 procedures) who had a
minimum follow-up of at least 2 years. Patients were divided into 3 groups based on their age at the
time of surgery: younger than 2 years, 2 to 3 years old, and older than 3 years. The average preopera-
tive arc of motion was 16 degrees (0 degrees to 30 degrees) for the children younger than 2, 33.5
degrees (5 degrees to 60 degrees) for the children 2 to 3, and 45 degrees (25 degrees to 80 degrees)
for the children older than 3. The average postoperative arc of motion was 88.2 degrees (70 degrees
to 103 degrees), 60 degrees (15 degrees to 85 degrees), and 54.33 degrees (23 degrees to
70 degrees) for the respective age groups. The authors conclude that children who underwent
posterior elbow release before the age of 2 had a clinically important increase in their postoperative
flexion and overall passive arc of elbow motion compared with older children. These data suggest
that earlier release may be better at restoring total passive arc of elbow motion (Level IV evidence).
Van Heest A, James MA, Lewica A, Anderson KA. Posterior elbow capsulotomy with triceps lengthening
for treatment of elbow extension contracture in children with arthrogryposis. J Bone Joint Surg Am.
2008;90:1517–1523.
The authors report their experience of 29 posterior elbow capsulotomies with triceps lengthening in 23
children with amyoplasia. The average duration of follow-up was 5.4 years. The arc of motion of all
29 elbows improved from an average of 32 degrees (range, 0 degrees to 75 degrees) preoperatively
to an average of 66 degrees (range, 10 degrees to 125 degrees) at the time of final follow-up. All
children were able to reach the mouth using passive assistance (e.g., table-push, trunk-sway, and
cross-arm techniques), and 22 children were able to feed themselves independently. No child under-
went subsequent tendon transfer surgery. The authors conclude that elbow capsulotomy with triceps
lengthening successfully increases passive elbow flexion and the arc of elbow motion of children
with arthrogryposis, enabling hand-to-mouth activities (Level IV evidence).
Carpal Wedge Osteotomy
Van Heest AE, Rodriguez R. Dorsal carpal wedge osteotomy in the arthrogrypotic wrist. J Hand Surg
Am. 2013;38:265–270.
The authors report results of 20 carpal wedge osteotomies in 12 patients. All 12 patients’ parents
reported subjective improvement in position and appearance and in performing activities of daily
living. Wrist extension was significantly increased (mean, 43 degrees), wrist flexion was significantly
decreased (mean, 34 degrees from neutral), and there was no significant change in wrist motion arc.
Significantly greater improvement in wrist extension was observed in children operated on at 7 years
of age or older and in patients treated concomitantly with an ECU tendon transfer (Level IV evidence).
Foy CA, Mills J, Wheeler L, Ezaki M, Oishi SN. Long-term outcome following carpal wedge osteotomy
in the arthrogrypotic patient. J Bone Joint Surg Am. 2013;95:e150.
The authors reviewed their experience of 75 carpal wedge osteotomies in 46 patients with amyoplasia.
The average resting position of the wrist postoperatively (11 degrees of flexion) was significantly
different from that measured preoperatively (55 degrees of flexion; p < .001). The arc of wrist motion
measured preoperatively (32 degrees) did not differ significantly from that measured postoperatively
(22 degrees; p = .4903). The average active extension of the wrist changed from −37 degrees of
extension preoperatively to −11 degrees of extension postoperatively (p < .001). Active wrist flexion
also significantly changed from 69 degrees preoperatively to 33 degrees postoperatively (p < .001).
Parent-guardian surveys indicated that the mean overall satisfaction score after surgery was 9.1 of
10 possible points and that the mean ranking for task completion in activities of daily living was 4
(easier after surgery). The authors conclude that surgery results in a sustained improvement and par-
ents or guardians were satisfied with the result (Level IV evidence).
Patient-Reported Outcomes
Wall LB, Vuillerman C, Miller PE, Bae DS, Goldfarb CA; CoULD Study Group. Patient-reported
outcomes in arthrogryposis. J Pediatr Orthop. 2020;40(7):357–360.
The authors sought to evaluate patient-reported outcomes (PROs) in patients with arthrogryposis using
the Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes
Data Collection Instrument (PODCI) questionnaires. A total of 29 patients completed all question-
naires. This cohort was divided into distal arthrogryposis and amyoplasia groups, with 15 and
14 patients in each group, respectively. For both cohorts, the median upper extremity (UE) function
PROMIS scores were significantly less than population norms, 31 for distal arthrogryposis and
22 for amyoplasia. PODCI UE function was statistically lower for amyoplasia compared with the
distal arthrogryposis cohort. PROMIS pain, depression, anxiety, and peer relations were in the normal
range for both cohorts. Median PODCI pain and happiness ranged from 85 to 88 for all patients with
no statistical difference between groups. The authors conclude that arthrogryposis patients have
lower UE function scores but have emotional states consistent with populations norms. Furthermore,
amyoplasia patients were functionally worse than distal arthrogryposis patients (Level II evidence).
ddsf
SECTION XIII
Tumors
CHAPTER 116 Hand Masses 883
CHAPTER 117 Excision of Vascular Lesions of the Hand 892
CHAPTER 118 Excision of Enchondroma 893
CHAPTER 119 Excision of Peripheral Nerve Schwannoma 894
CHAPTER 120 Excision of Malignant Skin Tumors 900
882
CHAPTER 116
Hand Masses
Mucous Cyst Excision

INDICATIONS
• One indication for this procedure is a cyst causing pain.
• It is important to distinguish between a painful cyst and a painful arthritic distal
interphalangeal (DIP) joint.
• Other indications include aesthetic deformity (unsightly lesion or nail ridge) and recur-
rent infection or wound.
Contraindications
• If diagnosis of mucous cyst is not clear, consider excisional biopsy before perform-
ing a rotational skin flap.
• If the cyst is acutely infected, manage the infection before definitive excision.
• The finger is examined, noting the size and location of the mass. The mass is pal-
pated to determine whether it is firm or soft. Transillumination of the mass can help
differentiate a fluid-filled mass from a solid tumor.
• Mucous cysts may cause pressure on the nail matrix and lead to a nail plate defor-
FIGURE 116.1 Mucous cyst located between the
mity with a ridge or depression (Fig. 116.1). Any nail plate deformity is documented distal interphalangeal (DIP) joint and eponychial
preoperatively because only 60% of deformities are reported to resolve after surgery fold. Chronic pressure on the nail matrix has led
and new nail deformities can also present after surgery. to a nail deformity (black arrow).
• The skin around the mass and the distal finger is examined and palpated. The sur-
rounding skin is often rotated or advanced to cover a defect left after excision. Any
skin around the mass that is severely atrophic is excised with the mass. A longer
rotational advancement flap is designed if a larger defect is created.
• The DIP joint is examined to identify osteophytes. A patient with a painful or de-
formed arthritic joint deformity is a candidate for a simultaneous DIP arthrodesis.
IMAGING
Plain films can be used to evaluate the amount of osteoarthritis and assess osteophyte
formation.
SURGICAL ANATOMY
• Mucous cysts are found on the dorsal aspect of the distal phalanx between the DIP
joint and the eponychial fold. EXPOSURES PEARLS
• Cysts have a stalk that connects them to the DIP joint. • A no. 15 blade is used to elevate the skin flap
• The stalk lies between the terminal slip and the collateral ligament and may connect and avoid injury to the eponychium and extensor
to the ipsilateral or contralateral side of the cyst (Fig. 116.2). tendon. The plane is directly on top of the termi-
• The cyst grows slowly and may erode the skin and adjacent structures, such as the nal tendon.
• Although fragile cysts may rupture during expo-
nail matrix.
sure, try to visualize the stalk and its trajectory
toward the DIP joint.
POSITIONING
The procedure is performed with a digital nerve block and a finger tourniquet.
EXPOSURES PITFALLS
EXPOSURES The subdermal plexus is the main vascular supply
• If the overlying skin is pliable, a transverse curvilinear incision (proximally based) is of the skin flap. The flaps are raised with some
subcutaneous tissue to preserve their circulation.
centered over the DIP joint. This design facilitates DIP joint exploration (Fig. 116.3A)
883
884 CHAPTER 116 Hand Masses
Dissection site
Cyst
Joint capsule
Stalk
Extensor
tendon
Collateral
ligament
FIGURE 116.2 The cyst stalk lies between the terminal tendon and the collateral ligament.
Good quality Thinned

overlying skin overlying skin
C
A B
Transverse incision Longitudinal elliptical incision

FIGURE 116.3 If the skin overlying the cyst is good quality, a simple curvilinear incision is used to allow exposure of the cyst
and the distal interphalangeal (DIP) joint. If the skin is poor quality, it is excised, and a rotational flap is designed by extending
one side of the curvilinear incision proximally to allow for the advancement of skin over a residual defect (white arrow).
• If the overlying skin is of poor quality, an elliptical skin incision is used around the cyst
STEP 1 PEARLS and a local rotational advancement flap is designed for closure (see Fig. 116.3B–C)
• The proximal extension of the flap is dependent on the defect size. This flap usually
• If the cyst is adherent to the nail bed or healthy
overlying skin, a portion of the cyst wall can be extends to the proximal interphalangeal (PIP) joint and sometimes a back cut is required.
left behind rather than aggressively debrided.
• The fragile cyst and stalk may be difficult to PROCEDURE
identify. When the fragile wall ruptures, use the
mucinous drainage as a guide to its probable Step 1: Cyst and Stalk Mobilization
path toward the joint.
• The cyst is mobilized from the surrounding tissue.
• The stalk is traced toward the DIP joint where it enters between the collateral ligament
STEP 1 PITFALLS and terminal tendon (see Fig. 116.2).
• With a no. 15 blade, incise sharply just lateral to the terminal tendon to create a
Most of the cysts emerge on the dorsum of the distal
phalanx or DIP joint, but their stalk may originate capsulotomy and expose the DIP joint.
from anywhere around the DIP joint. A single stalk
may have multiple cysts, with some cysts that sit Step 2: Removal of Distal Interphalangeal Joint Osteophytes
behind the extensor tendon. A meticulous dissection • The osteophytes of the DIP joint are removed with a fine rongeur.
and careful joint examination are performed in every • If a stalk is not definitively identified, we recommend capsulotomies and osteo-
case.
phyte resections on both radial and ulnar side of the terminal tendon.
• Bipolar or handheld cautery is then used to ablate cyst wall tissue and entry point of
the stalk into the DIP joint (Fig. 116.4).
• Do not ablate the nail matrix or terminal tendon.

• If no or minimal skin was excised, then primarily close the skin with interrupted skin
sutures.
• If using a rotational skin flap, advance distally to cover the wound and joint.
• If there is tension on the flap, a back-cut incision at the proximal portion of the flap
is made.
• Even though the defect may be small, the entire dorsal skin should be mobilized
proximal to the PIP joint to achieve tension-free closure. The incision is made over
the ulnar noncontact surface of the finger in the junction between glabrous and
nonglabrous skin.

• The DIP joint is immobilized with a splint for 5 to 7 days, and range-of-motion (ROM)
exercises are started thereafter. FIGURE 116.4 The dissection plane is immediately
superficial to the terminal tendon (green arrow).
• Simple excision alone without osteophyte removal is reported to have a 30% to 50%
The mucous cyst has been removed (red arrow).
recurrence rate. If DIP osteophytes are removed, the recurrence is less than 2%. Between the terminal tendon and collateral liga-
• Postoperative extension loss is reported in 17% of patients with a mean loss of 10 ments, capsulotomies were performed and osteo-
degrees. phytes were removed (blue arrows). Residual cyst
• Nail deformities resolve in about 16% of patients. tissue was ablated with cautery (red and blue
arrows).
Ganglion Cyst Excision STEP 2 PEARLS

• The location of osteophytes is correlated with
INDICATIONS x-rays (if obtained preoperatively) to ensure
removal of all pathology.
• Ganglion cysts are the most common hand mass. They are mucin-filled structures
• Cyst excision without osteophyte removal will
that associate with a joint capsule, tendon, or tendon sheath and often communi- have a higher rate of cyst recurrence.
cate with the synovial compartment by a stalk.
• A mass with symptoms, including pain, deformity, decreased ROM or strength, par-
esthesia from nerve compression, and impending or present skin ulceration, requires STEP 3 PEARLS
removal. • Do not close the skin with undue tension. If the
• Aesthetic concerns and suspicion of malignancy are additional indications. skin flap color is abnormal, sutures are re-
moved, and flap mobilization is reassessed.
CLINICAL EXAMINATION • If a tension-free closure cannot be obtained,
the distal defect and area of the exposed joint
• Ganglia are protuberant masses that arise in predictable locations: or tendon is prioritized for coverage. The proxi-
• Dorsal wrist (60%–70%): Arise from the scapholunate (SL) interval. mal defect created by the flap advancement
• Volar wrist (20%): Arise from the radioscaphoid or scaphotrapezial joint. can be left to heal by secondary intention.
• Other (undefined frequency): Volar flexor sheath ganglia; intraosseous, intratendi-
nous, and intraneural ganglia. POSTOPERATIVE PITFALLS
• For deeper masses, flexion or extension of the wrist can make the mass more visible Careful application of the bandage is essential to
(Fig. 116.5). prevent either premature removal by a child or a
• When a suspected ganglion cyst is seen in an unusual location, other tumors are constricting bandage.
considered.
• Transillumination may help differentiate cystic masses, such as ganglia, from solid
tumors.
• Radial and ulnar pulses are assessed. For extensive volar ganglia, an Allen test is
performed to reassure that hand circulation will remain intact in the event of an in-
advertent arterial injury.
• Examine hand sensation, because ganglia can cause compressive neuropathy (e.g.,
ganglia within the Guyon canal causing ulnar nerve compression).
IMAGING
• Routine preoperative imaging is not warranted unless the mass arises in an unusual
anatomic location.
FIGURE 116.5 Dorsal wrist ganglion (white arrow) is more easily appreciated with the wrist flexed.
• For recurrent ganglia, an x-ray may delineate an osteophyte that is contributing to

recurrence.
• A third of volar wrist ganglion are related to carpal arthritis.
• Ultrasound can be used to distinguish a volar ganglion from a radial artery pseu-
doaneurysm.
• Ultrasound or MRI can provide information regarding masses of uncertain diagnosis
or occult ganglia.
SURGICAL ANATOMY
• Most ganglions have a stalk or neck associated with the joint capsule.
• Dorsal ganglia most commonly arise from the SL interval. Superficially, a dorsal
ganglion can emerge between any of the extensor tendons because of a long stalk
but most commonly occurs between the third and fourth extensor compartment.
• Volar ganglion cysts can originate from the radiocarpal joint, scaphotrapeziotrape-
zoid ligament joint, or, less commonly, the pisotriquetral joint. Superficially, a volar
ganglion typically emerges between the first extensor compartment and flexor carpi
radialis (FCR) tendon sheath.
• The cyst may extend 360 degrees around the joint and sometimes can have
multilobulated anatomy.
• The cyst may be in close contact with the branches of the radial artery and its
accompanying veins or nearby tendon sheaths.
POSITIONING
• The patient is placed in the supine position with the arm extended on a hand table.
EXPOSURES PEARLS • All procedures are done under tourniquet application on the affected extremity.
Protect dorsal radial and ulnar sensory nerves. • Local or regional anesthesia is typically used.
EXPOSURES PITFALLS DORSAL WRIST GANGLION EXCISION

The ganglion is always larger than it appears
clinically. Make the incision large enough to permit Exposures
full circumferential visualization of the ganglion. • A transverse incision is designed over the mass in a natural wrist crease (Fig. 116.6).
• The skin incision is made, and superficial veins are identified and retracted from the field.
STEP 1 PEARLS Step 1: Mobilization of Cyst

Dissect directly on the cyst wall. Often, a thin fascial • Delicately dissect through the subcutaneous tissue with tenotomy scissors (Fig. 116.7).
layer immediately encasing the cyst must be entered
• Spread overlying tissue to expose the ganglion tissue.
to identify the true cyst wall (see Fig. 116.7).
• Using forceps, gently retract the cyst and circumferentially dissect around the cyst.
FIGURE 116.6 A transverse incision is designed within a natural crease and centered over the mass.
B
A
FIGURE 116.7 Perform circumferential dissection of the ganglion by dissecting immediately on the cyst wall (red arrow). Often a thin fascial
layer (blue arrow) must be incised to gain access to the ganglion cyst wall. The yellow arrow is the extensor retinaculum, which must be in-
cised to identify and follow the stalk toward the joint.
Step 2: Identify Stalk Communicating With Joint Space STEP 2 PEARLS

• Incise the extensor retinaculum and follow the stalk toward the dorsal wrist capsule. For large cysts, it may be helpful to incise the cyst
• Dorsal ganglia often arise from the SL interval proximal to the dorsal SL ligament. and drain the mucinous material. The cyst can
• Visualize, protect, and retract extensor tendons (Fig. 116.8). then be manipulated more easily. Furthermore,
• Dorsal ganglia often arise between the extensor digitorum communis tendons the inside of the cyst can be probed to identify the
trajectory of the stalk.
and extensor pollicis longus but may arise between any compartments.
Step 3: Excision of Ganglion Cyst With Its Stalk

• Using bipolar cautery, the ganglion is transected at the stalk with a rim of the dorsal
wrist capsule (see Fig. 116.8).
STEP 3 PEARLS
• Leave the stalk defect open because inflam-
mation and scarring will seal the opening.
Suturing the defect in the joint capsule may
cause stiffness and limit the ROM of the wrist.
• Sequentially cauterizing the cyst wall and joint FIGURE 116.8 After incising the extensor retinaculum, the stalk is traced between the extensor
capsule during excision ensures visualization tendons. This stalk traversed between the third (extensor pollicis longus [EPL]—blue arrow) and
and elimination of the entire stalk. Further- fourth (extensor digitorum communis [EDC]—red arrow) extensor compartment. The yellow
more, this is a more efficient way to achieve silhouette shows the retracted ganglion.
hemostasis from the heavily vascularized cyst
stalk and joint capsule. Uncontrolled bleeding
from the wrist capsule is agonizing and pro-
longs surgical time to stop the bleeding. • For larger ganglia, perform this step in a sequential manner.
• Transect a portion of the stalk with tenotomy scissors and then cauterize the raw
edges.
STEP 3 PITFALLS • Circumferentially work around the cyst wall by transecting another portion of the
• Leaving a ganglion stalk to the joint will cause stalk and cauterizing the raw edge.
a higher rate of recurrence. • Repeat until the entire specimen has been transected.
• Care is taken to not injure the SL ligament
• Cauterize the base of the cyst to obliterate any cystic tissue (including accessory
during cauterization of the stalk.
cysts) communicating with the joint (Fig. 116.9 and 116.10).
A B
FIGURE 116.9 For large ganglion cyst, the stalk is sequentially divided and cauterized. (A) The inferior
portion of the cyst (red portion of circle) is being cauterized. (B) The ganglion cyst (blue arrow) is being
reflected and the top half of the cyst is ready to be cauterized in a counterclockwise manner (red portion
of circle).
A B
FIGURE 116.10 The base of the cyst is cauterized to remove any residual cystic tissue. The excised
cyst is often larger than expected based on clinical findings. Notice the base of the cyst has a well-
cauterized edge to prevent bleeding (red arrow).
Step 4: Hemostasis and Skin Closure

• Deflate the tourniquet and obtain hemostasis.
• Close subcutaneous tissue and skin with buried absorbable sutures.
EXPOSURES PEARLS
VOLAR WRIST GANGLION CYST EXCISION • If the longitudinal curvilinear incision is extended
to the distal wrist, the palmar cutaneous branch
Exposures of median nerve is more at risk for injury.
• A longitudinal chevron incision is designed over the mass (Fig. 116.11). • A volar cyst usually arises between the FCR and
• The skin incision is made, and superficial veins are identified and retracted from the the first extensor compartment (Fig. 116.12).
field. Avoid injury to these tendons during retraction
and dissection.
• The forearm fascia is incised, and the volar ganglion cyst is identified.
Step 1: Mobilization of the Cyst STEP 1 PEARLS

• The radial artery is identified and dissected away from the cyst (Fig. 116.13). It can be easier to dissect a perforated cyst from
• If the capsule of the cyst is adhered widely with the artery, the cyst is opened, and surrounding tissue, especially if the ganglion is
the cyst wall is divided. A partial cyst wall is left with the artery to avoid inadvertent adherent to the radial artery.
vascular injury. There is no need to separate the cyst wall from the radial artery. The
problem is the cyst stalk, not the pseudocyst wall adherent to the radial artery. STEP 1 PITFALLS
If the radial artery is injured during dissection, it
should be repaired using a microscope.
FIGURE 116.11 A chevron incision is used directly over the volar ganglion to avoid using a straight
line incision that crosses the wrist crease.
FIGURE 116.12 Volar ganglia typically arise in the interval between the flexor carpi radialis (blue arrow)
and first extensor compartment (yellow arrow). The radial artery (red line) is often adherent to the gan-
glion (green arrow).
A B
FIGURE 116.13 The ganglion cyst (blue arrow) is easily mobilized on the ulnar side. The radial artery (red arrow) is closely associated
with the cyst on the radial side. Rather than performing a tenuous dissection, we advocate opening the ganglion and leaving the cyst
wall adherent to the radial artery.
STEP 2 PEARLS • The ganglion is mobilized with its stalk from the surrounding tissue and traced down
• Do not spend excessive time dissecting out the to the volar joint capsule.
cyst. The goal is to identify the stalk of the cyst
and eliminate the connection to the joint. Step 2: Excision of Ganglion Cyst and Stalk
• Avoid injury to superficial veins that cause
• The ganglion sac and stalk are traced down to the joint capsule (radiocarpal or sca-
bleeding and can obscure the surgical field.
Cauterize every vein during the dissection photrapezial joint). The joint capsule is opened proximally and distally to the stalk.
when under tourniquet control so that when • The ganglion and stalk are tangentially excised with a small portion of the volar joint
the tourniquet is let down, the field will not be capsule. This can be performed in a similar manner as previously described for dor-
filled with blood that will require an extensive sal ganglia.
amount of effort to control.
• Bipolar cautery is used to obliterate the origin of the stalk at the joint capsule and
• If there is associated carpal arthritis, synovec-
tomy and debridement of the arthritic carpal any residual cystic tissue (without injuring the radial artery).
articulations (e.g., osteophytes) may be per-
formed. Step 3: Hemostasis and Skin Closure
• Deflate the tourniquet and obtain hemostasis.
• Close subcutaneous tissue and skin with buried absorbable sutures.

• A nonadhesive gauze and soft wrap is applied to the wound.
• The dressing is removed 3 days postoperatively.
• Splint the wrist in a volar resting position for 7 days if a sizable portion of the joint
capsule was excised or if debridement of the carpus was performed.
• ROM exercise is initiated as soon as the dressing is removed.

• All stitches are removed 10 to 14 days postoperatively.
• There is a 5% to 50% rate of recurrence after excision. A higher rate of recurrence
is associated with tumors that are poorly defined and show localized bone erosion
and tendon involvement.
see videos 116.1, 116.2 and 116.3
EVIDENCE
Crawford C, Keswani A, Lovy AJ, et al. Arthroscopic versus open excision of dorsal ganglion cysts:
A systematic review. J Hand Surg Eur Vol. 2018;43(6):659–664.
This systematic review evaluated 16 studies comparing open versus arthroscopic dorsal ganglion exci-
sion of which 11 needed to be excluded because of low quality and high bias potential. The remain-
ing five studies were pooled, and they found no difference in cyst recurrence rates (8% vs. 10%) and
complications (4% vs. 6%) between arthroscopic and open excision. The authors concluded that
results from these procedures were comparable.
Head L, Gencarelli J, Allen M, Boyd K. Wrist ganglion treatment: Systematic review and meta-analysis.
J Hand Surg Am. 2015;40:546–553.e8.
The authors performed a comprehensive search of Medline for ganglion treatment. Ultimate inclusion/ex-
clusion criteria limited the analysis to 35 studies. Across all study designs, recurrence for arthroscopic
surgery was 6% (512 ganglions), for open surgical excision was 21% (809 ganglions), and for aspiration
was 59% (489 ganglions). Mean complication rates for arthroscopic surgical excision, open surgical
excision, and aspiration (3 studies; 134 ganglions) were 4%, 14%, and 3%, respectively. This systematic
review and meta-analysis shows that open surgical excision offers a significantly lower chance of
recurrence compared with aspiration. Open surgical excision carries the higher risk for complications
according to the study, although the specifics of the types of complications are not individually
reported. The authors conclude that aspiration is a simple option with a low risk for complications,
but it does provide significant benefit with respect to ganglion resolution.
CHAPTER 117
Excision of Vascular Lesions of the Hand

This chapter includes the following video: Video 117.1 – Subungual Glomus Tumor
Excision.
KEY CONCEPTS
• Vascular lesions, including vascular malformations and hemangiomas, are types of
benign neoplasms that occasionally arise in the hand. Distinguishing between hem-
angiomas and vascular malformations is essential, given their substantially different
natural histories and treatment options.
• Vascular malformations are congenital inborn errors that transpire during embryonic
development and may affect the venous, lymphatic, capillary, or arterial tissue. Vas-
cular malformations often grow over time and never spontaneously involute.
• Hemangiomas are masses composed of disorganized vascular endothelial cells.
Unlike vascular malformations, hemangiomas can be present at birth or within the
first few weeks of a newborn’s life. Hemangiomas grow rapidly during the first sev-
eral weeks of life, followed by a plateau in growth and finally spontaneous involution.
These benign masses are often treated nonoperatively with chemical sclerotherapy,
lasering, or embolization.
• The relevant imaging studies should be readily available during the procedure for
review during incision planning and deep dissection.
• Recurrence of vascular malformations is common after even wide excision. Thus
normal structures such as nerves, arteries, or tendons should not be sacrificed to
ensure a wide margin.
• If there is concern for malignancy, a small specimen should be sent for frozen pa-
thology to confirm a diagnosis.
• Revision surgery may be performed when the wound has healed and the tissues are
soft. Staged resections may be necessary for large or diffuse vascular malformations.
A B
Hypothenar vascular malformation

FIGURE 117.1 (A–B) Hypothenar vascular malformation.
892
CHAPTER 117
Excision of Vascular Lesions of the Hand
INDICATIONS
• Vascular lesions, including vascular malformations and hemangiomas, are types of
benign neoplasms that occasionally arise in the hand.
• Vascular malformations are congenital inborn errors that transpire during embryonic
development of the vascular systems and may affect the venous, lymphatic, capil-
lary, or arterial tissue.
• Malformations are classified by the speed at which blood or other bodily fluid
circulates through the malformation. Arterial malformations, or arterial fistulas, are
classified as fast/high-flow, whereas venous, lymphatic, and capillary malforma-
tions are slow/low-flow.
• Hemangiomas, also known as strawberry marks, are masses composed of disorga-
nized vascular endothelial cells. Unlike vascular malformations, many hemangiomas
present within the first few weeks of a newborn’s life, although they can be present
at birth. The hallmark of a hemangioma is rapid growth or expansion during the first
several weeks of life, followed by a plateau in growth and involution of the mass.
• These benign masses are often treated nonoperatively, with chemical sclerotherapy,
lasering, or embolization.
• Regardless of whether the lesions are being treated conservatively or surgically, daily
aspirin is regularly given to patients to prevent clotting within venous or arterial mal-
formations.
• Although rare, the literature describes how malignant sarcomas, such as angiosar-
coma and epithelioid hemangioendothelioma, may arise within the distal upper ex-
tremity. Their appearance can be remarkably similar to the benign lesions. Rapid
development of a vascular lesion after childhood, especially if painful, should raise
concerns for malignancy.
• Hemangiomas are characterized by variable spontaneous involution over time.
Conversely, vascular malformations often grow over time and never spontaneously
involute. Distinguishing between hemangiomas and vascular malformations is es-
sential, given their substantially different natural histories and treatment options
(Table 117.1).
TABLE
117.1 Vascular Lesions and Subtypes
Types of Vascular Lesions Subtypes
Hemangioma Hemangioma of infancy
Rapidly involuting congenital hemangioma (RICH)
Noninvoluting congenital hemangioma (NICH)
Vascular malformation Low flow (CM, VM, LM)
High flow (AVF)
Combined (CLM, CLVM)
AVF, arteriovenous fistula; CLM, capillary-lymphatic malformation; CLVM, capillary-lymphaticovenous

malformation; CM, capillary malformation; LM, lymphatic malformation; VM, venous malformation.
892.e1
892.e2 CHAPTER 117 Excision of Vascular Lesions of the Hand
A B
Hypothenar vascular malformation

FIGURE 117.1 (A-B) Hypothenar vascular malformation.
• Physical examination should focus on the appearance of the skin, involvement of the
muscular compartments, texture of the underlying tissues (compressible, rubbery,
soft), changes with limb positioning, and the presence of a bruit or thrill (Fig. 117.1).
• Associated manifestations of syndromes (blue rubber bleb nevus, Klippel-Trenaunay,
Kasabach-Merritt, Maffucci, Parkes-Weber) should be evaluated.
IMAGING
• Classically, soft tissue hemangiomas may form phleboliths, which are small calcified
deposits formed by thrombosed vessels. These appear on plain radiographs.
• Ultrasound may be used in the diagnosis of lymphatic malformation (LM) or an arte-
riovenous fistula (AVF).
• Magnetic resonance imaging (MRI) with and without contrast may be useful to define
the location and extent of disease and to confirm vascularity of the mass. Lymphatic
and venous malformations are isointense on T1-weighted MRI and hyperintense on
T2-weighted MRI (Fig. 117.2).
• Angiography may be used to outline the extent of an AVF.
A B
FIGURE 117.2 (A–B) Magnetic resonance imaging (MRI).

CHAPTER 117 Excision of Vascular Lesions of the Hand 892.e3
EXPOSURES PEARLS
POSITIONING
The relevant imaging studies should be readily
• The operation is performed under general anesthesia with the patient placed supine available during incision planning and deep dissection.
on the operating table.
• The affected extremity is placed on a hand table and an upper arm tourniquet is
applied. EXPOSURES PITFALLS
EXPOSURES Incisions and deep dissection should never cross into

or contaminate adjacent muscular compartments
• The location of the vascular lesion will dictate the necessary exposure. A thorough because this would necessitate more extensive re-
understanding of the anatomy of the entire upper extremity is essential. resection in the case of an unplanned sarcoma or
• Surgical precautions should be taken to prevent unnecessary wound contamination carcinoma excision.
in the case that the mass is identified as malignant on final pathology. Assume the
mass is malignant unless preoperative biopsy has confirmed a benign neoplasm.
• Longitudinal incisions are preferred over horizontal incisions and should be designed
to facilitate direct access to the underlying mass and violate as few compartments
as possible.
PROCEDURE
Step 1
• The incision is marked to extend proximal and distal to the lesion (Fig. 117.3).
• Dissection is taken down sharply through skin and subcutaneous tissue, then skin
flaps are elevated with a no. 15 blade to expose the vascular lesion.
• If there is concern for malignancy, a small specimen should be sent for frozen pa-
thology to confirm a diagnosis.
Step 2
• A combination of blunt dissection and bipolar electrocautery is used to “shell-out”
the tumor circumferentially from the normal adjacent tissue (Fig. 117.4). Identify key
structures, such as nerves and critical vessels, early in the dissection because tu-
mors will wrap around these structures. The principle of tumor surgery is to isolate
key structures first, then remove all intervening tissues that contain the tumor.
• Suture or clip ligation may be used for vascular lesions with large afferent or efferent FIGURE 117.3 Incision design.
vessels.
STEP 2 PEARLS
Tumor may distort the normal course of neurovascular
structures, such as common and proper digital
arteries/nerves, and volar and dorsal sensory
branches of the hand. To avoid damaging these
structures, they should first be identified proximally
or distally in unaffected tissue and then gradually
identified along a possible aberrant path (Fig. 117.5).
STEP 2 PITFALLS
Recurrence of vascular malformations is common,
*
even after wide excision. Thus normal structures,
* like nerves, arteries, or tendons, should not be
sacrificed to ensure a wide margin (Fig. 117.6).
The star indicates the ulnar The star indicates the distorted course of the
neurovascular bundle identified palmar neurovascular structures, which may
proximally adhere to the under surface of tumor.
FIGURE 117.4 Identification of tumor and neuro- FIGURE 117.5 Distorted course of the palmar
vascular bundles. neurovascular structures.
892.e4 CHAPTER 117 Excision of Vascular Lesions of the Hand
Preserved neurovascular bundles FIGURE 117.7 Wounds closed.

FIGURE 117.6 Preserved neurovascular bundles.
FIGURE 117.8 Final mass.
Step 3
• The tourniquet is released and hemostasis is secured.
• Tissue sealants and drains are used when necessary.
• Excess skin is sharply resected when necessary to permit well-approximated skin
closure without tension or dog-ears (Fig. 117.7).
• The final mass should be sent to pathology for permanent section (Fig. 117.8).

• A well-padded splint is applied to prevent disruption of the incision and bleeding.
The splint is removed 2 weeks postoperatively.
• Complications arise in up to 28% of patients; these include swelling, bleeding, and
wound healing problems. Revision surgery may be performed when the wound has
healed and the tissues are soft. Staged resections may be necessary for large or
diffuse vascular malformations.
See Video 117.1
CHAPTER 117 Excision of Vascular Lesions of the Hand 892.e5
EVIDENCE
Upton J, Coombs CJ, Mulliken JB, Burrows PE, Pap S. Vascular malformations of the upper limb:
A review of 270 patients. J Hand Surg Am. 1999;24:1019–1035.
The authors reviewed their experience treating 270 upper-extremity vascular malformations over a
28-year period. These anomalies were slightly more common in females than males (ratio, 1.5:1.0).
The malformations were categorized as either slow flow (venous, n = 125; lymphatic, n = 47; capil-
lary, n = 32; combined, n = 33) or fast flow (arterial, n = 33). MRI with and without contrast best
demonstrated site, size, flow characteristics, and involvement of contiguous structures for all types
of malformations. Algorithms for treatment of both slow-flow and fast-flow anomalies are presented.
Two hundred sixty surgical resections were performed in 141 patients, including 24 of 33 fast-flow
anomalies. Preoperative angiographic assessment, with magnified views, was an important
preoperative adjunct before any well-planned resection of fast-flow arteriovenous malformations.
The surgical strategy in all groups was to thoroughly extirpate the malformation, with preservation of
nerves, tendons, joints, and uninvolved muscle, and microvascular revascularization and skin
replacement as required. Resections were always restricted to well-defined regions and often com-
pleted in stages. Symptomatic slow-flow malformations and types A and B fast-flow anomalies were
resected without major sequelae. Type C arterial anomalies, involving diffuse, pulsating lesions with
distal vascular steal and involvement of all tissues (including bone) progressed clinically and resulted
in amputation in 10 of 14 patients. The complication rate was 22% for slow-flow lesions and 28%
for fast-flow lesions (Level III evidence).
Greene AK, Goss JA. Vascular anomalies: From a clinicohistologic to a genetic framework. Plast
Reconstr Surg. 2018;141(5):709e–717e.
The authors perform a literature review to aggregate much of the underlying basic science research
that investigated the cellular and biochemical mutations causing vascular malformations. A sound
understanding of the underlying causes and possible therapeutic targets of vascular malformations
is important because initial management for these malformations is increasingly nonoperative.
CHAPTER 118
Excision of Metacarpal Enchondroma

This chapter includes the following video: Video 118.1 – Excision of Metacarpal
Enchondroma.
KEY CONCEPTS
• Enchondromas are benign bone lesions that occur within the medullary space of
bones. They are the most common bone tumor found within the phalanges and
metacarpals of the hand.
• Enchondromas are almost always painless, asymptomatic lesions and are com-
monly found incidentally on radiographs after acute hand trauma.
• Excision is indicated for symptomatic lesions that cause pain or deformity. In rare
circumstances, a pathologic fracture can occur through an enchondroma from
weakening of the surrounding cancellous and cortical bone. Patients with multiple
enchondromas, or a rapidly expanding, painful enchondroma, should undergo a
more exhaustive evaluation, including biopsy, before excision.
• The diagnosis of enchondroma is often established by plain film radiography. These
tumors appear as an intramedullary radiolucency with a lytic pattern that may in-
clude “popcorn” stippling and chondroid calcifications.
• Dorsolateral incisions directly overlying the cortical bone enclosing the enchon-
droma are used for metacarpal, proximal phalanx, and middle phalanx lesions.
Dorsal sensory branches of the ulnar nerve and the superficial branch of radial nerve
should be identified and protected during exposure to metacarpal and carpal le-
sions. Digital neurovascular bundles are protected in treatment of digital lesions.
• The creation of periosteal flaps is important because they permit closure over the
cortical window, containing the bone graft.
• After complete enchondroma removal, demineralized bone matrix can be injected
via the window to fill the entire dead space.
FIGURE 118.3 The fifth metacarpal demonstrates expansion and scalloping with heterogenous lu-
cency, consistent with enchondroma.
893
CHAPTER 118
Excision of Enchondroma
INDICATIONS
• Enchondromas are benign bone lesions that occur within the medullary space of
bones. They are the most common bone tumor found within the phalanges and
metacarpals of the hand.
• Enchondromas are almost always painless, asymptomatic lesions and are commonly
found incidentally on radiographs after acute hand trauma.
• Excision is indicated for symptomatic lesions that cause pain or deformity. In rare
circumstances, a pathologic fracture can occur through an enchondroma from
weakening of the surrounding cancellous and cortical bone.
Contraindications
• The presence of multiple skeletal lesions or enchondromas should raise concern for
enchondromatosis. Maffucci syndrome and Ollier disease are two well-described
conditions with sporadic genetic inheritance that cause multiple enchondroma for-
mation. The concern with these conditions is a high rate of malignant transforma-
tion, with Maffucci syndrome (enchondromatosis with multiple soft-tissue angiomas)
having a near 100% chance of sarcomatous transformation.
• Patients with multiple enchondromas, or a rapidly expanding, painful enchondroma,
should undergo a more exhaustive evaluation—including—biopsy before excision.
Unplanned resection of an unidentified sarcoma is a never-event because the posi-
tive margins and wound contamination result in devastating outcomes for the patient.
• Note any symptoms such as pain, inflammation, or deformities (Fig. 118.1).
• Assess and document the preoperative function and neurovascular status of the
hand and fingers.
• Palpate and examine both hands for painless or concealed masses that may indicate
enchondromatosis or previously unidentified soft-tissue extension.
IMAGING
• Radiographically, these tumors appear as an intramedullary radiolucency with a lytic
pattern that may include “popcorn” stippling, rings (white arrow), and arcs (black
arrows) of chondroid calcifications (Fig. 118.2).
FIGURE 118.1 Preoperative evaluation. FIGURE 118.2 Radiographic appearance.
893.e1
893.e2 CHAPTER 118 Excision of Enchondroma
Note the cluster and lobulated

calcifications in T2 weight MRI
FIGURE 118.3 Radiographic appearance with red dotted line FIGURE 118.4 Magnetic resonance imaging (MRI)
indicating the periphery of the lesion. appearance.
• The majority of enchondromas arise in the metaphyseal region, presumably because

of their origin from the growth plate, although they are frequently seen in the di-
aphysis. They are rarely seen in the epiphysis, and a cartilaginous lesion in an
epiphysis is more likely to be a chondrosarcoma.
• Three-view hand radiography (anteroposterior [AP], lateral, oblique) should be ob-
tained for diagnosis and any follow-up radiographic examination. (Note the red dot-
ted line surrounding the periphery of the large, expansile lesion, which has nearly
broken through the ulnar border of the fifth metacarpal [Fig. 118.3].)
• In the majority of cases, the diagnosis of an enchondroma can be established by
plain film radiography. If there is an atypical clinical history that includes pain, rapid
growth, adjacent soft tissue involvement, or an uncommon location, computed to-
mography (CT) scan and magnetic resonance imaging (MRI) are indicated.
• CT scan will demonstrate the characteristics of an enchondroma, which include a
lucent mass with arc or ring calcifications. The mass should show no evidence of
soft tissue invasion. If there is a soft tissue component indistinct from the bony le-
sion, a chondrosarcoma should be suspected.
• MRI is indicated to differentiate enchondroma from bone infarction or medullary os-
teonecrosis within the metaphysis. Bone infarction is more likely in patients with a
history of pancreatitis, organ transplantation, hemoglobinopathies, or previous radia-
tion therapy. An enchondroma on MRI has lobulated borders with a cluster of numer-
ous tiny lobules of high-signal-intensity foci on T2-weighted images (Fig. 118.4).
SURGICAL ANATOMY
• Dorsolateral incisions directly overlying the cortical bone enclosing the enchon-
droma are used for metacarpal, proximal phalanx, and middle phalanx lesions.
Dorsal sensory branches of the ulnar nerve and the superficial branch of the radial
nerve should be identified and protected during exposure to metacarpal and carpal
lesions. Digital neurovascular bundles are protected in treatment of digital lesions.
• To expose a metacarpal enchondroma distally, juncturae tendinum can be incised to re-
tract the extensor tendons away from the lesion to facilitate direct dissection to the bone.
POSITIONING
• The patient is placed supine with the arm extended and hand pronated on a hand
table.
• The operation is performed under tourniquet application.
CHAPTER 118 Excision of Enchondroma 893.e3
• The incision is made along the dorsum for the long and ring fingers. For the border Avoid making an incision directly over an extensor
tendon to decrease the chance of postoperative
digits—index and small fingers—the incision is made along the dorsal lateral line
tendon adhesions.
(Fig. 118.5).
• Dissection is made through the soft tissue, avoiding injury to the superficial veins
and sensory nerves. EXPOSURES PITFALLS
• The extensor tendons are retracted to expose to the diaphysis of the metacarpal Minimize extensor tendon injury by keeping the
bone. paratenon intact and avoiding exaggerated traction.
• In the phalanges, a dorsal lateral longitudinal incision is used. The exposure to the
bone is made between the lateral band and extensor mechanism dorsally and the
neurovascular bundle volarly. STEP 1 PEARLS
The creation of periosteal flaps is important because
PROCEDURE they permit closure over the cortical window,
containing the bone graft.
Step 1: Periosteal Flap and Cortical Exposure
The periosteum is sharply incised, and a key elevator is used to elevate dorsal and STEP 2 PITFALLS
volar flaps to expose the entire length of the lesion (Fig. 118.6). Ensure that the window is large enough to permit
easy insertion and manipulation of the curettes.
Step 2: Creation of a Cortical Bone Window Attempting to make a minimally invasive cortical
• A lateral or dorsolateral cortical window is designed 2 to 3 mm in width along the window only risks inadvertent fracture as one
length of the lesion. struggles to manipulate the curette within the
tumor (Fig. 118.7).
• The designed cortical window is decorticated by a low-speed bur or osteotome.
FIGURE 118.6 Lesion is exposed.

893.e4 CHAPTER 118 Excision of Enchondroma
FIGURE 118.7 Cortical window.
FIGURE 118.8 Excised lesion.
STEP 3 PEARLS
• Intraoperative fluoroscopy should be used to Step 3: Curette or Tumor Removal
confirm the completeness of removal.
• Use small, straight, curved, and reverse cutting curettes to completely remove the
• Also place a small curette within the defect
and confirm that the curette can reach the tumor via the cortical window.
periphery of the defect along all borders. • Enchondroma tumor is a soft, cartilaginous-like substance. Tumor should be sent to
pathology for confirmation of a benign cartilaginous lesion (Fig. 118.8).
STEP 4 PEARLS Step 4: Bony Reconstruction

• The demineralized bone matrix syringe should • After complete enchondroma removal, demineralized bone matrix can be injected
be injected from deep to superficial to ensure via the window to fill the entire dead space (Fig. 118.9).
placement throughout the cavity. The perios-
• For sizeable defects, autograft bone can also be harvested from the distal radius or
teum can be partially closed to reduce the
window size and prevent extrusion of the proximal ulna.
matrix during injection (Fig. 118.10).
• Use a Freer elevator and small bone tamp to
pack the graft within the cavernous defect.
• Fluoroscopy can be used to confirm that a
bone graft is fully packed in all peripheral
aspects of the defect.
STEP 4 PITFALLS
• Multiple methods for treatment of the bone
cavity after curettage are proposed, including
curettage alone or placement of autograft,
allograft, or bone substitutes.
• Outcomes are reported to be similar with all
methods, though autograft has inherent
donor site morbidity.
FIGURE 118.9 Demineralized bone matrix injection.
• If bone strength or quality is in question, use
of bone cement can provide more immediate
strength, though this has not been shown to
have a beneficial effect in outcomes.
FIGURE 118.10 Periosteum partially closed.

CHAPTER 118 Excision of Enchondroma 893.e5
FIGURE 118.11 Flap closure.
Step 5: Incision Closure STEP 5 PEARLS

Do not sew the extensor apparatus to the
• The periosteal flaps are closed to cover the bony window when possible (Fig. 118.11). surrounding soft tissue; this can interfere with
• Juncturae tendinum are repaired if they were previously divided. tendon gliding.
• The skin is approximated with interrupted nonabsorbable sutures in the fingers and
a running absorbable suture over the hand.
ADDITIONAL PEARLS
Treatment in the Setting of Pathologic Fracture
• With the presentation of a pathologic fracture, the traditional teaching is to let the
fracture heal first. Patients should undergo therapy to regain motion before definitive
treatment of the enchondroma.
• Multiple authors have described various methods for simultaneous treatment with
curettage and use of bone cements with and without adjunctive fixation.
• With delayed or immediate treatment, the goal should be to restore active range of
motion (ROM) as soon as possible and limit morbidity from prolonged immobilization.
• In the setting of a healed pathologic fracture with a single isolated lesion, some
surgeons advocate serial monitoring with no definitive treatment of the enchon-
droma because of the low risk for malignancy. The healed callus/enchondroma is
thought to be stronger than before the fracture.

• In the setting of an acute fracture, the patient is immobilized in a splint until the
fracture has healed. In all other cases, a soft dressing is applied.
• Dressings are removed after 3 days and patients are started on active ROM exercises.
• Patients are told to avoid lifting more than 5 pounds or performing heavy exercises with
the hand for 6 weeks to permit healing of the medullary cavity before strengthening is
performed.
• Follow-up for all patients is necessary to establish radiographic healing.
• After healing, patients with isolated healed lesions can have a 1-year follow-up and
then subsequent follow-ups as needed.
• Patients with multiple lesions should be followed serially to check for recurrence or
new lesions.
See Video 118.1
EVIDENCE
Klein C, Delcourt T, Salon A, et al. Surgical treatment of enchondromas of the hand during childhood in
Ollier disease. J Hand Surg Am. 2018;43(10):946.e1–e5.
Ten pediatric patients (average: 10.7 years), all affected with enchondromatosis/Ollier disease, with a mean
follow-up of 7.5 years after surgical management. They demonstrated that early management of lesions
with curettage and corticoplasty without bone grafting leads to improved cosmesis and functionality, as
measured by the QuickDASH (Disabilities of the Arm, Shoulder, and Hand) outcome measure.
CHAPTER 119
Excision of Peripheral Nerve Schwannoma
INDICATIONS
• Excision is recommended for a concerning subcutaneous lesion of the upper ex-
tremity.
• Generally, patients present with a slow-growing, firm mass that may or may not be
painful, and the diagnosis is made intraoperatively. Other patients may present with
a neurologic deficit, such as dysesthesia, neuropathic pain, and/or sensorimotor
dysfunction.
Contraindications
Excision may be contraindicated in asymptomatic cases without clinical findings con-
cerning for more aggressive pathology. Misdiagnosis and subsequent nerve resection
contribute to significant morbidity and have been reported in 6% to 10% of cases.
• Although they are the most common benign tumor of the peripheral nervous sys-
tem, schwannomas of the hand and upper extremity are relatively rare. Fewer
than 8% of soft tissue tumors are identified as schwannomas. Up to 19% of
schwannomas occur in the upper extremity, the majority of which are found in the
hand and wrist.
• Clinical examination may reveal a soft, mobile, nontender mass more frequently located
over the volar aspect of the upper extremity. In the upper extremity, schwannomas
most commonly arise from the ulnar, median, or radial nerves (Fig. 119.1A–C).
• Percussion over the mass may produce paresthesias in the distribution of the
affected nerve.
• Clinical findings can be nonspecific, leading to misdiagnosis in many cases. Do not
confuse a schwannoma with a ganglion. These can be differentiated by the lack of
a Tinel sign (tingling at the lesion or more distally when the lesion is percussed) over
a ganglion cyst.
IMAGING
• Preoperative magnetic resonance imaging (MRI) may be useful to evaluate the
lesion’s origin and relationship to surrounding structures. Peripheral nerve sheath
tumors are dark on T1-weighted MRI and bright on T2-weighted MRI. Fig. 119.2A
shows an axial view and Fig. 119.2B shows a sagittal view of T1-weighted MRI of a
median nerve schwannoma.
• MRI findings alone are not adequate to differentiate between benign and malignant
nerve tumors. MRI is 79% sensitive and 84% specific in detecting malignant periph-
eral nerve sheath tumors.
SURGICAL ANATOMY
A thorough understanding of upper extremity peripheral nerve anatomy is required
when embarking on excision of a peripheral nerve tumor. Fig. 119.3A shows a normal
cross-sectional nerve topography. Fig. 119.3B shows nerve topography in the setting
of a schwannoma.
POSITIONING
• The patient is placed in the supine position on the operating table with the entire
upper extremity positioned on an arm board.
894
Left index finger Left palm

digital sensory schwannoma involving
nerve schwannoma the median nerve
A B
Median nerve
schwannoma at
the distal forearm
FIGURE 119.1 (A) Digital schwannoma and (B) palmar schwannoma. (C) Median nerve schwannoma
at the distal forearm.
Median nerve
schwannoma
A B
FIGURE 119.2 (A) Axial view of T1-weighted magnetic resonance imaging (MRI). (B) Sagittal view of
T1-weighted MRI.
896 CHAPTER 119 Excision of Peripheral Nerve Schwannoma
Mesoneurium
External
epineurium
Axon Internal Connective
Nerve
fiber epineurium tissue
components
Myelin Perineurium
Endoneurium
Schwannoma
B
FIGURE 119.3 (A) Anatomic components of a nerve fiber and (B) illustration of schwannoma.
EXPOSURES PEARLS
• The relevant imaging studies should be readily • General anesthesia is provided and a nonsterile tourniquet is applied on the upper arm.
available during the procedure for review during
• The arm is prepared and draped in the standard fashion.
dissection.
• Ensure that microsurgical instruments are • The limb is exsanguinated fully to permit a completely bloodless field.
available for fine dissection.
• Be prepared to address a nerve gap if a EXPOSURES
portion of the nerve requires resection (i.e., The location of the lesion will dictate the necessary exposure. A thorough understand-
if intraoperative findings are consistent with
ing of the anatomy of the entire upper extremity is essential.
a neurofibroma).
PROCEDURE
Step 1
• The incision is marked to extend proximal and distal to the lesion (Fig. 119.4).
• The skin flaps are elevated with a no. 15 blade to expose the peripheral nerve tumor.
FIGURE 119.4 Incision marking.

Median nerve
A B
FIGURE 119.5 (A–B) Exposure of schwannoma and identification of nerve.
STEP 2 PEARLS
Step 2 • Schwannomas are encapsulated lesions of the
Surrounding vascular structures are identified and protected. The affected nerve is dis- nerve sheath that do not infiltrate individual
fascicles. Therefore the lesion can be enucle-
sected proximally to distally (Fig. 119.5A–B). ated or “shelled out” from the nerve, leaving
the parent nerve fascicles intact.
Step 3 • Be aware of nerve branches on the surface of this
• The schwannoma is removed from the parent nerve using microsurgical dissection. tumor because the tumor can splay the nerve fi-
bers; these can be injured if not carefully dissected.
Fig. 119.6A–C shows microsurgical excision of a median nerve schwannoma of the
• If the mass is difficult to remove, it likely represents
right distal forearm that measured approximately 3 cm x 3 cm. a neurofibroma. In this case, the affected area is
resected and reconstructed with a nerve graft.
Mass elevated with

vascular pedicle Mass had splayed and
compressed the nerve fibers
A B
FIGURE 119.6 (A–C) Elevation and excision of schwannoma.

898 CHAPTER 119 Excision of Peripheral Nerve Schwannoma
A B
FIGURE 119.7 (A–B) Postoperative outcome at 2 months.
STEP 3 PITFALLS • The tourniquet is then deflated and hemostasis is ensured.

Symptomatic neuromas may occur in 25% of • The skin is closed using 4-0 or 5-0 nonabsorbable suture.
patients who undergo intraneural dissection. As
such, intraneural dissection should be avoided. POSTOPERATIVE CARE AND EXPECTED OUTCOMES
• The arm is placed in a soft dressing and activities are limited for 2 weeks. Most
patients will have full motor and sensory function after surgery, unless nerve resec-
tion is required for extensive involvement of small nerve branches or an interposition
nerve graft is required for reconstruction.Fig. 119.7A–B demonstrates excellent me-
dian nerve function at 2 months postoperatively.
• There is a higher risk for postoperative neurologic deficit in patients who have previ-
ously undergone biopsy or who have developed recurrent disease.
• Recurrence is uncommon.
See Video 119.1
EVIDENCE
Furniss D, Swan MC, Morritt DG, et al. A 10-year review of benign and malignant peripheral nerve
sheath tumors in a single center: Clinical and radiographic features can help differentiate benign
from malignant lesions. Plast Reconstr Surg. 2008;121:529–533.
In a retrospective review of primary peripheral nerve sheath tumors, the authors identified 32 cases of
malignant peripheral nerve sheath tumor over a ten-year period. The authors compared clinical findings
associated with malignant peripheral nerve sheath tumors to characteristics found in a cohort with
benign peripheral nerve tumors. Statistically significant findings associated with malignant peripheral
nerve sheath tumors were: shorter duration of symptoms (p < .0001), large size (p < .0001), located
deep to fascia (p < .0001) and presence of pain (p = .0004). In comparing malignant lesions directly
to schwannomas, short duration of symptoms (p = .0002) and larger size (p <0.0001) were indicative
of malignancy. MRI was determined to be 79% sensitive and 84% specific in detecting malignant
peripheral nerve sheath tumors.
Rockwell GM, Thoma A, Salama S. Schwannoma of the hand and wrist. Plast Reconstr Surg.
2003;111:1227–1232.
The authors performed a retrospective review examining 280 cases of schwannomas over a 6-year
period. They further studied the schwannomas localized to the hand and wrist, which accounted for
7.5% of lesions. The volar surface of the hand or wrist was affected in 81% of these cases. The
authors report that preoperative diagnosis was correct in only 19% of cases. Ganglion was the most
frequent misdiagnosis, accounting for 38% of cases. All schwannomas affecting the hand (most
often the common digital nerves) presented with pain. In the seven patients with schwannomas of
the median, radial, or ulnar nerves, four presented with a painless, enlarging mass; three of seven
presented with pain (Level III evidence).
Kang HJ, Shin SJ, Kang ES. Schwannomas of the upper extremity. J Hand Surg Br. 2000;25:604–607.
This study presented the clinical characteristics, MRI features, and postoperative results of 20 schwanno-
mas in the arms of 13 patients. Twelve tumors had a positive Tinel sign, one caused weakness of the
wrist and another in the Guyon canal caused hypothenar muscle atrophy. Of the nine cases that under-
went MRI preoperatively, six were correctly diagnosed as schwannomas. All masses were excised us-
ing microsurgical techniques and two transient neurologic complications occurred (Level III evidence).
Phalen GS. Neurilemmomas of the forearm and hand. Clin Orthop Relat Res. 1976;114:219–222.
In this classic article, preoperative evaluation and surgical excision of 17 neurilemmomas were de-
scribed. Six were present in the forearm and 11 were in the hand and wrist. There were five tumors
in fingers, one in the thumb, three in the palm, and two in the wrist. In the forearm, three tumors in-
volved the median nerve, two involved the ulnar nerve, and one arose from a small sensory branch of
the radial nerve. The tumors are well-encapsulated and may be easily enucleated from the parent
nerve. Resection of the involved nerve is seldom necessary except when small nerves are extensively
involved (Level III evidence).
CHAPTER 120
Excision of Malignant Skin Tumors

This chapter includes the following video: Video 120.1 – Nail Tumor Excision and
Dermal Substitute Coverage.
KEY CONCEPTS
• Wide local excision of skin tumors is indicated for all malignant lesions with proven
survival benefit after resection.
• The goals of treatment are complete cancer removal with preservation of function
and appearance.
• Important preoperative considerations include defining margins for wide local exci-
sion, regional lymph node management, and mode of reconstruction.
• The National Comprehensive Cancer Network (NCCN) provides guidelines for exci-
sion margins and regional lymph node management for malignant melanoma, squa-
mous cell carcinoma, and basal cell carcinoma.
• Clinical examination should include documentation of size, color, ulceration, and
mobility of all primary lesions. Regional lymph nodes around the elbow and axilla are
palpated.
• Routine imaging studies and blood tests are not recommended in patients without
clinical concerns for metastasis because they have high rates of false-positive findings.
• If microvascular flap reconstruction is planned, the potential recipient and donor
vessels should be located and evaluated preoperatively.
• For locally invasive cancers, the deep structures, such as deep fascia, paratenon,
tendons, muscles, or even the bone should be evaluated and resected en bloc with
the tumor if involved. The deep resection margins are one fascial layer beneath the
involved tissue.
• Wide local excision of cutaneous melanoma and reconstruction with skin graft and/
or skin substitute
• Wide local excision of subungual melanoma
• Wide local excision and reconstruction with a local flap
• Wide local excision and reconstruction with lateral arm free flap
FIGURE 120.5 Subungual melanoma.
900
CHAPTER 120
Excision of Malignant Skin Tumors
INDICATIONS
• All malignant lesions with proven survival benefit after cancer resection are indica-
tions for this procedure.
• The goals of treatment are complete cancer removal with preservation of function
and appearance.
• There are a few preoperative key considerations:
1. Wide local excision margins
2. Regional lymph node management
3. Mode of reconstruction
MALIGNANT MELANOMA
• For malignant melanoma, the excision margin is dependent on tumor thickness, Recommended Margins for
TABLE Wide Excision of Primary
which is also known as the Breslow depth. Table 120.1 shows the recommended 120.1
excision margins based on the NCCN Clinical Practice Guidelines in Oncology Melanoma
(NCCN Guidelines®) version 1.2021. Breslow Recommended
• In terms of regional lymph node management, one of the most predictive indica- Thickness Surgical Margins
tors of lymphatic metastasis of melanoma is tumor thickness. In cases where In situ 0.5–1.0 cm
the Breslow depth is less than 0.8 mm without ulceration (T1a), the probability # 1.0 mm 1.0 cm
that the patient will have a positive sentinel lymph node biopsy (SLNB) is less
than 5%. SLNB should be considered in patients with tumor thickness less than .1.0–2 mm 1–2 cm
0.8 mm with ulceration (T1b) or 0.8 to 1.0 mm with or without ulceration (T1b) .2.0–4 mm 2.0 cm
because the probability of identifying a positive sentinel node increases from .4 mm 2.0 cm
5% to 10%. SLNB is indicated in nearly all patients with a Breslow depth greater
than 1.0 mm because the risk for node positivity increases to greater than 10% Adapted with permission from the NCCN Clinical
Practice Guidelines in Oncology (NCCN Guidelines®)
in these patients. Patients with clinically positive lymph nodes should also un- for Melanoma: Cutaneous V.2.2021 © 2020
dergo lymph node biopsy. A positive SLNB increases the risk for recurrence and National Comprehensive Cancer Network, Inc. All
is an indication for complete lymph node dissection (CLND) and/or adjuvant rights reserved. The NCCN Guidelines® and illustra-
tions herein may not be reproduced in any form for
treatment. any purpose without the express written permission
• In treating subungual melanoma, options include wide local excision and amputa- of NCCN. To view the most recent and complete
tion. In outcomes comparisons, there is not a clear prognostic or survival benefit to version of the NCCN Guidelines, go online to NCCN.
org. The NCCN Guidelines are a work in progress
amputation over wide excision. Traditionally, surgeons tend to amputate at the most that may be refined as often as new significant data
distal unaffected joint. Amputation level has not been shown to affect prognosis. becomes available. NCCN makes no warranties of
Elective lymph node dissection does not significantly decrease the incidence of any kind whatsoever regarding their content, use or
application and disclaims any responsibility for their
lymph node recurrence versus amputation alone. application or use in any way.
SQUAMOUS CELL CARCINOMA

• According to the American Joint Committee on Cancer and NCCN Guidelines®
version 1.2021 for squamous cell carcinoma (SCC), patients are stratified into high-
risk and low-risk groups. Extremity lesions are considered high risk if they have any
of these characteristics: diameter greater than 20 mm; poorly defined borders; rapid
growth; neurologic symptoms; recurrence; Patients on immunosuppression or with
lesions at the site of prior radiation therapy or chronic inflammation are also consid-
ered high risk. Upwards of 91% of patients treated with surgical excision and
confirmed negative margins are disease-free at 5 years. Excision margins of 4 mm
in low-risk lesions and 6 mm margins in high-risk lesions achieve histologically
negative margins in 95% of cases.
• Absolute indications and criteria for determining which patients should undergo
SNLB have yet to be fully elucidated. SLNB is generally indicated for high-risk
900.e1
900.e2 CHAPTER 120 Excision of Malignant Skin Tumors
patients with a clinically suspicious node. Nevertheless, 12% to 17% of patients

with high-risk lesions will present with subclinical nodal metastases. In addition,
patients with nodal disease are at higher risk for recurrence and metastases, rang-
ing from 33% to 45%, even after undergoing CLND. Per the V1.2021 NCCN Guide-
lines, although SLNB may have prognostic value, it is “unclear” whether further
interventions, including CLND and adjuvant therapy, improve outcomes.
BASAL CELL CARCINOMA

• According to the NCCN Guidelines for basal cell skin cancer, as with cutaneous
SCC, excision margins for basal cell carcinoma are determined based on whether a
lesion is determined to be a low risk or high risk for recurrence. High-risk features
for lesions on the extremities include diameter greater than 20 mm, poorly defined
borders, recurrence, site of prior radiation, immunosuppression, aggressive pathol-
ogy, and perineural involvement. For low-risk lesions, an excision margin of
4 mm achieves negative margins in greater than 95% of cases. An excision margin
of 4 to 6 mm is suggested for treatment of high-risk lesions; however, Mohs micro-
graphic surgery (MMS) is the preferred treatment in this group.
• Nodal metastases for basal cell skin cancer are exceptionally rare. As with other types
of skin cancer, a clinically suspicious node should undergo further workup. Results
from SLNB will determine the need for subsequent CLND and adjuvant therapy.
MOHS SURGICAL EXCISION

With traditional margins, the 5-year recurrence rate is 3% to 10% for primary tumors and
more than 17% for recurrent basal cell carcinoma. Mohs surgery has shown a 5-year re-
currence rate of between 1.0% and 1.7% for primary tumors and between 4.0% and 5.6%
in recurrent cases. The benefits of margin control via Mohs surgery are recommended for
lesions with ill-defined borders, areas with need for tissue conservation (digits), aggressive
histologic behavior, perineural invasion, recurrent lesions, or history of radiation.
• A generalized skin examination is performed from head to toe. Documentation
should be made of any precancerous lesions or lesions suspicious for malignancy.
Satellite or in-transit lesions should also be assessed.
• Characteristics of all primary lesions, including size, color, ulceration, and mobility,
should be documented.
• A hand examination with evaluation of neurovascular status and functional capabil-
ity, including range of motion (ROM), is performed.
• Regional nodes around the elbow and axilla are palpated.
• Signs and symptoms of distant metastasis, such as bone pain, weight loss, or
hepatomegaly, are noted.
IMAGING
• Routine imaging studies and blood tests are not recommended in patients without
clinical concerns for metastasis because they have high rates of false-positive findings.
• If deep structure involvement is suspected, magnetic resonance imaging (MRI) may
be helpful. A computed tomography (CT) scan may offer benefit over MRI for evalu-
ation of bony invasion.
• CT angiogram or angiogram of upper extremities can be helpful to evaluate vascular
invasion or preoperative vascular reconstruction planning.
SURGICAL ANATOMY
• There are many anatomic differences between the skin of the palmar and dorsal
surfaces of the hand. The dorsal skin is thin, pliable, and anchored by loose areolar
tissues. Multiple veins and lymphatic vessels course underneath the dorsal skin.
• The glabrous skin of the palm and volar fingers is a specialized organ with a thick
dermal layer and heavily cornified epithelium. Vertically oriented fibrous septae
anchor it to the underlying palmar fascia. An extensive network of sensory end or-
gans and eccrine sweat glands exists in the absence of pilosebaceous structures.
CHAPTER 120 Excision of Malignant Skin Tumors 900.e3
EXPOSURES PEARLS
POSITIONING
If microvascular flap reconstruction is planned, the
• The patient is placed supine with the arm abducted and extended on a hand table. potential recipient and donor vessels should be
• The ipsilateral axilla is exposed if there are any indications for lymphadenectomy. located and evaluated preoperatively.
• All procedures are done under tourniquet application on the affected extremity.
• Donor sites of flaps or grafts are prepared as necessary.
EXPOSURES PITFALLS
EXPOSURES In cases with multiple surgical sites or with large
body surface areas exposed, the surgeon must be
The circumferential margins of the lesion and perilesional inflammatory skin are marked continuously aware of the patient’s temperature
and the excisional markings are placed according to the guidelines for each cancer and work with the anesthesia team to prevent
(Fig. 120.1). hypothermia.
Wide Local Excision of Cutaneous Melanoma and STEP 1 PEARLS

Reconstruction With Skin Graft and/or Skin Substitute • For locally invasive cancers, the deep struc-
tures, such as deep fascia, paratenon, tendons,
PROCEDURE muscles, or even the bone should be evaluated
and resected en bloc with the tumor if involved.
Indications The deep resection margins are one fascial
• As previously discussed, all cases of melanoma require wide surgical excision. The layer beneath the involved tissue (Fig. 120.2).
• A “no-touch” technique is required to diminish any
extent of margins and need for adjuvant therapy are determined based on risk fac-
tumor spillage. Covering the lesion with a swab or
tors for metastases and recurrence. a transparent adhesive pad during cancer resec-
• Wound coverage with a skin graft or skin substitute is often indicated in cases with tion can reduce any tumor spillage.
a viable wound bed with an overlying defect that cannot be closed primarily.
Step 1: Wide Local Excision of Cancer STEP 1 PITFALLS
Appropriate margins are marked and incisions are made through the skin, down to • Tumor rupture should be avoided during
resection.
fascia. The resection removes all of the tissue above the underlying deep fascial layer.
• In cases that are questionable regarding
Nonabsorbable sutures are placed to geographically orient the lesion. incomplete margins, frozen sections may
be requested as necessary.
Step 2: Application of Dermal Substitute (Optional in Many Cases)
• Careful hemostasis is obtained.
• The dermal substitute is prepared according to the instructions for the product.
• Bovine collagen dermal analog (i.e., Integra) should be wet before application.
• The product is trimmed according to the defect size and fixed to the wound bed with
4-0 absorbable sutures (Fig. 120.3).
• A bolster dressing, compressive wrap, or wound vac is applied to promote contact
and prevent shear of the graft.
• The initial dressing is replaced at 1 week, and the patient then performs dressing
changes until 2 to 3 weeks postoperatively.
FIGURE 120.1 Circumferential margins of the lesion and markings for FIGURE 120.2 Deep resection margins are one fascial layer
excision. beneath the affected tissue.
FIGURE 120.3 Integra is fixed to the wound bed. (Courtesy FIGURE 120.4 Dermal substitute improves skin quality of grafted
Dr. Steven Haase, Michigan Medicine.) area. (Courtesy Dr. Steven Haase, Michigan Medicine.)
STEP 2 PEARLS
STEP 3: SKIN GRAFT
• Substitutes provide coverage to small areas of
exposed tendon/bone, can serve as a tempo- • A thin sheet graft (0.011–0.015 inches [0.30–0.40 mm]) is harvested from an appro-
rizing measure if there are significant concerns priate donor site.
for margin control, and often improve the con- • If a dermal substitute with a superficial silicone membrane has been previously used,
tour of defects by interposition of a layer that the overlying silicone layer must be removed before autograft placement.
forms a “neodermis.” The quality of the grafted • The skin graft is sewn in with 4-0 absorbable suture and a compression wrap or
area after dermal substitute placement is more
pliable and has better texture than split-thick- bolster is placed.
ness skin graft alone (Fig. 120.4).
• Revascularization of the dermal substitute is Wide Local Excision of a Subungual Melanoma
based on contact to the underlying vascular
bed. Small longitudinal “pie-crusting” cuts
permit small amounts of fluid to drain and PROCEDURE
prevent formation of interposing seroma or
microhematomas. Indications
• Melanocytic or dark lesion of the nail bed is present for greater than 3 to 4 weeks. If
the lesion appears to advance or move distally with nail plate growth, it is acceptable
STEP 2 PITFALLS to continue to monitor without treatment.
Dermal substitute is not necessary for many • Size increase, irregular borders, extension beyond the nail fold, and nail plate lifting
cases. For these cases, proceeding directly to skin are more concerning signs. If the hyperpigmented lesion progressively grows along
grafting is sufficient. with these clinical signs, this is an indication for tissue biopsy (Fig. 120.5).
FIGURE 120.5 Subungual melanoma.

FIGURE 120.6 (A–B) Germinal matrix exposed with 45-degree radial cuts to the eponychial fold.
STEP 1 PEARLS
• Ensure that the nail bed and plate are fully
Step 1: Diagnostic Biopsy separated. You do not want to avulse the nail
• The nail plate is removed with use of a periosteal elevator and scissors. bed with plate removal.
• Placement of the sharpened end of the eleva-
• The germinal matrix is exposed with 45-degree radial cuts to the eponychial fold
tor against the nail plate will avoid damage to
(Fig. 120.6A–B). the nail bed when separating.
• A full-thickness elliptical biopsy is taken and the nail bed is repaired with 6-0 or 7-0
absorbable suture. The nail fold is stented with a piece of sterile foil to prevent synechia.
STEP 1 PITFALLS
Step 2: Complete Resection and Reconstruction Melanonychia can be caused by a number of
• Once malignant pathology is confirmed, definitive treatment is performed. benign conditions; however, biopsy is indicated if
• Wide local excision margins require ablation of the entire nail bed in most cases un- there is any doubt surrounding the diagnosis. Poor
less proceeding with an amputation (Fig. 120.7A–B). repair of the nail bed during excisional biopsy can
• The folds are carefully elevated using the radial incisions. The sterile and germinal lead to permanent deformity of the nail bed. Nail
repair should be meticulous.
matrix are removed, leaving a bed of periosteum on the distal phalanx.
A B
FIGURE 120.7 (A) Markings for wide local excision. (B) Excised subungual melanoma.
A B
FIGURE 120.8 (A–B) Dermal substitute placed.
STEP 2 PEARLS • A full-thickness skin graft is harvested and sewn to the defect with 6-0 absorbable
suture. The periosteum over the distal phalanx should be preserved to facilitate
Carefully raised flaps and visualization are
imperative to complete nail bed ablation. grafting over it. A dermal substitute can also be used (Fig. 120.8A–B). If the tumor is
deeply invasive, amputation is more appropriate.
STEP 2 PITFALLS Wide Local Excision and Reconstruction With a Local Flap
• Incomplete removal of the nail bed will result
in recurrent nail growth. PROCEDURE
• Do not excise the periosteum and expose the
bone of the distal phalanx. Indications
• Procedural indications include complex defects that require composite tissue recon-
structions, exposure of vital structures or avascular structures over the wound bed,
STEP 2 PITFALLS and an area over a joint with potential for scar contracture.
The dorsum of the hand is one anatomic location • Free tissue transfer is necessary for complex composite reconstruction, postopera-
where the skin is very forgiving. This does not hold tive adjuvant radiation candidate, surrounding scarring of local tissue, or preopera-
true for many other locations on the hands and
tive radiated tissue.
fingers.
Step 1: Wide Local Excision
• Appropriate margins are marked according to the latest NCCN Guidelines (Fig. 120.9).
• The lesion is excised and the defect is analyzed.
Step 2: Flap Elevation and Inset

• The surrounding skin and soft tissue are assessed. If they are of adequate quality,
abundance, and elasticity, a local flap can be designed (Fig. 120.10A–B).
• The flap is elevated in the same plane as the resection.
• The skin edges are closed with interrupted nonabsorbable suture.
Wide Local Excision and Reconstruction With Lateral Arm

Free Flap
PROCEDURE
Step 1: Wide Excision, Defect Analysis, and Defect Preparation
• The appropriate wide excision margins are marked from the old biopsy scar. The
skin is incised down to fascia and the lesion is sharply excised (Fig. 120.11). Non-
FIGURE 120.9 Wide local excision markings. absorbable sutures are used to orient the geography of the specimen.
A B
FIGURE 120.10 (A–B) Local flap.
FIGURE 120.11 Wide excision markings in preparation for reconstruction with lateral free arm free
flap.
STEP 1 PEARLS
• Tumor recurrence surveillance is more difficult
• In this patient, the physical examination demonstrated cancer invasion through to after bulky flap reconstruction.
the extensor pollicis longus tendon. The extensor tendon is removed with the lesion • In a case with concern for clearance of the
(Fig. 120.12). tumor at the initial surgery, the wound will be
• The recipient vessels are identified by intraoperative handheld Doppler. Vascular treated temporarily with a moist dressing.
loops are placed around the pedicle to facilitate dissection and identification. Permanent closure will wait for pathologic
determination of margin control.
• The artery and veins are dissected and cleaned for microvascular anastomoses.
Step 2: Extensor Pollicis Tendon Reconstruction and Lateral Arm

STEP 1 PITFALLS
Free Flap Harvesting
Complicated reconstruction in the setting of
• The palmaris longus tendon graft is harvested from the ipsilateral forearm via mul- inadequate local cancer control does not benefit
tiple stab incisions. The length of tendon graft is determined according to the re- the patient.
sected tendon specimen.
• The tendon graft is woven to the proximal and distal ends of the extensor pollicis
tendon and repaired with 4-0 braided multifilament absorbable sutures. The tension
is set with slight extension of the interphalangeal (IP) joint and flexion of metacarpo-
phalangeal (MCP) joint of thumb (Fig. 120.13).
EDC EIP ECRB
ECRL
FIGURE 120.12 Underlying extensor tendon removed with lesion. Palmaris longus tendon for EPL
FIGURE 120.13 Tendon graft is sutured to the extensor pollicis tendon.
Deltoid
Lateral
tuberosity
humeral
epicondyle
FIGURE 120.14 Skin island’s axis of the lateral arm flap is centered over a line between the deltoid
tuberosity to the lateral epicondyle.
STEP 2 PEARLS • The dimension of the lateral arm flap is designed to match the defect. A template of
• Perforator location can be determined with a the defect can be created with a sponge or paper. The donor and recipient pedicle
pencil Doppler preoperatively and can help location should be considered during template designation. The skin island’s axis of
facilitate flap dissection.
the lateral arm flap is centered over a line between the deltoid tuberosity to the lat-
• A two-team approach is often preferable in
cases involving free tissue transfer. One team eral epicondyle (Fig. 120.14).
prepares the donor site and recipient vessels, • For flap harvesting details and closure, refer to Chapter 92.
and the second team harvests the free flap. • The length of the pedicle is measured from the border of the flap and is dissected
• If a sensate flap is planned, the lateral brachial to a length adequate for the anastomosis distally in the hand. The maximum length
cutaneous nerve can be incorporated in the
of the posterior radial collateral artery is reached at the profunda brachii artery. The
flap for sensory neurotization.
flap is elevated from the triceps muscle posteriorly and from the brachialis anteriorly.
The pedicles are the posterior radial collateral vessels (Fig. 120.15).
STEP 2 PITFALLS
Step 3: Microvascular Anastomoses and Flap Inset
During the anterior dissection of the flap, the
brachialis and brachioradialis muscles may be • The lateral arm flap is inset over the defect and oriented in a way that will not com-
adherent to the flap. The radial nerve passes promise the flow by bending the pedicle or placing unnecessary tension.
between these two muscles. The wrong plane of • The flap is temporally fixed to the defect with 4-0 nonabsorbable sutures, and the
dissection or bleeding of the perforator muscular skin paddle over the pedicle area is folded over to expose the pedicle to facilitate
branches can obscure the operative field and risk
microvascular anastomoses.
injuring the radial nerve.
• Arterial and venous anastomoses are meticulously completed using 9-0 or 10-0
nylon suture. The patency is confirmed, and the vascular condition of the flap is
Posterior radial
collateral artery Lateral
intermuscular
septum
Triceps
Septocutaneous perforators Flap
FIGURE 120.15 Posterior radial collateral vessels are the free flap’s pedicle.
FIGURE 120.16 Closure of donor site and free lateral arm flap.
observed. If there are any signs of vascular compromise, the pedicle is inspected for
kinking, tension, or technical error.
• A drain is placed beneath the flap and the flap is inset with 4-0 nylon suture. The
donor site is closed in layered fashion (Fig. 120.16).

• Postoperative protocol consists of intensive care unit (ICU) admission for close POSTOPERATIVE PITFALLS
observation and hourly flap monitoring. Prolonged immobilization should be avoided. This
• The extremity should be elevated to reduce edema and venous congestion. will create joint stiffness or scar contracture.
• In the follow-up appointments, splints are discontinued and sutures are removed
10 to 14 days postoperatively.
• A rehabilitation program is initiated depending on the specific reconstruction
required. Patients with isolated soft tissue coverage rarely require therapy.
• If the flap is too bulky, postoperative compression can be helpful in the short term.
Persistent bulkiness can be addressed with liposuction or open lipectomy. The vas-
cularity of the flap should be well established before undertaking any revisions. We
recommend waiting at least 3 to 6 months after initial flap inset.
See Video 120.1
EVIDENCE
Cochran AM, Buchanan PJ, Bueno Jr RA, Neumeister MW. Subungual melanoma: A review of current
treatment. Plast Reconstr Surg. 2014;2:259–273.
This article discusses the controversy in the treatment of subungual melanoma. The paucity of uniform
information, lack of accurate depths of melanoma invasion, and biased treatment prevent any defini-
tive treatment protocol for subungual melanomas. There is evidence that melanoma in situ can be
treated with wide local excision. Only four publications on this topic compare wide local excision and
amputation treatments for melanoma directly and all do so in a retrospective manner. Studies do not
universally support the finding that amputation improves survival benefit.
Ilyas EN, Leinberry CF, Ilyas AM. Skin cancers of the hand and upper extremity. J Hand Surg Am.
2012;37:171–178.
This is a review article on the topic of skin cancers in the hands, and it summarizes recommendations
from the cancer boards and societies regarding diagnostic evaluation, intervention, and cancer sur-
veillance.
Marsden JR, Newton-Bishop JA, Burrows L, et al. British Association of Dermatologists (BAD) Clinical
Standards Unit. Revised UK guidelines for the management of cutaneous melanoma 2010. J Plast
Reconstr Aesthet Surg. 2010;63:1401–1419.
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OPERATIVE TECHNIQUES IN HAND AND WRIST SURGERY, ISBN: 978-0-323-79415-2

Previous editions copyrighted 2008, 2012, 2018

Library of Congress Control Number: 2021932735

Content Strategist: Belinda Kuhn

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Phillip R. Ross, MD

Operative Techniques in Hand and Wrist Surgery, 4th Edition

Kevin C. Chung, MD, MS

Section I Anesthesia and Emergency Procedures, 1

CHAPTER 1 Anesthesia of the Hand, 2

Section II Hand Fractures and Dislocations, 17

CHAPTER 7 Principles of Bone Fixation and Healing, 18

CHAPTER 15  pen Reduction for Metacarpophalangeal Joint

Section III Wrist Fractures and Carpal Instability, 53

CHAPTER 19 Wrist Arthroscopy, 54

CHAPTER 31  rocedures for Avascular Necrosis of the Lunate

Section IV Forearm Fractures, 211

CHAPTER 32 Operative Treatment of Distal Radius Fractures, 212

Section V Rheumatoid Arthritis and Degenerative Disease, 277

CHAPTER 36  etacarpophalangeal Joint Synovectomy, Crossed

CHAPTER 47  rapeziectomy and Abductor Pollicis Longus

Section VI Nerve Conditions, 426

CHAPTER 55 Open Carpal Tunnel Release, 427

Section VII Nerve Injuries and Palsy, 465

CHAPTER 60 Digital Nerve Repair, 466

CHAPTER 65  endon Transfers for Low and High Ulnar Nerve

Section VIII Tetraplegic Conditions, 546

CHAPTER 69  endon and Nerve Transfers for Spinal Cord Injury

Section IX Tendon Conditions, 601

CHAPTER 77 Wide-Awake Approach for Tendon Transfers, 602

CHAPTER 81 Tenolysis of Flexor Tendons, 637

Section X Flaps and Microsurgery, 642

CHAPTER 85 Management of Mangled Extremities, 643

Section XI Contractures and Spastic Conditions, 744

CHAPTER 98  urgical and Nonsurgical Treatment of Dupuytren

CHAPTER 99 Biceps and Brachialis Lengthening, 757

Section XII Congenital Hand Disorders, 785

CHAPTER 105 Pediatric Trigger Digits, 786

Section XIII Tumors, 882

CHAPTER 116 Hand Masses, 883

CHAPTER 117 Excision of Vascular Lesions of the Hand, 892

1.1 Anesthesia of the Hand

27.1 Scaphoidectomy and Four-Corner Fusion

53.1 Total Wrist Fusion Using a Synthes Plate and Cadaveric

69.1 Supinator to Posterior Interosseous Nerve Transfer

103.1 Proximal Interphalangeal Volar Capsulotomy

Anesthesia and Emergency

Full text of this chapter is available online at expertconsult.com.

Superficial radial nerve

Dorsal cutaneous branch of ulnar nerve

FIGURE 1.1 Sensory distribution of dorsal hand.

Superficial radial nerve

Dorsal cutaneous branch of ulnar nerve

Extensor pollicis longus

A B Abductor pollicis longus

• Aspirate the syringe before injecting to avoid

RADIAL NERVE BLOCK

Flexor carpi radialis

CHAPTER 15 pen Reduction for Metacarpophalangeal Joint

CHAPTER 31 rocedures for Avascular Necrosis of the Lunate

Section V Rheumatoid Arthritis and Degenerative Disease, 277

CHAPTER 36 etacarpophalangeal Joint Synovectomy, Crossed

CHAPTER 47 rapeziectomy and Abductor Pollicis Longus

CHAPTER 65 endon Transfers for Low and High Ulnar Nerve

CHAPTER 69 endon and Nerve Transfers for Spinal Cord Injury

CHAPTER 98 urgical and Nonsurgical Treatment of Dupuytren