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Operative Techniques:
Hand and Wrist Surgery
Third Edition
Kevin C. Chung, MD, MS

Chief of Hand Surgery, University of Michigan Health System
Charles B. G. de Nancrede Professor of Plastic Surgery and Orthopaedic Surgery
Assistant Dean for Faculty Affairs
Associate Director of Global REACH
University of Michigan Medical School
Ann Arbor, Michigan
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
OPERATIVE TECHNIQUES: HAND AND WRIST SURGERY,

THIRD EDITION ISBN: 978-0-323-40191-3
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of p roducts
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Previous editions © 2012, 2008
Library of Congress Cataloging-in-Publication Data
Names: Chung, Kevin C., editor.

Title: Hand and wrist surgery / [edited by] Kevin C. Chung.
Other titles: Operative techniques.
Description: 3rd edition. | Philadelphia, PA : Elsevier, [2018] | Series:
Operative techniques | Includes bibliographical references and index.
Identifiers: LCCN 2016046027 | ISBN 9780323401913 (hardcover : alk. paper)
Subjects: | MESH: Hand--surgery | Orthopedic Procedures--methods | Atlases
Classification: LCC RD559 | NLM WE 17 | DDC 617.5/75059--dc23
LC record available at https://lccn.loc.gov/2016046027
Content Strategist: Kayla Wolfe

Senior Content Development Manager: Taylor Ball
Publishing Services Manager: Catherine Jackson
Project Manager: Kate Mannix
Design Direction: Amy Buxton
Illustrations Manager: Lesley Frazier
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Chin-Yin and William
and
in memory of my mother-in-law, Chun-Huei
v
Contributors
Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Taichi Saito, MD, PhD

Assistant Professor of Surgery Resident International Research Fellow
Division of Plastic Surgery Section of Plastic Surgery Section of Plastic Surgery
Riley Children’s Hospital Department of Surgery Department of Surgery
Indiana University School of Medicine University of Michigan University of Michigan
Indianapolis, Indiana Ann Arbor, Michigan Ann Arbor, Michigan;
Orthopaedic Surgery Section
Matthew Brown, MD Steven C. Haase, MD, FACS Okayama University
Hand Fellow Associate Professor of Surgery Okayama, Japan
Section of Plastic Surgery Section of Plastic Surgery
Department of Surgery Associate Professor of Orthopaedic Erika Davis Sears, MD, MS
University of Michigan Surgery Assistant Professor of Surgery
Ann Arbor, Michigan University of Michigan Medical School Section of Plastic Surgery
Ann Arbor, Michigan Department of Surgery
Kevin C. Chung, MD, MS University of Michigan Medical School
Chief of Hand Surgery Sirichai Kamnerdnakta, MD Ann Arbor, Michigan
University of Michigan Health System International Research Fellow
Charles B. G. de Nancrede Section of Plastic Surgery Jennifer F. Waljee, MD, MPH, MS
Professor of Plastic Surgery and Department of Surgery Assistant Professor
Orthopaedic Surgery University of Michigan Section of Plastic Surgery
Assistant Dean for Faculty Affairs Ann Arbor, Michigan; Department of Surgery
Associate Director of Global REACH Division of Plastic Surgery University of Michigan Medical School
University of Michigan Medical School Department of Surgery Ann Abor, Michigan
Ann Arbor, Michigan Faculty of Medicine
Siriraj Hospital Guang Yang, MD
Yuki Fujihara, MD Mahidol University Associate Professor
International Research Fellow Salaya, Thailand Department of Hand Surgery
Section of Plastic Surgery China-Japan Union Hospital of
Department of Surgery Brian P. Kelley, MD Jilin University
University of Michigan Resident Changchun, Jilin Province, Peoples’
Ann Abor, Michigan; Section of Plastic Surgery Republic of China
Department of Hand Surgery Department of Surgery
Nagoya University Graduate School University of Michigan
of Medicine Ann Arbor, Michigan
Nagoya, Japan
Brett Michelotti, MD
Nasa Fujihara, MD Hand Fellow
International Research Fellow Section of Plastic Surgery
Section of Plastic Surgery Department of Surgery
Department of Surgery University of Michigan
University of Michigan Ann Arbor, Michigan
Ann Arbor, Michigan;
Department of Hand Surgery
Nagoya University Graduate School of
Medicine
Nagoya, Japan
vi
Preface
Welcome to the third edition of this classic treatise on hand and wrist operative
techniques. There is a general view that new editions are simply updating current infor-
mation without structurally changing a textbook. However, this third edition is different
because every chapter is rewritten and augmented with new pictures and videos to
provide a strong foundation for carrying out operations in a safe and efficient manner.
For the past two years, my team and I have meticulously collected pictures and videos
in anticipation of refurbishing this entire textbook so that it will be consistently high qual-
ity in lieu of a multiauthor textbook that may not have a uniform effort. All the operations
were done by me and my colleagues at the University of Michigan and organized by my
team of international scholars and staff members. I am certain that this textbook will
meet your high expectations of my team’s work.
As I travel around the world as a visiting professor, I see this textbook on a number of
bookshelves and book stores. Many of you have approached me to share your enthu-
siasm for this book. With such encouragement and fervor to leverage this textbook to
provide the best care for our patients, I have worked intensely for several years to pro-
duce this book, which sets the standard for meticulous illustrations and pictures, clear
scientific writing, and a dazzling array of more than 100 operative videos to cover all
procedures in hand surgery. Even though you may have purchased the first and second
editions, this third edition provides incremental knowledge to previous editions that
makes all three editions a seamless encyclopedic collection of hand surgical proce-
dures. I hope you will treasure this textbook as much as I do. Ultimately, this textbook
was made through your prodding and your enthusiasm.
A textbook like this requires many hours of intense effort by everyone involved. I
would like to acknowledge my trusted assistants Brianna Maroukis and Helen Huette-
man, who worked together to make this book a reality. Furthermore, my international
scholars Nasa Fujihara, Yuki Fujihara, Sirichai Kamnerdnakta, Taichi Saito, and Michiro
Yamamoto have meticulously captured every picture and video and spent countless
hours to organize the pictures and illustrations, as well as editing the videos to ensure
the highest quality possible. I would also like to acknowledge Taylor Ball from Elsevier,
who has worked with me on all three editions of this textbook. Without his dedication,
the book would not be able to be produced on time and presented to you seamlessly.
My thanks go to Elsevier’s Dolores Meloni, who vouched to the Elsevier leadership
that this third edition represents the most creative and comprehensive product in the
publishing world. Finally, my tribute to my patients, who are my best mentors; I learned
so much by their entrustment of themselves and their family members under my care.
Every patient in my practice has had preoperative, intraoperative, and postoperative
pictures taken so that I can review their treatment course to reflect and learn from their
outcomes. Someone asked me who my best mentor is. Without hesitation, I responded:
my patients.
I am eternally grateful to you for your interest and your support of this textbook
series. I look forward to seeing this textbook on your shelves. Please do seek me out at
national and international meetings so that I can thank you personally for your friendship
and encouragement.
Kevin C. Chung, MD, MS
vii
Foreword
It is with great honor and pleasure that I write the foreword for the third edition of Opera-
tive Techniques: Hand and Wrist Surgery, written by my friend and colleague Dr. Kevin
C. Chung. Current readers of hand surgery and plastic surgery texts all know Dr. Chung,
the Charles BG de Nancrede Professor of Surgery, Plastic Surgery, and Orthopae-
dic Surgery at the University of Michigan. Although he has published more than 400
peer-reviewed papers, 200 book chapters, and 18 textbooks, this may be the prolific
Dr. Chung’s best work. Why? Because it is consistent, concise, comprehensive, and
contemporary—four critical attributes of a classic textbook.
The format and prose are consistent. Although there are excellent coauthors, this
is essentially a single author textbook. Dr. Chung’s expert voice is present throughout.
With prior experience as an editor of the Journal of Hand Surgery and Plastic & Recon-
structive Surgery, Dr. Chung’s style of writing is crisp and clear.
A well-used surgical textbook should be concise. The chapters have bullet point
sections on Indications, Clinical Examination, and Surgical Anatomy. This is a proce-
dure-based textbook, and each key procedure is outlined as a step-by-step technique
guide. I agree with Dr. Chung that operations are best taught in this manner. The exten-
sive video library complements each chapter brilliantly. The figures have been carefully
presented with just the key anatomic points, and only the classic articles are referenced
for collateral reading.
Most importantly, this textbook is comprehensive and contemporary. The 105
chapters are based on Dr. Chung’s vast experience in all aspects of hand surgery.
Although many hand surgeons have chosen to focus on one specialized area, Dr. Chung
is known at his institution and internationally as adept at “doing it all”—from congenital
hand to complex distal radius fractures and microsurgical reconstruction. His practice
is dynamic; therefore, this third edition is up-to-date with new techniques such as per-
cutaneous needle aponeurotomy and nerve transfers.
Only a select few have the breadth and depth of clinical experience to present a
single primary author textbook of hand surgery. Dr. Kevin Chung has done so in out-
standing fashion. This third edition has refined an already classic textbook, one that I
have always recommended to my own trainees.
James Chang, MD
Chief, Division of Plastic & Reconstructive Surgery
Johnson & Johnson Distinguished Professor of Surgery & Orthopedic Surgery
Stanford University Medical Center
72nd President of the American Society for Surgery of the Hand (2017-2018)
viii
PROCEDURE 1
Anesthesia of the Hand

Aviram M. Giladi and Kevin C. Chung
Indications
• Postoperative pain control
• Aid in functional evaluation of traumatic injuries
• Bedside procedures in the emergency department
• Minor hand surgery procedures (“wide awake” hand surgery)
• Avoidance/reduction of sedation or airway instrumentation in higher risk patients
• Performing procedures that benefit from testing intraoperative movement (tenolysis,
trigger finger release, etc.)
Clinical Examination
Anesthetic Agents
• Lidocaine is most widely used—onset approximately 3 to 5 minutes, duration of ac-
tion 60 to 120 minutes.
• Bupivacaine (Marcaine) is also commonly used for longer durations of pain control
(∼400–450 minutes); however, onset takes up to 15 minutes or more.
• Use of epinephrine mixed in with the local anesthetic (1:200,000 or even 1:100,000)
is not contraindicated in the hand or fingers and may increase duration of anesthetic
action while aiding in minimizing blood loss.
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 arbo-
rizes 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 sty-
loid and as far dorsal/ulnar as the area in line with the middle finger metacarpal
(Fig. 1.3A and B).
• 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.
• To identify PL, have patient pinch thumb to ring/small finger and see tendon bulge
in wrist (Fig. 1.4A and B).
• If not present or identifiable, the ulnar border of FCR tendon can be used as the
landmark.
• The ulnar nerve crosses the wrist in the area of the flexor carpi ulnaris tendon, proxi-
mal to its insertion on the pisiform (prior to nerve entering Guyon canal).
• The ulnar artery is radial to the nerve and to the flexor carpi ulnaris (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. 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 metacar-
pophalangeal joint.
• Each finger has a volar and dorsal nerve on the ulnar and radial sides (total four
digital nerves). The volar branches are larger, and within the finger will be volar to the
corresponding digital artery. The volar branches pass from the common digital nerve
proximal to each webspace and enter the finger (Fig. 1.6).
3
4 PROCEDURE 1 Anesthesia of the Hand
Superficial radial nerve
Dorsal cutaneous branch of ulnar nerve
Median nerve
Ulnar nerve
FIGURE 1.1
Ulnar
nerve
Median
nerve
Radial
nerve
FIGURE 1.2
Positioning
Blocks are most easily performed with patient supine and arm extended out on a hand
table with dorsum down. This is especially true for the median nerve block. However,
as long as the wrist and elbow are free to be moved, these blocks can generally be
performed in a variety of hand and arm positions.
PROCEDURE 1 Anesthesia of the Hand 5
Extensor pollicis longus
Superficial radial nerve
Styloid process
of radius
Scaphoid
Abductor pollicis longus

B
FIGURE 1.3
Procedure: Radial Nerve Block RADIAL NERVE BLOCK: STEP 1 PEARLS

• The radial nerve block at the wrist is, in
Step 1 essence, a superficial field block in the area
Begin with volar injection radial to the radial artery (along the radial border of the fore- around the radial styloid (Fig. 1.8).
arm/wrist), proximal to the radial styloid. Inject in the subcutaneous plane, being sure • Block is performed superficial to the first and
to aspirate before injecting to confirm no violation of the radial artery that could result second extensor compartment as well as the
anatomic snuffbox.
in an intraarterial injection (Fig. 1.7).
Step 2 RADIAL NERVE BLOCK: STEP 1

PITFALLS
Adjust position and move the needle along the radial border of the radius and then
The nerve branches travel in the subcutaneous
dorsally, to the area of the radial styloid, and inject again into the subcutaneous plane. plane; there is no need for deep injection with this
block.
Step 3
• Continue these subcutaneous injections along the dorsum, beyond the styloid, as far
ulnar as the area inline with the middle finger metacarpal.
Flexor carpi radialis
Median nerve
B Palmaris longus
FIGURE 1.4
Ulnar nerve
FIGURE 1.5
Dorsal sensory nerve Dorsal branch of the volar digital nerve
Volar digital nerve
FIGURE 1.6
Range of infiltration
Styloid process
1% Lidocaine + 0.5% Marcain

FIGURE 1.8
FIGURE 1.7
RADIAL NERVE BLOCK: STEP 3 PEARLS

• This technique often requires multiple needle
insertion points to cover adequate territory
around the curvature of the wrist without
injecting too deeply.
• This injection requires more anesthetic than
the others, with upwards of 10 mL needed for
adequate infiltration of the entire area.
FIGURE 1.9 MEDIAN NERVE BLOCK: STEP 1 PEARLS

• The injection is performed at the level of the
• One can also move slightly more proximal to confirm adequate anesthesia of the proximal wrist crease, in line with the ulnar
carpus (Fig. 1.9). styloid (Fig. 1.10).
• Flex or extend the fingers to see if the needle
“bobs.” This confirms localization at the
Procedure: Median Nerve Block entrance to the carpal tunnel.
Step 1
Identify the nerve between PL and FCR (or just ulnar to FCR). Enter approximately MEDIAN NERVE BLOCK: STEP 1
PITFALLS
1 cm deep, through the flexor retinaculum, and infiltrate with approximately 5 mL of
local anesthetic. • The median nerve block is done with injections
in a deep as well as superficial plane. The
landmarks described in the anatomy section
Step 2 are critical to proper localization of the nerve.
Slowly withdraw, and inject another small aliquot superficial to the retinaculum to
block the palmar cutaneous branch.
Flexor carpi radialis
FIGURE 1.11
Palmaris longus
FIGURE 1.10
ULNAR NERVE BLOCK: STEP 1 PEARLS

The ulnar nerve block can be done radial or ulnar Procedure: Ulnar Nerve Block
to FCU; however, we prefer the ulnar approach to
minimize risk of injection into the ulnar artery. Step 1
Identify FCU, and move ulnar and dorsal to the tendon (Fig. 1.11).
INTERMETACARPAL BLOCK: STEP 1
PEARLS
Step 2
• Injection site is at the distal palmar crease,
• At the level of the distal ulna, insert the needle and slide under the area of FCU (dor-
proximal to the metacarpophalangeal joint.
• Approach can be volar or dorsal, many report sal and ulnar to the tendon).
less patient discomfort with a dorsal approach. • Inject approximately 5 mL of anesthetic solution in this plane.
SUBCUTANEOUS DIGITAL BLOCK: Step 3

STEP 1 PEARLS
Withdraw slowly, and inject again in the subcutaneous tissues to block the dorsal
• If dorsal anesthesia is not required, a single- sensory branch as well.
injection volar technique is preferred by some.
This is done with a single injection over the Procedure: Digital Nerve Block
volar aspect, just proximal to the palmodigital
crease. The needle can be moved to the Blocking digital nerves can be done with a variety of techniques.
radial border webspace and then withdrawn
slowly and redirected to the ulnar side to allow Step 1: Intermetacarpal Block
injection of both sides with one needlestick. • If the goal is to block multiple adjacent fingers, an intermetacarpal block (also known
• However, our preferred technique is to inject a
as a transmetacarpal block) technique can be used (Figs. 1.12 and 1.13).
subcutaneous wheal dorsally, and then enter
vertically into that anesthetized wheal area • Inject alongside the metacarpal neck to block the common digital nerves to the fin-
to then drive the needle ulnar and then radial gers on either side of the corresponding webspaces (Fig. 1.14).
from that position (similar to the “single-
injection” technique), minimizing the need for Step 1: Subcutaneous Digital Block
additional skin injection sites.
• To block just one finger, the subcutaneous digital block technique can be used.
SUBCUTANEOUS DIGITAL BLOCK:
• One must infiltrate along the radial and ulnar border of the digit proximally, at the
STEP 1 PITFALLS webspace (Fig. 1.15).
• There is a debate on dorsal versus volar
approach, with many preferring dorsal Step 1: Intrathecal Block
because it is reportedly less painful. • Alternatively, a digital block can be performed using an intrathecal block technique,
• Volar-only techniques often still require a injecting into the flexor tendon sheath.
subcutaneous wheal injected on the dorsum of
• Injection is performed at the level of the palmodigital crease (Fig. 1.16).
the finger to block the dorsal digital nerves
Step 2: Intrathecal Block
INTRATHECAL BLOCK: STEP 1 PEARLS
Can insert needle until contact with bone is made; then pull back slowly while inject-
Intrathecal block offers anesthesia with one injec- ing until a loss of resistance is felt—this is the plane between periosteum and tendon
tion and reportedly has a faster onset.
within the sheath (Fig. 1.17).
INTRATHECAL BLOCK: STEP 1
PITFALLS
Some patients report more and prolonged discom-
fort with intrathecal block technique.
INTRATHECAL BLOCK: STEP 2 PEARLS

Also, needing to contact the bone can be avoided
by slowly approaching with the volar injection until
the sheath is entered and injecting superficial to
the tendon; similarly here, injection plunger pres-
Flexor tendon sure on the syringe will have a loss of resistance
when the injection is entering the tendon sheath
space rather than the subcutaneous tissues or the
Common tendon substance itself.
digital nerve
Distal
palmar crease INTRATHECAL BLOCK: STEP 2
PITFALLS
Injection superficial to the tendon is often less
accurate, and in some cases no intrathecal injec-
tion occurs, because the injection is all performed
in the subcutaneous space.
FIGURE 1.12
Common
digital nerve
FIGURE 1.13
Flexor tendon
Common
digital nerve
Distal
palmar crease
FIGURE 1.14
A B
FIGURE 1.15
Digital crease
Flexor tendon
FIGURE 1.16
Flexor tendon sheath

Flexor digitorum
profundus Volar digital nerve
Flexor digitorum Volar digital artery
superficialis
Proximal
phalangeal bone
FIGURE 1.17
Postoperative Care and Expected Outcomes

• Most of these blocks can be expected to provide adequate reduction of pain and POSTOPERATIVE PITFALLS
sharp sensation for the areas targeted. • Neuropraxia is uncommon, especially with
• Duration of block is based on which anesthetic agent was used, as outlined earlier. these distal nerve blocks. However, should
they occur, they will often resolve within
See also Video 1.1, Anesthesia of the Hand, on ExpertConsult.com 4 weeks. Patient support and reassurance is
usually the only necessary treatment. In the
EVIDENCE rare event of complete or near-complete palsy,
additional evaluation is warranted to rule out
Bas H, Kleinert JM. Anatomic variations in sensory innervation of the hand and digits. J Hand Surg Am
new sources of compression.
1999;24:1171-84.
• Toxicity from the local anesthetic, although
Thirty fresh cadaver hand dissections were performed to investigate the course and interconnec-
incredibly uncommon with these small
tion of the sensory nerves. The authors found interconnecting nerves between the median and
doses, should always be considered if patient
ulnar nerve just distal to the transverse carpal ligament. The dorsal branch of the volar digital nerve
experiences central neurologic or cardiac
branched out at the proximal level of the A1 pulley in 62% of the specimens. The dorsal sensory
changes.
nerve extended to the nail level in the thumb and little fingers. (Level IV evidence)
Gebhard RE, Al-Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for outpatient
carpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge time. Anesth
Analg 2002;95:351-5.
This retrospective study of 62 consecutive patients compared Bier block, peripheral nerve (median
and ulnar nerve) block, and general anesthesia for carpal tunnel surgery. Peripheral nerve blocks
had greater intraoperative cardiovascular stability and earlier postoperative discharge from postan-
esthesia care unit. (Level IV 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;30:581-4.
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 meta-
carpal 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;22:901-5.
Randomized double-blind study on 142 patients comparing transthecal digital block and subcuta-
neous digital block. No difference 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;33:515-8.
Twenty patients were randomized to digital block with 2% lidocaine and 2% lidocaine with 1:80,000
adrenalin. PO2 and SaO2 in the digits were not significantly different between the groups. No con-
cerning issues with digital perfusion were reported. Return of sensation in digits without adrena-
lin returned an average of 4.8 hours later, and with adrenaline occurred 8.1 hours later. (Level II
evidence)
PROCEDURE 2
Fasciotomy for Compartment Syndrome of the

Hand and Forearm
Indications
• Compartment syndrome—when pressure within a fibroosseous space increases to a
level that results in a decreased perfusion gradient across tissues
• Reperfusion after prolonged ischemia time, including tourniquet, wraps, casts, com-
pression, and others
• Crush injury with resultant edema, causing increased pressure in the closed muscle
space
• Other high-risk causes of compartment syndrome: injection injury, extravasation in-
jury, electrical injury, penetrating trauma, circumferential burns, snake or insect bites
• Certain injection injuries (air, water, other hydrophilic liquids) can potentially be
observed depending on volume, clinical presentation, etc.
• Injection of paint or other oil-based liquid requires early decompression and
additional exploration/debridement as needed. These injection injuries tend
to develop ischemia as well as deep space infections and worsen rather than
improve with time (Fig. 2.1A and B).
• The ischemia caused by compartment syndrome affects nerves and then muscle;
irreversible damage can occur within 6 hours for muscle or even less for nerves.
• The diagnosis is generally a clinical one, based on findings of nerve or muscle injury.
• Pain (out of proportion to injury, especially on passive stretch), paresthesia, paralysis,
pallor, pulselessness, and inability to regulate limb temperature (poikilothermia).
• Pain out of proportion to injury and paresthesias are the two earliest findings, where-
as pulselessness and pallor are often (too) late of findings; they may not occur at all.
• The limb/compartment is often firm to palpation, and overlying skin may become
shiny and even develop blisters (Figs. 2.2A and B and 2.3).
A B
FIGURE 2.1
13
14 PROCEDURE 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm
A B
FIGURE 2.2
FIGURE 2.3
FIGURE 2.4
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
compartment pressures. Although many techniques have been described, the Stryker
system has been found to be quite accurate, with an arterial line manometer as a more
easily accessible secondary option that is quite accurate if used properly (Fig. 2.4).
PROCEDURE 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm 15
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 2.5
• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg

is an indication for urgent fasciectomy, and readings of 20 or above warrant very
close monitoring if not early surgical intervention based on the clinical scenario. Ad-
ditionally, some consider a difference of >20 mm Hg between diastolic pressure and
compartment pressure as an indication for fasciotomy as well (hypotensive/septic
patients).
• Slit catheters and side port needles are more accurate than straight needles when
measuring compartment pressures.
Surgical Anatomy
• The forearm has three major compartments—volar, dorsal, and lateral (mobile wad).
Within the volar and dorsal compartments, there are superficial and deep subcom-
partments. Some consider there to be a third separate volar subcompartment around
the pronator quadratus. The deep volar compartment is most susceptible and most
often affected by compartment syndrome, whereas the mobile wad is least com-
monly involved (Fig. 2.5 and Table 2.1).
• The carpal tunnel is susceptible to compressive pressures and is often released
when other upper extremity fasciectomies are performed.
• The hand is reported to have as many as 10 compartments, but the clinical sig-
nificance of each compartment is debated, and most surgeons do not release all
compartments in the setting of hand compartment syndrome. The compartments
that may need release include thenar, hypothenar, adductor pollicis, dorsal interos-
seous (4), and volar interosseous (3).
• Digital compartments are also described, bound by Cleland ligament 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
in order to allow for adequate debridement of ischemic tissue in the area of injection
(Fig. 2.1A and B).
Table
2.1 Myofascial Compartments of the Upper Extremity and Their Contents
Compartment Muscle Artery Nerve

Arm Anterior Biceps, brachialis, coracobrachialis Brachial Musculocutaneous
Posterior Triceps Profunda brachii Radial
Deltoid Deltoid — Axillary
Forearm Volar Radial and ulnar Median, ulnar, and
anterior interosseous
Superficial Pronator teres, flexor carpi radialis, palmaris longus,
flexor digitorum superficialis, flexor carpi ulnaris
Deep Flexor pollicis longus, flexor digitorum profundus,
pronator quadratus
Dorsal Pos. interosseous Pos. interosseous
Superficial Extensor digitorum communis, extensor digiti minimi,
extensor carpi ulnaris
Deep Abductor pollicis longus, extensor pollicis brevis,
extensor pollicis longus, extensor indicis proprius,
supinator
Mobile wad Brachioradialis, extensor carpi radialis longus, extensor — Radial
carpi radialis brevis
Hand Thenar Abductor pollicis brevis, opponens pollicis, flexor Digital Recurrent motor
pollicis brevis
Hypothenar Abductor digiti minimi, opponens digiti minimi, flexor — Ulnar
digiti minimi
Adductor Adductor pollicis — Ulnar
Interosseous Four dorsal and three palmar interosseous muscles — Ulnar
Carpal tunnel Flexor digitorum profundus, flexor digitorum — Median
superficialis, flexor pollicis longus
Digit Digital Digital
Exposures
• Forearm
• Volar release is traditionally done via a curvilinear incision from the medial epicon-
dyle to the proximal wrist crease. However, this places the distal flexor tendons
and median nerve at risk for exposure and dehiscence, and we disagree with us-
ing this approach.
• We advocate using two longitudinal incisions—one over the volar radial aspect
(over the flexor muscles) and the other over the dorsal ulnar aspect of the exten-
sor muscles. This approach decompresses the volar and dorsal compartments
without exposing the median nerve or distal forearm tendons (Figs. 2.6 and 2.7).
• The more traditional dorsal release is performed via a single longitudinal inci-
sion along a line between Lister tubercle and an area 4 cm distal to the lateral
epicondyle (incision is made in the space between extensor digitorum and
extensor carpi radialis brevis; Fig. 2.8). This is an acceptable approach for dorsal
release; however, we have found success with the more limited incision shown in
Figs. 2.6 and 2.7.
• Hand
• The carpal tunnel is approached via a single incision between the thenar and
hypothenar spaces, in line with the webspace between the middle finger and ring
finger (Figs. 2.9–2.11).
• The thenar compartment is approached via an oblique longitudinal incision along
the radial margin of the thenar eminence (Figs. 2.9 and 2.10).
• The hypothenar compartment is released via a longitudinal incision along the ulnar
aspect of the palm (Fig. 2.9).
Arm incision
Volar radial Dorsal ulnar

Forearm incision
FIGURE 2.6
FIGURE 2.7
Skin incision, dorsal forearm
FIGURE 2.8
Thenar release
Carpal tunnel release
Hypothenar release
FIGURE 2.9
FIGURE 2.10
EXPOSURES PEARLS
• Hypothenar compartment release should
not be done directly on the ulnar border, but
instead should be slightly radial to the border,
so that the scar is not on a direct pressure
area of the hand.
• If carpal tunnel decompression is also
warranted, there is no reason to use an
incision that crosses the wrist, as this
increases risk of an open wound exposing the
medial nerve and flexor tendons.
FIGURE 2.11
EXPOSURES PITFALLS
Making release incisions distal in the midvolar • Dorsal hand compartments are released by two longitudinal incisions parallel and
forearm that result in exposure of the median radial to the index and ring finger metacarpals (Figs. 2.12–2.14).
nerve or distal flexor tendons is not necessary and • Finger
risks desiccation and necrosis of these vital struc- • Decompression can be done with a midaxial incision along the noncontact
tures. Avoid these exposure approaches whenever (radial for index and thumb, ulnar for middle, ring, and small) side of the finger
possible (Fig. 2.16A and B).
(Fig. 2.15).
Dorsal hand release
FIGURE 2.12
FIGURE 2.13
FIGURE 2.14
Skin incision, finger
FIGURE 2.15
FIGURE 2.16
STEP 1 PEARLS
• If the muscle still appears white after opening Procedure: Fasciotomy of the Forearm
fascia, divide the epimysium as well.
• Prior to approaching deep flexor muscles, Step 1: Volar Forearm Release
identify the median nerve and stay ulnar to
it to avoid injury to the palmar cutaneous • The incision (Fig. 2.17) is made through skin and subcutaneous tissues, and the deep
branch. fascia investing the muscles of the forearm is divided.
• After electrical injury, even if the superficial • Subcutaneous flaps can be elevated allowing for mobilization of the incision site and
volar forearm is soft, exposure and release improved exposure in all directions.
of the deep compartment is often performed • Dissect between flexor carpi radialis and palmaris longus to expose the deep flex-
because this compartment can be injured from
the electrical energy conducted through bone ors (pronator quadratus, flexor pollicis longus, and flexor digitorum profundus) and
with sparing of the superficial compartment. decompress as needed with fascial incisions.
• It is critical to visualize deep compartment flexor muscles.
• Visualizing the deeper compartment is especially important after electrical injury.
STEP 1 PITFALLS
• Avoid exposure of median nerve and distal
Step 2: Dorsal Forearm Release
flexor tendons (Fig. 2.16A and B). • For approaching the dorsal forearm compartment, our preferred incision is longitudi-
• Traditional teaching of wide extensile nal along the dorsoulnar forearm (Fig. 2.6).
exposure for forearm fasciotomy is shown • Alternatively, the incision can safely be made along a line between extensor digito-
in Fig. 2.16A.
rum and extensor carpi radialis brevis.
• Fig. 2.16B shows the risk of this approach
for volar fasciotomy, a nonhealing wound • The incision is made through skin and subcutaneous tissues and the deep fascia is
with resulting exposure and desiccation of exposed and divided (Fig. 2.18).
flexor tendons (black arrow pointing to flexor • Via the same incision, approach the muscles of the mobile wad (brachioradialis,
carpi radialis [FCR] tendon) and median nerve extensor carpi radialis longus, and extensor carpi radialis brevis) and divide the
(white arrow); patient required amputation.
investing fascia to release that compartment.
FIGURE 2.17
FIGURE 2.18
STEP 4 PEARLS
FIGURE 2.19 • Most of the incision sites should be left open,
but closure over vital structures should be
done. Although using our approach should not
put these structures at risk, if median nerve
Step 3 and flexor carpi radialis tendons are exposed,
Release tourniquet (if one was used) and obtain hemostasis. Proceed with debride- place a few tacking sutures to secure soft
ment of nonviable soft tissues back to healthy bleeding tissue. tissue over them.
• Closure of the wounds immediately post-
Step 4: Postrelease release risks additional ischemia, and is
technically difficult due to the edema causing
• Place any other soft tissue retention system as appropriate. large gaps between wound edges; however,
• Place bulky moist dressing over any open wounds and fit removable splint in retention systems can be used (e.g., staples
functional position. and vessel loops; Fig. 2.19) to minimize wound
• Initiate regular dressing changes to prevent desiccation of exposed muscles and gaps spreading and making reconstruction
more challenging.
tendons.
Procedure: Fasciotomy of the Hand

Step 1: Carpal Tunnel Release
STEP 1 PEARLS • The incision is made between the thenar and hypothenar spaces in line with the
After releasing the carpal tunnel, close skin to pre- webspace between middle finger and ring finger.
vent desiccation and necrosis of tunnel structures. • Dissect down to and through the longitudinal aponeurotic fibers and identify the
transverse fibers of the transverse carpal ligament.
• Divide the transverse carpal ligament across the full distal and proximal extent of the
STEP 2 PITFALLS ligament to completely free the carpal tunnel.
Use caution with the distal extension of the incision
so as not to expose metacarpophalangeal joint. Step 2: Thenar Decompression
• Deepen incision until abductor pollicis brevis is encountered.
• Divide fascia over abductor pollicis brevis.
STEP 3 PITFALLS
Step 3: Hypothenar Decompression
Be careful not to divide the ulnar digital nerve to
the small finger. • Deepen the incision until abductor digiti minimi is visualized.
• Divide fascia over abductor digiti minimi.
Step 4: Dorsal Decompression

STEP 4 PEARLS • Incision along index finger metacarpal is used to decompress the first dorsal interos-
To fully decompress the dorsal interossei, one seous, adductor pollicis, as well as second dorsal interosseous.
must incise the overlying muscle fascia, which • Incision along the ring finger metacarpal is used to decompress the third and fourth
requires the extensor tendons be mobilized and
dorsal interossei.
retracted to adequately access this fascia in each
intermetacarpal space.
Step 5
Release tourniquet (if one was used) and obtain hemostasis. Proceed with debride-
STEP 4 PITFALLS ment of nonviable soft tissues back to healthy bleeding tissue.
Be cautious of the branches of the superficial radial
nerve and dorsal branches of the ulnar nerve.
Step 6: Postrelease
• Place a few tacking sutures to secure soft tissue over the carpal tunnel and other
exposed critical structures.
• Place bulky moist dressing over remaining open wounds, and fit a removable splint
in functional position.
• Initiate regular dressing changes to prevent desiccation of exposed muscles and tendons.

• Elevation of the extremity postoperatively is critical in reducing edema and improving
pain control.
• Reexamine the extremity within 12 to 24 hours to evaluate need for additional
debridement.
• If there is any concern for muscle viability, plan on return to OR approximately 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 in preventing dessication of any open wounds.
POSTOP PEARLS • Attempt closure of open wounds (whether primary wound closure or skin graft) within
If the patient can tolerate it, one may elevate the 3 to 5 days when tissues are still somewhat pliable and in order to limit infection risk.
area by putting a stockinette on the arm and sling- • If fasciotomy was performed within 4 to 6 hours of compartment syndrome onset,
ing the arm on an IV pole. If this is attempted, be patient may regain full function and sensation; however, any delay beyond 3 to 4
sure to support the elbow with pillows. hours may result in some degree of permanent nerve and/or muscle damage.
See also Video 2.1, Fasciotomy for Compartment Syndrome of the Hand and Forearm,
on ExpertConsult.com.
EVIDENCE
Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis,
treatment, and outcome. J Pediatr Orthop 2001;21:680–8.
Retrospective study of 33 pediatric patients. Seventy-five percent developed compartment
syndrome due to fracture. “Traditional” signs and symptoms of pain, pallor, paresthesia, paralysis,
and pulselessness were not reliable for early diagnosis. However, with early diagnosis and
intervention, >90% achieved full restoration of function (Level IV evidence).
Chan PSH, Steinberg DR, Pepe MD, Beredjiklian PK. The significant of the three volar spaces in forearm
compartment syndrome: A clinical and cadaveric correlation. J Hand Surg 1998;23A:1077–81.
On seven arms, all three volar spaces (superficial, deep, pronator quadratus) were evaluated for
relief of pressure after compartment release. In six arms, superficial release was adequate to relieve
pressure in deep and PQ spaces; in the seventh arm the PQ space needed independent release.
Authors advocate release of superficial volar compartment and rechecking pressures in deep and
PQ before additional dissection and release (Level V evidence).
Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg 1996;78:1515–22.
This is a retrospective review of 17 patients after fasciotomy for compartment syndrome of the hand. All
patients were diagnosed based on tense, swollen hand and pressure elevation in at least one interos-
seous compartment. Full hand decompression as well as carpal tunnel release was performed for all 17
patients; 13 of 17 had satisfactory results, 4 patients had poor results (Level IV evidence).
Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop
Surg 2011;19:49–58.
This is a review of the pathophysiology of compartment syndrome, pertinent surgical anatomy,
surgical approaches, and care recommendations based on up-to-date evidence (Level III
evidence).
Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma.
Case report with study of the literature. Strat Traum Limb Recon 2008;3:27–33.
This article is a case report and discussion on management of oil and paint gun injection injuries
in the hand. The authors discuss the need for early debridement due to the ischemia and in some
cases infection that results from delayed treatment.
PROCEDURE 3
Finger Amputations
Indications
• 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.
• Injury that damages a digit to a degree that vascularity and function cannot be re-
stored (unsuccessful or unfeasible revascularization).
• Complete amputation of digit(s) that cannot successfully be replanted—either due
to degree of injury to the digit, or to the likely impairment that a poorly functioning
replanted digit would cause for the rest of the hand.
• Finger injury that substantially destroys structural and/or functional integrity beyond
ability to adequately reconstruct—this includes multisegment injuries, avulsions that
cause traction injury to the vessels and nerves, and loss of bone segment(s).
• Patient preference after substantial trauma to digit(s). For injuries in which the prog-
nosis 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.
• Ischemic necrosis of the finger(s)
• Malignancy requiring adequate resection margins
• 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 injured
sites.
• Use bone, tendon, vessel, or nerve for grafting in reconstruction of other injured digits.
• Check perfusion of the finger, looking at capillary refill, color, and turgor (Fig. 3.1).
Note the color difference between the pink, vascularized finger (upper finger) and the
white devascularized finger (lower finger).
• Check that refill takes approximately 2 seconds. This is most easily done by compres-
sion and release at the nail bed if available (especially in patients with darker skin tone).
• If the finger feels soft and compressible, vascular inflow may have been lost result-
ing in this loss of turgor.
FIG. 3.1
24
PROCEDURE 3 Finger Amputations 25
• Evaluate sensation.
• Check response to sharp stimulus at fingertip—use a sterile needle to test sharp
sensation.
• Examine two-point discrimination (although often difficult in the recently injured
patient). Can be done using a premade device if available, or by opening up a
paper clip to the desired prong width. Can also gently press using the tips of
sharp iris scissors opened to various widths. The objective is to test at what width
between the two points the patient is able to distinguish two points from feeling
like one point of pressure.
• Examine the structural integrity of each involved finger—test the function of flexion
(superficialis and profundus) and extension against gravity and resistance.
Imaging
• X-ray is generally the only modality used to evaluate traumatized digits when decid-
ing about structural integrity and potential for long-term function if salvaged.
Surgical Anatomy
In general, revision finger amputations are done through the bony shaft, rather than at
joint level. Knowing the anatomy of the fingers is important for maintaining attach-
ments of flexor and extensor tendons if possible, as well as contouring bone appro-
priately for the revision stump (Fig. 3.2A and B).
For metacarpal amputations, one must decide between a transmetacarpal amputation
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 to preserve hand curvature and shape.
• For central digits, and for border digits in patients unhappy with hand function/ap-
pearance after border amputation, one often will do complete ray amputation with
removal of the metacarpal.
• For index and middle fingers, one must keep the metacarpal base to preserve the
extensor carpi radialis longus (ECRL)/extensor carpi radialis brevis (ECRB) attach-
ments (respectively).
Although some advocate leaving cartilage in place, it is our general practice to denude EXPOSURES PEARLS
cartilage at the amputation site. Denuding cartilage has remained standard teaching
• Peroxide soak/wash can be helpful in cleaning
in hand surgery; however, there is no clear evidence to support leaving the cartilage
off dried blood.
cap versus denuding it. • Use of a finger tourniquet facilitates operating
Identify the neurovascular bundles on radial and ulnar sides of digit. Ligate/cauterize in a dry field. An extra glove can be used if
the vessel for hemostasis and appropriately manage the nerve to prevent neuroma no prefabricated finger tourniquet option is
(discussed later) (Fig. 3.3). available (Fig. 3.5).
• Put a clamp on the finger tourniquet so
In a ray amputation, identify and protect the common (palmar) digital vessel and nerve
that the surgeon has a reminder to remove
so as not to injure inflow or sensation to the bordering digit (Fig. 3.4). the tourniquet after surgery. In the chaotic
The A1 pulley must be divided to identify the flexor tendons during transmetacarpal/ray environment of the emergency room, the
amputation (Fig. 3.4). surgeon may forget the tourniquet is still on
without a reminder. In the anesthetized finger,
Positioning the patient may not feel tourniquet pain until it
is too late.
With an adequate digital block, a revision finger amputation can often be performed in the
emergency department or in a small procedure room rather than the operating room.
EXPOSURES PITFALLS
Exposures
One should not stop active bleeding from the
Thoroughly clean the hand during examination and evaluation. This will aid in visu- injured finger before the examination has been
alization of skin color and perfusion, as well as the extent of deformity and soft performed, as tourniquet/pressure on the digital
tissue injury. Often, once the sensory examination has been completed, it is easi- bundles can potentially alter sensory examina-
est to place the digital block and then thoroughly clean the anesthetized finger(s) tion—attempt to use direct pressure on the bleed-
ing site if necessary.
(see Chapter 1).
26 PROCEDURE 3 Finger Amputations
DIP joint Terminal tendon
Lateral band
Middle phalanx
Central slip
PIP joint
Proximal phalanx
Sagittal bands
MP joint
Juncturae tendineae
Extensor tendon
FDP
FDS
FIG. 3.2
Palmar digital
arteries
and nerves
Superficial
palmar arch
FIG. 3.3
Flexor tendon
Palmar digital
arteries A1 pulley
and nerves
Superficial
palmar arch
FIG. 3.4
STEP 1 PEARLS Procedure: Revision Amputation

• Allow adequate time for the block to set in. It
is often easiest to place the block early, even Step 1: Set Up for the Procedure: Thoroughly Clean, Anesthetize,
before thorough cleaning, so the block has and Place Tourniquet
time to set in. • After the injury, the surgical site is often bloody and dirty from manual labor at the
• If possible, mark any areas of clearly nonviable time of the injury. Cleaning with peroxide can help clear away blood and grime.
soft tissue before placing the tourniquet.
• For most posttraumatic revision amputations, the only required anesthesia is a digital
block (see Chapter 1). After the sensory examination is completed, the block can be
placed to facilitate more thorough cleaning and functional testing.
STEP 1 PITFALLS • Mark out the areas of clearly nonviable skin.
Be sure the tourniquet is tight enough to prevent • Use a finger tourniquet for hemostasis, placed at the base of the finger after ad-
any arterial inflow—if tourniquet is somewhat lax equately anesthetized (Fig. 3.5).
(especially if using a makeshift tourniquet, e.g., • If finger amputation is performed in the operating room under anesthesia, one can
rubber glove) then congestion and backflow bleed-
ing will make the procedure more difficult. use a standard arm tourniquet. Use the standard tourniquet for transmetacarpal/ray
amputation.
Step 2: Confirm Viability of Skin and Debride Away Any Clearly Non-
viable Tissue
• Devitalized skin should be sharply excised (scalpel preferable).
• Even under tourniquet, the transition to healthier, more viable tissue can be seen.
• In general, all skin and soft tissue proximal to laceration sites should be pre-
served even if traumatized, unless it is clearly no longer viable. This extra soft
STEP 2 PEARLS tissue length will be needed to provide adequate durable coverage over the bony
Attempt to preserve volar skin to cover distal bone. stump.
This will move the scar to a noncontact surface, • Bone will need to be resected proximal to the injury site to provide adequate soft
and likely will improve sensation of the stump tissue to close over the bone. This tissue therefore must be dissected off of the
(Fig. 3.6). bone with minimal injury to preserve viability.
• With sharp scissors or elevator directly on the phalanx, elevate the soft tissue
envelope off of the bone.
STEP 2 PITFALLS
• If the flexor or extensor tendon remains attached to the distal bone segment that
Caution overresection—adequate length and will be excised, pull on the tendon and divide as proximally as possible and al-
thickness of soft tissue flaps is required to cover low to retract into the palm. This prevents the tendon from being tethered distally,
over the distal bony stump.
which could restrict tendon excursion of the other fingers.
Step 3: Identify and Treat the Neurovascular Bundles

• Bundles are identified along volar region of radial and ulnar borders of the injured
digit.
• If soft tissue connections remain between the distal segment and the remaining
digit, the neurovascular bundles may be in that soft tissue. Closely examine before
transecting these soft tissue connections.
• In the finger, the nerve is volar to the artery; in the palm, artery is volar to nerve.
• In amputated digits, confirm arterial end of each digital vessel is coagulated or ligated.
FIG. 3.5
• In amputated digits, the nerve should be placed on traction (Fig. 3.7) and then STEP 3 PEARLS
transected with sharp scissors so it can retract proximally away from the scar site.
If the nerve does not adequately retract after trans-
Nerves trapped in the sutured skin cause debilitating pain, whereas a nerve retracted section, attempt to tunnel the nerve end into soft
into the palm shields the nerve end from contact. tissue or potentially into bone to prevent pain-
• In metacarpal-level amputations, management of the primary neurovascular bundles ful neuroma. All nerves will form a neuroma, but
is a more delicate matter, as the common branches in the palm also feed the adja- nerves trapped in contact areas and not buried
cent digits and therefore must be preserved (Fig. 3.8). The blue arrow indicates the may cause painful neuromas.
common branch in the palm.
• Identifying the digital nerve distally in the finger can aid in finding it proximally in
the intermetacarpal space. Putting traction on the digital nerve in the finger can STEP 3 PITFALLS
help identify the branch-point in the webspace or the common nerve in the palm, If controlling bleeding from the digital artery is dif-
showing a safe transection point for the nerve to the finger being amputated ficult before tourniquet placement, use pressure to
• When approaching the metacarpal, approach over the bone and peel soft tissue control the bleeding rather than trying to control
bleeding before isolating the nerve.
off to either side, protecting the neurovascular bundles.
FIG. 3.6
FIG. 3.7
FIG. 3.8
FIG. 3.9
Step 4: Perform the Bony Amputation Based on Level of Injury and

Available Soft Tissue
• Level of amputation is determined by available soft tissue.
• After trauma to multiple digits, one may need to use soft tissue from one digit to
cover wounds on neighboring digits or the hand (Fig. 3.9A–C).
• Level of amputation also can be guided by level of fracture or bony injury.
• In the fingers, perform amputation through phalangeal shaft if possible.
• If possible, aim to preserve the attachments of flexor digitorum superficialis
(FDS), flexor digitorum profundus (FDP), and extensor digitorum communis (EDC)
tendons (see Fig. 3.3).
• If amputation occurs through the joint, then denude the cartilage along the distal
aspect of the remaining phalanx.
• Contour the distal bone (Fig. 3.10).
• For digits, do not leave sharp edges, and avoid leaving flared/boxy distal aspect
just proximal to the joint.
• For metacarpals, angle distal osteotomy of border digits to be approximately 45
STEP 4 PEARLS
degrees angled toward the hand, providing natural curved contour to match the
Attempt to trim any bony spicules or radial/ulnar rest of the hand (Fig. 3.11).
prominence to avoid leaving the stump with abnor- • For ray amputations, leave the base of index and middle finger metacarpals to
mally wide or prominent edges.
preserve the insertion of ECRL/ERCB.
FIG. 3.10
FIG. 3.11
Step 5: Close the Skin Flaps Over the Distal Bone STEP 5 PEARLS
• No buried sutures are needed. Place interrupted nylons in the skin (Fig. 3.10). If there is a question of viability of remaining soft
• Do not suture the flexor tendon to the extensor tendon or tack the tendons down as tissues, examine again in approximately 48 hours
this can substantially limit function of the hand. to determine whether additional debridement is
• Consider loosely closing the skin flaps to allow drainage of any contaminated fluid as required or if it can be treated with local wound
care.
the wounds heal (rather than tight closure of all wound margins).
• In children, consider closing with chromic suture that does not need removal, as
compliance with suture removal may be a challenge. STEP 5 PITFALLS
Procedure: Elective Amputation (Transmetacarpal or Ray • Suturing the flexor tendon to the extensor
tendon, or otherwise tethering the flexor
Amputation) tendon to the finger during closure, risks
If performing transmetacarpal or ray amputations to remove nonfunctional digit after developing quadregia.
revision finger amputation or for ischemia/malignancy, consider these additional • Avoid volar-based wound closure if possible,
steps. as this risks painful scars on the functional
surface of remaining fingers (Fig. 3.12).
Step 1
The base/metacarpophalangeal joint of the finger to be amputated should be marked
with a curvilinear teardrop-shaped incision on the volar aspect, and a Y-shaped in-
cision more proximal over the metacarpal on the dorsal aspect (Fig. 3.13Aand B ).
FIG. 3.12
FIG. 3.13
Step 2
• Start with volar incision, and identify the digital neurovascular bundles to the finger
(Fig. 3.14).
• After identifying a nerve, place on slight traction and see if it pulls in the webspace;
if there is a tethering in the webspace, this is the proper digital nerve and it can be
transected. If not, one may have the common digital nerve and need to explore
further so as not to damage sensation of the adjacent digit.
• Identify the A1 pulley, divide it, and transect the flexor tendons to the digit.
Step 3
Cut down to bone, and elevate whatever volar soft tissues are tethered to bone, protect-
ing soft tissues on either side of the metacarpal.
Step 4
• Turn to the dorsal side, make the Y incision overlying the bone.
• Cut down, divide the extensor tendon to that digit, and continue down to bone be-
fore using 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.
FIG. 3.14
FIG. 3.15
A B
FIG. 3.16
Step 5
• Divide the transmetacarpal ligaments, preserving as much length as possible.
• Use saw to cut through metacarpal and remove the finger and metacarpal (see
Step 4: Revision Amputation for additional information about the bony cut).
Step 6
• Use 2-0 Ethibond (or other braided suture of choice) to bring transmetacarpal liga-
ments together and close down the open space (Figs. 3.15 and 3.16A and B ).
• Be cautious not to overtighten this suture because it can pull in the adjacent fin-
gers and they can end up crossing over each other.
• 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 interrupted nylon suture (Fig. 3.17A and B ).
FIG. 3.17

• Often the patient with finger amputations is 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.
• Once the wounds heal, patients are cleared to return to activities gradually. It is often
a much more rapid recovery than if complex reconstruction was performed.
• After metacarpal-level amputations, we often will place patient in intrinsic-plus volar
splint while healing to prevent collapse of border metacarpals and abnormal remain-
ing finger cascade.
See Video 3.1, Revision Amputation and Treatment of Painful Neuroma, on Expert
Consult.com.
EVIDENCE
Blazar PE, Garon MT. Ray resections of the fingers: indications, techniques, and outcomes. J Am Acad
Orthop Surg 2015;23:476–84.
Review of ray amputation. Major negative outcome reported is 15% to 30% loss of grip and pinch
strength, otherwise patients with overall high satisfaction and successful long-term function.
Chow SP, Ng C. Hand function after digital amputation. J Hand Surg Br 1993;18:125–8.
This article is a review of outcomes after finger amputations. Power grip and key pinch returned to
70% of unaffected side by 1 year. Multiple finger amputation injuries resulted in weaker grip and key
pinch. Twenty-five percent of patients had to change jobs and 20% expressed concerns regarding
the appearance of their injured hand.
Wang K, Sears ED, Shauver MJ, Chung KC. A systematic review of outcomes of revision amputation
treatment for fingertip amputations. Hand (NY) 2013;8:139–45.
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 3rd WP, Riser WH, Kilgore E. Retaining the articular cartilage in finger joint ampu-
tations. Plast Reconstr Surg 1972;49:542–7.
This article presents an experiment in cats that evaluated disarticulation amputation vs. cartilage
removal at distal amputation site. Inflammation and remodeling occurred more quickly in the disar-
ticulation 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
discrimination was 5 mm, with total active motion 93% of normal (slightly better after revision ampu-
tation compared with local flap coverage). Seventy-seven percent of patients report cold intolerance.
Ninety-one percent reported satisfactory or good/excellent overall function regardless of treatment.
PROCEDURE 4
Drainage of Septic Arthritis (Including Fight Bite)

and Septic Tenosynovitis
Drainage of Septic Arthritis (Including Fight Bite)

Indications
• Clinical diagnosis of infective arthritis—purulent exudate within the closed joint
space.
• Associated with painful, erythematous, and swollen joint (Fig. 4-1). Many patients will
hold the finger in slight flexion. Pain with axial loading is a telling finding. May see soft
tissue injury/puncture along dorsum of joint (inoculation site).
• Higher concern in diabetic or immunocompromised patients.
• For concerns about septic arthritis of the wrist, one may use joint aspiration to aid
in diagnosis. Aspiration is also an option for infection in smaller joints of the hand,
although fluid yield from such small joints is not as consistently reliable.
• Fight bite injury is a unique presentation of a septic arthritis, in which dorsal metacar-
pal injury occurs from closed-fist contact with teeth, causing an inoculating puncture
wound with possible tendon injury (often proximal to the joint once fingers are ex-
tended) and high incidence of subsequent septic arthritis (Fig. 4.2A and B).
• Low threshold to operate on these patients even before fulminant pyogenic infection
develops.
Imaging
• X-ray to rule out associated osteomyelitis, gas in the joint, or any retained foreign
body (especially in the setting of fight bite injury).
Surgical Anatomy
• If attempting to aspirate fluid from the wrist, Lister tubercle on the dorsum of the
distal radius is the landmark. The radiocarpal joint can be approached 1 cm distal to
Lister tubercle, with an 18-gauge needle directed in a slightly proximal direction to
account for the tilt of the distal radius (Fig. 4.3).
Fig. 4.1
36
PROCEDURE 4 Drainage of Septic Arthritis (Including Fight Bite) and Septic Tenosynovitis 37
A B
Fig. 4.2 A-B
Fig. 4.3
• If aspiration of the midcarpal joint is required, this can be done approximately 1 cm
distal to the approach for the radiocarpal joint.
• Approaching the infected metacarpophalangeal (MCP) joint is done with a dorsal ap-
proach. The joint can be accessed either by splitting the extensor tendon longitudinal-
ly, or by making an incision through the sagittal band adjacent to the extensor tendon.
• In approaching the proximal interphalangeal (PIP) joint, a midaxial approach is used.
One must divide the transverse retinacular ligament and then make a window in the
accessory collateral ligament to access the joint (Fig. 4.4). Digital bundle is retracted
volarly into the volar skin flap.
38 PROCEDURE 4 Drainage of Septic Arthritis (Including Fight Bite) and Septic Tenosynovitis
Skin incision, finger
Fig. 4.4
Fig. 4.5
• The distal interphalangeal (DIP) joint is approached dorsally. The terminal aspect of
the extensor tendon should be retracted, avoiding any injury. This will allow access
to the joint.
Positioning
• If using a tourniquet, avoid compression/wrap before inflation so that the infected
materials are not milked proximally. Use gravity to augment venous drainage before
tourniquet inflation.
Exposures
• Surgical incision to approach the wrist is made in relation to Lister tubercle. This inci-
sion is made longitudinally, just ulnar to the tubercle. This allows for a dorsal wrist
approach between the third and fourth dorsal compartments (Fig. 4.5).
• Approaching the PIP joint is done through a midaxial incision. This incision allows the
surgeon to mobilize the digital bundle volarly; however, dorsal sensory branches can
still be injured especially if any dorsal elevation is performed (Fig. 4.4).
• The incision approach to the PIP joint can be extended as far proximal as the web- EXPOSURES PEARLS
space, and as far distal as the DIP joint.
• For index finger, incision should be on ulnar
• DIP joint is approached dorsally, usually through an H-shaped incision or a T-shaped aspect to avoid the contact surface.
incision. • For small finger, incision should be on radial
aspect.
Procedure • For middle and ring fingers, incision can be
placed on either side.
Step 1: Approach
Septic Arthritis of the Wrist
• Approach via dorsal incision.
• Longitudinal incision is made ulnar to Lister tubercle. STEP 1 PEARLS
• Avoid injury to dorsal veins and radial sensory branches. • Septic arthritis of the PIP joint
• Identify interval between third (extensor pollicis longus [EPL]) and fourth (extensor • Avoid dorsal soft tissue elevation in the
digitorum) dorsal compartments and divide it to approach the joint. Retract EPL radi- area of the PIP joint; this may damage
dorsal sensory branches or dorsal veins.
ally to protect it.
• Septic arthritis of the DIP joint
• Divide dorsal joint capsule with a longitudinal incision. This may require exposure of • Incision should be made superficial; the
proximal radiocarpal joint as well as midcarpal joint if the proximal joint does not ap- tendon is very superficial at this level and
pear to be infected. can easily be injured.
Septic Arthritis of the MCP Joint

• Approach via dorsal incision. STEP 1 PITFALLS
• Longitudinal or S-shaped incision directly over the joint. • Septic arthritis of the DIP joint
• Identify the extensor tendon. • Any injury to the extensor tendon insertion
• One can split the tendon longitudinally for access to the joint. must be addressed; an untreated injury can
• Alternatively, one can split the sagittal band to the side of the extensor tendon. lead to mallet deformity.
• Divide the joint capsule (if it was not divided with the previous incision, which may occur).
Septic Arthritis of the PIP Joint

• Approach via midaxial incision.
• Incision is made along midaxial line.
• Retract soft tissue bundle volarly, protecting the neurovascular bundle.
• Divide transverse retinacular ligament.
• Excise window of accessory collateral ligament.
• Perform capsulectomy to access the joint space.
Septic Arthritis of the DIP Joint

• Approach via dorsal H-shaped incision.
• Make the dorsal incision over the joint.
• Identify the distal extensor tendon attachments to the base of the distal phalanx.
• Retract the extensor tendon to expose the dorsal joint space.
Step 2: Copious Irrigation of the Infected Joint

• Use TUR tubing or other gentle flow washout to clear infected fluid. Avoid pulse ir-
rigation as this can damage the weakened cartilage.
• Put joint on traction to open up the space.
• Flex/extend the joint to open up the space and clear infected material.
Step 3: Debridement
• Any area of necrotic tissue or inflammatory synovium should be debrided.
• Send specimens of debrided tissue for culture and pathology examination.
• Inspect joint surfaces and avoid debridement of these areas unless the areas are
frankly infected and risk development of osteomyelitis.
• This is especially important for fight bite injury, as a tooth fragment can be trapped
within the joint cartilage, or an injury to the joint may have occurred that requires
debridement (Fig. 4.6).
Step 4: Closure
• To prevent early closure of the capsulotomy site, a wick should be placed to allow
continued drainage.
40 PROCEDURE 4 Drainage of Septic Arthritis (Including Fight Bite) and Septic Tenosynovitis
5-mm articular surface

defect after fight bite injury
Fig. 4.6
• There is no need to close the dorsal wrist capsule after debridement, but skin should
be tacked together loosely using nylon suture, with the wick in place.
• For MCP, if tendon was split during the approach, the tendon should be repaired with
absorbable suture. Similarly, the sagittal band should be repaired if it was divided.
Tack overlying skin closed loosely with nylon suture.
• For PIP and DIP, loosely tack skin closed with nylon suture.
• On all of these closures, the loosely tacked wounds should be dressed with moist
gauze that is changed three times daily starting on postoperative day 1 (POD 1).
• Remove wicks at 36 to 48 hours postoperative.
• Plan for return to operating room (OR) for additional washout and debridement
within 48 hours if there is any concern for retained infectious material after first
debridement.

• Moist dressings overlying the loosely closed wounds should be changed three times
daily.
• On POD 1 the patient can begin with soaks three times a day, along with dressing
changes. These can be done in a 1:1 mix of peroxide and water. Active and passive
range-of-motion (ROM) exercises should be done during the soaking.
• If wick does not fall out with soaks, it should be removed within 36 hours.
POSTOPERATIVE PEARLS
• Removable splints should be used for elevation and resting, but patient should come
Duration of IV and oral therapy is debated. We use out for early ROM exercises to help clear retained infectious fluid and prevent ad-
IV antibiotics for approximately 2 weeks, or until
symptom improvement if that takes slightly longer. ditional stiffness.
Then oral antibiotics are used to complete a total • Intravenous (IV) antibiotics should be used, tailored to culture results. Can transition
of 6 weeks of therapy. to oral antibiotics once appropriate organism is identified.
Drainage of Septic Tenosynovitis

Indications
Clinical diagnosis of acute infective tenosynovitis
Indicated by Kanavel’s signs—fusiform digit swelling, pain with passive exten-
sion, tenderness over the flexor tendon, and/or finger held in slight flex-
ion (Fig. 4.7A and B). Many believe that pain along the tendon and pain with
passive extension are the most indicative. For mild cases a course of ad-
mission with IV antibiotics before surgery is warranted. Consider wash-
out especially when symptoms have been present for over 24 hours and are
worsening.
May see volar soft tissue injury as inoculation site (Fig. 4.8).
Fig. 4.7 A-B
The abscess at incision

of trigger finger release.
Fig. 4.8
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oligarchi. Fu assassinato nel 1832, da Sarah Jenkins, il cui marito era
stato ucciso trent’anni prima dai compagni di Farley, che impedivano gli
scioperi.
85. Le predizioni sociali di Everhard erano degne di nota. Con la stessa

chiarezza, come leggeva gli avvenimenti, prevedeva le defezioni dei
Sindacati privilegiati, la nascita e la lenta decadenza delle caste operaie,
come la lotta fra queste e l’oligarchia, per la direzione della macchina
del Governo.
86. Dobbiamo ammirare l’intuito di Everhard. Molto prima che la semplice

idea di città meravigliose, come Ardis e Asgard, nascesse nella mente
degli oligarchi, egli intravedeva queste città splendide e la necessità
della loro creazione.
87. Da quel giorno, sono passati tre secoli di dominio dell’Uomo, e oggi
calpestiamo le vie e abitiamo le città edificate dagli oligarchi. È vero che
abbiamo continuato a costruire, ma le città degli oligarchi sussistono; io
scrivo queste righe, in Ardis, una dalla più belle fra tutte.
88. Tutti i Sindacati delle ferrovie entrano in questa associazione. È

interessante osservare che la prima vera applicazione della politica delle
«parti dell’avanzo» era stata fatta nel Secolo XIX da un Sindacato di
ferrovieri, «l’Unione Fraterna del Meccanici delle locomotive», della
quale un certo P. M. Arthur era da vent’anni il capo. Dopo lo sciopero
della Pennsylvania Railroad nel 1877, egli sottopose ai meccanici delle
locomotive un disegno secondo il quale avrebbero dovuto intendersi
colla Direzione, staccandosi dagli altri Sindacati. Questo disegno
egoistico riuscì perfettamente; donde la parola «Arthurisation», per
significare la partecipazione dei Sindacati alla spoliazione. L’origine di
questa parola è stata per molto tempo dubbia per gli etimologi; ma mi
pare che tale origine sia ormai ben chiara.
89. Alberto Pocock, altro Farley, godeva, in quei lontani tempi, della stessa
notorietà; e fino alla morte riuscì a tenere soggetti tutti i minatori dal
Paese. Suo figlio, Levis Pocock, gli successe, e durante cinque
generazioni, il rinomato lignaggio del guardiaciurma ebbe la supremazia
sulle miniere di carbone. Pocock, il vecchio, conosciuto col nome di
Pocock Iº, è stato dipinto così: «Una testa lunga e sottile, mezzo
circondata da una frangia di capelli scuri e grigi, con zigomi salienti e un
grosso mento... Colorito pallido, occhi grigi senza splendore, voce
metallica, e un atteggiamento languido.» Era nato da genitori poveri e
aveva cominciato la sua carriera come garzone di bar. Divenne in
seguito poliziotto privato al servizio di una corporazione di tranvieri e al
trasformò a poco a poco in crumiro di professione.
Pocock Vº, l’ultimo della casata, morì in una camera, per lo scoppio di
una bomba durante una rivolta di minatori sul territorio indiano. Questo
avvenimento ebbe luogo nel 2073 dopo Gesù Cristo.
90. Quei gruppi di azione furono modellati in genere sul tipo delle
organizzazioni consimili della Rivoluzione Russa, e, nonostante gli sforzi
incessanti del Tallone di Ferro, durarono tre secoli, per tutto il periodo di
dominio del Tallone stesso. Composti di uomini e di donne ispirati da
propositi sublimi, e impavidi davanti alla morte, i Gruppi di
Combattimento esercitarono una prodigiosa influenza e moderarono la
brutalità dei governanti. La loro opera non si limitò a una guerra invisibile
contro gli agenti dell’oligarchìa. Gli oligarchi stessi e spesso, persino i
sottocapi degli oligarchi, ufficiali dell’esercito e capi delle caste operaie,
furono obbligati a prendere in considerazione i decreti dei Gruppi.
Le sentenze di questi rivendicatori organizzati erano conformi alla più
rigorosa giustizia; e soprattutto notevole era la loro procedura senza
passione e perfettamente giuridica. Non c’erano giudizi improvvisati.
Quando un uomo era preso, lo si giudicava lealmente e gli si lasciava la
possibilità di difendersi. Necessariamente, molti furono processati e
condannati per procura, come nel caso del generale Lampton, nel 2138
dopo G. C. Questi era forse il più sanguinario e il più crudele dei
mercenarii dell’oligarchia. Fu informato dai Gruppi di Combattimento che
era stato giudicato, riconosciuto colpevole e condannato a morte; e
questo avvertimento gli venne dato dopo di averlo tre volte esortato a
cessare dal trattare ferocemente il proletariato. Dopo questa condanna,
Lampton si circondò d’ogni mezzo di protezione, e, per anni ed anni i
Gruppi di Combattimento si sforzarono invano di eseguire la loro
sentenza. Molti compagni, uomini e donne, fallirono successivamente
nei loro tentativi e furono crudelmente condannati dall’oligarchia. Perciò
fu rimessa in vigore la crocifissione come mezzo di esecuzione legale.
Ma alla fine il condannato trovò il suo boia nella persona di una
giovinetta di diciassette anni, Maddalena Provence, che per ottenere il
suo scopo, serviva da due anni nel palazzo, come guardarobiera. Essa
morì dopo torture orribili e prolungate, in una cella. Ma oggi la sua statua
di bronzo sorge sul Pantheon della Fratellanza, nella meravigliosa Città
di Serles.
Noi che, per esperienza personale, non sappiamo che cosa sia un
omicidio, non dobbiamo giudicare troppo severamente gli eroi dei
Gruppi di Combattimento. Essi hanno dato la loro vita per l’umanità; per
la quale nessun sacrificio sembrava troppo grande. E, d’altra parte, una
necessità inesorabile li obbligava a dare al loro sentimento una forma
sanguinosa, in un’epoca sanguinaria. I Gruppi di Combattimento furono
l’unica freccia nel fianco che il Tallone di Ferro non potè mai estirparsi. A
Everhard spetta la paternità di questo strano esercito. I suoi successi e
la sua resistenza, durante trecento anni, mostrano la saggezza con la
quale egli organizzò, e la solidarietà della fondazione legata da lui ai
costruttori avvenire. Da certi punti di vista, questa organizzazione può
essere considerata come la sua opera principale, a parte il grande
valore dei suoi lavori economici e sociali e le sue gesta di capo supremo
della Rivoluzione.
91. Condizioni simili si osservano in India, nel secolo XIX, sotto il dominio
britannico. Gli indigeni morivano di fame a milioni, mentre i loro padroni
li privavano del frutto del lavoro e lo spendevano in cerimonie e cortei
feticisti. Non possiamo non vergognarci, in questo secolo di lumi, della
condotta dei nostri antenati, e dobbiamo limitarci a pensare
filosoficamente che nell’evoluzione sociale lo stadio capitalistico sia,
pressa poco, come l’età scimmiesca all’epoca dell’evoluzione animale.
L’Umanità doveva superare quei periodi per uscire dal fango degli
organismi inferiori; e le era naturalmente difficile liberarsi interamente di
quella viscida feccia.
92. Questa espressione è una trovata dovuta al genio di H. G. Wells, che

viveva alla fine del Secolo XIX. Era un veggente, in fatto di sociologia,
uno spirito sano e normale, e nello stesso tempo un cuore veramente
umano. Numerosi frammenti delle sue opere sono giunti fino a noi, e
due delle sue opere migliori: «Anticipations» e «Mankind in the Making»,
ci sono state conservate intatte. Prima degli oligarchi, e prima di
Everhard, Wells aveva preveduto la costruzione di città meravigliose di
cui parla nel suoi libri chiamandole «pleasure cities», città del piacere.
93. Persuasa che le sue memorie sarebbero state lette, nel suo tempo, Avis
Everhard ha tralasciato il risultato del processo per alto tradimento. Ci
sono nel manoscritto molte altre lacune del genere. Cinquantadue
membri socialisti del Congresso, furono giudicati e ritenuti colpevoli.
Cosa strana, però: nessuno fu condannato a morte. Everhard e undici
altri, fra cui Teodoro Donnelson e Matthew Kent, furono condannati al
carcere a vita.
Gli altri quaranta furono condannati, chi a trenta, chi a quarantacinque
anni; e Arturo Simpton, che il manoscritto dice ammalato di tifoidea al
momento dell’esplosione, non ebbe che quindici anni di carcere.
Secondo la tradizione, fu lasciato morire di fame nella sua cella per
punirlo della sua intransigenza ostinata, e del suo odio ardente ed
assoluto contro tutti i servi del dispotismo. Morì a Cabanas, nell’Isola di
Cuba, dove tre altri de’ suoi compagni erano detenuti. I cinquantadue
socialisti del Congresso furono rinchiusi nelle fortezze militari sparse sul
territorio degli Stati Uniti: così, Dubois e Woods furono rinchiusi a Porto
Rico; Everhard e Merryweather nell’isola di Alcatraz, nella baia di San
Francisco, che da molto tempo serviva da prigione militare.
94. Avis Everhard avrebbe dovuto aspettare molte generazioni prima di

ottenere la rivelazione del mistero. Quasi cento anni fa, e quindi più di
seicento anni dopo la sua morte, fu scoperta negli archivi segreti del
Vaticano, la confessione di Pervaise. Non è forse inopportuno fare un
cenno di quest’oscuro documento sebbene esso non abbia per gli storici
più alcun valore, ormai.
Pervaise, un americano di origine francese, nel 1913 era prigioniero a
Nuova York, in attesa di essere processato per omicidio. Sappiamo,
dalla sua confessione, che senza essere un criminale indurito, aveva un
carattere impulsivo, impressionabile ed appassionato. In un impeto di
gelosia folle aveva ucciso la moglie, cosa abbastanza comune, a quel
tempo. Il terrore della morte si impadronì di lui, come raccontò egli
stesso; e per sfuggirle si sentì disposto a fare qualunque cosa. Gli
agenti segreti, per ridurlo alle loro mire, gli confermarono che si era reso
colpevole di omicidio di primo grado, delitto che era punito colla pena
capitale, giacchè il condannato veniva legato a una poltrona apposita, e
per cura di medici specialisti era ucciso dalla corrente elettrica. Questo
modo di esecuzione chiamato elettrocuzione, era molto in voga, a quel
tempo: solo tempo dopo, fu sostituito dall’anestesia. Quest’uomo, che
non aveva cuore cattivo, ma una natura superficiale improntata a
un’animalità violenta, a che aspettava in una cella l’inevitabile morte, si
lasciò facilmente convincere a gettare una bomba alla Camera.
Dichiara, anzi, nella sua confessione, che gli agenti del Tallone dì Ferro
gli affermarono che l’ordigno sarebbe stato inoffensivo, e che non
avrebbe ucciso nessuno. Egli fu introdotto di nascosto in un palco
ostentatamente chiuso col pretesto ch’era in riparazione, e, incaricato di
scegliere il momento opportuno per gettare la bomba, conferma
ingenuamente che tanto era l’interessamento pel discorso di Ernesto e
pel tumulto suscitato da questo, che per poco non dimenticò il compito
affidatogli.
Non soltanto Pervaise fu liberato, ma gli fu concessa una pensione per
tutta la vita. Ma non potè fruirne a lungo: nel settembre del 1914 fu
colpito da reumatismo al cuore e morì dopo tre giorni. Allora mandò a
chiamare un prete cattolico, al quale fece la confessione. Il Padre
Durban, considerandola molto grave, la scrisse e la firmò, come
testimonio. Noi possiamo soltanto fare delle congetture su quanto
avvenne dopo. Il documento era certo abbastanza importante per
trovare la via di Roma. Potenti influenze furono messe in movimento per
evitare la divulgazione. Soltanto nel secolo scorso, Lorbia, il celebre
scienziato italiano, durante le sue ricerche, lo scoprì. Oggi, dunque, non
rimane alcun dubbio che il Tallone di Ferro sia il responsabile
dell’esplosione del 1913. Ed anche se la confessione di Pervaise non
avesse mai veduto la luce non vi sarebbe potuto essere dubbio
ragionevole: quell’atto che mandò in prigione cinquantadue deputati, è
della stessa natura degli altri innumerevoli delitti commessi dagli
oligarchi, e, prima di essi, dai capitalisti.
Come esempio classico di massacri di innocenti, commessi con ferocia
e indifferenza, bisogna citare quello dei cosiddetti anarchici di
Haymarket, a Chicago, nella penultima decade del secolo XIX. Bisogna
considerare a parte l’incendio doloso e la distrazione dei possedimenti
capitalistici compiuti dai capitalisti medesimi. Per delitti di questo genere
furono puniti numerosi innocenti, messi in ferrovia, (railroaded) secondo
un’espressione usata allora, nel senso che i giudici si erano intesi prima,
per liquidare i conti.
Durante le rivolte del lavoro che scoppiarono nella prima decade del
secolo XX fra i capitalisti e la Federazione Occidentale dei Minatori, fu
adoperata una tattica simile, ma più sanguinosa. Gli agenti dei capitalisti
fecero saltare in aria la stazione della ferrovia a Indipendenza: tredici
uomini furono uccisi, e molti altri feriti. I capitalisti che guidavano il
meccanismo legislativo e giudiziario dello Stato del Colorado,
accusarono di questo delitto i minatori e per poco non li fecero
condannare. Romaines, uno degli strumenti di questo «affare», era in
prigione in un altro Stato, nel Kansas, quando gli agenti del capitalisti gli
proposero il colpo. Ma le confessioni di Romaines furono pubblicate
durante la sua vita, al contrario di quelle di Pervaise. Nello stesso
tempo, vi fu ancora il caso di Moyer e Haywood, due capi di lavoratori,
forti e risoluti: l’uno presidente e l’altro segretario della Federazione
Occidentale dei Minatori. L’ex Governatore dell’Idaho era stato
assassinato misteriosamente; i socialisti e i minatori avevano
apertamente incolpato di questo delitto i proprietarî delle miniere. Pure,
violando le norme costituzionali statali, in seguito a una intesa fra i
governatori dell’Idaho e del Colorado, Moyer e Haywood furono presi,
gettati in carcere e accusati dell’omicidio.
Questo fatto provocò la seguente protesta di Eugenio V. Deba, capo del
Socialismo americano: «I capi del lavoratori, che non si possono
corrompere, si arrestano o si assassinano. Moyer e Haywood, sono
colpevoli soltanto del reato di fedeltà tenace e inconcussa alla classe
operaia. I capitalisti hanno spogliato il nostro paese, corrotto la nostra
politica, disonorato la nostra giustizia; ci hanno calpestato coi loro
scarponi ferrati, ed ora si propongono di ammazzare coloro che non
sono così abbietti da sottomettersi al loro brutale dominio. I governatori
del Colorado e dell’Idaho non fanno che eseguire gli ordini dei loro
padroni: i plutocrati. La lotta è incominciata fra i lavoratori e la
plutocrazia. Questa può, sì, assestare il primo colpo violento, ma noi
daremo l’ultimo».
95. Questa scena ridicola costituisce un documento tipico dell’epoca, e

dipinge bene la condotta di quel padroni senza cuore. Mentre il popolo
moriva di fame, i cagnolini di lusso avevano delle speciali cameriere. Il
travestimento dì Avis Everliard era una cosa ben pericolosa, ma era un
caso di vita o di morte ed era in gioco la causa, ed è perciò da
considerarsi veritiero.
96. Pullman, si chiamavano così le vetture più lussuose dei treni di quel
tempo, dal nome del loro inventore.
97. Nonostante i continui pericoli, quasi inimmaginabili, Anna Roylston

raggiunse la bella età di anni novantuno. Come i Pococks sfuggirono
agli esecutori del Gruppi di Combattimento, essa sfidò quelli del Tallone
di Ferro. Prospera in mezzo ai pericoli, la suo vita sembrava protetta da
un sortilegio. Essa stessa si era fatta giustiziera per conto di Gruppi di
Combattimento: la chiamavano la Vergine Rossa e diventò una delle
eroine della Rivoluzione. All’età di sessantanove anni, uccise Halcliffe «il
sanguinario», circondato da una scorta, e scappò, senza neppure una
scalfittura. Morì di vecchiaia nel suo letto, in un rifugio segreto e sicuro
di rivoluzionarî, sulle montagne di Ozark.
98. Socialista Labor Party.
99. Nonostante tutte le ricerche fra i documenti dell’epoca, non abbiamo

potuto trovare nessuna allusione al personaggio in questione. Non ne
parla che il manoscritto di Everhard.
100. Il viaggiatore curioso che si dirigesse verso il Sud, partendo da Glen-

Ellen, si troverebbe su un viale che segue precisamente l’antica strada
di sette secoli or sono. Un quarto di miglio da Glen-Ellen, dopo aver
passato il secondo ponte, vedrebbe a destra un botro che si estende
come una cicatrice, attraverso un gruppo di monticelli boscosi. Questo
botro rappresenta il posto dove si esercitava l’antico diritto di passaggio
che esisteva in quel tempo di proprietà individuale attraverso i terreni di
un certo signor Chauvet, pioniere francese venuto in California all’epoca
del cercatori d’oro. I monticelli boscosi, sono quelli di cui parla Avis
Everhard. Il grande terremoto del 2368, staccò il fianco di uno di quei
rialzi che riempì il baratro ove gli Everhard avevano il loro rifugio. Ma
dopo la scoperta del manoscritto sono stati fatti degli scavi, ed è stata
trovata la casa con le due camere interne contenenti gli utensili
accumulati durante una lunga residenza. Fra le altre reliquie degne di
nota, è stato trovato l’apparecchio distruttore del fumo, di cui si parla in
questo racconto. Gli studiosi che si interessassero dell’argomento in
questione, potrebbero leggere il volume di Arnold Bentham, che uscirà
in questi giorni.
A un miglio a nord ovest dei monticelli, si trova l’area della Wake Robin
Lodge, alla confluenza della Wild Water e della Sonoma. Osserviamo di
sfuggita che la Wild Water si chiamava un tempo Graham Greek, come
si legge in alcune vecchie carte. Ma il nuovo nome perdura. A Wake
Robin Lodge, Avis Everhard dimorò, poi, a parecchie riprese, quando,
mutatasi in agente provocatore del Tallone di Ferro, potè rappresentare
impunemente la sua parte, in mezzo agli uomini e agli avvenimenti. Il
permesso ufficiale le fu concesso da un signorotto non meno autorevole
del signor Wickson, l’oligarca secondario di cui tratta il manoscritto.
101. In quest’epoca il travestimento diventò una vera arte. I rivoluzionarî

avevano delle scuole di attori in tutti i loro rifugi. Sdegnavano gli
accessorî degli artisti ordinari come false barbe e parrucche, ch’erano
una trappola. Il travestimento doveva essere fondamentale, intrinseco,
doveva costituire nell’individuo come una seconda natura. Si racconta
che la Vergine Rossa fosse diventata seguace di quest’arte, alla quale si
deve il successo della lunga carriera di lei.
102. Queste sparizioni erano uno degli orrori dell’epoca. Di esse si parla
continuamente, nelle canzoni e nelle storie. Erano un risultato inevitabile
della guerra insidiosa che infuriò durante quei tre secoli. La cosa era
però frequente anche presso gli oligarchi e le classi operaie. Senza
preavviso, senza chiasso, uomini, donne e bambini sparivano; non si
rivedevano più, e la loro fine rimaneva avvolta nel mistero.
103. Du Bois, attuale bibliotecario di Ardis, discende in linea diretta da quei

rivoluzionarî.
104. Oltre le caste operaie, vi era la casta militare formata da un esercito

regolare di soldati di professione, i cui ufficiali erano membri
dall’Oligarchia, conosciuti tutti col nome di Mercenarî. Questa istituzione
sostituiva la milizia, divenuta impossibile sotto il nuovo regime. Era stato
istituito un servizio segreto di Mercenarî, oltre quello del Tallone di Ferro,
ch’era un che di mezzo fra l’esercito e la polizia.
105. Solo dopo la sconfitta della seconda rivolta, il gruppo dei Rossi di San
Francisco ricominciò a prosperare; e per due generazioni fu fiorente.
Allora un agente del Tallone di Ferro riuscì a farsi ammettere in esso e a
penetrarne tutti i segreti, conducendolo così alla fatale distruzione. Ciò
accadde nel 2002. I membri del Gruppo furono giustiziati, ad uno ad
uno, a tre settimane d’intervallo, e i loro cadaveri furono esposti nel
Ghetto del Lavoro di San Francisco.
106. Il rifugio di Benton Harbour era una catacomba la cui entrata era
abilmente dissimulata da un pozzo. È stata conservata in buono stato;
così che i visitatori possono attualmente percorrere il labirinto dei
corridoi fino alla sala delle riunioni, dove certamente avvenne la scena
descritta da Avis Everhard. Più oltre, sono le celle dove erano tenuti i
prigionieri, e la camera mortuaria dove avevano lungo le esecuzioni; più
lontano ancora, il cimitero: un insieme di lunghe e tortuose gallerie
scavate nella roccia, aventi, a ogni lato, nicchie dove riposano i
Rivoluzionari ivi deposti dai loro compagni, da tanti anni ormai.
107. A quest’epoca vi era ancora la poligamia in Turchia.
108. Il fior fiore del mondo artistico e intellettuale era composto di

rivoluzionarî. Ad eccezione di pochi musicisti e cantanti e di qualche
oligarca, tutti i grandi creatori dell’epoca, tutti coloro i cui nomi sono
giunti sino a noi, appartenevano alla rivoluzione.
109. Anche in quest’epoca la panna e il burro si estraevano ancora dal latte

di vacca, con procedimenti grossolani. Non era incominciata la
preparazione chimica del cibi.
110. Nei documenti letterarî dell’epoca si parla costantemente dei poemi di

Rudolph Mendenhall, che i suoi compagni chiamavano «La Fiamma».
Era di grande ingegno, però, tranne qualche frammento fantastico, citato
da altri autori, di lui non ci è giunto altro. Fu giustiziato dal Tallone di
Ferro, nel 1928.
111. Il caso di questo giovanotto non è straordinario. Molti figli d’oligarchi,

moralmente o romanticamente, votarono la loro vita all’ideale
rivoluzionario, spinti da un sentimento di onestà o dal fatto che la loro
fantasia era stata sedotta dall’aspetto glorioso della rivoluzione. Già
prima molti figli di nobili russi avevano fatto lo stesso, durante la lunga
rivoluzione del loro paese.
112. I Mercenarî ebbero una parte importante, negli ultimi tempi del Tallone di
Ferro. Essi mantenevano l’equilibrio del potere nei conflitti fra Oligarchi e
caste operaie, gettando il peso della loro forza sull’uno o sull’altro
piattello, secondo il gioco degli intrighi e delle cospirazioni.
113. Dall’inconsistenza e incoerenza del capitalismo, trassero tuttavia gli

Oligarchi una nuova etica coerente e definita, decisa e rigida come
l’acciaio, la più assurda e la meno scientifica e nello stesso tempo la più
possente che abbia mai servito una classe di tiranni. Gli oligarchi
credevano nella loro morale, sebbene essa fosse smentita dalla biologia
e dall’evoluzione, e per tre secoli poterono arrestare il movimento
potente del progresso umano: esempio profondo, terribile, sconcertante
per il moralista metafisico, e che deve ispirare al materialista molti dubbi
e ritorni su se stesso.
114. Ardis fu terminata nel 1924, e Asgard nel 1984. La costruzione di

quest’ultima durò cinquantadue anni, e occorse un lavoro continuo di
mezzo milione di servi. In certi periodi, il loro numero superò il milione,
senza tener conto delle centinaia di migliaia di lavoratori privilegiati e di
artisti.
115. Fra i Rivoluzionarî, c’erano numerosi chirurghi che avevano acquistato

una grande abilità nella vivisezione. Secondo le parole stesse di Avis
Everhard, potevano letteralmente trasformare un uomo in un altro. Per
essi l’eliminazione di cicatrici e deformità era un gioco. Mutavano le
linee del volto con tale cura minuziosa, che non rimaneva traccia
dell’operazione. Il naso era uno degli organi preferiti per tali operazioni.
Innestare la pelle e trasportare i capelli era una cosa ordinaria per essi,
che ottenevano cambiamenti d’espressione, con un’abilità strana, e
modificavano radicalmente gli occhi, le sopracciglia, le labbra, la bocca,
le orecchie. Mediante speciali procedimenti, alla lingua, alla gola, alla
laringe, alle fosse nasali, poteva essere modificato persino il modo di
parlare. A quell’epoca di disperazione occorrevano rimedî disperati, e i
medici rivoluzionarî assurgevano all’altezza del tempi. Tra gli altri
prodigi, era la possibilità d’ingrandire un adulto di tre o quattro pollici o
rimpicciolirlo di uno o due. La loro arte oggi è perduta. Non ne abbiamo
più bisogno.
116. Chicago era il pandemonio industriale del XIX secolo.

Viene riferito in proposito un curioso aneddoto di John Burns, grande
capo socialista inglese, che fu per qualche tempo membro del
Gabinetto. Egli visitava gli Stati Uniti quando, a Chicago, un giornalista
gli domandò cosa pensasse di questa città: «Chicago! — rispose, — è
un’edizione tascabile dell’inferno». Poco tempo dopo, mentre
s’imbarcava per ritornare in Inghilterra, un altro reporter lo avvicinò per
chiedergli se avevo modificato la sua opinione su Chicago: «Sì,
certamente! — rispose John Burns — La mia opinione attuale è che
l’inferno è un’edizione tascabile di Chicago».
117. Nome del treno reputato, a quell’epoca, il più rapido del mondo.
118. A quell’epoca la popolazione era così rada che pullulavano le bestie

selvatiche ed erano un vero flagello. In California si introdusse l’uso
delle cacce battute contro i conigli. A un dato giorno, tutti i fittavoli d’una
località si riunivano e percorrevano la contrada in linee convergenti,
spingendo i conigli a ventine di migliaia verso un recinto preparato
prima, dove uomini e ragazzi li uccidevano a colpi di randello.
119. Si è a lungo chiesto se il ghetto del sud fosse stato incendiato

incidentalmente o volontariamente dai Mercenarî. Ora è assodato che
furono questi ad appiccar l’incendio
120. Molte case resistettero più di una settimana: una di esse resistette
undici giorni. Ogni casa fu presa d’assalto come un forte, e i Mercenarî
furono obbligati ad attaccare piano per piano. Fu una lotta micidiale.
Non si chiedeva nè si concedeva tregua. In quel genere di
combattimento, i rivoluzionarii avevano il vantaggio di essere in alto.
Furono alla fine distrutti, ma a prezzo di forti perdite. Il fiero proletariato
di Chicago si mostrò degno della sua antica reputazione. Tanti morti
ebbe, altrettanti nemici uccise.
121. Gli annali di questo intermezzo di sconforto furono scritti col sangue. La
vendetta era il motivo dominante; i membri delle organizzazioni terroriste
non si preoccupavano punto della loro vita e non sapevano nulla
dell’avvenire. I Danites, ch’ebbero nome dagli angeli vendicatori della
Mitologia dei Mormoni, e origini nelle montagne del Great West, si
sparsero lungo tutta la costa del Pacifico, dal Panama all’Alaska. Le
Valchirie erano una organizzazione di donne, e la più terribile di tutte.
Non era ammessa nell’organizzazione se non colei che avesse avuto
parenti prossimi assassinati dall’Oligarchia. Avevano la crudeltà di
torturare i loro prigionieri fino alla morte. Un’altra famosa organizzazione
femminile era quella delle Vedove di Guerra. I Berserkers (guerrieri
invulnerabili della mitologia scandinava) formavano un gruppo affine a
quello delle Valchirie, composto di uomini che non davano importanza
alla vita. Furono essi a distruggere completamente la città dei Mercenarî
chiamata Bellona, con una popolazione di più di centomila anime. I
Bedlamiti e i Helldamiti erano associazioni gemelle di schiavi. Una
nuova setta religiosa, che non prosperò a lungo, si chiamava «Lo
sdegno di Dio». Questi gruppi di gente terribilmente seria, avevano i
nomi più fantastici; fra gli altri: «I cuori sanguinanti»; «I figli dell’alba»;
«Le stelle mattutine»; «I fenicotteri»; «I tre triangoli»; «Le tre Barre»; «I
Rubonici»; «I Vendicatori»; «Gli Apaches» e gli «Erebusiti».
122. Qui è interrotto il manoscritto di Everhard. Fu interrotto bruscamente, a

mezzo d’una frase. Avis dovette essere avvisata dell’arrivo dei
Mercenarî, perchè ebbe tempo di mettere in salvo il manoscritto prima di
scappare o di essere fatta prigioniera. È doloroso che non sia vissuta
per finirlo, poichè avrebbe certamente fatta la luce sul mistero che, da
settecento anni, avvolge la condanna e la morte di Ernesto Everhard.
Nota del Trascrittore
Ortografia e punteggiatura originali sono state

mantenute, correggendo senza annotazione minimi
errori tipografici.
Copertina creata dal trascrittore e posta nel pubblico
dominio.
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Operative Techniques : Hand and Wrist

Surgery 3rd. Edition Chung

Kevin C. Chung, MD, MS

OPERATIVE TECHNIQUES: HAND AND WRIST SURGERY,

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Content Strategist: Kayla Wolfe

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Taichi Saito, MD, PhD

Kevin C. Chung, MD, MS

Anesthesia of the Hand

Superficial radial nerve

Dorsal cutaneous branch of ulnar nerve

Extensor pollicis longus

Superficial radial nerve

Abductor pollicis longus

Procedure: Radial Nerve Block RADIAL NERVE BLOCK: STEP 1 PEARLS

Step 2 RADIAL NERVE BLOCK: STEP 1

Flexor carpi radialis

Dorsal sensory nerve Dorsal branch of the volar digital nerve

Volar digital nerve

1% Lidocaine + 0.5% Marcain

RADIAL NERVE BLOCK: STEP 3 PEARLS

FIGURE 1.9 MEDIAN NERVE BLOCK: STEP 1 PEARLS

Flexor carpi radialis

1% Lidocaine + 0.5% Marcain

ULNAR NERVE BLOCK: STEP 1 PEARLS

SUBCUTANEOUS DIGITAL BLOCK: Step 3

INTRATHECAL BLOCK: STEP 2 PEARLS

Flexor tendon sheath

Postoperative Care and Expected Outcomes

Fasciotomy for Compartment Syndrome of the

Flexor carpi radialis muscle

Extensor carpi radialis muscle Ulnar nerve

Radius Anterior interosseous nerve

Posterior interosseus nerve

• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg

Compartment Muscle Artery Nerve

Volar radial Dorsal ulnar

Skin incision, dorsal forearm

Carpal tunnel release

Dorsal hand release

Skin incision, finger

Procedure: Fasciotomy of the Hand

Step 4: Dorsal Decompression

Postoperative Care and Expected Outcomes

DIP joint Terminal tendon

STEP 1 PEARLS Procedure: Revision Amputation

Step 3: Identify and Treat the Neurovascular Bundles

Step 4: Perform the Bony Amputation Based on Level of Injury and

Postoperative Care and Expected Outcomes

Drainage of Septic Arthritis (Including Fight Bite)

Drainage of Septic Arthritis (Including Fight Bite)

Fig. 4.2 A-B

Skin incision, finger

Septic Arthritis of the MCP Joint

Septic Arthritis of the PIP Joint

Septic Arthritis of the DIP Joint

Step 2: Copious Irrigation of the Infected Joint

5-mm articular surface

Postoperative Care and Expected Outcomes

Drainage of Septic Tenosynovitis

• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg