Principles of Hand Surgery and Therapy [Third edition.] 0323399754, 9780323399753

Table of contents :
Cover
Principles of Hand Surgery and Therapy
Copyright
Contributors
Preface
Acknowledgments
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
INTRODUCTION
Elbow Anatomy
Bones
Ligaments
Musculature
Forearm Anatomy
Radius and Ulna
Ligaments
Musculature
Carpus
Carpal Bones
Ligaments
Extrinsic Extensor Tendons and Muscles
First Dorsal Compartment
Second Dorsal Compartment
Third Dorsal Compartment
Fourth Dorsal Compartment
Fifth Dorsal Compartment
Sixth Dorsal Compartment
Extrinsic Flexor Tendons and Muscles
Wrist Flexor Tendons and Muscles
Palmaris Longus Tendon
Digital Flexors
Hand and Digital Anatomy
Metacarpals and Phalanges
Ligaments
Tendons and Intrinsic Muscles of the Hand
Extrinsic Tendons of the Thumb.
Hypothenar Muscles
Finger Flexors
Thenar Muscles and Adductor Pollicis
Flexor Tendon Sheath
Finger Extensors, Extensor Hood Mechanism, and Intrinsic Muscles of the Hand
Extrinsic Extensors
Interosseous Muscles
Lumbrical Muscles
Proximal Extensor Mechanism (The Extensor Hood)
Distal Extensor Mechanism
Coordinated Function of Finger Range of Motion
Metacarpal-Phalangeal Joint
Proximal Interphalangeal Joint
Distal Interphalangeal Joint
Coordinated Grip
Peripheral Nerves
Median Nerve
Ulnar Nerve
Anomalous Innervation
Digital Nerves
Arterial Anatomy
EXAMINATION OF THE HAND AND UPPER EXTREMITY
Patient History
Examination of the Extremity
Vascularity
Assessing Range of Motion and Tendon Function
Elbow
Forearm
Wrist
Neurologic Evaluation
Median Nerve
Ulnar Nerve
Radial Nerve
ACKNOWLEDGMENTS
REFERENCES
Regional Anesthesia for the Upper Extremity
General Considerations
General Considerations
Historical Perspective
Regional Anesthesia for Ambulatory Surgery
Pharmacology
Local Anesthetics
Mechanism of Action
Additives
Sodium Bicarbonate
Preservatives
Epinephrine
Sedation
Premedication
Intraoperative Sedation
Complications
Nerve Injury After Regional Anesthesia
Mechanism of Injury
Prevention and Treatment of Nerve Injury
Anaphylaxis
Local Anesthesia Systemic Toxicity
Incidence
Recognition
Prevention
Treatment of Local Anesthesia Systemic Toxicity
Regional Anesthesia Techniques
Brachial Plexus Blocks
Considerations.Interscalene brachial plexus blocks consistently block the ipsilateral phrenic nerve, although this phenomenon ma...
Technique.The patient is positioned supine with the arm resting comfortably by the side and the head turned away from the side b...
Considerations.Due to the compactness of the brachial plexus at this site, this block has a rapid onset and extends to all compo...
Technique.The midpoint of the clavicle is marked. The lateral border of the sternocleidomastoid muscle is identified, and the in...
Considerations.The brachial plexus is deeper from the skin than other upper extremity blocks, making the block potentially more ...
Technique.There are at least two different approaches to the infraclavicular brachial plexus block. A midclavicular needle inser...
Considerations.The axillary approach is commonly taught and is a simple approach to use. Complications are rare and generally at...
Technique.The axillary block is performed by placing the patient supine with the arm supinated and abducted 90 degrees. The axil...
Local Anesthetic Choice
Continuous Brachial Plexus Anesthesia
Peripheral Nerve Blocks
Blocks at the Elbow
Blocks at the Wrist
Metacarpal Blocks
Advantages.Blocks performed at the base of the metacarpal will anesthetize the distal metacarpal and entire digit, allowing the ...
Disadvantages.Common digital nerves provide innervation to two adjacent finger surfaces; thus two metacarpal blocks must be perf...
Digital Nerve Blocks
Advantages
Disadvantages
Intravenous Regional Anesthesia: The Bier Block
Indications and Contraindications
Considerations
Technique
Tourniquet Management
Practical Tips for Facilitating Regional Anesthesia
REFERENCES
1 - Fractures and Ligament Injuries of the Thumb and Metacarpals
Anatomy
Physical Examination
Radiographic Examination
Thumb Fractures
Thumb Metacarpal Base Fractures
Treatment.Attempted closed manipulation may rarely anatomically align the fracture subluxation. If this can be obtained, thumb s...
Closed Reduction and Percutaneous Pinning.Closed reduction is obtained by longitudinal traction combined with abduction and pron...
Open Reduction and Internal Fixation.Closed manipulation may fail to restore anatomic alignment of the TM joint. This is an indi...
Rehabilitation.Pins that cross are removed at 6 to 8 weeks. Because fixation crosses the TM joint, cast immobilization should be...
Thumb Metacarpal Shaft Fractures
Treatment
Closed Reduction and Immobilization.Nondisplaced metacarpal shaft fractures can be effectively managed by a period of cast immob...
Surgical Treatment.Because of its mobility, indications for surgical treatment of thumb metacarpal fractures differ considerably...
Rehabilitation.Pins should be protected with a cast or splint immobilization until their removal. This period may vary from 3 to...
Thumb Metacarpal Head Fractures
Thumb Proximal Phalanx Fractures
Thumb Distal Phalanx Fractures
Thumb Dislocations and Ligament Injuries
Thumb Trapeziometacarpal Joint Dislocations
Treatment.Stable injuries and those with anatomic alignment after closed reduction may be immobilized in a thumb spica splint if...
Rehabilitation.The thumb is immobilized in a cast or splint for 4 weeks. The Kirschner wire is removed at 4 weeks. Range of moti...
Thumb Metacarpal Phalangeal Joint Ligament Injuries
Complete Collateral Ligaments Injuries.Acute, complete UCL injuries in the presence of Stener lesions must be repaired surgicall...
Chronic Thumb Metacarpal Phalangeal Collateral Ligament Injuries.Chronic instability is usually the result of an improperly trea...
Rehabilitation.Thumb spica splint or cast immobilization with the IP free to move is used for 3 weeks. Thereafter the thumb is p...
Thumb Metacarpal Phalangeal Joint Dislocation
Treatment.Closed reduction should be attempted by traction, hyperextension, and pressure at the base of the proximal phalanx, fo...
Rehabilitation.Following closed or open treatment of dorsal MCP dislocation, the joint should be immobilized with an extension b...
Thumb Interphalangeal Joint Injuries
Metacarpal Fractures
Intraarticular Base Fractures With or Without Carpal Metacarpal Joint Instability.Intraarticular injuries of the metacarpal base...
Avulsion Base Fractures.These injuries are not typically associated with instability of the CMC joint. Avulsion fractures are us...
Treatment
Nonoperative Management.Nondisplaced fractures and transverse fractures that are stable after closed reduction may be treated wi...
Open Reduction and Internal Fixation.Open reduction is indicated whenever closed reduction does not result in anatomic alignment...
Primary Arthrodesis.Some authors advocate primary arthrodesis in the setting of severe fracture-dislocations in the CMC joints o...
Rehabilitation.Following surgery the patient’s hand should be placed into an intrinsic-plus splint, as described for nonoperativ...
Metacarpal Shaft Fractures
Treatment
Nonoperative Management.Hematoma and/or wrist block provide adequate anesthesia to perform closed reduction. Transverse fracture...
Intramedullary Fixation.Intramedullary fixation has evolved as an extension of percutaneous pinning. Standard Kirschner wires ca...
Open Reduction and Internal Fixation.Open reduction and internal fixation are indicated when closed reduction does not successfu...
External Fixation.The principal indications for external fixation have been open fractures with potential for infection and comm...
Rehabilitation.Following surgery, the patient’s hand should be placed in an intrinsic-plus splint as described above. DIP and PI...
Metacarpal Neck Fractures
Treatment
Nonoperative Management.Anesthesia for closed reduction can be performed as for metacarpal shaft fractures. Improving and mainta...
Surgical Management.Indications for surgical treatment of metacarpal neck fractures are not well established. Rotational deformi...
Closed Reduction and Percutaneous Pin Fixation.After a closed reduction is performed as described above, it is maintained with 0...
Open Reduction and Internal Fixation.Open reduction and internal fixation are indicated when closed reduction is not successful....
Rehabilitation.Following surgery, the extremity should be placed into an intrinsic-plus position, as described above. DIP and PI...
Metacarpal Head Fractures
Treatment
Open Reduction With Internal Fixation.Displaced fractures require reduction and fixation. Occasionally a nondisplaced fracture m...
Salvage Techniques.The MCP joint is vital to hand function. Restoration of its anatomy is always the primary goal following inju...
Rehabilitation.The timing of postoperative mobilization depends on the severity of the injury and type of fixation used. Injurie...
Carpal Metacarpal Dislocations
Rehabilitation.Following surgery, the patient’s arm should be placed into an intrinsic-plus immobilizing splint as described for...
Surgical Treatment.Open reduction of a complex dislocation can be performed through a dorsal or volar approach. Unless the dislo...
Rehabilitation.Following closed reduction, most MCP dislocations are stable. A dorsal extension blocking splint that maintains a...
Special Considerations
Open Fractures
Segmental Bone Loss
Pediatric Fractures
Fracture Complications
Compartment Syndrome
Fight Bite Infection
Malunions
Nonunions
Acknowledgment
2 - Phalangeal Fractures and Interphalangeal Joint Injuries
Proximal Phalangeal Fractures
Anatomy
Physical Examination
Radiographic Evaluation
Treatment
Closed Reduction
Open Fracture Treatment
Intraarticular Base Fractures.Nondisplaced, comminuted, intraarticular fractures have a propensity to settle and displace. Percu...
Rehabilitation.Therapy is initiated based on the fracture stability. An initial period of immobilization is typically used for u...
Transverse Shaft Fractures.Transverse fractures with minimal comminution are usually stable after reduction and can tolerate app...
Rehabilitation.With rigid internal fixation, early range-of-motion exercises are started within a few days to a week of surgery....
Comminuted Fractures With Extensive Bone Loss.Extensive comminution may preclude stabilization with internal fixation devices al...
Rehabilitation.Range-of-motion exercises at uninvolved joints, while securely stabilizing around the fracture, minimize stiffnes...
Condylar Fractures
T- and Y-Shaped Bicondylar Fractures.T- or Y-shaped fracture patterns require exposure of both sides of the joint to obtain anat...
Rehabilitation.Active exercises in a removable intrinsic-plus splint are started immediately if stable fixation is obtained. In ...
Mechanism of Injury
Anatomy
Physical Examination
Diagnostic Imaging Evaluation
Treatment
Dorsal Subluxation and Dislocation
Simple Dislocation.Simple dislocations are defined as injuries that hyperextend past the joint’s normal range, but the base of t...
Rehabilitation.Passive and active finger flexion exercises are started with the goal of finger flexion to the distal palmar crea...
Complex Dislocation.Unlike simple dislocations, in complex dislocations the base of the middle phalanx is no longer in contact w...
Rehabilitation.If the joint is stable to passive extension, buddy-taping alone will be sufficient. If the joint is not stable to...
Irreducible Dislocation.When the joint cannot be reduced by closed manipulation, an open reduction is required using a dorsal ap...
Subluxation and Dislocation With Avulsion Fractures of the Base of the Middle Phalanx.The narrow insertion of the volar plate on...
Rehabilitation.At 5 to 6 weeks, active PIP flexion exercises with a dynamic extension splint are started. Night extension splint...
Avulsion of the Central Slip With Fracture.Avulsion fractures displaced less than 1 mm are treated similar to tendon avulsion wi...
Rehabilitation.Postoperatively the hand is immobilized in a PIP extension, Bunnell splint, or a transarticular Kirschner wire fo...
Complex Volar Dislocations.Volar PIP dislocations without an associated fracture are rare. Closed reduction is attempted but not...
Rehabilitation.When a closed reduction is successful, the patient must be tested for the competence of the central slip. If an i...
Rehabilitation.The digit is started on early active and passive motion to achieve full flexion, which is most limited due to the...
Ligamentous Injuries With Avulsion Fractures.An avulsion fracture involving less than 25% of the joint can often be treated in a...
Rehabilitation. Rehabilitation after repair is the same as described for injuries without avulsion fractures
Pediatric Injuries.Although dislocations are exceedingly rare in children, radiographic evaluation should be performed to rule o...
Middle Phalangeal Fractures
Middle Phalangeal Shaft Fractures Without Comminution
Middle Phalangeal Shaft Fractures With Comminution
Condylar Fractures
Distal Phalangeal Fractures
Mechanism of Injury
Anatomy
Physical Examination
Radiographic Evaluation
Treatment
Bony Mallet Finger Injuries
Rehabilitation.Six to eight weeks of full-time splinting is recommended followed by gentle progressive DIP flexion exercises, if...
Rehabilitation.Skeletal fixation with Kirschner wires can maintain the alignment of the digit without requiring tight splints or...
Tuft Fractures
Distal Interphalangeal Joint Subluxation and Dislocation
Rehabilitation.The Kirschner wires can generally be removed within 4 weeks, and the patient can be started on gentle active rang...
Joint Contractures
Nonunions
Malunions
ACKNOWLEDGMENTS
REFERENCES
3 - Pediatric Fractures
Introduction
Hand Fractures
Scaphoid Fractures
Distal Radius Fractures
Forearm Fractures
Pediatric Elbow Fractures
REFERENCES
4 - Carpal Instability
Core Knowledge
Biomechanics of the Carpus
Anatomy
Carpal Instability Patterns
Carpal Instability Diagnosis and Treatment
Definition
Classification
Diagnosis of Scapholunate Instability
Stages of Scapholunate Instability
Arthroscopy in Scapholunate Instability
Treatment of Acute Scapholunate Injury
Treatment of Chronic Scapholunate Injury
Limited Intercarpal Arthrodesis
Radiofrequency Shrinkage
Reduction Association Scaphoid and Lunate
Techniques of Capsulodesis
Techniques of Tenodesis
Bone-Soft Tissue-Bone Reconstruction
Emerging Techniques
Salvage Techniques
Introduction
Biomechanics
Initial Management
Surgical Treatment
Outcomes
Ulnar Carpal Instability (Midcarpal or Volar Intercalated Segment Instability Patterns)
Radiographic Evaluation
Surgical Reconstruction
Volar Intercalated Segment Instability Ligament Repair.Lunotriquetral ligament repair can provide correction of the VISI while p...
Lunotriquetral Ligament Reconstruction.In chronic cases where the quality of the residual LTIL is poor, ligament reconstruction ...
Limited Arthrodesis.Lunotriquetral arthrodesis is an option for patients who experience chronic wrist pain with daily activities...
Outcomes
Vertical Shear Fracture-Dislocation
Classification
Mechanism of Injury
Diagnosis
Treatment
Fractures of (Nonscaphoid) Carpal Bones
Overview
Trapezial Fractures
Triquetral Fractures
Hamate Fractures
Lunate Fractures
Trapezoid Fractures
Capitate Fractures
Pisiform Fractures
Future Directions
REFERENCES
5 - Scaphoid Fractures
Mechanism of Injury and Classification of Acute Scaphoid Fractures
Anatomy
Biomechanics
Acute Fractures
Physical Examination
Diagnostic Imaging of the Scaphoid
Early Management
Definitive Management
Nonoperative Management of Acute Scaphoid Fractures
Operative Management of Scaphoid Fractures
Scaphoid Nonunions
Factors in Treating Scaphoid Nonunions
Limited Approach for Percutaneous Cannulated Headless Screw Fixation With or Without Arthroscopic Manipulation
Volar Percutaneous Scaphoid Fixation
Dorsal Percutaneous Scaphoid Fixation
Open Volar Approach for Acute Scaphoid Waist Fractures
Volar Approach for Scaphoid Waist Nonunion With a Viable Proximal Pole
Open Dorsal Approach to the Scaphoid
Dorsal Approach for Scaphoid Nonunion With a Viable Proximal Pole
Outcome
Complications and Pitfalls
Salvage Procedures
REFERENCES
6 - The Distal Radioulnar Joint and Triangular Fibrocartilage Complex
Anatomy
Ligamentous Structures
Interosseous Membrane
Distal Radioulnar Joint Capsule
Triangular Fibrocartilage Complex
Biomechanics
Mechanism of Injury
Physical Examination
Imaging Studies
Radiographs
Computerized Tomography
Arthrography
Magnetic Resonance Imaging
Arthroscopy
Acute Dislocation
Fractures of the Ulnar Head and Sigmoid Notch
Galeazzi Fracture-Dislocations
Essex-Lopresti Injuries
Ulnar Styloid Fracture
Class 1A Tear
Class 1B Tear
Class 1C
Class 1D Tear
Repair of Peripheral Triangular Fibrocartilage Complex Tears Open Repair.Incise the skin longitudinally between the fifth and si...
Chronic Distal Radioulnar Joint Instability
Radioulnar Ligament Reconstruction8
Degenerative Triangular Fibrocartilage Complex Tears (Palmer Class 2), Ulnar Impaction Syndrome
Ulnar Shortening Osteotomy
Wafer Resection
Distal Radioulnar Joint Arthritis
Management of Failed Distal Ulna Excision
Extensor Carpi Ulnaris Tendonitis and Subluxation
Distal Radioulnar Joint Contracture
REFERENCES
7 - Diagnostic and Therapeutic Arthroscopy for Wrist Injuries
Specific Techniques
Dry Wrist Arthroscopy
Other Tips
Ganglion Cyst Excision
Triangular Fibrocartilage Complex Debridement or Repair
Scapholunate Ligament Injury: Assessment and Treatment
Arthroscopic Debridement for Arthritis
Arthroscopic Management of Wrist Stiffness
REFERENCES
8 - Fractures and Malunions of the Distal Radius
BACKGROUND
Anatomy
Mechanism of Injury
Classification of Distal Radius Fractures
AO-ASIF (Association for Study of Internal Fixation) Classification
Fernandez and Jupiter Classification
Associated Injuries
Initial Assessment
Radiographic Studies
Treatment of Distal Radius Fractures
Percutaneous Pinning
Extrafocal Pinning
Intrafocal Pinning (Kapandji Technique)
External Fixation
Approaches for Open Reduction and Internal Fixation
Dorsal Approach
Volar Radial Approach
Volar-Ulnar (Extended Carpal Tunnel) Approach
Combined Volar and Dorsal Approach
Carpal Tunnel Syndrome
Volar Locking Plate
Volar Plate Application
Fragment Specific Fixation Devices
Arthroscopically Assisted Open Reduction and Internal Fixation
Distraction Plating for Fractures With Extensive Comminution
Distal Radial Ulnar Joint
Rehabilitation After Distal Radius Fracture
Outcomes of Treatment
Malunions of the Distal Radius
Surgical Technique
Postoperative Rehabilitation
ACKNOWLEDGMENTS
REFERENCES
9 - Compartment Syndrome and Volkmann Ischemic Contracture
History
Acute Compartment Syndrome
Anatomy
Compartments of the Hand
Evaluation
History
Examination
Diagnostics
Treatment
Reduction of Risk Factors
Surgical Compartment Release: Volar
Surgical Compartment Release: Dorsal
Finger Compartment Syndromes
Postoperative Care and Rehabilitation
Neonatal Compartment Syndrome
Chronic Compartment Syndrome
Diagnosis of Chronic Compartment Syndrome
Treatment of Chronic Compartment Syndrome
Volkmann Ischemic Contracture
Treatment of Volkmann Ischemic Contractures
Mild Contractures
Moderate Contractures
Severe Contractures and Salvage
Conclusion
REFERENCES
10 - Nail Bed and Fingertip Injuries
Core Knowledge
Sensory Organelles in the Fingertip
Nail Bed Anatomy
Finger Pulp Anatomy
EVALUATION AND TREATMENT OF FINGERTIP INJURIESNail
Nail Bed Injuries
Evaluation
Classification
Repair.Nail bed lacerations typically result from crushing injuries that lead to ragged, stellate lacerations. Sufficient nail p...
Nail Bed Grafts.Split-thickness grafts from the nail bed can successfully take when used for nail bed defects. Grafts from the g...
Partial Fingertip Amputations
Examination
Classification
Expected Outcomes.Complete reepithelialization with restoration of some protective sensibility can occur with conservative treat...
Technical Tips.Even if a small amount of bone is exposed, this “open” technique may still be effective. The bone should not exte...
Type 2.In these injuries with more than 50% of the nail damaged along with loss of its underlying supportive distal phalanx, it ...
Technical Tips.Nail bed ablation is easily performed with tangential dissection just under the nail fold, leaving the overlying ...
Type 3.These volar oblique injuries spare more than 50% of the nail and often have open wounds at the tip that are greater than ...
Type 4 (Amputations at the Distal Interphalangeal Joint).In sharp amputations, replantation can be considered. This may be most ...
Technical Tips.Revision of amputations at the DIP joint level should be performed in the operating room, where attention can be ...
Management of Specific Structures
Nail
Nerve
Technical Tips.It is important to separate the artery from the nerve before performing neurectomy because inadvertently dividing...
Tendon
Bone and Cartilage
Local and Regional Flap Options
Description (Fig. 10.9).This flap can be executed either as a single proximally based flap or a double H flap. When designed as ...
Description (Fig. 10.10).After the recipient site (the fingertip defect) has been properly debrided, a paper or cloth template i...
Advantages
Disadvantages
Technique.The technique is similar to that used in the standard cross-finger flap but provides coverage for the dorsum of an adj...
Advantages
Disadvantages
Cross-Finger to Thumb Flap
Indications.This flap is indicated in patients with ulnar-sided soft-tissue loss involving the thumb tip or pulp, including expo...
Description (Fig. 10.13).This flap originates over the dorsum of the middle phalanx of the index or middle finger and is usually...
Advantages
Disadvantage
Description (Fig. 10.14).The flap is designed by making midlateral incisions on either side of the thumb. Then a skin pedicle is...
Advantages
Disadvantages
Description.The flap depends on the perforating subdermal vessels for its blood supply (Fig. 10.15). The skin is incised in a di...
Advantages
Disadvantages
Advantages
Disadvantages
Description (Fig. 10.17).The ulnar aspect of the middle finger is generally used as the donor site if there is no median nerve d...
Advantages
Disadvantages
Description (Fig. 10.18).After preparation of the thumb defect, a template is made for flap planning over the dorsal aspect of t...
Advantages
Disadvantages
Protection
Range of Motion
REFERENCES
11 - Amputations and Prosthetics
Core Knowledge
Functional Patterns of Digital Amputations
General Principles
Nerves
Tendons
Bone
Soft Tissue
Thumb
TREATMENT OF SPECIFIC UPPER EXTREMITY AMPUTATIONS
Digital Level Amputations
Amputations Through the Distal Phalanx and Distal Interphalangeal Joint
Amputations Through the Middle Phalanx
Phantom Limb Pain
Rehabilitation of Digital Level Amputations
Ray Amputations
Ray Amputation of the Index Finger
Ray Amputation of the Middle Finger
Middle Finger Gap Closure Versus Transposition
Ring Finger Ray Amputations
Small Finger Ray Amputation
Management of Multiple Digits Amputations
Below-the-Elbow Amputations
Amputations Through the Carpus
Technique for Below-the-Elbow Amputation
Krukenberg Operation
Elbow Disarticulation and Above-the-Elbow Amputation
Surgical Technique
Shoulder Disarticulations and Forequarter Amputations
Prosthetics
General Types
External Prostheses: Signal Sources
Targeted Muscle Reinnervation
External Prostheses: Sensory Feedback
Indications for Prosthetic Prescription
Digital Prosthesis
REFERENCES
12 - Hand Infections, Injection Injuries, Snake Bites, and Extravasation Injuries
Urgency
History
Tetanus
Cultures and Stains
Exam
Imaging
Treatment
Clinical Presentation (Specific Infections)
Human Bites (Clenched-Fist Injuries) and Septic Arthritis
Animal Bites and Scratches
Insect Bites
Necrotizing Fasciitis
Paronychia
Acute Presentation
Chronic Paronychia Infections
Felons
Flexor Tendon Sheath Infections
Flexor Tendon Sheath Infections Without an Abscess
Flexor Tendon Sheath Infections With an Abscess
Deep Space Infections
Web Space Abscesses
Parona Space Infection
Midpalmar, Thenar, and Hypothenar Space Abscesses
Horseshoe Abscesses
Specific Infectious Organisms
Methicillin-Resistant Staphylococcus aureus
Mycobacterial Infections
Fungal Infections
Candida
Sporothrichosis
Histoplasmosis
Coccidioidomycosis
Viral Infections
Herpetic Whitlow
Orf Virus
Human Immunodeficiency Virus
Occupational Bloodborne Pathogen Exposure
High-Pressure Injection
Surgical-Site Infection
Extravasation
Snake Bites
Methicillin-Resistant Staphylococcus aureus
Mycobacterial Infections
Fungal Infections
Candida
Coccidioidomycosis
Viral Infections
Herpetic Whitlow
Orf Virus
Human Immunodeficiency Virus
Occupational Bloodborne Pathogen Exposure
High-Pressure Injection
Surgical-Site Infection
Snake Bites
Extravasation
REFERENCES
13 - Burns and Frostbite of the Hand
Introduction and Epidemiology
Skin Anatomy
Thermal Burns
Classification of Burns
Acute Burn Management
Initial Evaluation
Escharotomy
Fasciotomy
Wound Care
Occupational Therapy and Hand Therapy
Excision and Skin Grafting
Skin Substitutes
Cultured Epithelial (Epidermal) Autografts.These grafts are generated from the patient’s own keratinocytes by culture expansion ...
Integra.Integra Dermal Regeneration Template (Integra Life Sciences) is a two-layer construct consisting of bovine tendon collag...
Human Acellular Dermal Matrix.Acellular dermal matrix (ADM) is a processed human dermis with the cellular components removed to ...
MatriDerm.MatriDerm (MedSkin Solutions) is similar to human ADM but from a bovine source. The bovine collagen matrix is cross-li...
Coverage of Deep Burns
Reverse Radial Forearm Flap.Many modifications of the reverse radial forearm flap have been described. Traditionally it is harve...
Reverse Posterior Interosseous Flap.This fasciocutaneous flap is harvested from the dorsal aspect of the forearm and can provide...
Abdominal and Groin Flaps.When local or regional flaps are not feasible due to the extent of injury, the abdomen or groin may pr...
Free Flaps.With the expansion of flap selections and refinement of microsurgical techniques, free flaps are becoming more common...
Pinning of Hand Joints
Amputation
Secondary Reconstructive Surgery
Scar Contracture Release
Laser Treatments
Electrical Burns
Chemical Burns
Hydrofluoric Acid
Phenol (Carbolic Acid)
Lye (Sodium Hydroxide)
White Phosphorus
Elemental Sodium, Potassium, and Lithium
Cold Injury
Pathophysiology
Classification
Treatment
REFERENCES
14 - Flexor Tendon Injuries
History and Epidemiology
Tendon Injury and Repair
What Key Information Is Required for Surgeons Performing Tendon Repair?
What Is the Ideal Research Model for Studying Flexor Tendon Injuries?
What Is the Best Way to Determine the Strength of Tendon Repair?
Can the Flexor Tendon Repair Increase Tendon Friction (Work of Flexion) During Digital Flexion?
How Strong Are Flexor Tendon Repairs?
Does Suture Locking Increase Time-Zero Tendon Repair Strength?
Does the Knot Location of the Core Sutures Affect Tendon Strength and Tendon Healing?
Should the Core Sutures Be Placed in the Dorsal or the Palmar Segment of the Tendon?
Does the Epitenon Suture Improve the Strength and Quality of the Tendon Repair?
Should One or Two Tendons Be Repaired in Zone II?
Does the Surface Area of the Tendon Repair Affect the Strength of Repair?
Does the Timing of Tendon Repair Affect the Quality of the Patient’s Functional Result?
Do Partial Tendon Lacerations Need to Be Repaired, and If So, When?
What Is the Role of Tendon Sheath Repair Following Repair of Lacerated Flexor Tendons?
Intrinsic Versus Extrinsic Tendon Healing
What Type of Rehabilitation Will Optimize the Functional Result?
Is the Lack of Vascularity of Tendon Grafts a Problem?
Physiology of Tendon Injury and Repair
Cytokines and Growth Factors
Tendon Nutrition and Blood Supply
Tendon Structure and Biomechanics
Flexor Tendon Anatomy
Zone I
Zone II (No Man’s Land)
Zone III
Zone IV
Zone V
Examination
Acute Tendon Repair
Zone I
Zone II (No Man’s Land)
Zone III Injuries
Zone IV Injuries
Zone V Injuries
Flexor Pollicis Longus Injuries
Rehabilitation of Flexor Tendon Injuries
Description
Initial 24 to 48 Hours Postoperative
Twenty-Four to 72 Hours Postoperative to 4 Weeks
Four Weeks Postoperative
Four Weeks
Five Weeks
Six Weeks
Seven Weeks
Eight Weeks
Nine Weeks
Ten to 14 Weeks
Adhesions
Treatment. Hand therapy is necessary to maximize digital PROM. Surgical treatment of stiffness should be delayed until all the s...
Bowstringing
The Plantaris Tendon.A longitudinal incision is made parallel and medial to the Achilles tendon. The incision is carried down th...
Ring-Toe Extensor.Because of the toe extension from the short toe extensors, this graft can be harvested without any deleterious...
Long Toe Flexor (Intrasynovial Tendon Graft).72The second toe flexor is the best choice of intrasynovial tendon graft given its ...
Tendon Allografts.As a last option, tendon allografts can be useful when the supply of available autografts has been exhausted. ...
Prerequisites for Two-Stage Flexor Tendon Reconstruction
First Stage
Second Stage.Incisions are made distally at the level of the DIP joint to identify the distal end of the tendon. Sutures anchori...
Postoperative Rehabilitation.This is similar to zone II flexor tendon rehabilitation (passive protocol) in the acute setting, bu...
Pedicled Intrasynovial Graft.In chronic lacerations in which both the FDP and FDS tendons have been lacerated, use of a pedicled...
Stage III Flexor Tendon Reconstruction (Tenolysis of Adhesions).In our experience, tenolysis is frequently necessary. Flexor ten...
Assessment. Evaluate PROM, AROM, and muscle strength of the extrinsic finger flexors and extensors
Treatment
One to 3 Days Postoperative Precautions
Treatment
Splinting
One to 2 Weeks Preoperative Precautions
Treatment
Splinting. Splinting, as needed, to maintain flexion and/or extension range of motion
Two to 6 Weeks Postoperative Precautions
Treatment
Splinting
Six to 8 Weeks Postoperative Precautions. No heavy resistance or lifting
Treatment
Splinting. As needed for joint contracture
Eight to 10 Weeks Postoperative Precautions. Progress resistance as tolerated
Treatment
Splinting. As needed for joint contracture
Conservative Program Following Flexor Tenolysis for Fragile (Frayed) Tendons.Always remember to confer with the surgeon regardin...
Initial Treatment
One to 2 Weeks
Two to 6 Weeks. CPM may be indicated for longer periods in these patients
Six to 8 Weeks. Delay resistive activity
Eight to 12 Weeks. Begin light resistive activity
Sixteen Weeks. Progress to full resistive activity
REFERENCES
15 - Extensor Tendon Injuries
Acute Extensor Tendon Injuries
Anatomy
Classification of Extensor Tendon Injuries
Clinical Presentation
Treatment
Zone 1
Zone 2
Rehabilitation Protocol for Zone 1 and 2 Injuries
Zone 3
Elson Test
Zone 4
Zones 3 and 4 Rehabilitation Protocols
Zone 5
Zone 6
Zone 7
Zone 8
Zone 9
Zone 5 to 9 Rehabilitation Protocols
Outcomes of Extensor Tendon Repairs
Late Extensor Tendon Reconstruction
General Considerations
Chronic Mallet Finger Deformity
Advancement of Tendon to Bone
Dermatotenodesis
Swan Neck Deformity
General Considerations
Chronic Boutonnière Deformity
Extensor Pollicis Longus Degenerative Injury
Extensor Tendon Injuries With Segmental Tendon Loss
Injuries With Two Intact Finger Extensor Tendons
Injuries With a Loss of All Finger Extensor Tendons
REFERENCES
16 - Nerve Repair and Nerve Transfers
Introduction
Anatomy of Peripheral Nerves
ANATOMY AND PHYSIOLOGY OF PERIPHERAL NERVES
Physiology of Peripheral Nerves
Basic Electrophysiology2,3
Neuromuscular Junction Transmission
Axonal Transport
Sensory Receptors
Distal Axon.The distal axon cannot survive without its connection to the cell body and disintegrates (ie, wallerian degeneration...
Proximal Axon.Following transection, there is demyelination of the distal stump. The axons degenerate to one or more proximal in...
Axon Regeneration
Role of Schwann Cells.Following nerve transection the Schwann cell removes the axonal and myelin debris in both the severed nerv...
Nerve Biomechanics.A normal nerve has longitudinal excursion, which subjects it to a certain amount of stress and strain in situ...
Clinical Assessment
Laboratory Assessment
Nerve Conduction Studies2,3
Lumbrical-Interosseous Latency Differences.A recording electrode is placed over the second palmar interspace at the distal palma...
Ulnar Nerve.Normal values include a DML greater than 3.6 ms and an amplitude greater than 4.0 mV. The latencies can be measured ...
Radial Nerve.Normal values include a DML of less than 3.4 ms, with amplitudes greater than 4.0 mV. Normal SNAPs consist of a pea...
Electromyography
Axonotmesis and Neurotmesis.The axons are disrupted but the surrounding stroma is intact. This cannot initially be distinguished...
Partial Lesions.Partial lesions usually represent axonotmesis, in which recovery depends on axonal sprouting and regeneration. W...
Complete Lesions.When the nerve is divided completely, recovery is dependent solely on axonal regeneration. The EMG is initially...
Magnetic Resonance Imaging
Treatment of Nerve Injuries
Nerve Repair
Group Fascicular Suture.The motor and sensory groups of fascicles are identified as described. In a major nerve, such as the med...
External Epineurial Splint.Jabaley has used the external epineurium as a splinting device.31 The external epineurium is incised ...
Nerve Repair: Secondary
Repair at the Elbow.The median nerve is located through an S-shaped anteromedial incision at the cubital fossa. The lacertus fib...
Repair in the Forearm.The median nerve is approached through a volar incision. The nerve is identified on the undersurface of th...
Repair at the Wrist.The median nerve at the wrist has approximately 30 fascicles. The motor recurrent branch often consists of t...
Repair in the Hand.The median nerve is approached through an extensile carpal tunnel approach, with division of the TCL. The rec...
Digital Nerve Repair.There are often two fascicles in the typical digital nerve. An external epineurial repair gives the same re...
Repair in the Forearm.The motor fascicles lie dorsal and slightly ulnarly to the sensory fascicles at the wrist level and usuall...
Repair at the Wrist.The ulnar nerve has 15 to 25 fascicles at the wrist. It can be clearly divided into a volar sensory componen...
Repair in the Hand.The nerve is approached through a volar ulnar incision in line with the ring finger. The deep motor and more ...
Digital Nerve Repair.Repair or grafting in the digits is similar to the median nerve (Fig. 16. 22)
Repair in the Forearm and Wrist.The PIN nerve is approached through a dorsolateral approach, developing the plane between the ex...
Postoperative Rehabilitation.After nerve repair the rehabilitation focuses on three areas: initial immobilization to protect the...
Outcomes Following Repair and Graft.Most series report the results of nerve repair using the BMRC grading system, which has been...
Alternate Methods of Nerve Reconstruction
Nerve Conduits
Indications.Conduits are indicated for reconstruction of small-diameter, noncritical sensory nerves with a gap of less than 3 cm...
Contraindications.These include uncertainty about the viability of the nerve ends, especially with avulsion injuries, blast inju...
Autogenous Vein Grafts.The use of autologous veins as a biologic tube to reconstruct a nerve gap has been well described over th...
Postoperative Rehabilitation.Repair of other tendon or muscle injuries will influence the rehabilitation. With an isolated nerve...
Outcomes.The use of conduits for mixed nerves is still experimental and cannot be considered a standard of treatment as yet, alt...
Processed Nerve Allografts.Taras et al.52 reported the outcomes of 14 patients with an average age of 39 years (range, 18 to 76 ...
End-to-Side Repairs
Neurotization
Nerve Transfers
Nerve Transfers to Restore Wrist and Finger Extension
Median Nerve.Just distal to the cubital fossa, the motor branches of the median nerve consistently collect into three fascicular...
Posterior Interosseous Nerve Palsy.In a PIN palsy the presenting symptoms are weakness and/or paralysis of the extensor muscles,...
Electrodiagnostic Studies.PIN lesions do not affect the superficial radial SNAP, which should be normal. The compound motor acti...
Indications.The time for reinnervation must take the distance from the injury to the motor end plate into account. As a general ...
Contraindications.Contraindications include nerve palsies that may recover spontaneously, such as proximal radial nerve lesions ...
Radial Nerve Exposure.The radial nerve is isolated through the same incision. It can be found between the BR and brachialis as i...
Nerve Transfer.MacKinnon recommends coapting the FDS motor fascicles with the ECRB branch because this can reproduce the tenodes...
Postoperative Rehabilitation.An above-elbow splint is applied with the elbow at 90 degrees and the shoulder, wrist, and fingers ...
Outcomes.In Mackinnon’s series, 17 of 19 patients had complete radial nerve palsy, whereas two had intact wrist extension with l...
Contraindications.The absolute contraindication for this nerve transfer is a global brachial plexus palsy with no recovery of ul...
Relevant Anatomy.The musculocutaneous nerve (MCN) is the terminal branch of the lateral cord of the brachial plexus, containing ...
Surgical Technique.The patient is placed supine on the operating table, with the arm placed out on a hand table. The entire extr...
Outcomes.A total of 100 cases can be identified in the English literature.68 Eighty percent of patients recovered ≥M4 motor stre...
Double Fascicular Transfer
Indications.The most common indication for this procedure is a proximal ulnar nerve injury to restore function to the ulnar inne...
Contraindications.An AIN transfer should be performed within 6 months of injury, with an upper limit of 12 months.73 Damage to t...
Surgical Technique.73The patient is positioned supine with the arm abducted to 90 degrees on a hand table, with use of a tourniq...
Outcomes.Despite the enthusiasm with this procedure, there is a paucity of published outcomes. Pace and Wood74 describe a case o...
Sensory Nerve Transfers
Indications.Sensory nerve transfers can be performed for areas requiring critical sensation in cases in which a proximal nerve s...
Contraindications.The main contraindication for nerve transfer is when a direct end-to-end nerve repair is possible or in the ca...
Surgical Technique.The patient is positioned supine with the arm abducted on a hand table under general anesthesia. Tourniquet t...
Nerve Transfer for Median Nerve Injury.The ulnar sensory fascicles to the fourth web space can be transferred to the median inne...
Nerve Transfer for Ulnar Nerve Injury.A sensory nerve transfer can be performed using the median sensory fascicles to the third ...
Outcomes.Despite the number of technical reports, published outcomes following sensory nerve transfers are lacking. Most of thes...
REFERENCES
17 - Brachial Plexus Injuries
Core Knowledge
Anatomy
Epidemiology of Adult Brachial Plexus Injuries
Mechanism of Injury in Adult Brachial Plexus Injuries
Brachial Plexus Injury During Birth
Classification of Brachial Plexus Injuries
Preganglionic Injuries
Postganglionic Injuries
C5 and C6 or Upper Trunk (Erb-Duchenne) Paralysis.These injuries produce paralysis of the deltoid, supraspinatus, infraspinatus,...
C5, C6, and C7 Injury.This combination of neural injuries features all the deficits of Erb-Duchenne paralysis plus paralysis of ...
Entire Brachial Plexus Injury.This results in an initial flail and anesthetic arm. Frequently there is a combination of pregangl...
C8 and T1 (Klumpke Palsy).These injuries are extremely rare in both birth injuries and adults and may be nonexistent as an isola...
Evaluation
History and Examination
Magnetic Resonance Imaging.With the ability to highlight the resonance of nerve tissue and adjust the plane of the images to cor...
Myelography and Myelo-Computerized Topography Scans.When traction from the injury is applied to the intradural portion of the sp...
Angiography.Angiography is rarely indicated, usually when there is clinical evidence to suggest a closed, hemodynamically stable...
Electrodiagnostic Studies
History and Examination
Imaging Studies
Electrodiagnostic Studies
Treatment
Rehabilitative Examination
Rehabilitative Treatment
Surgical Treatment
Avulsion and Open Injuries
Entire Plexus Palsy
C5-C6 or C5-C6-C7 Postganglionic Injuries
Priorities for Reconstruction of the Brachial Plexus
Technique for Exploration of the Brachial Plexus
Neurolysis of the Brachial Plexus.When the injured area of the brachial plexus has been localized, nerve action potentials can b...
Surgical Technique for Nerve Grafting.Both proximal and distal sections of the nerve are sectioned until normal-appearing fascic...
Neurotization.Neurotization has been defined as implanting distal nerve ends directly into muscle tissue. This occurs when the n...
Nerve Transfers.A number of potential donors for nerve transfers are possible for the reconstruction of the brachial plexus, inc...
Intercostal Nerve Transfer Technique16,17.When performing intercostal nerve transfers, it is important to make sure that the pat...
Partial Ulnar Nerve Transfer Technique19.The patient is positioned supine with the arm abducted and externally rotated on an arm...
Long Head of Triceps Nerve Transfer to Axillary Nerve22.A transaxillary approach with posterior axillary extension is used. The ...
Partial Spinal Accessory (Cranial Nerve XI) Nerve Transfer20.In C5-C6 avulsion situations, and even nowadays in some rupture cas...
Tendon Transfers
Tendon Transfers for Elbow Flexion
Transfer of Flexor Pronator Origin (Steindler Flexorplasty).In 1918 Steindler reported his technique for proximal advancement of...
Surgical Technique.An incision is made over the medial midaxial line of the elbow. The subcutaneous tissue is separated and the ...
Postoperative Rehabilitation.The patient is maintained with the elbow in a long-arm splint or cast holding the elbow in 110 degr...
Latissimus Dorsi Transfer to Biceps.The thoracodorsal nerve innervates the latissimus dorsi muscle, which is a branch from the p...
Postoperative Rehabilitation. This is similar to that for Steindler flexorplasty
Pectoralis Major (Clark Transfer).The pectoralis major muscle receives innervation from the lateral pectoral nerve, arising from...
Surgical Technique.An incision is made, curving from just below the clavicle laterally to the medial border of the costochondral...
Postoperative Rehabilitation. This is similar to the rehabilitation program described previously for the Steindler flexorplasty
Anterior Transfer of the Triceps.Transfer of the entire triceps muscle sacrifices elbow extension for elbow flexion. Consequentl...
Surgical Technique.The tendon transfer is performed using a longitudinal midline incision extending from the posterior aspect of...
Postoperative Rehabilitation. The rehabilitation is performed similar to the other tendon transfers for elbow flexion
Surgical Technique.Exposure is either by a long transaxillary or by a small anterior axillary and larger posterior axillary inci...
Rehabilitation.Postoperatively, the shoulder is maintained in a position of minimal abduction and full external rotation for 4 w...
Humeral External Rotation Osteotomy.In older children with a history of BPBP and established severe glenohumeral dysplasia, a ro...
Surgical Technique.In thin patients the osteotomy can be performed through a medial incision on the distal forearm to achieve a ...
Rehabilitation.Rehabilitation is initiated upon the presence of radiographic healing. Due to the surgical repositioning of the h...
Shoulder Arthrodesis.Shoulder arthrodesis allows for the patient’s scapulothoracic motion to power the shoulder to move the hume...
Surgical Technique.The patient is placed in a semi-sitting position with the arm draped free so that the posterior scapula and a...
Correction of the Supination Deformity.Although it is uncommon in adults, older children with prior birth palsies can have a fun...
REFERENCES
18 - Management of Chronic Upper Extremity Pain and Factitious Syndromes
Core Knowledge
History and Clinical Challenge
Classification of Pain: Complex Regional Pain Syndrome
Synonyms
Physiology of Pain
Descending Pain Pathways and Gate Theory.The pairing of ascending and descending pain pathways provides a mechanism to modulate ...
Norepinephrine as the Sympathetic Neurotransmitter.The sympathetic response to certain stimuli is processed by the sympathetic g...
Innervation Changes in Complex Regional Pain Syndrome.The physiologic changes that correspond to CRPS suggest altered innervatio...
Changes in the Sympathetic Nervous System in Complex Regional Pain Syndrome.There appears to be an abnormal coupling (sympatho-a...
Diagnostic Criteria for Complex Regional Pain Syndrome
Staging and Phases of Complex Regional Pain Syndrome
Incidence, Prevalence, Genetics, and Natural History of Complex Regional Pain Syndrome
Evaluation: Diagnosis
Clinical Evaluation
Blood Tests
Testing for Sympathetically Maintained Pain
Imaging
Extremity Vascular Laboratory Testing
Psychological Tests
Depression, Stress, and Anxiety
Management
Timing
Hand Therapy
Oral Medications
Parenteral Medications
Surgical and Ablative Therapies
Correction of the Nociceptive Focus
Sympathectomy
Late Surgical Intervention
Outcomes
Practical Pain Management
Factitious Injury and Self-Abuse Syndromes
Conversion Reaction
Malingering
Posttraumatic Stress Disorder
Focal Dystonias
Fibromyalgia and Myofascial Pain Syndromes
REFERENCES
19 - Management of Upper Extremity Vascular Disorders and Injuries
Core Knowledge
Significance
Components of Peripheral Blood Flow
Control of Blood Flow
Anatomy
Diagnosis and Evaluation
History
Physical Examination
Laboratory Testing
Medical Testing
Noninvasive Testing
Invasive and Structural Testing
Types of Vascular Pathobiology, Work-Up and Treatment
Raynaud Disease and Raynaud Phenomenon
Work-Up
Oral Pharmacologic Intervention.Oral medications are used to reduce vasospasm and pain and prevent thrombosis. Most medications ...
Botulinum Toxin Type A (Botox) Injections.Over 80% of patients can improve with a single injection of botox therapy with 50 to 1...
Peripheral Sympathectomy.Peripheral sympathectomy in the palm or digits is effective in maximizing nutritional digital flow. As ...
Cervicothoracic Sympathectomy.This procedure is discussed here primarily to discourage its use. The permanent interruption of th...
Thrombolytic Therapy.An alternative to surgery is the use of intraarterial anticoagulants for acute upper extremity thrombotic-e...
Prevention of Thrombosis.Several drugs that alter platelet function and coagulation pathways can be used over the long term, inc...
Embolectomy.An embolectomy is employed less frequently in the upper extremity than the lower extremity. However, this procedure ...
Technique.After verifying the extent and location of embolic events, an arteriotomy is performed at either the wrist or elbow. T...
Arterial Reconstruction. Reconstruction options include end-to-end repair, interposition grafting, and bypass grafting
Technique.Veins may be harvested through a simple longitudinal incision, multiple short longitudinal incisions, transverse incis...
Arterialization.If the patient presents with unreconstructable distal vasculature, a salvage procedure may be performed consisti...
Peripheral Vascular Small Vessel Disease
Work-Up
Treatment
Occlusive Disease (Radial and Ulnar Artery Thrombosis) and Hypothenar Hammer Syndrome
Work-Up
Technique
Occlusive Disease (Aneurysms)
Work-Up
Arteriovenous Malformations
Work-Up
Treatment
Hemangiomas
Work-Up
Treatment
Acute Trauma
Work-Up
REFERENCES
20 - Compressive Neuropathies
Pathophysiology
Basic Science
Systemic Disorders
Electrodiagnostic Studies
Areas of Compression
Epidemiology
Anatomy and Pathology
Symptoms
Examination
Diagnostic Tests
Treatment
Carpal Tunnel Release.CTR surgery can be divided into open and endoscopic procedures. Endoscopic CTR offers the advantage of dec...
Open CTR.An incision is made in line with the radial border of the ring finger from the distal volar wrist crease toward the pro...
Single Portal Versus Two Portal Endoscopic Release.The single portal technique was designed by John Agee, MD, to minimize the sc...
Complications
Postoperative Rehabilitation
Anatomy and Pathology
History
Examination
Diagnostic Tests
Treatment
Ulnar-Sided Hand Numbness
Differential Diagnosis
Epidemiology
Anatomy
Symptoms
Examination
Diagnostic Tests
Treatment
In Situ Release.The authors use this procedure for most cases of uncomplicated cubital tunnel syndrome, except in cases of nerve...
Endoscopically Assisted Cubital Tunnel Release.There are several products to assist in cubital tunnel release and the nerve can ...
Anterior Submuscular Ulnar Nerve Transposition.This technique is appropriate for patients with nerve subluxation or recurrent sy...
Anterior Subcutaneous Transfer of the Ulnar Nerve.This procedure (Fig. 20.17) is well suited for elderly patients or patients re...
Medial Epicondylectomy.This procedure has the advantage of not disturbing the vascular supply of the ulnar nerve (Fig. 20.18). C...
Complications
Epidemiology
Anatomy and Pathology (Figs. 20.20 and 20.21)
Symptoms
Examination
Diagnostic Tests
Treatment
Complications
Thoracic Outlet Syndrome
Epidemiology
Anatomy
Symptoms
Examination
Diagnostic Studies
Treatment
Supraclavicular Approach.The surgery is performed with the patient in the beach chair position. An incision is made 1 cm above a...
Transaxillary First Rib Resection.The incision for this procedure is more cosmetically appealing than the supraclavicular approa...
Results
Complications
Radial Nerve Compression
Epidemiology
Anatomy and Pathology
Symptoms
Examination
Diagnostic Studies
Treatment
Anterior Approach.This approach gives the widest exposure. The incision begins proximal to the antecubital fossa between the bra...
Transmuscular Approach.A curvilinear incision is made directly over the mobile wad. Distal branches of the lateral antebrachial ...
Posterior Approach.The posterior approach uses an incision along the posterior border of the extensor origin using a line drawn ...
Rehabilitation.For either approach, the arm is postoperatively bandaged in a long-arm splint. Range-of-motion exercises of the w...
Release of Wartenberg’s Syndrome.At the level of the wrist, the sensory branch of the radial nerve exits between the tendon of t...
Complications.The most common complication for any of the above procedures is paresthesias in the lateral antebrachial cutaneous...
REFERENCES
ADDITIONAL READING
21 - The Paralytic Hand and Tendon Transfers
Core Knowledge
Principles of Tendon Transfer
Muscle Physiology
Muscle Tension
Functional Anatomy
Rehabilitation
Radial Nerve Palsy
Rehabilitation
Median Nerve Palsy
Low Median Nerve Palsy
High Median Nerve Palsy
Rehabilitation
Ulnar Nerve Palsy
Low Ulnar Nerve Palsy
High Ulnar Nerve Palsy
Rehabilitation
Combined Nerve Palsies
ACKNOWLEDGMENT
REFERENCES
22 - Cerebral Palsy, Stroke, and Traumatic Brain Injury
Overview
Cerebral Palsy
Core Knowledge
Clinical Evaluation
Motor Evaluation
Cognition
Voluntary Control of Hand Placement
Sensibility and Stereognosis
Dynamic Electromyography
Splints and Therapy
Surgical Treatment
Elbow Flexion Deformity
Surgical Technique.Elbow contractures can be released with an S-shaped incision centered over the antecubital fossa, with the pr...
Rehabilitation.The elbow is splinted for 2 weeks in the position of maximal extension that was achieved during surgery. The post...
Complications.Wound problems, such as hematomas, can occur with these large surgical releases. It is advisable to place suction ...
Wrist Flexion Deformity
Surgical Technique for Flexor Carpi Ulnaris Lengthening.A simple step-cut lengthening of the FCU is recommended. An incision alo...
Surgical Technique for Flexor Pronator Slide.The flexor-pronator slide is performed using the incision along the medial midaxial...
Surgical Technique for Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis Tendon Transfer.The FCU is exposed using two incis...
Rehabilitation.Patients with the Green tendon transfer are casted in wrist extension for 4 weeks before starting active wrist ex...
Surgical Technique: Dorsal Wrist Approach With Proximal Row Carpectomy and Dorsal Plate Fixation.An oblique dorsal wrist incisio...
Rehabilitation.Patients are treated after surgery in a short-arm cast for 6 weeks, followed by a removable orthosis, until union...
Complications.Wrist arthrodesis can improve appearance, hygiene, function, and overall satisfaction in those suffering with a sp...
Surgical Technique for Fractional Tendon Lengthening.A finger flexor fractional lengthening is performed using an incision on th...
Surgical Technique for Step-Cut Lengthening.This surgery is performed using the same type of incision as a fractional lengthenin...
Rehabilitation.Patients with fractional lengthening are allowed to start active finger and wrist flexion and extension while usi...
Surgical Technique for Flexor Carpi Ulnaris to Extensor Digitorum Communis Tendon Transfer.A longitudinal incision is made on th...
Swan Neck Deformities of the Fingers Secondary to Contractures of Intrinsic Muscles.Spasticity and contractures of the intrinsic...
Surgical Technique for Central Slip Tenotomy.16.Central slip tenotomy is performed using a transverse incision 1 cm proximal to ...
Rehabilitation.After central slip tenotomy, the PIP joint is pinned for 4 weeks. After removal of the pins in the office, active...
Rehabilitation.Postoperatively the patients are splinted in the intrinsic-minus position with the MCP joints extended and the PI...
Surgical Technique for Superficialis Tenodesis to Correct Swan Neck Deformity.For patients with moderate-to-severe swan neck def...
Surgical Technique for Release of Nerve/Nerve Block of the Adductor Pollicis and Flexor Pollicis Brevis.A carpal tunnel approach...
Surgical Technique for Release of the Adductor Pollicis and Flexor Pollicis Brevis.Mild contractures of the AddP can be released...
Surgical Technique for FPL Lengthening.A step-cut lengthening technique can be very successful (Fig. 22.14). After surgery the t...
Surgical Technique for Transferring the Thumb FPL to the APB.The FPL is identified and released via a radial midaxial exposure o...
Surgical Technique for Extensor Pollicis Longus Rerouting.The EPL tendon is exposed using a curved incision over the proximal ph...
Surgical Outcomes
Stroke and Traumatic Brain Injury
Stroke
Sensory Impairment.The sensory impairment can vary in individuals but usually results in a profound loss of discrimination, usin...
Motor Impairment.In the first several days to weeks following the stroke the patient has flaccid paralysis followed by gradually...
Cognitive Impairment.Memory loss, decreased learning ability, and decreased mentation can all complicate the rehabilitation of p...
Traumatic Brain Injury
Treatment of Stroke and Traumatic Brain Injury
Upper Extremity Involvement
Spasticity
Wrist and Finger Flexion Contracture.Wrist and finger flexion deformities are considered together because the finger muscles are...
Individual Step-Cut Tendon Lengthening.This surgery is performed using the same type of incision as the FDS to FDP transfer. Pat...
Fractional Tendon Lengthening.When the finger can be passively extended several centimeters from the palm in patients who have s...
Rehabilitation.The patients with fractional lengthening are allowed to start active finger and wrist flexion and extension while...
Complications Following Correction of Finger Flexion Contractures.Loss of grip strength is a common problem, especially followin...
Lengthening of Wrist Flexor Tendons.For mild deformities in patients who can actively extend to within 30 degrees of neutral wri...
Rehabilitation.The wrist is splinted in 30 degrees of wrist extension after surgery for 6 weeks on a full-time basis. Nighttime ...
Complications.Recurrence of the deformity may be a problem for patients who do not follow through with their postoperative splin...
Thumb-in-Palm Deformity.This deformity can occur in adults with stroke or TBI, although it does not usually require surgical tre...
REFERENCES
23 - Upper Limb Reconstruction in Persons With Tetraplegia
INTRODUCTION
Demographics of Spinal Cord Injury
Nerve Injury in Tetraplegia
Timing of Surgery
High-Level Tetraplegia
Shoulder Girdle
Functional Electrical Stimulation
Mid-Level Cervical Tetraplegia
Classification
Treatment
Elbow
Forearm
Technique: Biceps Tendon Rerouting
Technique: One-Bone Forearm
Wrist and Hand
Rehabilitation and Outcome
Summary
24 - Tendinopathies of the Hand, Wrist, and Elbow
Adult Trigger Finger
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Percutaneous Trigger Finger Release
Open Trigger Finger Release
Trigger Thumb Release
Trigger Digit Postoperative Rehabilitation
Complication
Locking Metacarpal Phalangeal Joint
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Release of the First Dorsal Compartment With Fascial Reconstruction
Complications
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Rehabilitation After Second Dorsal Compartment Release
Complications
Flexor Carpi Radialis Stenosing Tenosynovitis
Surgical Treatment
Rehabilitation After Flexor Carpi Radialis Release
Flexor Carpi Ulnaris Tendinosis
Surgical Treatment
Extensor Carpi Ulnaris Stenosing Tenosynovitis
Surgical Treatment
Rehabilitation After Extensor Carpi Ulnaris Release
Lateral Elbow Tendinosis (Tennis Elbow)
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Rehabilitation
Complications
Medial Elbow Tendinosis (Golfer’s Elbow)
Anatomy
Clinical Presentation
Treatment of Golfer’s Elbow
Rehabilitation
Posterior Tennis Elbow
Anatomy
Clinical Presentation
Nonoperative Treatment of Posterior Tennis Elbow
Surgical Treatment
Rehabilitation
REFERENCES
25 - Osteoarthritis
Osteoarthritis and Posttraumatic Arthritis
Clinical Presentation and Medical Management
Treatment Principles
Arthroplasty
Arthrodesis
Osteoarthritis or Degenerative Arthritis
Clinical Presentation
Distal Interphalangeal Joint (Heberden Node and Mucous Cyst)
Proximal Interphalangeal Joint
Proximal Interphalangeal Joint Arthrodesis
Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthrodesis.Initially the finger is immobilized in a splint an...
Proximal Interphalangeal Joint Arthroplasty
Dorsal Approach.One dorsal approach for PIP arthroplasty is similar to that used for arthrodesis, with the key distinction being...
Lateral Approach.In the lateral approach (best for the index finger with ular approach to preserve the PIP radial collateral lig...
Volar Approach.The volar approach is the author’s preferred approach for a primary arthroplasty. In some cases of revision surge...
Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthroplasty.Postoperative rehabilitation for PIP joint arthro...
Carpometacarpal Joint Arthritis of the Thumb
Nonoperative Treatment of Basal Joint Arthritis
Surgical Treatment of Basal Joint Arthritis
Surgical Procedure for Ligament Reconstruction and Tendon Interposition.A Wagner incision is used beginning just dorsal to the t...
Suspensionplasty Using the Abductor Pollicis Longus.This approach to the basal joint is similar to the ligament reconstruction a...
Costochondral Interposition Hemiarthroplasty or Complete Trapezial Arthroplasty.Costochondral allograft has been suggested as a ...
Carpometacarpal Implant Arthroplasty.A multitude of implants have been proposed and attempted. Several different Silastic implan...
Tightrope Ligament Reconstruction With or Without Implant Arthroplasty.A major breakthrough and basal joint arthroplasty for the...
Abduction Osteotomy of Thumb Metacarpal.In young patients who do manual labor, an abduction osteotomy can delay or prevent the n...
Arthrodesis of the Thumb Carpometacarpal Joint.Isolated trapeziometacarpal arthritis can be effectively treated with a number of...
Postoperative Rehabilitation After Thumb Carpometacarpal Arthrodesis.A short-arm, thumb-spica splint is used until radiographic ...
Scaphotrapeziotrapezoid Arthritis
Scapholunate and Scaphoid Nonunion Advanced Collapse Pattern Arthritis
Scaphoid Excision and Capsulorraphy
Four-Bone Fusion
Postoperative Rehabilitation After Four-Bone Arthrodesis.Postoperatively, the wrist is immobilized for 6 weeks. Patients are the...
Proximal Row Carpectomy
Postoperative Rehabilitation After Proximal Row Carpectomy.The wrist is immobilized for 4 weeks, at which time active range-of-m...
Total Wrist Arthrodesis
Total Wrist Arthroplasty
REFERENCES
26 - Rheumatoid Arthritis
OVERVIEW
INFLAMMATORY ARTHRITIS
Rheumatoid Arthritis
Clinical Presentation
Pathophysiology
Laboratory Studies
Histology
Radiographic Findings in Rheumatoid Arthritis
Medical Management
Disease-Modifying Antirheumatic Drugs and Surgery
Juvenile Rheumatoid Arthritis
Other Inflammatory Arthritis
Systemic Lupus Erythematosus
Scleroderma
Fingertip Ulcerations
Psoriatic Arthritis
Crystalline Arthropathy
Gout.Gout results from hyperuricemia and the deposition of sodium urate crystals. It occurs commonly in males in the fifth and s...
Chondrocalcinosis (Pseudogout).In contrast to gout, pseudogout is a less aggressive form of crystalline arthropathy and is also ...
Diagnostic Joint Aspirates
Patterns and Common Treatment Measures
Rheumatoid Arthritis
Synovitis and Tenosynovitis
Extensor Compartment Synovitis.Synovitis of the distal radioulnar joint (DRUJ) and dorsal extensor compartment may coexist. Swel...
Procedure for Distal Ulna Resection and Dorsal Tenosynovectomy.A modified Darrach procedure is performed with or without the add...
Ruptured Extensor Tendons.Extensor tendon ruptures can be quite debilitating and are treated with either tendon transfer or an i...
Postoperative Rehabilitation After Extensor Tendon Repairs and Transfers.The wrist is immobilized in 20 degrees of extension and...
Flexor Tenosynovitis.Fingers with greater passive than active motion may be affected by tenosynovitis, which can be refractory t...
Postoperative Rehabilitation for Flexor Tenosynovectomy.Patients are typically started on active and passive flexion exercises w...
Flexor Pollicis Longus Tendon Rupture.Flexor pollicis longus (FPL) tendon rupture in the setting of RA has been called Mannerfel...
Note on Concomitant Carpometacarpal Joint Arthritis.It is fairly common to find the thumb affected by some amount of carpometaca...
Swan Neck Deformity of the Thumb.This deformity often exists in patients without inflammatory arthritis. It is believed to be a ...
Swan Neck Deformity With Flexible Metacarpal Phalangeal Joint.In this setting the MCP joint position can be corrected by release...
Ulnar Collateral Ligament Instability.In the setting of rheumatoid disease, UCL instability is the result of synovitis and repet...
Silicone Implant Arthroplasty for Reconstruction of the Metacarpal Phalangeal Joint. These implants are preferred when the patie...
Postoperative Rehabilitation for Metacarpal Phalangeal Joint Silicone Implant Arthroplasty.The splint and dressing are changed a...
Overall Functional Outcomes of Silicone Metacarpal Phalangeal Arthroplasty.In general, silicone arthroplasty of the MCP joint pr...
Swan Neck Deformity.The etiology of swan neck deformity in rheumatoid patients is multifactorial. In addition to intrinsic tight...
Flexible (Supple) Swan Neck Deformity.Surgical management of swan neck deformities can be frustrating, with frequent recurrence....
Postoperative Rehabilitation After Swan Neck Correction.A hand-based splint is used that block the PIP in 30 degrees of flexion ...
Rigid Swan Neck Deformity.For rigid swan neck deformity, PIP joint arthrodesis in a functional position is recommended. PIP join...
Boutonnière Deformity.Boutonnière deformity is nearly always secondary to PIP joint swelling and synovitis. The central tendon o...
Fixed Boutonnière Deformity.It is rare that a fixed boutonnière deformity requires extensive treatment because the finger is oft...
Postoperative Rehabilitation for Proximal Interphalangeal Fusion.The guidelines for postoperative management of small joint fusi...
Wrist Arthritis
Rheumatoid Pattern of Wrist Degeneration
Radiolunate Arthrodesis for Ulnar Translocation
Postoperative Rehabilitation for Partial Wrist Fusion.The wrist is immobilized for 6 to 8 weeks. After radiographs have confirme...
Involvement of the Midcarpal and Radiocarpal Joints
Wrist Arthrodesis
Postoperative Rehabilitation After Wrist Arthrodesis.Total wrist arthrodesis has a high fusion rate and relatively few major com...
Total Wrist Arthroplasty
Postoperative Rehabilitation After Total Wrist Arthroplasty.On average, the wrist is splinted for 3 weeks before allowing wrist ...
REFERENCES
27 - Carpal Avascular Necrosis: Kienböck Disease and Preiser Disease
Kienböck Disease
Core Knowledge
Historical Background
Etiology
Vascular Anatomy.The vascular anatomy of the lunate and its vulnerability to disruption have long been suspected as causes for A...
Load Distribution.Osseous anatomy and the load borne through the lunate may also be significant factors in the development of lu...
Epidemiology
Evaluation and Treatment
Diagnostic Studies.Initially, any patient with suspected Kienböck disease should be evaluated with plain radiographs (Fig. 27.3)...
Staging.The most common method for staging Kienböck disease was first developed by Stahl in 1947. Lichtman et al. modified this ...
Treatment
Stage I.The appropriate treatment for stage I disease remains controversial. Some authors have argued that patients in this stag...
Stages I, II, or IIIA With Ulnar-Negative Variance.In these three stages the carpus has not collapsed into an instability patter...
Surgical Technique for Radial Shortening (Dorsal Approach).The distal radius may be approached either dorsally or palmarly. The ...
Surgical Technique for Radial Shortening (Volar Approach).An 8-cm longitudinal incision is made over the radial border of the fl...
Vascularized Bone Graft.The use of a VBG may be combined with lunate unloading procedures or used as an alternative to other pro...
Surgical Technique for Vascularized Bone Graft From the Radius.The incision curves from the dorsal wrist, centered over the luna...
Surgical Technique for Vascularized Bone Graft From the Base of the Second or Third Metacarpal.This technique takes advantage of...
Stages I, II, or IIIA With Ulnar-Positive or Neutral Variance.In this situation the radius is as short as or shorter than the ul...
Surgical Technique for Capitate Shortening.The capitate is approached using a straight midline dorsal incision. The tendons of t...
Stages I, II, or IIIA (Other Techniques).In 2001 Illarramendi et al. described their technique of coring out the metaphyseal reg...
Stage IIIB.If the disease has progressed to stage IIIB, salvage procedures must be considered. In this stage, carpal instability...
Surgical Technique for Scaphotrapeziotrapezoid Arthrodesis.An incision is made along the dorsoradial aspect of the wrist, beginn...
Surgical Technique for Scaphocapitate Arthrodesis.This technique may be used as an alternative to the STT fusion in stage IIIB K...
Rehabilitation After Osteotomies or Arthrodeses for Kienböck Disease.In general, patients are splinted for 2 weeks after surgery...
Stage IV.In stage IV, there is significant collapse of the lunate combined with perilunate arthritis. These degenerative changes...
Surgical Technique for Wrist Arthrodesis.A longitudinal incision is made over the dorsum of the wrist just ulnar to Lister tuber...
Rehabilitation After Wrist Arthrodesis.A splint is worn for 2 weeks. Patients are started on immediate finger range-of-motion ex...
Pediatric Kienböck Disease
Preiser Disease
Core Knowledge
Diagnosis
Diagnostic Imaging
Treatment
Summary
REFERENCES
28 - Dupuytren Disease
History
Epidemiology
Predisposing Factors
Etiology
Pathophysiology
Anatomy
Pathology
Microcords
Palmar Cords
Palmodigital Cords
Digital Cords
Thumb Diseased Tissue
Clinical Presentation
Clinical Types
Differential Diagnosis
Treatment
Nonoperative Treatment
Surgical Treatment
Methods of Skin Management
Rehabilitation
Complications
Intraoperative Complications
Early Postoperative Complications
Late Postoperative Complications
Summary
REFERENCES
29 - Ganglion, Mucous Cyst, and Carpal Boss
Ganglions
Core Knowledge
Pathology
Diagnosis
Treatment
Dorsal Wrist Ganglion
Volar Wrist Ganglion
Occult Wrist Ganglions
Surgical Technique
Ganglion of Tendon Sheath
Surgical Technique
Rehabilitation
Complications
Mucous Cyst
Diagnosis
Treatment
Surgical Technique
Ganglion Cyst of the Proximal Interphalangeal Joint
Surgical Technique
Postoperative Rehabilitation
Carpal Boss
Treatment
Surgical Technique
Postoperative Rehabilitation
Complications
REFERENCES
30 - Replantation
INTRODUCTION
Assessment and Surgical Preparation
Classification
Surgical Anatomy
Indications and Contraindications
Transport and Care of the Patient and Amputated Part
Preparation of the Part and Stump
Surgical Technique
Surgical Sequence
Major Limb Replantation
Ring Avulsion Injuries
Postoperative Care
Postoperative Complications: Immediate
Postoperative Complications: Late
Secondary Surgery
Outcomes of Replantation
REFERENCES
31 - Thumb Reconstruction Following Partial or Complete Amputation
History
Classification of the Thumb Injuries
Reconstruction of Level A Amputations
Postoperative Rehabilitation.The thumb is immobilized for 2 weeks and then range of motion is initiated at the IP and MCP joints...
Advantages and Disadvantages.The advantage of the Moberg flap is that it provides sensate coverage with no additional donor site...
Surgical Technique.The skin over the dorsal aspect of the index finger proximal phalanx is elevated as a radially based flap, le...
Postoperative Rehabilitation.Thumb adduction and flexion contractures may develop following index-to-thumb cross-finger flaps. T...
Advantages and Disadvantages.The advantage to this technique is that it provides a greater area of soft-tissue coverage than is ...
Additional Options for Large Palmar Soft-Tissue Deficits
Reversed Dorsal Digital Island Flap.The use of an innervated reverse dorsal digital island flap for palmar coverage has been rep...
Venous Flaps
Retrograde Arterialized Free Venous Flaps for the Reconstruction of the Thumb.These flaps provide thin flexible cutaneous flaps ...
Postoperative Rehabilitation.The hand, forearm, and elbow were wrapped in a bulky dressing and were elevated for 5 days while th...
Advantages.For reconstruction of the hand, retrograde arterialized free venous flaps offer a custom-made, thin, and pliable flap...
Disadvantages.They require microsurgery, which increases the surgical time, effort, and cost compared with local flaps. Postoper...
Great Toe Pulp Neurovascular Free Flap
Dorsal Soft-Tissue Deficits of the Thumb Measuring 3 cm2 or Less Treated With Dorsal Rotation Flap From the Index Finger
Technique for Dorsal Rotation Flap From the Index Finger to the Thumb.The flap is elevated in a similar manner as the cross-fing...
Postoperative Rehabilitation. This is identical to that of the volar cross-finger flap
Advantages and Disadvantages of the Dorsal Rotation Flap.The advantage of the dorsal rotation flap is that it does not require a...
Surgical Technique: Reversed Radial Forearm Flap and ­Fascia-Only Flap.The reversed radial forearm flap is elevated as a pedicle...
Surgical Technique: Radial Artery Preserving Forearm Fascial Flap.The radial forearm fascia may also be harvested without sacrif...
Postoperative Rehabilitation.A protective splint is applied that is designed to avoid compression of the vascular pedicle. Posto...
Advantages and Disadvantages for Reverse Radial Forearm Flaps.The advantage of these flaps is that substantial soft tissue cover...
The Posterior Interosseous Flap.The axis of the flap is the line drawn from the lateral epicondyle of the humerus to the ulnar s...
Postoperative Rehabilitation Following Posterior Interosseous Flap.The patients are splinted and required to elevate their arms....
Advantages of Posterior Interosseous Flaps.They can be harvested without sacrificing a major artery, and they provide a regional...
Disadvantages.The flaps often have some flap necrosis, and they are challenging to raise. Posterior interosseus nerve (PIN) inju...
Metacarpal Lengthening
Surgical Technique.The skin overlying the planned osteotomy site is retracted toward the osteotomy at the time of incision to mi...
Postoperative Rehabilitation Following Thumb Metacarpal Lengthening.After surgery the patient is maintained in a thumb spica spl...
Advantages and Disadvantages for Thumb Metacarpal Lengthening.One advantage of thumb metacarpal lengthening is that the donor si...
Web Space Enlargement
Postoperative Rehabilitation. A palmer abduction night splint is used for 4 to 6 weeks after surgery
Toe-to-Thumb Transplantation
Vascular Anatomy of the Great and Second Toe.Arterial supply to the foot is conveyed through a dorsal system from the dorsalis p...
Great Toe Transplant
Surgical Technique: Great Toe Harvest.Dissection is begun after placement and inflation of a sterile high thigh tourniquet. The ...
Surgical Technique: Great Toe Wraparound Flap.The use of a filleted composite tissue flap of skin, neurovascular pedicle, and na...
Second Toe Transplant
Surgical Technique.The course of the dorsalis pedis artery and proximal veins are identified and outlined as with the great toe ...
Postoperative Rehabilitation.The transplanted digit is monitored for viability after surgery. Monitoring can be aided with the u...
Advantages and Disadvantages of Toe-to-Thumb Transplant.The advantage of toe transplant is that it can provide reconstruction of...
Osteoplastic Thumb Reconstruction
Stage 2: Creation of a Thumb Post Using an Iliac Crest Bone Graft.Once the scar tissue around the groin flap on the thumb has be...
Stage 3: Providing Sensation With a Neurovascular Island Flap.The neurovascular island flap is outlined on the ulnar aspect of t...
Postoperative Rehabilitation.A splint is worn until there is evidence of healing at the bone graft site. Patients are encouraged...
Advantages and Disadvantages.The donor sites for osteoplastic thumb reconstruction are well tolerated and concealed. Advantages ...
Surgical Technique.Use of the reverse radial forearm flap requires the existence of a complete palmar arch, and its dissection h...
Postoperative Rehabilitation.A thumb spica splint is used for 3 to 4 weeks to protect the reconstructed thumb. When radiographic...
Advantages and Disadvantages.The primary advantage of this technique is the single-stage nature of the reconstruction and attach...
Dorsal Rotation Flap
Surgical Technique.The dorsal rotational flap is elevated using an incision that extends dorsally from the level of the CMC join...
Postoperative Rehabilitation.The skin graft is protected until its incorporation is apparent. The transfixation wires between th...
Advantages and Disadvantages.The advantage of the dorsal rotation flap is that it provides a single-stage procedure with sensate...
Dorsal Rotation Flap for Phalangization of the Metacarpal Hand.Various techniques are available to improve the pinch function be...
Surgical Technique.The dorsal rotation flap is elevated as previously described. The index ray remnant is removed along with the...
Postoperative Rehabilitation.The dressings are removed in 2 to 3 weeks to assess skin graft incorporation and the patient begins...
Advantages and Disadvantages.The advantages of this technique are its simplicity and the opportunity to avoid an additional dono...
Reconstruction of Level D Amputations at the Base of the Thumb Metacarpal and Trapezium
Pollicization
Surgical Technique.Various incisions have been described using modifications of an apex-proximal V that extends to the proximal ...
Postoperative Rehabilitation.The hand is protected with a spica splint and the pollicized digit is evaluated for vascular insuff...
Advantages and Disadvantages.Pollicization of the index finger provides satisfactory treatment for the proximally amputated thum...
Staged Multiflap Total Thumb Reconstruction
Surgical Technique.Planning is of paramount importance in total thumb reconstruction with multiple flaps. Goals include stabiliz...
Stage 1: Stabilization of the Soft-Tissue Envelope.Adequate and supple soft tissue can be supplied by the pedicled groin flap or...
Stage 2: Reconstruction of the CMC Joint and Metacarpal.Free fibula harvest is detailed in Chapter 32. A skin paddle based on pe...
Stage 3: Reconstruction of the Phalanges.Toe-to-thumb transplant is performed as described earlier in this chapter. Osteosynthes...
Stage 4: Opponensplasty, Tenolyses and Revision of the CMC Joint.Multiple techniques for opponensplasty have been described, inc...
Postoperative Rehabilitation.Standard monitoring for free tissue transplantation is used in the immediate postoperative period. ...
Advantages and Disadvantages.Multiflap reconstruction of the thumb can provide an aesthetic and functional result that arguably ...
REFERENCES
32 - Soft-Tissue Coverage of the Hand
Core Knowledge
Goals for Reconstruction
Preparation of the Wound Bed
Choosing the Right Flap
Pedicled Flaps (Random Versus Axial)
Random Pattern Flaps
Axial Pattern Flaps
Staging of Pedicle Flaps
Techniques for Tissue Transfer
Four Flap Z-Plasty.In the four-flap Z-plasty, all sides should be the same length, so the flap angles which have been arranged o...
Double-Opposing Z-Plasties.This flap is well suited for discrete linear contractures in the first web space, when the scar line ...
Rhomboid Flaps.In this flap design, all sides of the defect are of equal length including the transverse diagonal of the defect....
Dorsal Hand Flap.This flap is well suited for cutaneous defects at the radial or ulnar aspects of the dorsum of the hand. The fl...
Pedicle Flaps
Random Pedicle Flaps
Abdominal Flap.The abdominal flap is useful for soft-tissue coverage in the region of the wrist or forearm. A flap can be raised...
Abdominal Pocket Flaps.This flap is extremely useful for burn injuries when there has been a substantial area of skin loss on th...
Axial Pedicle Flaps
Groin Flap.McGregor and Jackson introduced the groin flap in 1972.5 In its heyday, the pedicled groin flap was the mainstay for ...
Anatomy.The vascular pedicle for the flap is based on the SCIA. While the SCIA provides an axial blood supply to the area of the...
Surgical Technique.It is important to inspect the patient for previous incisions from hernia repairs or lymph node biopsies or d...
Reversed Radial Forearm Flap.The radial forearm flap was initially described in 1978 for the reconstruction of burn injuries to ...
Anatomy.A full description of the vascular anatomy of the radial forearm flap is presented in the free flap reconstruction secti...
Surgical Technique.A line drawn from the mid-antecubital fossa to the tubercle of the scaphoid marks the axis of the radial arte...
Posterior Interosseous Flap.The posterior interosseous flap was initially described in the 1980s and has been a good alternative...
Anatomy.As the name describes, this flap is based on the posterior interosseous artery. When used in reverse fashion, it require...
Surgical Technique.With the forearm pronated, the flap is centered on a line between the lateral epicondyle and the ulnar head (...
Microvascular Transplantation
Fasciocutaneous Free Flaps
Lateral Arm Flap.The lateral arm flap is ideal for upper extremity reconstruction because it can be harvested within the same li...
Anatomy.The blood supply to the lateral arm flap is via the posterior radial collateral artery (PRCA), which arises from the pro...
Surgical Technique.The entire arm and shoulder are prepped and draped out free, and a sterile tourniquet is applied high on the ...
Advantages and Disadvantages.Advantages: The flap can be harvested from the ipsilateral arm to avoid another donor site in anoth...
Radial Forearm Free Flap.We use the free radial forearm flap for coverage of small soft-tissue defects over exposed joints or te...
Anatomy.Branches of the radial artery perfuse skin along the entire volar forearm. The flap is usually designed along the longit...
Surgical Technique.It is important to perform an Allen test to ensure the patency of an ulnar artery that will become the sole v...
Advantages and Disadvantages.Advantages: The advantages of the flap are that it is thin with relatively little subcutaneous fat....
Anterolateral Thigh Flap.The anterolateral thigh (ALT) flap is an axial fasciocutaneous or fascia-only flap, based on perforator...
Anatomy.The vascular pedicle of the ALT flap is the descending branch of the lateral circumflex femoral artery, which in turn ar...
Surgical Technique.A line is marked from the ASIS to the superolateral patella. The main perforator enters the flap at around th...
Advantages and Disadvantages.Advantages: There is minimal functional deficit, especially when harvested as a fascial flap. A lar...
Scapular Flap.The scapular and parascapular flaps provide a large surface area of skin with a pedicle that is based on the circu...
Anatomy.The subscapular artery is 3 mm in diameter and takes its origin from the axillary artery. The subscapular artery then br...
Surgical Technique.The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest c...
Advantages and Disadvantages.Advantages: The donor site defect from the scapular flap leaves no functional impairment and can be...
Muscle Free Flaps
Anatomy.The latissimus dorsi is a fan-shaped muscle that originates from the thoracolumbar fascia, the lower six thoracic verteb...
Surgical Technique.The contralateral latissimus dorsi muscle is usually chosen to perform the surgery without any position chang...
Advantages and Disadvantages.Advantages: This is a workhorse flap with a long pedicle of good diameter and it can include the se...
Partial Superior Latissimus Muscle Flap.We find this option very useful for hand coverage because a full latissimus flap is rare...
Surgical Technique.The patient is positioned as per the latissimus dorsi flap described above. The landmarks of the latissimus d...
Advantages and Disadvantages.Advantages: The PSL flap leaves behind part of the latissimus that will still be functional and pre...
Gracilis Muscle Flap.The gracilis muscle is a long strap-like muscle that lies on the medial thigh (Fig. 32.30). It can be used ...
Anatomy.The gracilis muscle lies medially underneath the deep fascia of the medial portion of the thigh. It arises as a thin apo...
Surgical Technique.With the patient lying supine, the leg is prepared circumferentially from the groin to the toes. The hip is p...
Functional Muscle Transplantation.Functional muscle transplantation is indicated in cases of major functional loss for which the...
Advantages and Disadvantages.Advantages: The gracilis muscle is expendable and leaves no functional loss. It is thin and long an...
Rectus Abdominis Muscle Flap.The rectus abdominis muscle is supplied by the superior epigastric artery (SEA) and the deep inferi...
Anatomy.The rectus abdominis muscle is a long strap muscle interrupted by three to five tendinous intersections or inscriptions....
Surgical Technique.Patients who have had prior abdominal surgery, particularly incisions in the groin or lower abdomen, may not ...
Fascial Flaps
Dorsal Thoracic Fascia Flap.For a detailed description of the landmarks and anatomy of the DTF flap, please refer to the scapula...
Surgical Technique.The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest c...
Anatomy.The fibula has a slender shaft with thick cortices and it is the only expendable long bone in the body that is strong en...
Surgical Technique.The patient is prepared in the supine position with the hip flexed and abducted and the knee flexed. The inci...
Flap Insetting
Postoperative Care and Monitoring
REFERENCES
33 - Benign and Malignant Neoplasms of the Upper Extremity
Core Knowledge
History
Examination
Laboratory Tests
Imaging Studies
Tumor Growth
Staging Tumors
Biopsy
Management of Benign and Malignant Neoplasms of the Upper Extremity
Location.The cyst is typically located within the dermis, although it can be deposited in any subcutaneous tissue, including bon...
Imaging.Although not typically needed, an ultrasound or MRI will show a well-circumscribed oval lesion without internal enhancem...
Histology.Keratin debris forms a thick gelatinous material that extrudes from the cyst. The wall of the cyst is lined by epithel...
Treatment.A marginal excision of the cyst is usually curative because recurrence is rare. 17
Location.These lesions are commonly located near the proximal and distal interphalangeal joints. 17
Imaging.If longstanding, the mass may cause pressure changes in the bone that can be seen radiographically. Alternatively, ultra...
Histology.The tumors have abundant histiocyte-like cells and multinucleated giant cells (Fig. 33.6A). The cells may have a surro...
Differential Diagnosis.GCT of the tendon sheath can present similar to malignant soft-tissue masses, such as synovial sarcoma or...
Treatment.Marginal excision is the mainstay of therapy (see Fig. 33.6B). However, recurrence has been a concern. Historically, l...
Location.These lesions can occur anywhere, but in the upper extremity the most common location is in the forearm. 19
Imaging. Plain radiographs may show a soft-tissue shadow of the lipoma
Histology.These tumors consist of a capsule with mature adipose tissue (Fig. 33.8A). 19
Differential Diagnosis.The differential diagnosis for these lesions includes atypical lipomatous tumor (ALT) or liposarcoma. Sus...
Treatment.Treatment is symptomatic with excision of a lipoma only with symptoms. If a lipoma is removed, typically it can be she...
Imaging.MRI, although illustrative, often cannot definitively distinguish neurilemomas from malignant peripheral nerve sheath tu...
Histology.The schwannoma, or neurilemoma, is of Schwann cell origin and histologically is composed of a cellular component with ...
Treatment.Preoperative evaluation with nerve conduction studies and MRI will help to determine whether the lesion is on the surf...
Benign Aggressive Fibrous Tissue Lesions
Imaging.Desmoid tumors are soft-tissue lesions and as such do not typically involve the bone. Radiographs may demonstrate disrup...
Histology.Histologically, these are clonal lesions of connective tissue. They have densely packed collagen with well-differentia...
Treatment.Surgery remains the primary mode of therapy for patients with desmoid tumors.33,36 Historically, up to a 68% recurrenc...
Vascular Lesions
Imaging.Radiographic features depend on the involvement of the underlying bone. If the AVM is located within the bone, cortical ...
Histology.Lakes of vessels are noted without evidence of hypercellularity or abnormal mitoses in the endothelium (Fig. 33. 14A)
Treatment.This lesion can be very difficult to completely eradicate.40 AVMs that are stable or adjacent to critical structures m...
Imaging.MRI enhanced with gadolinium can differentiate these lesions from sarcomas and vascular malformations, eliminating the r...
Treatment.Hemangiomas during the neonatal period and childhood are treated nonoperatively because most eventually involute. Spli...
Malignant Soft-Tissue Lesions
Location.Fibrosarcomas involve the upper extremity in 30% of cases and the lower extremity in 60%. 45
Imaging.MRI is the most useful imaging modality for this type of lesion. Plain radiographs may show soft-tissue density changes ...
Histology.Histologically, fibrosarcomas are often described as composed of spindle cells arranged in a herringbone pattern (Fig....
Treatment.Wide surgical excision with limb salvage, when feasible, is the preferred treatment. Using this approach with the addi...
Location.Although synovial sarcomas most frequently involve the lower extremities, Brien et al. reported they are the most commo...
Imaging.On plain radiographs a soft-tissue density may be observed at the location of the mass, and 15% to 30% will have calcifi...
Histology.Synovial cell sarcomas are histologically composed of epithelial cells (that form glandular structures) and spindle ce...
Treatment.Treatment consists of wide surgical excision with chemotherapy and radiation.3 Results of limb salvage are compromised...
Location.These are rare malignant lesions of the upper extremity. When the tumor is present, it is most likely to be identified ...
Imaging.Although pleomorphic sarcomas can occur in bone, they usually occur in the soft tissues. MRI is the imaging modality of ...
Histology.The tissue consists of spindled and pleomorphic cells. The pleomorphic elements may be bizarre, multinucleated, or “hi...
Treatment.Treatment remains wide or radical excision with limb salvage as the goal. The decision to use chemotherapy and radiati...
Imaging.MRI is useful to clearly show the extent of the tumor because these have a tendency to spread along soft-tissue planes (...
Histology.The tumor is composed of epithelioid cells surrounding a central area of necrosis.3 Nuclei are relatively bland with s...
Differential Diagnosis.When these lesions ulcerate, they may mistakenly be diagnosed as an infection. They may also be diagnosed...
Treatment.Wide excision is the recommended treatment for epithelioid sarcoma. When the digits are involved, a ray amputation may...
Location.Angiosarcoma often involves the skin and subcutaneous tissue. It rarely involves the bone, but when it does, it typical...
Histology.Histologically, they are typically composed of epithelioid cells with vascular channels (Fig. 33.20). 60
Differential Diagnosis.When it occurs at the site of previous radiation for breast cancer, the mass may be confused for recurren...
Treatment.Five-year survival is dismal and estimated at 15%.62 The tumor is poorly responsive to chemotherapy or radiation, and ...
Benign Bone Tumors
Age.The average age at presentation for solitary enchondromas is typically in the fourth decade of life. In one study, patients ...
Location.The most frequent locations in the hand are the proximal phalanges, followed by the middle phalanges and metacarpals.1,...
Imaging.Plain radiographs are usually sufficient for diagnosis. Typical findings include cortical expansion or endosteal scallop...
Histology.Enchondromas contain well-differentiated areas of hyaline cartilage within lamellar bone. In the hand, more cellular a...
Differential Diagnosis.The differential diagnosis includes GCTs, fibrous dysplasia, unicameral bone cyst (UBC), chondroblastoma,...
Treatment.Treatment is largely symptomatic. Painless lesions may be observed with serial plain radiographs. In a review by O’Con...
Location.UBCs have a propensity to involve the long bones, typically the proximal femur and proximal humeral metaphysis. 75,76
Imaging.The lesions are benign, causing slight expansion of the surrounding bone. They are often well marginated with a thin, sc...
Histology.The cavity of the lesion is entirely cystic. A thin fibrous membrane lines the cavity. The fluid within the cavity is ...
Differential Diagnosis.The differential diagnosis should include such entities as an aneurysmal bone cyst (ABC), fibrous dysplas...
Treatment.Although there are several described treatment options for UBCs, all typically begin with aspiration of the cyst. This...
Location.These lesions mostly occur in the metaphysis of long bones. They typically lie in an eccentric location within the bone...
Imaging.Plain radiographs will demonstrate an expansile lesion that is often located in the metaphysis of long bones. The lesion...
Histology.Macroscopically, these lesions are composed of a cavitary lesion that is divided with multiple fibrous septations. The...
Differential Diagnosis.The differential diagnosis includes UBC, GCT, telangiectatic osteosarcoma, and osteoblastoma. Biopsy is e...
Treatment.The type of treatment is dependent on the location of the lesion. In most circumstances, curettage and bone grafting i...
Location.Osteochondromas of the hand and wrist are rare, occurring only 4% of the time, according to one study. The proximal pha...
Imaging.These lesions may be sessile (broad based) or pedunculated (narrow stalk). They have a cartilage cap that is not appreci...
Histology.The stalk is composed of cortical bone with a medullary canal. The cartilage cap is hyaline cartilage (see Fig. 33.34B...
Differential Diagnosis. The differential diagnosis includes parosteal osteosarcoma and periosteal chondroma
Treatment.Excision is reserved for symptomatic lesions or lesions with a rapidly expanding cartilage cap. For most lesions a mar...
Location. The lesion is most frequently found in the small tubular bones of the hands and feet
Imaging.Radiographs demonstrate a well-circumscribed bony mass arising from the cortical surface (Fig. 33.35A and B). A CT scan ...
Histology.The lesion demonstrates areas of cartilage and bone. The hypercellular fibrocartilage and hyaline cartilage is haphaza...
Differential Diagnosis.The key differential diagnosis is with osteochodroma.2 In contrast to osteochondroma, BPOP typically lack...
Treatment.Although no difference in recurrence rates has been reported between intralesional and marginal excision, some series ...
Location.This unusual tumor presents in the diaphysis or in the junction between the diaphysis and the metaphysis. Although most...
Imaging.Plain radiographs demonstrate a small lucent zone surrounded by dense sclerosis (Fig. 33.36). They are usually less than...
Histology.There is a vascular cellular nidus composed of benign osteoblasts and osteoclasts forming irregular seams of ­osteoid ...
Differential Diagnosis.The differential diagnosis includes osteoblastoma, infection, and fracture. A contrast-enhanced CT has be...
Treatment.Most patients have a trial of nonoperative management with NSAIDs.1,92 There are reports that these lesions will spont...
Location.The most common locations for osteoblastomas are the diaphysis of long bones or the pedicles of the spine. Although one...
Imaging.Radiographically, these lesions may appear similar to osteoid osteomas but are typically larger (>1.5 cm) and have less ...
Histology.There remains ongoing debate as to whether osteoid osteomas and osteoblastomas represent singular or separate entities...
Differential Diagnosis.The differential diagnosis is wide because these lesions may be confused with osteoid osteoma, ABC, infec...
Treatment.Recurrence rates up to 20% have been reported following intralesional curettage and bone grafting. Due to these high r...
Location.Approximately half of all cases occur around the knee. The distal radius is the third most common site of presentation....
Imaging.Plain radiographs demonstrate an eccentric, lytic lesion without bone formation or calcification (Fig. 33.39). The lesio...
Histology.Large numbers of giant cells and nuclei are present. The nuclei within the giant cells appear identical to the nuclei ...
Differential Diagnosis. The differential diagnosis includes ABC, osteosarcoma, and brown tumor of hyperparathyroidism
Treatment.Treatment recommendations for GCTs of bone vary widely, from intralesional resection to amputation, with the primary g...
Location.The disease can occur in almost any bone, but the most common locations include the skull, ribs, and femur. The metacar...
Imaging.The bone marrow appears to be expanded with matrix of ground-glass opacity on plain radiographs. The lesion is usually w...
Histology.The marrow cavity is filled with nonossified osteoid that displaces the normal marrow. A histologic hallmark is lack o...
Differential Diagnosis.The differential diagnosis includes UBC, ABC, GCT, infection, Paget disease, osteosarcoma, hemangioma, an...
Treatment.There is a role for nonsurgical management. Activity modification or administration of bisphosphonates may be helpful ...
Location.The proximal humerus is the most frequent site affected. In the hand, chondroblastoma is incredibly rare and may presen...
Imaging.Plain radiographs show a well-circumscribed lucent lesion, frequently with stippled calcification (Fig. 33. 48)
Histology.Microscopically the tissue has a chicken-wire calcification appearance because of ovoid or fried egg–appearing chondro...
Differential Diagnosis.The differential diagnosis includes GCT, enchondroma, fibrous dysplasia, degenerative cyst, and chondromy...
Treatment.Curettage or local excision and bone grafting is the recommended treatment. The historic recurrence rate is approximat...
Malignant Tumors of Bone
Location.An estimated 10% to 15% of cases of osteosarcoma arise in the humerus, making this the third most common location in th...
Imaging.Radiographically, classic osteosarcoma will present as a region of bone destruction with scattered areas of calcificatio...
Histology.Osteosarcoma is a malignant tumor derived from osteoblastic cells.1 As such, bizarre nuclei undergoing mitosis are not...
Differential Diagnosis.The differential diagnosis for osteosarcoma in the hand includes such entities as a subungual exostosis, ...
Treatment.Wide excision with adjuvant multiagent chemotherapy is the standard of care to help to improve survival. No significan...
Location.Although chondrosarcomas are the most common malignant primary bone tumor of the hand, they occur in the hand and wrist...
Imaging.Cortical destruction and the presence of a soft-tissue mass are typical of a chondrosarcoma (Fig. 33.54). Radiographs ma...
Histology.Microscopic features of an enchondroma and chondrosarcoma may be similar. The cartilage cells in chondrosarcoma show m...
Differential Diagnosis.As previously stated, it may be very difficult to differentiate a chondrosarcoma from a benign enchondrom...
Treatment.Chondrosarcoma is a surgical disease. Radiation therapy and chemotherapy are ineffective. In most instances the goal o...
Round Cell Tumors of Bone
Location.The disease occurs in the major long bones (femur, tibia, and humerus). An estimated 1.4% of Ewing sarcomas occur in th...
Imaging.Ewing sarcoma classically presents as a lytic lesion with a periosteal reaction and a soft-tissue mass. The expansion of...
Histology.Biopsy of a Ewing sarcoma often shows a liquefied gray-white appearance, which can be mistaken for the purulent exudat...
Differential Diagnosis.Osteomyelitis may be confused with Ewing sarcoma, based on a presentation of fevers and elevated inflamma...
Treatment.Prior to any operative treatment a complete workup must be performed because an estimated 25% of patients have metasta...
Location. This lesion typically affects the diaphysis of long bones with a predilection for the femur
Imaging.A moth-eaten appearance without a periosteal reaction usually occurs on plain radiographs. MRI identifies a large soft-t...
Histology. Densely packed round cells are noted, with the tumor invading bone without regard for cortical margins
Differential Diagnosis.Metastatic disease and myeloma should be included in the differential diagnosis for this group of patient...
Treatment.Chemotherapy and irradiation provide the best initial treatment. Surgery is reserved for prophylactic stabilization or...
Location. The tumor typically occurs in bones with the greatest hematopoietic potential
Imaging.The lesion is similar to lymphoma of bone, but the MRI does not show as significant a soft-tissue reaction (see Fig. 33....
Histology.The tumor consists of densely packed plasma cells with a cartwheel pattern to the nuclear material. Immunohistochemica...
Differential Diagnosis. Lymphoma and metastatic disease should be considered in the differential diagnosis
Treatment.Bisphosphonate therapy is effective at improving quality of life and the amount of bone pain. Bone pain can also be al...
Location.Skeletal metastases to the hand and wrist comprise approximately 0.1% of all metastatic skeletal lesions. Although any ...
Imaging.Radiographically, lesions appear aggressive, with either purely lytic or mixed lytic-blastic changes. CT or MRI may be h...
Histology. The primary site of tumor origin dictates histologic appearance
Treatment.An individualized approach is necessary. A thorough medical oncology evaluation is suggested to determine the need for...
Benign Pigmented Lesions of Skin
Benign Nevi
Nevus.Less common on the hand than elsewhere, nevi usually arise in late childhood, adolescence, or young adulthood. They can mi...
Blue Nevus.These are uncommon and present as a blue macule or papule, usually less than 6 mm in diameter. They represent a benig...
Histology.Histologically, they represent epidermal cell (keratinocyte) proliferations. There is no dermal component to these les...
Treatment.Before treatment (usually for cosmetic reasons), one must be sure that melanoma has been ruled out clinically or histo...
Histology. Histologically, lentigines represent an increased number of pigment cells (melanocytes) at the base of the epidermis
Treatment.Effective cosmetic removal may be achieved with topical bleaching creams, liquid nitrogen, or lasers, including Q-swit...
Histology.Caused by local infection with the fungus Hortaea werneckii (formerly Exophiala werneckii), it is diagnosed by culture...
Treatment.This lesion is more common in the coastal southeastern United States; suspicion for this lesion should lead to a small...
Benign Nonpigmented Skin and Nail Lesions
Imaging.Radiographs, if taken, may show cortical scalloping from the compression of the soft-tissue mass. 19
Histology.Small, round, basophilic cells in clusters surrounding small vessels are noted with glomus cell tumors (Fig. 33. 63)
Treatment.Surgical excision is the primary mode of treatment. Recurrence occurred in 41% of patients in one study. All of the re...
Histology.Histologically, pyogenic granulomas represent an uncontrolled proliferation of granulation tissue and are inflammatory...
Differential Diagnosis.A nodular melanoma can rarely mimic this condition, and therefore a biopsy is recommended to confirm the ...
Treatment.Nonsurgical treatment with silver nitrate application is sometimes effective, but surgical excision is a more definiti...
Histology.Although certain features of the histologic architecture suggest a keratoacanthoma, it may be difficult to distinguish...
Treatment.Because of the difficulty in distinguishing keratoacanthoma from SCC, observation is not usually recommended. Rather, ...
Location. Warts are common on the hands and periungual areas
Histology.Verrucae are epidermal proliferations similar to seborrheic keratoses. However, unlike seborrheic keratoses, they ofte...
Treatment.Due to possible difficulty in ruling out squamous or verrucous carcinoma, any large, refractory, or clinically unusual...
Malignant Skin Lesions
Location.The most common areas for these to occur are areas that are exposed to the sun, such as the face, hands, and back. Cuta...
Histology.Histologically, tumors originate in the epidermis and are seen to invade into the dermis or deeper. The tumor nests ar...
Differential Diagnosis.Precursor lesions to SCC include actinic keratosis and SCC in situ (Bowen disease). Actinic keratoses are...
Treatment.The risk of malignant progression to SCC of an individual actinic keratosis is felt to be low. Nevertheless, in one st...
Location.BCC is thought to occur in the hand in only 10% of cases (see Fig. 33.72C). 17
Histology. Histologically, there are large islands of basaloid cells with peripheral palisading and cleft artifacts
Differential Diagnosis.The differential diagnosis includes ulcerations, actinic keratosis, fungal infections, or psoriasis. 156
Treatment.Prognosis with complete removal is excellent because these tumors are usually slow growing (over months to years) with...
Subtypes of Melanoma
Nodular Melanoma.Nodular melanoma accounts for 15% to 30% of reported melanomas. The nodular variety is a more aggressive tumor ...
Lentigo Maligna Melanoma.This entity presents as a slowly enlarging pigmented patch on the sun-exposed skin (usually face) of el...
Acral-Lentiginous Melanoma.These lesions are most commonly found on the soles of the feet, but they can occur on the palms and n...
Histology.The malignant melanocytes can spread radially and vertically beneath the epidermis. Vertical growth occurs in the most...
Treatment.Excisional biopsy with a 1- to 2-mm margin to obtain staging pathologic information is the recommended biopsy techniqu...
ACKNOWLEDGMENTS
REFERENCES
34 - Congenital Hand Anomalies
Core Knowledge
History
Limb Development and Staging
The Pediatric Hand
Classification
Incidence and Etiology
Timing of Treatment
Principles of Treatment
Common Congenital Hand Differences
Shoulder and Arm
Clinical Presentation.In total phocomelia, there is at birth, a hypoplastic hand with a variable number of digital remnants atta...
Treatment.These are generally managed without surgery and are referred to an upper limb prosthetist and/or mechanical engineer. ...
Clinical Presentation.These are classified into four groups by their degree of hypoplasia,20 and many indices have been establis...
Treatment.The presence of a mild deformity with minimal restriction of movement does not require surgery (Fig. 34.6). Many surgi...
Elbow
Presentation.Young patients often do not complain of elbow pain but may have a lateral palpable click, a bony prominence, and so...
Treatment.Attempts at surgical reduction and reconstruction of the annular ligament in young children are not predictable. Radia...
Clinical Presentation.Males and females are affected equally. Almost 60% have bilateral involvement. Adaptive hypermobility of t...
Treatment.Unilateral synostosis or bilateral conditions with less than 30 degrees of fixed pronation do not cause major function...
Clinical Presentation.The entire upper limb is dysplastic with shoulders elevated and atrophic musculature. The arm is longer th...
Treatment.Treatment is similar to that for proximal radioulnar synostosis. These are usually effective helping limbs. Osteotomy ...
Forearm
Clinical Presentation.The shoulder is well developed, and there is usually excellent elbow motion despite occasional radial head...
Treatment.Surgery is performed in less than 10% of these children and consists of excision of nubbins, soft-tissue contouring of...
Clinical Presentation.Onset of symptoms is usually during late childhood or early adolescence. Females are affected 4:1 over mal...
Treatment.Most patients are treated conservatively when they present, often as adolescents or young adults (Fig. 34.13). In youn...
Clinical Presentation.The presence of a skin lesion on the dorsal forearm is the key to diagnosis. Flexed wrists and digits with...
Treatment.Early recognition and fasciotomy are crucial to decompress all muscle groups in the volar and sometimes dorsal forearm...
Clinical Presentation.The entire limb may be affected, the shoulders are narrow and rounded, and the supporting musculature is h...
Treatment.Passive stretching and splinting is recommended for correction of the hand and wrist deviation. Most surgeons agree th...
Clinical Presentation.This condition usually involves the entire upper limb. The shoulder is hypoplastic with limited active ext...
Treatment.Treatment must be individualized. Very little is necessary for the hypoplastic shoulder, other than soft-tissue stabil...
Clinical Presentation.The size of the radius has become the practical criterion for classification (see Fig. 34.20). There is a ...
Treatment.Treatment depends on the severity of the deformity. The surgical techniques to correct these deformities are beyond th...
Hand
Clinical Presentation.In the stiff type the affected joints have normal cartilage but contracted capsules and ligaments. In addi...
Treatment.Contractures are initially addressed with splinting, stretching, and serial casting. The surgical team should not offe...
Clinical Presentation.The hands and feet are primarily involved, and at birth many of these children look like AMC patients. Han...
Treatment.In contrast to AMC, surgical treatment carries a more predictable outcome. Initial goals are to release soft-tissue co...
Clinical Presentation.The typical cleft hand has a V-shaped, central cleft that can be unilateral or bilateral. The depth of the...
Treatment.Flatt has aptly described these hands as “functional triumphs and aesthetic disasters.” The major goals for reconstruc...
Clinical Presentation.The arm and forearm may be shorter than the opposite limb, and the hand is smaller than the unaffected sid...
Treatment.Some of these do not require treatment. For the short finger-type symbrachydactyly, web space release and later stabil...
Clinical Presentation.The patterns of hand involvement vary, and there is often lipomatous overgrowth within the subcutaneous ti...
Treatment.Early consultation by the family and expeditious treatment is required. There is initially a desire to retain the over...
Thumb
Clinical Presentation.There is a delayed appearance of normal ossification centers. The thumb is best analyzed by a systematic a...
Treatment.Prior to any surgery it is important for the hand surgeon to become coordinated with treatment of associated anomalies...
Clinical Presentation.The thumbs appear at birth longer and narrow and often have a deficient first web space. Bilateral cases a...
Treatment.The goals are to preserve a mobile, independent ray with an adequate web space on the radial border of the hand. A lon...
Clinical Presentation.The clinical presentation of thumb polydactyly is variable, with no two thumbs alike. The radial of the tw...
Treatment.The goals are to create a satisfactory web space, maintain motion in at least two of the three joints, and create the ...
Clinical Presentation.Trigger thumbs are not present at birth and are usually discovered by babysitters, grandparents, or parent...
Treatment.Conservative watchful waiting is recommended for children under 1 year of age. Surgery should is recommended earlier i...
Clinical Presentation.The thumb at birth or during infancy lies in varying degrees of flexion below the digits, depending upon t...
Treatment.In children with passively correctable thumbs, initial splinting is the mainstay of treatment. Night splinting plus pa...
Digits
Presentation.The affected finger or thumb will be deviated and in severe cases flexed and possibly also rotated. Many variations...
Treatment.Although some authors have recommended splinting for clinodactyly, this is a developmental skeletal disorder, which wi...
Clinical Presentation.Most PIP flexion contractures are slight and ignored, and patients compensate by hyperextending the MCP jo...
Treatment.Initial passive stretching and splinting is the hallmark of many cases. The majority of type I cases with isolated fif...
Clinical Presentation.Most small digital nubbins with a hypoplastic nail are attached along the base of the proximal phalanx. Th...
Treatment.The treatment varies from simple to complex. Ligation in the nursery has been reported to be associated with complicat...
Clinical Presentation.These are complex anomalies, which make surgical correction difficult.7,101-103 The spectrum varies tremen...
Treatment.The same principles for syndactyly release are observed, but correction involves more than separation of the conjoined...
Clinical Presentation.These digits and thumbs are shorter than normal and may have associated syndactyly (complete or incomplete...
Treatment.The management of brachydactyly runs the entire gamut of hand surgery, and each case must be individualized. Short dig...
Clinical Presentation.The PIP joint is most frequently involved. Distal joint fusions are unusual but seen in symbrachydactyly, ...
Treatment.There is no standardized treatment for these digits, which are not usually surgically released. Distraction lengthenin...
Clinical Presentation.There are many presentations, and the webbing may involve one or more of the four interdigital web spaces....
Treatment.The history of syndactyly correction has been well documented over the past century and appropriately reflects the int...
Apert Hand
Clinical Presentation.These deformities are always present at birth. One or all extremities may be affected. Deformities are asy...
Treatment.Management of these digital and thumb deformities should be individualized. At birth the goal is early liberation of t...
REFERENCES
35 - Fractures of the Forearm and Elbow
Forearm Fractures
Kinematic and Mechanical Considerations
Treatment Principles
Isolated Radius Fractures
Isolated Ulna Fractures
Monteggia Fracture-Dislocations
Essex-Lopresti Injuries
Fractures of the Distal Humerus
Preoperative Evaluation
Operative Treatment
Operative Exposure
Olecranon Osteotomy.The patient is placed in a lateral decubitus position with the arm supported over a bolster. A prior incisio...
Extensile Lateral Exposure.A midline posterior or a lateral skin incision can be used. The patient is positioned supine with the...
Capitellar and Complex Shear Fractures of the Distal Humerus.Apparent capitellar fractures are often more complex fractures of t...
Optimizing Outcome
Complications
Epicondylar Fractures with and without Incarceration
Radial Head Fractures
Preoperative Evaluation
Operative Approach
Operative Exposures
Open Reduction and Internal Fixation
Prosthetic Replacement
Optimizing Outcomes
Complications
Traumatic Elbow Instability
Indications and Contraindications
Preoperative Evaluation
Operative Techniques
Intraoperative Testing of Elbow Stability
Unstable Simple Elbow Dislocations
Posterior Dislocation and Fracture of the Radial Head
Terrible Triad Fracture-Dislocations
Surgical Procedure: Internal Fixation of a Tip Fracture of the Coronoid.Exposure and fixation of the small transverse fractures ...
Varus Posteromedial Rotational Instability Injuries
Surgical Procedure: Anteromedial Coronoid Facet Fracture.A medial skin flap is elevated with care taken to protect the medial an...
Optimizing Outcomes
Olecranon and Proximal Ulna Fractures
Indications and Contraindications
Preoperative Evaluation
Operative Techniques
Skin Incision
Tension Band Wiring
Kirschner Wire Technique
Screw Technique
Plate and Screw Fixation
Operative Technique for Fracture-Dislocations
Distal Humeral Shaft Fractures
Optimizing Outcomes
Rehabilitation of Elbow Injuries
Complications of Elbow Injuries
REFERENCES
36 - Elbow Arthroscopy and Instability
Proximal Anteromedial Portal
Anteromedial Portal
Proximal Anterolateral Portal
Anterior Superolateral Portal
Anterolateral Portal
Soft Spot Portal
Posterolateral Portals
Posterior Central Portal
Equipment and Setup
Prone Position
Lateral Position
Arthroscopes
Infusion Pumps
Capsular Capacity
Fluid Extravasation
Arthroscopic Elbow Procedures
Plica Syndrome
Procedure
Loose Bodies
Procedure
Synovectomy
Surgical Technique
Contracture Release
Procedure
Osteoarthritis
Procedure
Radial Head Excision
Procedure
Ulnar Humeral Arthroplasty
Procedure
Lateral Epicondylitis Release
Procedure
Osteochondritis Dissecans
Procedure
Valgus Extension Overload
Procedure
Radial Head Fractures
Procedure
37 - Elbow Arthritis
Rheumatoid Arthritis
Posttraumatic Arthritis/Contracture
Primary Osteoarthritis
Evaluation
History
Physical Examination
Radiographic Assessment
Treatment
Nonsurgical Management
Surgical Management
Technique.The patient is placed supine with the elbow on an arm table. A lateral incision is made proximally along the supracond...
Medial Column Approach.The medial column procedure is used for the same basic indications as the lateral column procedure, allow...
Technique.A medial incision is centered just posterior to the medial epicondyle and extends proximally posterior to the medial s...
Management With Elbow Arthroscopy
Technique.General anesthesia with or without regional nerve block is used. Supine, prone, and lateral decubitus patient position...
Surgical Management of Rheumatoid Arthritis
Technique.The patient is placed in the lateral decubitus position with a beanbag. A posterior midline incision is used, and the ...
Surgical Management of Osteochondral Lesions
REFERENCES
Hand Therapy
Certified Hand Therapist
Establishing Treatment Protocols
Ordering Hand Therapy
Patient Evaluation
Grip Strength Testing
Five Handle-Position Testing
Rapid Exchange Testing
Pinch Strength Testing
Lateral Pinch (Key Pinch)
Three-Point Pinch (Chuck, Three-Fingered Pinch)
Tip Pinch (Two-Point Pinch)
Sensibility Testing
Semmes-Weinstein Monofilament Testing
Static Two-Point Discrimination
Range-of-Motion Measurements
Edema Measurement
Dexterity Functional Testing
Custom Orthoses
Static Orthoses
Dynamic Orthoses
Serial Casting/Serial Static Orthosis
Static-Progressive Orthoses
Resting (Intrinsic-Plus) Hand Orthosis
Wrist Orthosis
Forearm Based Thumb Spica Orthosis
Forearm Based Thumb Spica Orthosis (Radially Based)
Dorsal Extension Block Orthosis
Tenodesis Orthosis
Dynamic Metacarpal Phalangeal Extension Orthosis
Muenster Orthosis
Posterior Elbow Orthosis
Anterior Elbow Orthosis
Elbow Flexion Block Orthosis
Short Opponens or Hand Based Thumb-Spica Orthosis
Carpometacarpal Orthosis
Mallet Orthosis
Serial Casting
Web Spacer Orthosis
Ulnar Nerve Palsy Orthosis
Static-Progressive Orthoses
Therapeutic Modalities
Therapeutic Heat and Cold Modalities
Superficial Heat Modalities
Deep Heat Modalities
Cold Modalities
Electrical Stimulation
Continuous Passive Motion
Biofeedback
Treatment Techniques
Active Range of Motion and Passive Range of Motion
Strengthening
Heat and Stretch
Joint Mobilization
Wound Care
Edema Control
Scar Massage
Sensory Reeducation
Computerized Exercise Equipment
Postsurgical Considerations for Ligamentous Injuries to the Carpus
Scapholunate Repair Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Collateral Ligament Injuries to the Digits
Thumb MCP Collateral Ligament Repair Protocol
Index Through Small Finger (SF) MCP Collateral Ligament Protocol
Proximal Interphalangeal Collateral Ligament
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Fractured Metacarpals and Phalanges
Metacarpal ORIF Protocol
Phalanx ORIF Protocols
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Distal Radius Fractures
Distal Radius ORIF Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Flexor Tendon Repairs
Flexor Tendon Zone 1 to 4 Early Active Protocol
Flexor Tendon Zone 1 to 4 Passive Motion Protocol
Zone 5 and FPL Flexor Tendon Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Extensor Tendon Injuries
Zone 1 or 2 Protocol
Zone 3 Central Slip Injuries Postoperative Protocol
Zone 4 Through 7 Immediate Controlled Active Motion
Zone 4 Through 7 Standard Early Motion Protocol
Extensor Pollicis Longus (EPL) Repair Protocol
Frayed or Weak Flexor Tendon Tenolysis Protocol.Three days postsurgery the rigid plaster postoperative dressing is removed and a...
Optimizing Hand Rehabilitation Outcomes
Considerations for Digit Amputations/Replantation
Digit Replantation Protocol
Optimizing Hand Rehabilitation Outcomes
Considerations for Complex Regional Pain Syndrome
Pain Assessment.A thorough pain assessment will include documentation of the location and distribution of the pain and a descrip...
Sensory Testing.Perform a thorough sensory assessment using objective measures such as the Semmes-Weinstein monofilament (thresh...
Edema.Include volumetric measurements and baseline circumferential measurements, as appropriate. Include descriptions of the typ...
Functional Outcomes Measure.Improving function and participation in meaningful activity is the goal of therapy; therefore an acc...
Treatment
Pain Management.Pain must be addressed first. Pain must be managed so that the patient is able to participate in therapy and use...
Desensitization.This may include the use of textures, pressure, percussion, and vibration. Avoid cyclic stimulation by maintaini...
Edema Management.Treat edema with light compression wraps or garments, active motion, and elevation. Brawny edema associated wit...
Range of Motion and Strengthening Program.Prevent stiffness and improve functional use of the UE in I/ADLs. Follow protocol for ...
Mirror Visual Feedback.MVF was originally developed in 1995 by V. S. Ramachandran for the treatment of phantom limb symptoms.54 ...
Graded Motor Imaging Program.GMI is a three-step program used to treat pain and movement problems, including CRPS. It is believe...
Orthotic Positioning or Casting.Static orthoses, dynamic orthoses, and casts may be used for the protection of healing tissues; ...
Activity Modification and Adaptive Equipment.This will need to be addressed based upon individual needs. In particular, instruct...
Discharge
Optimizing Hand Rehabilitation Outcomes
Considerations for Nonsympathetically Maintained Chronic Pain
Setting the Baseline.The baseline is the level to which the patient feels increased pain, weakness, and fatigue with a certain e...
The Exercise Program.Exercises should be tailored for the specific diagnoses, along with general aerobic and conditioning exerci...
The Discharge Evaluation.On completion of the prescribed duration of outpatient therapy, a discharge evaluation is completed. Th...
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Compressive Neuropathies in the Upper Extremity
Endoscopic Cubital Tunnel Release Protocol
Carpal Tunnel Release (Endoscopic or Open) Protocol
Radial Tunnel Release Protocol
Trigger Finger Release Protocol
Conservative and Postsurgical Considerations for Tendinopathy of Medial and Lateral Elbow.Tennis elbow, lateral epicondylitis, a...
What Is the Best TreatmentNo one specific protocol has been shown to be the best treatment for elbow epicondylosis. Such a wide ...
Suggested Treatment Protocol.Apply ultrasound to the medial or lateral epicondyle with parameters of 3.3 MgHz, 10% to 20%, 1.0 t...
Postsurgical Considerations for Total Joint Arthroplasties of the Hand
Metacarpal Phalangeal Arthroplasty (Pyrocarbon) Protocol
Thumb Carpometacarpal Joint Arthroplasty Protocol
Total Wrist Arthroplasty Protocol
Postsurgical Considerations for Dupuytren’s Disease
Postsurgical Considerations for Ganglion, Carpal Boss, and DIP Mucous Cyst Excision
Wrist Ganglion Excision Protocol
Mucous Cyst Excision at the DIP Protocol
Postsurgical Considerations for DRUJ and Triangular Fibrocartilage Complex (TFCC) Injuries
TFCC/DRUJ Repair Protocol
TFCC Debridement Protocol
Ulnar Osteotomy Protocol
Postsurgical Considerations for Elbow Instability
Simple Dislocation Protocol
Complex Dislocation Postoperative Protocol
Postsurgical Considerations for Elbow Fractures
Olecranon Fracture ORIF Protocol
Postsurgical Considerations for Elbow Arthritis
Arthroscopic/Open Debridement Protocol
Total Elbow Arthroplasty Protocol
Postsurgical Considerations for Nerve Repair or Transfers
Digital Nerve Repair Protocol
Isolated Median Nerve Repair Protocol Distal to Anterior Interosseous Nerve (AIN)
Radial Nerve Repair Protocol
Ulnar Nerve Repair at Forearm and Wrist Protocol
Postsurgical Considerations for Brachial Plexus/Tendon Transfer
REFERENCES

Citation preview

Principles of Hand Surgery and Therapy THIRD EDITION

THOMAS E. TRUMBLE, MD Chief of Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington

GHAZI M. RAYAN, MD Clinical Professor Orthopedic Surgery University of Oklahoma Adjunct Professor of Anatomy/Cell Biology University of Oklahoma Director of Oklahoma Hand Surgery Fellowship Program Department of Hand Surgery INTEGRIS Baptist Medical Center Oklahoma City, Oklahoma

JEFFREY E. BUDOFF, MD Orthopaedic Surgeon SouthWest Orthopedic Group Houston, Texas

MARK E. BARATZ, MD Vice Chairman Department of Orthopaedics University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

DAVID J. SLUTSKY, MD The Hand and Wrist Institute Torrance, California Chief of Reconstructive Hand Surgery Harbor-UCLA Torrance, California

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 PRINCIPLES OF HAND SURGERY AND THERAPY, THIRD EDITION

ISBN: 978-0-323-39975-3

Copyright © 2017 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). David J. Slutsky owns copyright for his original images, videos and other non-manuscript items which is used in the Work.

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 products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2010 and 2001. Library of Congress Cataloging-in-Publication Data Names: Trumble, Thomas, editor. | Rayan, Ghazi M., editor. | Budoff, Jeffrey   E., editor. | Baratz, Mark, editor. | Slutsky, David J., editor. Title: Principles of hand surgery and therapy / [edited by] Thomas E.   Trumble, Ghazi M. Rayan, Jeffrey E. Budoff, Mark E. Baratz, David J.  Slutsky. Other titles: Hand surgery and therapy Description: Third edition. | Philadelphia, PA : Elsevier, Inc., [2017] |   Includes bibliographical references and index. Identifiers: LCCN 2016041047 | ISBN 9780323399753 (hardcover : alk. paper) Subjects: | MESH: Hand--surgery | Hand Injuries--therapy | Hand  Deformities--therapy Classification: LCC RD559 | NLM WE 830 | DDC 617.5/75044--dc23 LC record available at https://lccn.loc.gov/2016041047

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Contributors Joshua M. Abzug, MD

Assistant Professor University of Maryland School of Medicine Director Pediatric Orthopaedics Timonium, Maryland United States 3: Pediatric Fractures 23: Upper Limb Reconstruction in Persons With Tetraplegia Brian D. Adams, MD

Baylor College of Medicine Department of Orthopedic Surgery Houston, Texas United States 6: The Distal Radioulnar Joint and Triangular Fibrocartilage Complex Julie Adams, MD

Associate Professor Orthopedic Surgery Mayo Clinic Rochester, Minnesota and Austin, Minnesota United States 7: Diagnostic and Therapeutic Arthroscopy for Wrist Injuries Salah Aldekhayel, MD, MEd

Hand & Microsurgery Fellow Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts United States 34: Congenital Hand Anomalies Mark E. Baratz, MD

Vice Chairman Department of Orthopaedics University of Pittsburgh Medical Center Pittsburgh, Pennsylvania United States 37: Elbow Arthritis Andrea S. Bauer, MD

Assistant Professor Department of Orthopaedic Surgery Harvard Medical School Hand and Upper Extremity Surgeon Department of Orthopaedic Surgery Boston Children’s Hospital Boston, Massachusetts United States 17: Brachial Plexus Injuries

Jeffrey D. Boatright, MD, MS

Adam H. Dalgleish, CRNA, MSN

Jeffrey E. Budoff, MD

Seth D. Dodds, MD

Department of Orthopaedic Surgery University of Virginia Health System Charlottesville, Virginia United States 21: The Paralytic Hand and Tendon Transfers Orthopaedic Surgeon SouthWest Orthopedic Group Houston, Texas United States 24: Tendinopathies of the Hand, Wrist, and Elbow Gregory M. Buncke, MD

The Buncke Clinic San Francisco, California United States 31: Thumb Reconstruction Following Partial or Complete Amputation 32: Soft-Tissue Coverage of the Hand Katherine A. Butler, MD

Orthopedic Surgery Resident MedStar Union Memorial Hospital Baltimore, Maryland United States 20: Compressive Neuropathies A. Bobby Chhabra, MD

Lillian T. Pratt Distinguished Professor and Chair Department of Orthopaedic Surgery University of Virginia Health System Charlottesville, Virginia United States 21: The Paralytic Hand and Tendon Transfers Jason A. Craft, MD

Mississippi Sports Medicine & Orthopaedic Center Jackson, Mississippi United States 36: Elbow Arthroscopy and Instability Alexander B. Dagum, MD, FRCS (C), FACS

Professor of Surgery and Orthopaedic Surgery Executive Vice Chair of Surgery and Chief of Plastic Surgery Stony Brook Medicine Department of Surgery Stony Brook, New York United States 30: Replantation

Director of Anesthesia Eastside Surgery Center Issaquah, Washington United States Regional Anesthesia for the Upper Extremity

Associate Professor Hand and Upper Extremity Surgery Department of Orthopaedics University of Miami Miller School of Medicine Miami, Florida United States 12: Hand Infections, Injection Injuries, Snake Bites, and Extravasation Injuries Zachary Elstad, BS

Medical Student Georgia Regents University–University of Georgia Medical Partnership Medical College of Georgia Athens, Georgia United States 2: Phalangeal Fractures and Interphalangeal Joint Injuries Brooke Eytchison, OTR/L

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States Appendix: Hand Therapy John R. Fowler, MD

Assistant Professor Department of Orthopaedics University of Pittsburgh Pittsburgh, Pennsylvania United States 9: Compartment Syndrome and Volkmann Ischemic Contracture William B. Geissler, MD

Alan E. Freeland Chair of Hand Surgery Professor and Chief, Division of Hand & Upper Extremity Chief, Section of Arthroscopic Surgery & Sports Medicine Department of Orthopaedic Surgery and Rehabilitation University of Mississippi Medical Center Jackson, Mississippi United States 36: Elbow Arthroscopy and Instability

v

vi

Contributors

Isak A. Goodwin, MD

Fellow The Buncke Clinic San Francisco, California United States 31: Thumb Reconstruction Following Partial or Complete Amputation Steven C. Haase, MD, FACS

Clinical Associate Professor of Surgery and Orthopaedic Surgery Surgery University of Michigan Health System Ann Arbor, Michigan United States 13: Burns and Frostbite of the Hand Jacques Henri Hacquebord, MD

Hand/Micro Fellow Department of Orthopaedic Surgery University of California Irvine Orange, California United States 26: Rheumatoid Arthritis Warren C. Hammert, MD

Professor of Orthopaedic and Plastic Surgery Chief Division of Hand Surgery Department of Orthopaedics and Rehabilitation University of Rochester Medical Center Rochester, New York United States 11: Amputations and Prosthetics Dennis J. Heaton, MSPA

DO Candidate 2017 Pacific Northwest University Yakima, Washington United States 35: Fractures of the Forearm and Elbow Thomas B. Hughes, MD

Clinical Associate Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine Orthopaedic Specialists UPMC Pittsburgh, Pennsylvania United States 9: Compartment Syndrome and Volkmann Ischemic Contracture Clyde Johnson, PT, CHT

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States Appendix: Hand Therapy Sanjeev Kakar, MD

Associate Professor of Orthopedics College of Medicine Mayo Clinic Orthopedic Surgery Mayo Clinic Rochester, Minnesota United States 33: Benign and Malignant Neoplasms of the Upper Extremity

Robin King, CRNA, MSN

Staff CRNA Anesthesia Department Eastside Surgery Center Issaquah, Washington United States Regional Anesthesia for the Upper Extremity Jason Kinney, BS

Medical Student Georgia Regents University–University of Georgia Medical Partnership Medical College of Georgia Athens, Georgia United States 2: Phalangeal Fractures and Interphalangeal Joint Injuries Scott H. Kozin, MD

Clinical Professor Department of Orthopaedic Surgery Temple University Chief of Staff Shriners Hospitals for Children Philadelphia, Pennsylvania United States 3: Pediatric Fractures 23: Upper Limb Reconstruction in Persons With Tetraplegia Opeyemi E. Lamikanra, MD

Orthopaedic Hand Surgery Fellow Department of Orthopaedics University of Miami Miller School of Medicine Miami, Florida United States 12: Hand Infections, Injection Injuries, Snake Bites, and Extravasation Injuries Lisa Lattanza, MD

Professor Chief of Hand and Upper Extremity Surgery Department of Orthopaedic Surgery University of California, San Francisco San Francisco, California United States 15: Extensor Tendon Injuries 35: Fractures of the Forearm and Elbow

Keith Lemay, PA-C

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States 14: Flexor Tendon Injuries 25: Osteoarthritis Kenneth R. Means, Jr., MD

Attending Physician & Clinical Research Director Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland United States 20: Compressive Neuropathies Siddhant K. Mehta, MD

Resident Department of Orthopaedic Surgery and Rehabilitation University of Mississippi Medical Center Jackson, Mississippi United States 36: Elbow Arthroscopy and Instability Scott A. Mitchell, MD

Baylor College of Medicine Department of Orthopedic Surgery Houston, Texas United States 6: The Distal Radioulnar Joint and Triangular Fibrocartilage Complex Susan Morehouse, PT, MSPT

Department of Physical Therapy and Occupational Therapy Service Level 3 Physical Therapist Boston Children’s Hospital Boston, Massachusetts United States 17: Brachial Plexus Injuries Peter M. Murray, MD

Longview Orthopedic Associates Longview, Washington United States 27: Carpal Avascular Necrosis: Kienböck Disease and Preiser Disease

Professor and Chairman Department of Orthopaedic Surgery Consultant Department of Orthopaedic Surgery and Neurosurgery Mayo Clinic Staff Physician Department of Orthopaedic Surgery and Nemoursurgery Children’s Clinic Jacksonville, Florida United States 33: Benign and Malignant Neoplasms of the Upper Extremity

Nels Leafblad, MD

Andrei Odobescu, MD

Anthony James Lauder, MD

University of Minnesota Medical School Minneapolis, Minnesota United States 22: Cerebral Palsy, Stroke, and Traumatic Brain Injury Thomas P. Lehman, MD, PT

Department of Orthopedic Surgery University of Oklahoma Oklahoma City, Oklahoma United States 1: Fractures and Ligament Injuries of the Thumb and Metacarpals

The Buncke Clinic San Francisco, California United States 32: Soft-Tissue Coverage of the Hand Kyle Oh, MD

Physician Kirkland Spinecare Kirkland, Washington United States 18: Management of Chronic Upper Extremity Pain and Factitious Syndromes

Contributors

Derek Omori, PA-C, MPAS

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States 5: Scaphoid Fractures Samantha Lee Piper, MD

Hand and Upper Extremity Surgery Department of Orthopedic Surgery Southern California Permanente Medical Group San Diego, California United States 15: Extensor Tendon Injuries Margaret A. Porembski, MD

Instructor Oklahoma Hand Surgery Fellowship Program Department of Hand Surgery Integris Baptist Medical Center Oklahoma City, Oklahoma United States 28: Dupuytren Disease Gregory Rafijah, MD

Associate Clinical Professor Orthopaedic Surgery University of California Irvine Orange, California United States Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow 8: Fractures and Malunions of the Distal Radius 26: Rheumatoid Arthritis Ghazi M. Rayan, MD

Clinical Professor Orthopedic Surgery University of Oklahoma Adjunct Professor of Anatomy/Cell Biology University of Oklahoma Director of Oklahoma Hand Surgery Fellowship Program Department of Hand Surgery INTEGRIS Baptist Medical Center Oklahoma City, Oklahoma United States 1: Fractures and Ligament Injuries of the Thumb and Metacarpals 28: Dupuytren Disease 34: Congenital Hand Anomalies Patrick L. Reavey, MD, MS

Assistant Professor of Surgery Section of Plastic and Reconstructive Surgery University of Chicago Medicine Chicago, Illinois United States Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow Carol Recor, OTR/L, CHT

University of Washington Medical Center Seattle, Washington United States Appendix: Hand Therapy

Melvin P. Rosenwasser, MD

Robert E. Carroll Professor of Hand Surgery Columbia University Medical Center Attending Physician New York-Presbyterian Hospital New York, New York United States 4: Carpal Instability Mellisa Roskosky, MSPH

Clinical Research Program Manager Research Athens Orthopedic Clinic Athens, Georgia United States 2: Phalangeal Fractures and Interphalangeal Joint Injuries Cameron Schick, MD

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States 7: Diagnostic and Therapeutic Arthroscopy for Wrist Injuries 10: Nail Bed and Fingertip Injuries 18: Management of Chronic Upper Extremity Pain and Factitious Syndromes 19: Management of Upper Extremity Vascular Disorders and Injuries Michael J. Schreck, MD

Resident Department of Orthopaedics and Rehabilitation University of Rochester Medical Center Rochester, New York United States 11: Amputations and Prosthetics Keith A. Segalman, MD

Associate Professor Orthopedic Surgery Johns Hopkins University Attending Physician Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland United States 20: Compressive Neuropathies Michael S. Shuler, MD

Hand & Upper Extremity Surgeon Athens Orthopedic Clinic Athens, Georgia United States 2: Phalangeal Fractures and Interphalangeal Joint Injuries David J. Slutsky, MD

The Hand and Wrist Institute Torrance, California Chief of Reconstructive Hand Surgery Harbor-UCLA Torrance, California United States 16: Nerve Repair and Nerve Transfers

vii

Megan Swanson, OTR/L, CHT

Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States Appendix: Hand Therapy Thomas E. Trumble, MD

Chief of Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington United States 5: Scaphoid Fractures 14: Flexor Tendon Injuries 18: Management of Chronic Upper Extremity Pain and Factitious Syndromes 19: Management of Upper Extremity Vascular Disorders and Injuries 25: Osteoarthritis 26: Rheumatoid Arthritis 29: Ganglion, Mucous Cyst, and Carpal Boss 31: Thumb Reconstruction Following Partial or Complete Amputation 32: Soft-Tissue Coverage of the Hand 35: Fractures of the Forearm and Elbow Joseph Upton, MD

Associate Professor Harvard Medical School Senior Associate in Surgery Boston Children’s Hospital Boston, Massachusetts United States 34: Congenital Hand Anomalies Ann E. Van Heest, MD

Professor Department of Orthopaedic Surgery University of Minnesota Minneapolis, Minnesota United States 22: Cerebral Palsy, Stroke, and Traumatic Brain Injury Thanapong Waitayawinyu, MD

Associate Professor Hand and Microsurgery Department of Orthopaedics Faculty of Medicine Thammasat University Klong-Luang, Pathumthani Thailand 27: Carpal Avascular Necrosis: Kienböck Disease and Preiser Disease 29: Ganglion, Mucous Cyst, and Carpal Boss Peter M. Waters, MD

Professor Department of Orthopaedic Surgery Harvard Medical School Orthopaedic Surgeon in Chief Department of Orthopaedic Surgery Boston Children’s Hospital Boston, Massachusetts United States 17: Brachial Plexus Injuries

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Contributors

Andrew James Watt, MD

Attending Physician Associate Program Director Plastic & Reconstructive Surgery The Buncke Clinic San Francisco, California Adjunct Clinical Faculty Plastic & Reconstructive Surgery Stanford University Hospitals & Clinics Stanford, California United States 31: Thumb Reconstruction Following Partial or Complete Amputation

Benjamin K. Wilke, MD

Department of Orthopedic Surgery Mayo Clinic Jacksonville, Florida United States 33: Benign and Malignant Neoplasms of the Upper Extremity

David W. Zeltser, MD

Hand Surgery Fellow Orthopaedic Surgery Columbia University Medical Center New York, New York United States 4: Carpal Instability

Preface The practice of medicine is unpredictable, which is part of the challenge but also the risk of caring for patients. As surgeons learn and develop their skills, they forge certain principles and guidelines that keep their patients safe. I call this collection of experience and wisdom “the surgeon’s intuition.” How does the experienced clinician avoid missing a critical diagnosis, such as a subtle compartment syndrome? How does the seasoned surgeon piece everything back together when things go badly between dangerous machinery and the delicate hand? Lastly, what do you do with the exasperating patient with a real problem but no ­obvious cause? The goal of Principles of Hand Surgery and Therapy is to distill the intangible intuitions from the Advanced Graduate Program of Hard Knocks into an algorithm, a manual, or the Holy Grail, much the same way Virginia Apgar taught her students what she looked for when she decided to hand a thriving baby to its mother or call for an intensive care team for a baby on the verge of collapse, so that maybe the next generation would not have to learn critical lessons by hard knocks that can be stressful for the physician and the patient. I have given a lot of thought to these lessons. My co-editors—Ghazi Rayan, MD, Jeffrey Budoff, MD, Mark Baratz, MD, and David Slutsky, MD—are the type of “go-to” surgeons you call when things get tough, and they helped to assemble an incredible group of authors who are always there in a pinch, whether it is by contributing a complex chapter or mapping out a solution to a heartbreaking complication being experienced by a patient. The goal of Principles of Hand Surgery and Therapy is to draw upon the collective insights of the community of hand surgeons and hand therapists to provide the best recommendations for surgery and rehabilitation to expertly and safely care for our patients. The following intuitions or guidelines are not always easy or expedient to follow, especially when my ego tries to get in the way, but they have served me when followed:    1. Whenever any member of the team is worried about something, such as a nerve at risk, I need to take time out to solve the problem and make sure it is safe to proceed.

2. Whenever I am tired, I need to make sure to avoid short cuts. 3. Bradburn’s law: I always need to believe my worst x-ray and act on it. 4. Full disclosure: I must understand the real problem ­causing the issue with the deformity, fracture displacement, and so on before starting surgery, no matter how many tests or how much research it takes on my part. 5. Emergency room recycle rule: If a patient returns to the emergency room in the same time window, I have to advance the workup and be ready for emergency surgery. 6.  Compartment syndrome dictum: If I think it might be compartment syndrome, it is my problem to solve it ­ ­immediately. 7. Reagan “Trust but verify”: If I ask for an emergency consult, I have to verify that the consult is done within 24 hours. 8. Lifeline rule: If I am over my head, I need to humbly call in a “lifeline” by phoning a friend to ask for advice. 9. Back-up plan: Even for the simplest case, such as hardware removal, I have to have a back-up plan to make sure I can find that elusive screwdriver (or other key equipment) or have permission to perform that additional surgery if the unexpected happens. 10. Hardest of all: When things are not going well in surgery, I need to stay calm because the rest of the team takes their clues from you the surgeon. If you get rattled and lose concentration, so does the entire team. If you are calm but determined, they will stay focused and work efficiently.    I am grateful for the lessons that someone else taught me, to spare me the agony and embarrassment of making such a mistake. Other lessons were painful. Much of what I am sharing is part of a collective experience. Feedback and more lessons from wiser surgeons are always welcome. The practice of medicine is always evolving. Thank you for understanding. Thomas E. Trumble, MD

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Acknowledgments This textbook is a labor of love, and it comes at a great cost in terms of time and finances. During the time the authors contributed to write a chapter, they could have been working clinically and paid for at least 1 year of college tuition for one of their children. Why do we write these textbooks? Because we learned a substantial portion of our craft the hard way, and we remember being up in the wee hours with that cold sweat trying figure out how to get that impossible fracture back together or to conjure up a way to cover that ever-expanding soft-tissue defect. We wanted to write our lessons into a practical book with detailed figures and videos to provide step-by-step instructions to help our c­ olleagues to solve tough problems for their patients to relieve pain and improve function. We also feel your pain when it comes to studying for “the boards.” This book contains all the core knowledge to pass a board examination in hand surgery. To my wife Sara—thank you for your steadfast love, support, and organizational skills to launch a book during a perfect storm of life’s challenges. To our team at Bellevue Hand Institute—I greatly appreciate our family of Alan Boyd, Elle Busch, Keith Lemay, PA-C, and Derek Omori, PA-C for tracking down figures, assisting with ­videos, and helping to edit. Of course, a shout-out goes to my IT

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wizard, Reid Malmquist, for computer solutions, video expertise, and overall IT troubleshooting. To the publishing team at Elsevier, especially Maureen ­Iannuzzi and Daniel Fitzgerald—thank you for babysitting us, keeping us on track, and letting us add the “cool stuff” for this third edition. To all the editors and coauthors, as my friends and c­ olleagues— we owe you a debt of gratitude for your leadership in our societies and your amazing contributions to this publication. You are the “band of brothers and sisters” that I turn to when I have tough questions, and I know that you are always available to our readers at meetings and on e-mail as that lifeline of support in this challenging world of medicine. But most of all, I want to thank you as my friends and family. Life is humbling, and I have enough sense at this point in my career to realize the mistakes that I have made and to give thanks for your support so that I can learn from them and overcome them. In remembrance of Dorothy Mae Trumble (April 28, 1928 to April 13, 1996), a loving mother and wife who “always believed in her boys.”

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow Patrick L. Reavey, MD, MS, Gregory Rafijah, MD

KEY SURGICAL VIDEOS Video E1-1 Elbow Anatomy See the video for a detailed anatomy of the elbow.  Video E1-2 Radius Anatomy See the video for a detailed anatomy of the distal radius. 

Video E1-4 General Examination of Hand and Wrist Tendon Function See the video for a detailed demonstration of an exam for tendon function in the wrist and digits.

Video E1-3 Wrist Anatomy See the video for a detailed anatomy of the wrist. 

INTRODUCTION The goal of this chapter is to provide a detailed discussion of the anatomy of the hand, wrist, forearm, and elbow, with a focus on critical information for the surgeon. Other chapters contain detailed descriptions of specific anatomy (ie, carpal ligaments; see Chapters 4 and 5) and key aspects of examining these pathologies. Except for the neurovascular anatomy, this chapter will be divided into anatomic areas. This results in some repetition of information, especially with regard to the musculature of the arm. However, this format will closely tie together with the examination section and will reinforce useful clinical knowledge. The anatomy of the upper extremity can be described by structural relationships (radial vs. ulnar, palmar or volar vs. dorsal) or relative to the position of the arm in a supine patient (medial vs. lateral, anterior vs. posterior). These different terms will be used interchangeably based on commonly used paradigms. It is important to remember that in the supine position the radius is in a lateral position while the ulna is medial, and the dorsal aspect of the forearm and hand is posterior while the volar surface is anterior. A list of common abbreviations used in this chapter appears in Box E1.1.

Elbow Anatomy Bones The elbow joint is a complex structure comprising three articulations: humerus and ulna, humerus and radius, and proximal ulna and radius. The axis for elbow rotation is centered at trochlea and capitellum. The trochlea of the distal humerus articulates with the trochlear notch (also called semilunar notch) of the ulna. The coronoid process of the ulna is a triangle-shaped anterior projection forming the distal portion of the trochlear notch and is more prominent on the radial aspect. The humeral capitellum articulates with the radial head. The humeroulnar and humeroradial joints together form a synovial hinge joint, allowing the elbow one axis of motion: flexion and extension. The medial ridge of the trochlea is slightly larger than the lateral ridge of the capitellum. This gives the articular surface approximately 6 degrees of outward motion along the epicondylar axis (carrying angle). Overall, the bony anatomy results in inherent elbow stability (Figs. E1.1 and E1.2): the coronoid and radial head articulations

with humerus both resist posterior subluxation and the coronoid additionally provides resistance to varus stress. The articulation between the radial head and radial notch of the proximal ulna forms a synovial pivot joint, allowing rotation of the forearm into supination and pronation (Fig. E1.3). Distal to the radial neck, the radial tuberosity is a medial-sided eminence that serves as an attachment for the biceps tendon. Radiographically the radial tuberosity projects medially and opposite to the radial styloid of the distal radius with the forearm in supination. 

Ligaments The stability of the elbow through the entire arc of motion is achieved by a complex group of ligaments anterior, posterior, lateral, and medial. The medial ligament complex is more developed and offers more stability than the lateral. This complex consists of anterior, posterior, and transverse bundles, of which the anterior bundle is the major medial stabilizer (Fig. E1.4).1 Isometric fibers do not exist within the anterior medial collateral ligament (AMCL); however, “nearly” isometric areas are located on the lateral aspect of the attachment site of the AMCL on the medial epicondyle, near the anatomic axis of rotation. The lateral collateral ligaments consist of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), the annular ligament (which encircles the radial head), and the accessory lateral collateral ligament (Fig. E1.5). The annular ligament and LUCL are considered the most important lateral stabilizers of the elbow.2 The anterior and posterior ligaments are merely thickenings of the capsule and offer little anteroposterior stability over the bony configuration. The insertion of the lateral (radial) collateral ligament complex close to the axis of rotation is therefore uniformly taut throughout flexion-extension movement. The annular ligament originates and inserts on the anterior and posterior margins of the lesser sigmoid notch. The anterior insertion becomes taut during supination, and the posterior origin becomes taut in pronation. The LUCL functions as the primary lateral stabilizer of the ulnohumeral joint (functions in stabilizing a varus) stress, and deficiency of this ligament results in posterolateral rotatory instability. The LUCL inserts on the distal humerus at the isometric point. 

Musculature The triceps muscle is the extensor of the elbow. The three heads of the triceps originate in the glenoid and humerus, and they

e1

e2

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

BOX E1.1   Abbreviations Used in Anatomy of the Hand   

OP: Opponens pollicis PIN: Posterior interossesous nerve PIP: Proximal interphalangeal PL: Palmaris longus TM: Trapeziometacarpal Digit Abbreviations TH: Thumb IF: Index finger MF: Middle finger RF: Ring finger SM: Small finger Bones C: Capitate H: Hamate L: Lunate P: Pisiform R: Radius S: Scaphoid Tp: Trapezoid Tq: Triquetral Tz: Trapezium U: Ulna

ADM: Abductor digiti minimi ADP: Adductor pollicis APB: Abductor pollicis brevis APL: Abductor pollicis longus CMC: Carpometacarpal DIP: Distal interphalangeal ECRB: Extensor carpi radialis brevis ECRL: Extensor carpi radialis longus ECU: Extensor carpi ulnaris EDC: Extensor digitorum communis EDM: Extensor digiti minimi EIP: Extensor indicis proprius EPB: Extensor pollicis brevis EPL: Extensor pollicis longus FCR: Flexor carpi radialis FCU: Flexor carpi ulnaris FDM: Flexor digiti minimi FDP: Flexor digitorum profundus FDS: Flexor digitorum superficialis FPB: Flexor pollicis brevis FPL: Flexor pollicis longus IP: Interphalangeal MCP: Metacarpal phalangeal ODM: Opponens digiti minimi

  

Spiral groove

Medial supracondylar ridge

Lateral supracondylar ridge

Coronoid fossa

Radial fossa

Medial epicondyle

Lateral epicondyle Capitellum

Trochlea Figure E1.1.  The anterior aspect of the distal humerus.

combine to insert onto the olecranon process of the ulna. The brachialis and biceps muscles lie on the anterior elbow. The brachialis originates from the distal humerus, inserts into the proximal ulna (distal to the coronoid process), and flexes the elbow. The biceps originates in the shoulder, inserts into the radial tuberosity of the proximal radius and the lacertus fibrosus, and is responsible for supinating the forearm and flexing the elbow. The elbow also serves as the origin to the extensor and flexor muscles of the wrist and hand and to the pronators and supinators of the forearm. The lateral epicondyle of the humerus gives origin to the common extensor tendon—supinator, extensor carpi ulnaris (ECU), extensor digiti minimi (EDM), and extensor digitorum communis (EDC)—and to the origin of the extensor carpi radialis brevis (ECRB). The “mobile wad of three” includes the ECRB, extensor carpi radialis longus

Medial supracondylar ridge

Lateral supracondylar ridge

Olecranon fossa

Lateral epicondyle

Medial epicondyle

Trochlea

Sulcus for ulnar nerve

Figure E1.2.  The posterior aspect of the distal humerus.

(ECRL), and brachioradialis (BR), the latter two of which originate from the lateral supracondylar ridge of the humerus. As a group, the muscles of the mobile wad help to initiate elbow extension; the ECRL and ECRB also extend and radially deviate the wrist respectively. The medial epicondyle is the origin of the common flexor tendon—origin of the humeral head of the pronator teres, flexor carpi radialis (FCR), palmaris longus (PL), and flexor carpi ulnaris (FCU)—and the humeral origin of the flexor digitorum superficialis (FDS).

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Triceps (cut)

Accessory collateral ligament

Olecranon process

Radial head

Coronoid process

Annular ligament

Coronoid tubercle

Radial tuberosity Oblique cord of interosseous membrane

Radius

Ulna lnterosseous membrane Figure E1.3.  The proximal radioulnar joint.

Medial supracondylar ridge Anterior bundle Annular ligament

Posterior bundle Transverse ligament

Radial tuberosity

Figure E1.4.  The medial collateral ligament complex of the elbow joint.

The superficial head of the supinator muscle originates from the lateral epicondyle, collateral ligament, and proximal ulna; this muscle’s deep head originates from the proximal ulna. The two heads of the pronator teres originate from the medial humeral epicondyle and medial border of the coronoid process of the ulna, respectively, inserting into the lateral shaft of the radius. For additional information regarding the anatomy of the elbow, review Video E1-1, “Elbow Anatomy.” 

Forearm Anatomy Radius and Ulna The radius and ulna are stabilized along the length of the forearm by a dense, fibrous interosseous membrane. Distally the radius has a

Lateral supracondylar ridge Radial collateral ligament

Radial notch of ulna

Semilunar notch

Triceps (cut)

Annular ligament

e3

Triceps (cut)

Radial tuberosity

Supinator crest

Lateral ulnar collateral ligament

Figure E1.5.  The lateral collateral ligament complex of the elbow joint.

prominent dorsal tubercle (Lister tubercle), which acts as a pulley for the extensor policies longus (EPL) tendon, and the prominent radial styloid. The distal radius articulates with the distal ulna, and both articulate with the carpal bones (Fig. E1.6). The radiocarpal joint is a synovial ellipsoid joint in which the scaphoid and lunate articulate with two concavities on the distal radius, the scaphoid fossa and lunate fossa. The sigmoid notch of the radius articulates with the distal ulna, forming the distal radial ulnar joint (DRUJ), allowing for 270 degrees of rotation of the radius around the ulna. The radial articular surface has 21 degrees of radial tilt and 11 degrees of palmar tilt. 

Ligaments The articulation of the distal ulna and carpal bones is bridged by the triangular fibrocartilage complex (TFCC). It consists of an articular disk, a meniscus homologue, ulnocarpal collateral ligament, dorsal and palmar radioulnar ligaments, and the ECU tendon sheath (Figs. E1.7 and E1.8). The radioulnar ligaments originate from attachments on the medial border of the distal radius and insert both into the ulnar styloid and ulnar fovea. The TFCC, especially the radioulnar ligaments, plays a crucial role in stabilizing the DRUJ while allowing for forearm rotation. 

Musculature The forearm is divided into two muscular compartments: anterior or flexor compartment and posterior extensor compartment. The flexor compartment contains the extrinsic flexors of the fingers and wrist, as well as the pronators of the forearm. These muscles can be subdivided into three groups: superficial, intermediate, and deep. The superficial group includes the muscles originating from the medical epicondyle of the humerus: pronator teres, FCU, FCR, and PL. The intermediate group includes only the FDS. However, in the mid-forearm this muscle has two distinct muscle bellies: the more anterior functioning on the middle and ring fingers and the posterior functioning on the index and small fingers. The deep flexor group includes the flexor pollicis longus (FPL), flexor digitorum profundus (FDP), and pronator quadratus (PQ). The posterior or dorsal compartment can also be divided into deep and superficial groups. The superficial group includes the muscles of the common extensor tendon originating at the lateral epicondyle: BR, ECRL, ECRB, EDC, EDM, ECU, and anconeus. The deep group includes the supinator, abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor indicis proprius (EIP), and EPL. In the distal forearm, the muscle bellies of the APL, EPB, EPL, and EIP can be identified by their relative radioulnar position, with the APL being the most radial and the EIP most ulnar. The APL and EPB muscle bellies cross over the ECRL and ECRB in the distal forearm, and this intersection is the reason for the misnomer of the “intersection syndrome” since the tendons actually do not touch. The tendonitis in this region is due to tendonitis in the

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Distal phalanx

Distal interphalangeal joint

Middle phalanx

Proximal interphalangeal joint

Proximal phalanx

Metacarpal phalangeal joint

Sesamoid

Interphalangeal joint

Metacarpal

Metacarpal phalangeal joint

Capitate

V IV III II

Carpometacarpal joint

Hamate

Trapezium

I

Pisiform

Trapezoid

Triquetrum Scaphoid Lunate Radius Ulna Figure E1.6.  The osseous anatomy of the hand.

Tq

S

P

L Radius

UT

UL

Meniscal homologue Volar radioulnar ligament

47–80°

Dorsal radioulnar ligament 15 mm mm 10

Ulna

Figure E1.7.  The radius of curvature of the sigmoid notch is 1.5 to 2 times that of the ulnar head.

second dorsal compartment alone. The true name for the pathology should be “2nd dorsal compartment tenosynovitis.” For additional information regarding anatomy of the distal radius, review Video E1-2, “Radius Anatomy.” 

Carpus Carpal Bones The carpus is divided into the proximal row (scaphoid, lunate, and triquetrum) and distal row (trapezoid, trapezium, capitate, and hamate; Figs. E1.9 and E1.10). The midcarpal joint is made up of the articulation between the two rows. The pisiform is a sesamoid bone within the FCU tendon and articulates with a facet on the palmar surface of the triquetrum. The hamate has a prominent volar hook that serves as a fulcrum for the digital flexors. The distal row is firmly fixed to the bases of the metacarpal bones. The scaphoid is the link between the two rows, which makes it relatively vulnerable to injury.

R

U

Figure E1.8.  The TFCC is composed of the triangular fibrocartilage disk, meniscal homologue, and supporting ligaments. L, Lunate; P, pisiform; R, radius; S, scaphoid; Tq, triquetrum; U, ulna; UL, ulnolunate ligament; UT, ulnotriquetral ligament.

The midcarpal and intercarpal joints are synovial joints. The intercarpal articulations allow a small but crucial degree of movement. No tendons have a major insertion on the carpus other than the pisiform, which is attached to and acts as a fulcrum for the FCU; therefore the wrist flexors and extensors apply moments of rotation to the hand, and the carpal bones respond to the forces directed to the hand. The proximal row is without any direct influence on motion, which is why it is often referred to as an intercalated segment. 

Ligaments Collectively, the complex arrangement of ligaments in the wrist provides stability and coordinates smooth motion through multiple articulations. The ligaments vary in their size, strength, and density, and their disruptions can have varying effects on carpal mechanics. The ligaments of the wrist will be discussed in more detail in Chapters 4 and 5; however, some general concepts will be presented here. There is a diversity of nomenclature and considerable variability among individuals regarding the size and shape of wrist

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Space of Poirier Triquetrocapitate

e5

EDM (V) EDC, EIP (lV)

ECU (Vl)

Capitotrapezoid

EPL (lll) Triquetrohamate

C

Tp

H

Tz

Scaphotrapezial

ECU insertion at MC 5 V

Tq Lunotriquetral

ECRB, ECRL (ll)

P

S

EPB, APL (l)

Scaphocapitate

L

Ulnotriquetral Ulnocapitate Ulnolunate

Long radiolunate

l

Dorsal intercarpal Dorsal radiocarpal Tp

Tz

C

H

S L

R

U

Figure E1.10.  The most significant dorsal ligaments include the dorsal radiotriquetral and the dorsal intercarpal ligaments. The key dorsal ligaments (the intercarpal ligament and the radiocarpal ligament) guide carpal rotation with radial and ulnar deviation. C, Capitate; H, hamate; L, lunate; R, radius; S, scaphoid; Tp, trapezoid; Tz, trapezium; U, ulna.

ligaments. In addition, when approached externally, most ligaments do not appear as discrete structures but tend to blend with each other and with the synovial capsule, making their identification difficult. Carpal ligaments are categorized into three main groups: extracapsular vs. intracapsular, extrinsic vs. intrinsic, and volar vs. dorsal. Other than the transverse carpal ligament and multiple soft tissue connections to the pisiform, all wrist ligaments are intracapsular— meaning they lie within the synovial lining of the wrist (see Fig. E1.9). Extrinsic ligaments connect the radius and ulna to carpal bones, and intrinsic (or interosseous) ligaments connect the carpal bones to each other. In general the volar extrinsic ligaments provide the majority of stability to the carpus. They form a double-chevron pattern with the distal “V” connecting the ulna and radius to the capitate and the proximal “V” connecting the ulna and radius to the lunate (Fig. E1.9). This ligamentous arrangement initiates the correct carpal rotation to compress the ulnar and radial height of the carpus during ulnar and radial deviation, respectively.3 This configuration also leaves a weak spot at the volar aspect of the

APL insertion at MC 1

lll

R

Figure E1.9.  The palmar carpal ligaments form a V-shaped pattern of support along the palmar aspect of the carpus, with an empty weak space centered at the level of the capitolunate joint, which is known as the space of Poirier. C, Capitate; H, hamate; L, lunate; P, pisiform; R, radius; S, scaphoid; Tp, trapezoid; Tq, triquetrum; Tz, trapezium; U, ulna.

ECRL insertion at MC 2

lV

Short radiolunate U

ECRB insertion at MC 3

ll

Radioscaphocapitate

V Vl

lV

lll

ll l

Ulna Radius Figure E1.11.  The six dorsal compartments of the extensor tendons are demonstrated. The first dorsal compartment (I) contains the APL and the EPB. The second dorsal compartment (II) contains the ECRL and the ECRB. The third dorsal compartment (III) contains the EPL. The fourth dorsal compartment (IV) contains the EDC and the EIP. The fifth dorsal compartment (V) contains the EDM. The sixth dorsal compartment (VI) contains the ECU.

proximal capitate, between the radioscaphocapitate and long radiolunate ligaments (named the space of Poirier).4,5 This space allows concomitant extension at the midcarpal joint but is also the location of lunate dislocation in perilunate instability. The radioscaphocapitate ligament crosses the scaphoid at its waist and is crucial to be preserved during proximal row carpectomy to prevent subsequent ulnar subluxation of the carpus. The radioscapholunate ligament (also known as the ligament of Testut) is a vestigial remnant that is considered to have played a role in the separation of the radiolunate from the radioscaphoid articulations in the fetus.6 This structure is seen during wrist arthroscopy and is not thought to provide significant stability to the wrist. The two key intracapsular ligaments include the scapholunate interosseous ligament and lunotriquetral interosseous ligaments. Both have dorsal and volar components and proximal membranous extensions facing the radial scaphoid and lunate fossae. The dorsal portion of the scapholunate ligament is more important in stabilizing flexion forces on the scaphoid, and the volar portion of the lunotriquetral ligament resists extension forces on the triquetrum. When one of these ligaments is disrupted, the lunate will extend or flex through its remaining connection to the triquetrum or scaphoid, respectively. Dorsally the two key ligaments are dorsal intercarpal and dorsal radiocarpal (see Fig. E1.10). The ligaments help to guide carpal rotation, especially with radial and ulnar deviation. Injury to these ligaments is a key factor in developing volar intercalated instability (VISI). For additional information regarding the bony and ligamentous anatomy of the wrist, review Video E1-3, “Wrist Anatomy.” 

Extrinsic Extensor Tendons and Muscles The extensor tendons form six discrete compartments at the level of the wrist as they pass under the extensor retinaculum (Fig. E1.11). These compartments prevent the bowstringing

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

that would otherwise occur across the wrist joint during extension. Knowing the anatomy of these compartments is important in treating various conditions, such as tenosynovitis, and properly locating tendons when repairing tendon lacerations or identifying tendons to use for transfers. The tendons in each compartment and their innervation are summarized in Table E1.1. First Dorsal Compartment.  The APL (Figs. E1.11-E1.13) and EPB enter the first dorsal compartment. The APL usually has two to four separate tendon slips. Most of the population has only a single slip of the EPB. The first compartment is a common location for tenosynovitis (de Quervain tendinopathy). In 60% of the population, there is a separate subcompartment for one of the slips of the APL or more commonly for the EPB. Therefore, when treating this condition surgically, care should be taken to look for and release all tendon slips. 

the tendon during pronation and supination—as it moves from palmar to dorsal, respectively. The subsheath is an important component of the TFCC. Ruptures or tears of the ECU subsheath can cause ulnar-sided wrist pain or characteristic snapping of the ECU tendon during pronation or supination as the tendon subluxes out of the ulnar groove. 

Extrinsic Flexor Tendons and Muscles Flexor tendons of the forearm are summarized in Table E1.2. At the level of the wrist, three flexor tendons pass outside of the carpal tunnel: the PL, FCR, and FCU. Nine flexor tendons pass within the carpal tunnel for the digits and thumb (Figs. E1.16 and E1.17). Wrist Flexor Tendons and Muscles.  The FCR originates from the medial epicondyle of the humerus and runs along

Second Dorsal Compartment.  The ECRL and ECRB are two powerful wrist extensors; the former also provides radial deviation to the wrist (Fig. E1.14). The ECRL inserts on the base of the index metacarpal bone and the ECRB on the base of the middle finger metacarpal bone. Both of these tendons attach on the radial side of the respective metacarpal bones, thus enhancing radial deviation. Due to its more central insertion, the ECRB is the preferred recipient for tendon transfers to restore wrist extension because it will not result in radial deviation.  Third Dorsal Compartment.  The EPL is the sole tendon in the third compartment. The tendon is intimately involved with the dorsal aspect of the distal radius as it passes around the ulnar aspect of Lister tubercle. As such, the EPL is at risk for attrition and delayed rupture from distal radius fractures. After leaving the extensor retinaculum, the EPL crosses tendons of the second compartment and forms the anatomic snuffbox along with the tendons of the first dorsal compartment (Fig. E1.15).  Fourth Dorsal Compartment.  The EDC and EIP are in the fourth dorsal compartment.  Fifth Dorsal Compartment.  The EDM (or quinti) is the only tendon in the fifth dorsal compartment. It is located over the DRUJ.  Sixth Dorsal Compartment.  The powerful ECU (Fig. E1.11) attaches on the ulnar side of the small finger metacarpal bone and causes wrist extension and ulnar deviation. This tendon runs in a grove in the distal ulna and has a dense subsheath that stabilizes

EPL

APL

EPB Figure E1.12.  The first dorsal compartment contains the APL and the EPB. The APL abducts and extends the thumb TM joint, and the EPB extends the MCP joint. The EPL extends the thumb IP joint.

TABLE E1.1   Dorsal Compartments of the Extrinsic Extensor Tendons, Including Function and Innervation of the Muscles Compartment

Tendons

Function

Innervation

First

Extensor pollicis brevis

Extends thumb metacarpal phalangeal joint

Posterior interosseous branch of radial nerve

Abductor pollicis longus Second Extensor carpi radialis longus Third Fourth Extensor indicis proprius Fifth Sixth

Extends and stabilizes trapeziometacarpal joint Extensor carpi radialis brevis Extends and radially deviates the wrist

PIN Extends the wrist Radial nerve

Radial nerve

Extensor pollicis longus Extensor digitorum communis Provides independent index finger extension Extensor digiti minimi Extensor carpi ulnaris

Extends the thumb interphalangeal joint Extends all four fingers PIN

PIN PIN

Provides independent small finger extension Ulnarly deviates and extends the wrist

PIN PIN

PIN, Posterior interosseous nerve.

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

the radial border of the volar wrist to attach onto the base of the index metacarpal. It passes within a groove on the volar trapezium and is at risk for injury during trapeziectomy. It provides wrist flexion and some radial deviation. The FCU is located on the ulnar side of the volar wrist and is considered the most powerful wrist flexor. It originates from the medial epicondyle and attaches primarily onto the pisiform. This tendon provides a very powerful wrist flexion and ulnar deviation force that is important in power activities, such as hammering.  Palmaris Longus Tendon (Fig. E1.17).  The PL muscle originates from the medial epicondyle of the humerus and inserts on the palmar fascia. The increased tension on the fascia may help with gripping activities. Approximately 20% of the population does not have a PL tendon; in these individuals a broader insertion of the FCR tendon has been described. In the distal forearm and wrist, the PL tendon is in proximity and immediately overlying the median nerve.  Digital Flexors.  The flexors to the thumb and fingers all enter the hand via the carpal tunnel. The FDS crosses the tunnel as four tendons, with those to the ring and middle finger being superficial to the index and small finger tendons (Fig. E1.18). A tool to remember this arrangement is that “34” in reference to the third and fourth digits is greater than “25,” corresponding to the second and fifth digits (Fig. E1.18). The FDS muscle originates from the medial epicondyle of the humerus and the proximal radius and inserts on the palmar surface of the middle phalanx to produce proximal interphalangeal (PIP) joint flexion. Each mus-

Figure E1.13.  The radial wrist. The superficial radial nerve branches crosses dorsally over the tendons of the first and third extensor compartments (solid arrow). The first compartment consists of the EPB (marked with stitch) and the APL (asterisk). The third compartment consists of the EPL (double arrow).

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cle belly of the FDS can usually be independently flexed, except perhaps for that of the small finger. Approximately 7% of people lack an FDS to the small finger, though this is bilateral only 60% of the time.7 Deep to the FDS is the FDP. The FDP originates from the proximal ulna and inserts on the palmar surface of the distal phalanx to cause distal interphalangeal (DIP) joint flexion. The FDP has a single muscle to the middle, ring, and small fingers, which prevents it from independently flexing each digit. The FDP to the index finger usually does have independent function. On the radial border of the carpal tunnel is the FPL tendon, which originates from the middle third of the radial shaft and the lateral aspect of the interosseous membrane, attaches onto the base of the distal phalanx of the thumb, and generates thumb interphalangeal (IP) joint flexion. 

Hand and Digital Anatomy Metacarpals and Phalanges The index and middle finger carpometacarpal (CMC) joints have minimal motion, and they form the stable central ray of the hand; the mobile ring and small finger metacarpal joints can flex and rotate toward the midline of the palm to enhance grip. This greater mobility is the reason that greater degrees of fracture malalignment can be tolerated with metacarpal neck fractures of the ring and small fingers as compared with the index and middle fingers. The thumb metacarpal articulates with the trapezium on a biconcave, saddle-shaped joint (Fig. E1.19A)—the trapeziometacarpal (TM) joint. This universal joint provides the thumb with a wide arc of multiplanar motions, including flexion-­ extension, abduction-adduction, opposition, circumduction, and rotation. The fingers have proximal, middle, and distal phalanges whereas the thumb has only proximal and distal phalanges. Each finger has three joints: metacarpal phalangeal (MCP), PIP, and DIP. The thumb has a TM joint and only one IP joint. The

First dorsal compartment – EPB and APL tendons Anatomic snuff box

Pressure

ECRB ECRL

Resistance Figure E1.14.  The second dorsal compartment contains the ECRB, which extends and radially deviates the wrist, and the ECRL.

Third dorsal compartment – EPL tendon

Figure E1.15.  The anatomic snuffbox is the concavity formed with extension of the thumb between the tendons of the first and third dorsal compartments. APL, Abductor pollicis longus; EPB, extensor pollicis brevis; EPL, extensor pollicis longus.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

TABLE E1.2   Extrinsic Flexor Muscles in the Forearm Flexor Groups

Muscle

Function

Innervation

Superficial

Pronator teres

Median

Intermediate

Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis

Deep

Flexor digitorum profundus

Pronation of forearm (rotates radius around ulna, especially with an extended elbow; with radius fixed, assists with elbow flexion) Wrist flexion and radial deviation Increased tension of palmar fascia Wrist flexion and ulnar deviation Flexion of proximal interphalangeal joints of all four fingers Flexion of distal interphalangeal joints of all four fingers

Flexor pollicis longus

Flexion of thumb interphalangeal joint

Pronator quadratus

Pronation of forearm (rotates radius around ulna)

Median Median Ulnar Median Anterior interosseous branch of median nerve to index and middle fingers Ulnar nerve to middle, ring, and small fingers Anterior interosseous branch of median nerve Anterior interossesous branch of median nerve

cam-shaped when viewed in the sagittal plane, the collateral ligaments tighten with flexion and are lax in extension. For this reason, abduction and adduction are possible with the fingers extended and restricted when the MCP joints are flexed. The volar plate is composed of crisscrossing fibers that resist hyperextension but collapse when the joint is flexed. The PIP and DIP joints are uniaxial and allow only one plane of motion: flexion and extension. The joints are supported by collateral and accessory collateral ligaments and a volar plate (Fig. E1.20). The volar plate moves as a unit, gliding proximally and distally during flexion and extension, respectively.3  Figure E1.16.  The volar wrist and contents of the carpal tunnel after excision of the transverse carpal ligament are exposed using the self-retaining retractor. The median nerve, marked by the stitches, is accompanied by the long flexor tendons to the fingers and is seen to branch out in the palm. Its palmar cutaneous nerve branches out more proximal and is marked by the blue background (solid arrow) with the FCR tendon behind it. The FCU is marked by an asterisk and may be seen inserting into the pisiform (double asterisks). The APB (of the thenar muscles) is marked by a double arrow.

surface anatomy has skin creases that are fairly independent from the bony anatomy (see Fig. E1.19B). 

Ligaments As described above, the TM joint is a saddle-shaped joint with a wide arc of motion. The joint has little inherent osseous stability because such numerous ligaments stabilize this joint during various thumb motion. The palmar oblique ligament (palmar “beak” ligament) has historically been described as the most important stabilizer of the TM joint. However, this ligament has more recently been shown to be taut only in the hitchhiker position. The dorsal ligament complex of the TM joint comprises the dorsal radial and posterior oblique ligaments and is the thickest and most important ligament of the TM joint. These dorsal ligaments provide stability during the important uses of the thumb in power grip and pinch.8 The MCP joints of the fingers have radial and ulnar collateral ligaments that provide lateral stability; the dense palmar plate prevents hyperextension. Because the metacarpal head is

Tendons and Intrinsic Muscles of the Hand

Extrinsic Tendons of the Thumb.  The APL (see Figs. E1.12 and E1.13) inserts on the base of the first metacarpal. The APL extends the TM joint, with its multiple tendon slips attaching around the base of the metacarpal, as well as stabilizing the TM joint when loaded during pinch. The EPB joins the sagittal band of the thumb; its primary attachment is to the base of the proximal phalanx to help to extend the MCP joint. The EPL attaches to the base of the distal phalanx of the thumb and generates extension of the thumb IP joint (Figs. E1.21 and E1.22; see also Fig. E1.13). Only the EPL tendon can cause true hyperextension of the IP joint. The intrinsic muscles of the thumb, which insert on the extensor hood, can weakly extend the IP joint but do not cause hyperextension or extend against resistance. The FPL enters a fibroosseous sheath (described later) proximal to the MCP joint and inserts onto the base of the distal phalanx of the thumb to cause IP joint flexion.  Thenar Muscles and Adductor Pollicis.  The thenar muscles are made up of the abductor pollicis brevis (APB), flexor pollicis brevis (FPB), and the opponens pollicis (OP). The adductor pollicis (AdP) is deep to the FPB and is not considered a thenar muscle. The location of the muscles in order from superficial radial to deep ulnar is APB, FPB, OP, and AdP. These muscles have differential innervation from the median and ulnar nerve. An easy way to remember the innervation of the thenar muscles is that all the muscles radial to the FPL are innervated by the median nerve, and all the muscles on the ulnar side are innervated by the ulnar nerve. The FPB muscle is divided into superficial and deep heads by the FPL tendon and has dual innervation by both the median and ulnar nerve (see Fig. E1.17).

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

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Lumbricals

Palmar aponeurosis with palmaris longus tendon Superficial palmar arch

Adductor pollicis FPB APB

Flexor digiti minimi

Opponens pollicis

Abductor digiti minimi

Median nerve with motor branch Transverse carpal ligament Radial artery

FCU Palmaris longus tendon Ulnar nerve

FCR FDS Ulnar artery FPL Figure E1.17.  Palmar anatomy under the transverse carpal ligament. The relationship between the branches of the median nerve, superficial palmar arch, thenar muscles, and structures passing through the carpal tunnel may be appreciated. The wrist flexor tendons consist of the FCR and the FCU. The PL mainly applies tension to the palmar fascia, possibly to improve gripping. APB, Abductor pollicis brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis longus.

Flexor retinaculum Flexor carpi radialis Radial artery Flexor pollicis longus

Transverse carpal ligament Palmaris longus Median nerve

Flexor digitorum profundus

Flexor carpi ulnaris

Trapezium Flexor digitorum superficialis

Trapezoid

Ulnar artery

Capitate

Ulnar nerve Hamate FDS Palmaris longus Median nerve

Ulnar artery

FCR FCU Radial artery

Pisiform Triquetral

FPL Ulnar nerve FDP Figure E1.18.  The median nerve, all the digital flexor tendons, and the FPL pass through the carpal tunnel. FCR, Flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Forearm

Supination

Opposing thumb to finger

Pronation

Flexion

Extension Ulnar deviation

Wrist

Radial deviation O

Palmar abduction

Extension

PA Wrist RA

Flexion

Abduction Adduction Finger

A

R PA

Radial abduction

Hyperextension

RA

Extension

Tz

O MC I

A

A

R

B

Flexion

Long Ring finger Index finger finger

Proximal interphalangeal crease Palmar digital crease

Small finger

ease ar cr se l palm r crea a t is D lma l pa ma i x Pro nar othe Hyp

Then ar cr ease

Distal interphalangeal crease

ar

en

Th

Ulnar border

C

Distal phalanx segment Middle phalanx segment Proximal phalanx segment Thumb Distal phalanx segment Proximal phalanx segment

Radial border Wrist crease

Figure E1.19.  (A) Common terminology for hand ROM. (B) The biconcave surfaces of the thumb TM joint allow for thumb rotation, flexion/extension, and abduction/adduction. A, Adduction; MC 1, thumb metacarpal; O, opposition; PA, palmar abduction; R, retropulsion; RA, radial abduction; Tz, trapezium. (C) Surface anatomy of the palm.

The APB originates from the palmar surface of the trapezium and transverse carpal ligament and inserts on the radial side of the MCP joint and the proximal phalanx to provide the key motions for thumb opposition (flexion, pronation, and palmar abduction) of the thumb metacarpal to allow opposition of the thumb to the digits. The FPB muscle is split by the FPL into a large superficial head and small deep head, with different innervation. The superficial head of the FPB is innervated by the median nerve and originates from the transverse carpal ligament and the trapezium and inserts into the radial side of the base of the thumb’s proximal phalanx. The radial sesamoid bone is in its tendinous insertion. The deep head of the FPB, on the ulnar side of the FPL tendon, and is innervated

by the ulnar nerve. It originates from the thumb metacarpal and inserts on the radial side of the base of the thumb’s proximal phalanx. The FPB produces MCP joint flexion. The OP lies deep to the APB and FPB. It also originates from the trapezium and transverse carpal ligament and inserts along the radial border of the thumb metacarpal and the radial sesamoid at the MCP joint to provide flexion of the thumb metacarpal at the TM joint. The deeper AdP has an oblique head arising mainly from the base of the index and middle finger metacarpal bones and a transverse head arising from the shaft of the third metacarpal. Both heads insert onto the volar plate of the MCP joint, base of the proximal phalanx, and ulnar sesamoid. This muscle plays a major

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

e11

role in key pinch. Without the function of the AdP such activities as using scissors or turning an ignition key would be very difficult. Electromyographic studies have emphasized the role of the intrinsic thumb muscles in the facilitation of thumb manipulative function. The first dorsal interosseous muscle is in a position to stabilize the base of the thumb on its ulnar side; the FPB contracts strongly on the radial side. The FPB and the AdP have been described as evolutionary developments of a “missing” first palmar interosseous muscle. 

Hypothenar Muscles

Collateral ligament

Palmar ligament (plate) Figure E1.20.  The anatomy of the palmar plate of the PIP joint.

EPL

These include the abductor digiti minimi (ADM), flexor digiti minimi (FDM), and the deeper opponens digiti minimi (ODM). The ADM originates from the palmar surface of the pisiform and from the FCU tendon and divides into two slips; one is inserted onto the ulnar side of the base of the proximal phalanx of the small finger and the other onto the ulnar border of the aponeurosis of the EDC tendon. It produces abduction of the small finger (Fig. E1.23). The FDM is more radial than the ADM, originates from the palmar surface of the hook of the hamate, inserts onto the ulnar side of the base of the proximal phalanx of the small finger, and flexes the small finger MCP joint. The ODM is deep to the remaining two hypothenar muscles; it originates from the body of the hamate and inserts onto the ulnar border of the small finger metacarpal to flex the metacarpal at the CMC joint and bring the small finger toward the midline. This results in narrowing of the arch of the palm important for gripping activities. The palmaris brevis is a thin, superficial, quadrilateral muscle on the ulnar side of the palm of the hand. It originates from the transverse carpal ligament and palmar aponeurosis and is inserted into the skin on the ulnar border of the palm. It is of little functional importance and is frequently encountered in the surgical approach to the ulnar tunnel and carpal tunnel. The muscles of the hypothenar eminence are innervated by the motor (deep) branch of the ulnar nerve. The palmaris brevis is innervated by the superficial (mainly sensory) branch of the ulnar nerve. 

Finger Flexors Figure E1.21.  The third dorsal compartment contains the EPL, which extends the IP joint of the thumb and brings the thumb out of the plane of the palm.

Figure E1.22.  The dorsal hand and wrist. Note the ulnar location of the EIP (solid arrow) and the multiple slips of the EDM (dotted arrow) in relation to the EDC tendons to the index and small fingers, respectively. The EDC tendon to the small finger (single asterisk) is typically less prominent than the EDM. Lister tubercle is marked with a dotted circle. The extensor pollicis longus tendon curves around the tubercle (double asterisk). The superficial radial nerve branches are marked with the double arrow.

The FDS divides into two slips near the level of the proximal phalanx to form Camper chiasm (Fig. E1.24). The two slips of the FDS attach on either side of the middle phalanx to flex the PIP joint. At the level of the proximal phalanx, the FDP tendon passes through the two slips of the FDS tendon (Fig. E1.25). The FDP then lies superficial to the FDS and continues on to insert onto the base of the distal phalanx to flex the DIP joint. The direct arterial supply to the tendons is maintained on their dorsal aspect by structures named vinculae (see Fig. E1.25). The vinculum longum to the FDS tendon originates near the middle of the PIP joint. The vinculum brevis to the FDS originates near the neck of the proximal phalanx and continues on to form the vinculum longum to the FDP. The vinculum brevis to the FDP originates near the neck of the middle phalanx and provides blood supply to the distal end of the FDP. In addition, synovial diffusion through the parietal paratenon facilitates passive nutrient delivery and waste removal from the flexor tendon within the flexor sheath. The region proximal to the vinculae and distal to the lumbrical muscles is a relatively hypovascular area of the flexor tendons and called the watershed zone. This region is maintained by passive diffusion alone. The ulnar nerve innervates the FDP muscle-tendon units of the small, ring, and half of the middle fingers in the majority of individuals. The anterior interosseous branch of the median nerve innervates the FDP of the index and half of the middle finger muscle. The median nerve innervates the FDS, and the

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

FDM ADM

Deep (motor) branch of ulnar nerve Deep branch of ulnar artery Pisiform

A

Ulnar artery and nerve

Branches to palmaris brevis Superficial branch of ulnar artery Superficial branch of ulnar nerve Hamate Transverse carpal ligament

Ulnar

ODM

Pisohamate ligament Transverse carpal ligament

Dorsal

B

Ulnar artery and nerve

Location of fascicles for deep motor branch

Figure E1.23.  (A) The ulnar nerve and artery enter the wrist through the Guyon canal (or ulnar tunnel). (B) The ulnar nerve innervates the muscles of the hypothenar eminence. ADM, Abductor digiti minimi; FDM, flexor digiti minimi; ODM, opponens digiti minimi.

Vinculum longus to FDP Vinculum brevis to FDP

Camper chiasm

FDS FDP

D Plate

Plate

M Plate P Vinculum brevis to Vinculum FDS longus to FDS

Figure E1.24.  The volar hand after excision of the digital flexor sheath and pulleys. Camper chiasm is marked with the single arrow. After crossing through the two limbs of the FDS tendon, the FDP becomes superficial to it (and is lifted in the image by the scissors). The vinculae to the tendons is marked by the asterisk. The double asterisks mark the superficial palmar arch as it crosses over the tendons. The digital neurovascular bundles to the middle finger are marked by the dotted arrows on both sides of the flexor tendons.

anterior interosseous branch of the median nerve innervates the FPL plus the PQ muscle. Flexor Tendon Sheath.  Proximal to the MCP joints the extrinsic flexor tendons enter a fibroosseous sheath. The purpose of the tendon sheath is to keep the flexor tendons close to the bone and prevent them from bowstringing during finger and thumb flexion. In the fingers the tendon sheath is divided into a series of five annular (designated A1 to A5) and three cruciate (C1 to C3) pulleys

MC Lateral collateral ligament

Accessory ligament

Figure E1.25.  The FDP passes through Camper chiasm in the FDS tendon. The vinculae provide the blood supply to the flexor tendons. D, Distal phalanx; FDP, flexor digi­torum profundus; FDS, flexor digitorum superficialis; M, middle phalanx; MC, metacarpal; P, proximal phalanx.

(Fig. E1.26). The annular pulleys increase the mechanical advantage by keeping the tendons close to the bone and to the centers of rotation of the IP joints and maximize tendon excursion at the expense of the moment of flexion. The odd-numbered annular pulleys are located over joints, whereas the two even-numbered pulleys (A2 and A4) are located over the shafts of the proximal and middle phalanges. Frequently the A1 and A2 pulleys merge and appear as one structure. The A2 and A4 pulleys are the most important pulleys to prevent bowstringing of the tendons and should be preserved during flexor tendon repairs. The A5 pulley is not consistently present. The three cruciate pulleys lie between adjacent annular pulleys, starting with the C1 pulley between the A2 and A3 pulleys. The cruciate pulleys collapse and expand, facilitating digital flexion and extension. The flexor tendon sheath of the thumb contains two annular and one oblique pulley. The oblique pulley lies over the mid portion of the proximal phalanx, contains part of the insertion

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Collateral ligament and joint capsule Digital synovial sheath A1

EDC

A2 A3 C2 A4 A5

C1 Metacarpal phalangeal joint

C3 Proximal interphalangeal joint

Distal interphalangeal joint Figure E1.26.  The flexor tendon sheath is composed of annular and cruciate pulleys.

of the AdP muscle, and is the most important pulley to prevent bowstringing of the FPL tendon. The A1 and A2 pulleys lie over the MCP and IP joints, respectively, and are less important in FPL function. 

Finger Extensors, Extensor Hood Mechanism, and Intrinsic Muscles of the Hand Extension of the joints of the fingers involves the synergistic interaction of the extrinsic extensors, the extensor hood, and the tendons of the interosseous and lumbrical muscles. Understanding this complex mechanism is key to evaluating patients with acute finger injuries and chronic disorders of finger range of motion (ROM). Extrinsic Extensors.  The EDC tendons blend onto the extensor hoods of all four fingers, forming the sagittal bands; the EIP blends with the extensor tendon of the index finger (see Fig. E1.22). At the level of the MCP joint the EIP tendon is on the ulnar side, which makes it identifiable for tendon transfers. The EIP allows for independent index finger extension, whereas the EDC provides combined extension of all four digits (Fig. E1.27). The EDC tendons are linked by junctura tendinea, which typically connect the middle finger EDC to the index and ring finger EDC (Fig. E1.28). The junctura tendinea allow the patient with a laceration of one tendon to extend the other digits weakly, although a pronounced extensor lag usually develops over time (Fig. E1.29). For 80% of patients the small finger EDC consists only of a junctura tendinea from the ring finger. The EDM blends into the sagittal band on the ulnar side of the EDC to the small finger (see Figs. E1.22 and E1.27). In many patients the EDC to the small finger appears only as a small slip from the EDC to the ring finger. Often the EDM tendon is bifid and provides the necessary finger extension. This may be related to the considerable motion at the small finger CMC joint in addition to the joints within the finger. The EDM and EIP allow for the independent extension of the small and index fingers, respectively. (This is essential in forming the “hook ‘em horns” sign [Fig. E1.27].)  Interosseous Muscles.  There are four dorsal interossei, which originate from the metacarpals and have insertions onto the proximal phalanges and extensor mechanism. Each dorsal interossei is bipennate, originating from both of its respective radial and ulnar metacarpals. Except for the third dorsal interosseous muscle, each has both deep and superficial heads. The superficial head attaches onto the base of the proximal phalanx to achieve abduction of the

EDM

EDC

EIP Figure E1.27.  The fourth dorsal compartment contains the EDC and the EIP. The EDC extends the IP joints of the fingers; the EIP extends the IP joints of the index finger. Both do so by merging into the extensor hood. The EDM (of the fifth compartment) similarly extends the small finger.

Figure E1.28.  The dorsal hand and wrist. The extensor retinaculum is marked by the looped stitch. The junctura tendinea of the EDC tendons are located superficial to the blue background.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

digit. The deep head of the dorsal interossei joins with the tendon from the volar interossei to form radial and ulnar lateral bands (Figs. E1.30 and E1.31). The small finger does not have a dorsal interosseous muscle and is abducted by the ADM muscle. The first dorsal interosseous muscle is large and is easily visualized on examination. It originates on the radial side of the second metacarpal and the proximal half of the ulnar side of the first metacarpal, inserting on the radial side of the base of the second proximal phalanx (index finger) and the extensor expansion. It is key for hand function providing an opposing force to thumb flexion during key pinch. There are three volar or palmar interossei; they are unipennate, originate from the metacarpals they insert on, and attach into the base of the proximal phalanges to provide adduction of the fingers (see Figs. E1.30 and E1.31). Adduction and abduction of the digits are achieved in the radioulnar plane on both sides of the middle finger metacarpus (which acts as the axis of the hand). The functions of the interossei can be remembered

Figure E1.29.  Laceration of the middle finger EDC tendon is simulated on the dorsal hand (tendon cut between solid arrows). The dotted arrow illustrates the possible role of the junctura tendinae in compensation of the extension deficit, masking the injury.

by the mnemonic PAD-DAB: palmar adduct-dorsal abduct. All interossei are innervated by the motor branch of the ulnar nerve.  Lumbrical Muscles.  The lumbricals are unique because they are the only muscles in the body to originate from a tendon and insert on a tendon (Fig. E1.32). They originate from the FDP tendon and insert on the radial aspect of the lateral bands. The lumbrical muscles of the small and ring fingers originate from two adjacent flexor tendons, the FDP to the small and ring fingers and the FDP to the ring and middle fingers, respectively. Both of these bipennate lumbricals are innervated by the ulnar nerve. The lumbricals to the middle and index fingers originate solely from their respective FDP tendons. These unipennate muscles are innervated by the median nerve.  Proximal Extensor Mechanism (The Extensor Hood).  The extensor hood apparatus (or dorsal hood expansion) is a complex of multidirectional fibers overlying the MCP joint (Figs. E1.33 and E1.34).9 The main portion of the proximal extensor hood is the sagittal band, which is a very strong bundle of transverse fibers that form a sling around the MCP joint. This band lies deep to the lateral tendons of all the interossei and superficial to the joint capsule. The extrinsic extensor tendons blend into the central portion of the sagittal band, and thus it helps to stabilize the extensor tendon and prevents it from displacing to one side of the convexity of the metacarpal head.  Distal Extensor Mechanism.  The EDC tendon and two lateral bands continue distal to the MCP extensor hood. The lateral bands are obliquely oriented relative to the axis central axis of the finger, changing from a volar (proximal) to a dorsal location at the distal portion of the proximal phalanx. The EDC tendon trifurcates in the middle of the proximal phalanx, forming a central slip and two lateral slips. The central slip of the EDC continues in the midline to insert onto the base of the middle phalanx. The two lateral slips merge with the intrinsic lateral bands, forming the conjoined lateral bands. The conjoined lateral bands merge in the midline over the distal aspect of the middle phalanx, forming the terminal tendon, which inserts onto the base of the distal phalanx.10 Second dorsal interosseous

Second palmar interosseous Third palmar interosseous

V

IV

Third dorsal interosseous

First dorsal interosseous

Fourth dorsal interosseous

First palmar interosseous III

II

I

I

II

III

IV

V

Adductor pollicis

Palmar Dorsal Figure E1.30.  Four dorsal interossei provide abduction and three volar interossei provide adduction of the fingers.

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Figure E1.31.  The dorsal hand. Stitches mark the index finger extensor tendon (left) and radial sagittal band (right). The first dorsal interosseous muscle is marked with a solid arrow, and the ulnar lateral band to the index finger is marked with a double arrow. The two heads of the second dorsal interosseous muscle are marked by single and double asterisks, respectively.

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A series of ligaments stabilize these tendons as they progress from proximal to distal, maintaining their positions relative to the central axis of the joints during motion. The oblique retinacular ligament connects the flexor tendon sheath of proximal phalanx to the dorsal terminal tendon. This can assist in the function of the terminal tendon to extend the DIP, though the true significance of this structure is difficult to determine exactly; there is great variability in its presence among individuals. The transverse retinacular ligaments extend from the volar plate and flexor tendon sheath of the PIP joint to the lateral bands. They prevent dorsal subluxation of the lateral bands during PIP extension (see Fig. E1.33). The triangular ligament is a confluence of transverse bands over the dorsal aspect of the middle phalanx connecting the lateral bands (see Fig. E1.34). This crucial ligament prevents volar subluxation of the conjoined lateral bands, especially in PIP flexion. Disruption of the transverse retinacular or triangular ligaments can result in pathologic migration of the conjoined lateral bands that contribute to characteristic swan neck or boutonniere deformities, respectively.  Coordinated Function of Finger Range of Motion.  To simplify the differing contributions of the tendons and ligaments of the digits to normal function, one must only consider each structure and its location relative to the central axis of rotation at each joint. Evaluating and diagnosing pathologic changes, ROM is facilitated by considering possible disruptions, alterations in function, or changes in the location of the same tendons and ligaments. 

Lumbrical relaxed

Metacarpal-Phalangeal Joint

Flexor digitorum profundus contracted

Lumbrical contracted Flexor digitorum profundus relaxed

Figure E1.32.  The lumbrical muscles’ function is to flex the MCP joint and extend the PIP joint.

Transverse retinacular ligament Extensor to middle phalanx Lateral conjoint band of extensor

There are no attachments of either the extrinsic flexor or the extensor tendons on the proximal phalanx. Attachment of the intrinsic muscles on the transverse fibers of the extensor hood mechanism provides for flexion of the MCP joint (Fig. E1.35). The EDC tendon is the only tendon that extends the MCP joint. Contraction of the EDC muscle will pull on the sagittal band and lift the proximal phalanx into extension. Because the sagittal bands encircle the proximal phalanx and with their attachment to the soft tissue confluence, they can provide MCP joint extension even though they do not attach directly to the phalanx (Fig. E1.36). Injury to the sagittal bands from trauma or attenuation from inflammatory diseases, such as rheumatoid arthritis, can lead to subluxation of the extensor tendons between adjacent metacarpal heads and volar to the axis of rotation of the joint. This can cause “locking” of the digits in flexion at the MCP joint until the tendon migrates back to its dorsal position, often with a characteristic snapping of the digit into extension.

Transverse fibers Sagittal band Oblique fibers Lateral tendon of

deep head of dorsal interosseous muscle

Oblique retinacular ligament

Interosseous muscle

Terminal tendon of extensor Flexor digitorum profundus termination

A5 C3 A4 C2 A3 C1 Flexor pulleys

A2

A1

Flexor digitorum profundus

Lumbrical muscle Flexor digitorum superficialis

Figure E1.33.  Lateral view of the intrinsic muscles and extensor hood components.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Extrinsic contribution Lateral conjoint tendon

Sagittal bands Central slip

Sagittal band Extensor

Extension

Dorsal and palmar interosseous tendons

Terminal tendon Triangular ligament

FDP FDS

Flexor pulleys Oblique fibers of dorsal aponeurosis

Transverse fibers of dorsal Lumbrical muscle and tendon aponeurosis

Intrinsic contribution

Dorsal view Figure E1.34.  Dorsal view of the intrinsic muscles and extensor hood.

Figure E1.36.  Sagittal bands of the extensor mechanism provide for extension of the MCP joint. FDP, Flexor digitorum profundus; FDS, flexor digitorum superficialis.

Disruption of the terminal tendon or FDP will result in a loss of extension or flexion of the DIP joint, respectively. 

Transverse band

Coordinated Grip

Lumbrical

Figure E1.35.  The lumbrical tendon attachment into the extensor mechanism aids in MCP joint flexion.

The intrinsic muscles with their attachments to the extensor hood, proximal phalanx, and lateral bands cross the MCP joint volar to the central axis of rotation; thus they assist with MCP joint flexion. The FDS and FDP tendons also cross the MCP joint and provide flexion at this joint. However, they exert their initial moment of flexion at the PIP and DIP joints, respectively. Loss of the intrinsic contribution to MCP joint flexion can disrupt the coordinated flexion arc of the digits, and patients will experience substantial loss in grip strength. 

Proximal Interphalangeal Joint The central tendon of the EDC is the primary extensor of the PIP joint. However, the intrinsic lateral bands also cross the PIP joint dorsal to the axis of rotation and assist with extension. Normally the FDS tendon is the major flexor of the PIP joint, with the FDP also assisting with flexion. As mentioned previously, any pathology that results in subluxation of the lateral bands volar to the central axis of rotation will add to PIP flexion and PIP extension leading to a boutonniere deformity. 

Distal Interphalangeal Joint The terminal tendon of the conjoined lateral bands is the sole extensor of the DIP joint and the FDP tendon is the sole flexor.

The interplay between relative extensor and flexor function, as well as wrist position, plays an important role in coordinating grip. Flexion strength of the digits is enhanced with wrist extension due to improved flexor excursion and laxity in the extensor tendons. The lumbrical muscles also play a crucial role in releasing grip. When a lumbrical muscle contracts, it pulls the FDP tendon distally and the lateral band proximally. By doing so it decreases the flexion force of the FDP on the distal phalanx and more effectively extends the IP joints. Therefore, the lumbrical muscle’s main function is to flex the MCP joint and extend the PIP joint. Contraction of both FDP and lumbrical will lead to counteracting flexion and extension forces on the PIP joint, respectively. By this action the lumbricals attenuate or amplify grip, enabling the performance of a tight grip around a small object versus a grip around a larger object. When the lumbrical muscles are paralyzed, clawing of the digits occurs due to the unopposed force of the extrinsic tendons. Without the lumbrical muscles, the extrinsic extensor tendons cause hyperextension of the MCP joints, and the extrinsic flexors cause digital IP joint flexion. The resulting clawing with hyperextension of the MCP joint makes it difficult to grip larger objects. Inflammatory diseases, such as rheumatoid arthritis, and crush injuries can cause contractures of lumbrical and interosseous muscles. Intrinsic contracture causes the fingers to acquire a posture of MCP joint flexion and PIP joint extension. Retraction of the FDP after its laceration may cause shortening or tightening of the lumbrical muscle. This will cause a paradoxical extension of the finger PIP joint with attempted flexion through the FDP, or a lumbrical-plus phenomenon (see Fig. 10.8). 

Peripheral Nerves Understanding the anatomy, variations, and patterns of the motor and sensory nerve supply to the upper extremity is crucial in evaluating patients with hand complaints or dysfunction and in planning surgical incisions to avoid injury to nerve branches (Fig. E1.37; see also Fig. E1.13). Fig. E1.37 provides a summary

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

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Posterior interosseous nerve

Radial nerve (C5–T1) Posterior cord • Triceps • Lateral brachialis • Brachioradialis • ERCL • Anconeus • ECRB*

• Supinator • ECRB • EDC • EDM • APL • EPB • EPL Superficial radial sensory

Posterior cutaneous nerve of forearm

Dorsal radial aspect of hand, first webspace and thumb, index, middle and radial half of index to DIP joints

Dorsal radial aspect of elbow and forearm

Anterior interosseous nerve

Median nerve (C5–T1) Medial and lateral cords

• FDP (index and middle finger) • FPL • PQ

Volar aspect of thumb, index, middle and radial ring and dorsal aspect of same distal to DIP • First and second lumbricals • APB • FPB (superficial head) • OP

• Pronator teres • FCR • PL • FDS Palmar cutaneous

Proximal thenar eminence Dorsal sensory Ulnar nerve (C8–T1) Medial cord

Dorsal ulnar aspect of hand and small and ulnar ring to DIP joints Superficial sensory

• FCU • FDP (ring and small)

Palmaris brevis

Volar aspect of small and ulnar ring finger and dorsal aspect of same distal to DIP Deep motor • ADM • FDM • ODM

• Third and fourth lumbricals • All interossei • FPB (deep head) • AdP

Figure E1.37.  Summary of innervation of the forearm and hand. Blue boxes indicate the muscles innervated by each nerve branch listed in order from proximal to distal. White boxes indicate areas of sensory innervation with bold text indicating areas of exclusive innervation useful for rapid sensibility examination. *The superficial sensory branch may have a branch to the ECRB in some individuals.

of the major nerves, their branches, and their motor and sensory innervation.

Cutaneous Innervation of the Forearm The musculocutaneous nerve terminates distal to the elbow as the lateral antebrachial cutaneous (LABC) nerve after it passes lateral to the biceps tendon and through the cubital fossa. It innervates the volar and radial aspects of the forearm. The medial antebrachial cutaneous (MABC) nerve arises directly from the

brachial plexus and passes on the medial side of the cubital fossa, accompanying the basilic vein. It innervates the volar and ulnar aspects of the forearm. The posterior cutaneous nerve of the forearm is a branch of the radial nerve and innervates the dorsal elbow and forearm. 

Radial Nerve The radial nerve is the terminal branch of the brachial plexus posterior cord (C5-T1) and branches into the posterior cutaneous

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

nerve of the forearm, posterior interosseous nerve (PIN), and the superficial radial sensory nerve. In the arm the radial nerve lies in the interval between the long and lateral heads of the triceps muscle as it courses posterior to the humerus in the spiral groove from medial to lateral. The nerve has separate branches to the different heads of the triceps muscle and gives off the posterior cutaneous

Ulnar Median Radial nerve nerve nerve

Radial nerve

nerve of the forearm at this level. The radial nerve then perforates the lateral intermuscular septum never less than 7.5 cm from the distal articular surface and courses between the brachialis and the BR muscle just proximal to the elbow joint and innervates them both. As it passes anterior to the lateral epicondyle, the radial nerve innervates the anconeus and the ECRL muscles. At the level of the humeroradial joint, the radial nerve divides into the superficial radial sensory nerve and posterior (or deep) interosseous nerve. A separate branch to the ECRB is an occasional variation. The sensory branch of the nerve innervates the ECRB in more than 50% of individuals and continues along the deep surface of the BR muscle. The sensory branch exits from under the BR tendon in a dorsal to radial direction and becomes superficial to the tendon by passing between this tendon and the ECRL, approximately 4 cm from the tip of the radial styloid. The nerve then fans out into multiple branches to innervate the dorsum of the hand, including nearly the entire dorsal surface of the thumb and the dorsal surface of the index finger, middle finger, and the radial half of the ring finger to the level of the DIP joints (see Figs. E1.37 to E1.39). After branching from the main radial nerve at the elbow, the PIN passes beneath the fascia of the supinator muscle (the fascia is known as the arcade of Frohse). This thick fascia of the supinator muscle can cause compression of the nerve. The PIN rapidly branches to innervate not only the supinator but also all of the extensor muscles in the forearm. In most individuals the EIP is the last muscle innervated by this nerve. This is useful in differentiating between partial and complete nerve injuries. At the level of the distal forearm the PIN lies on the interosseous membrane in the floor of the fourth extensor compartment and is thought to provide pain and proprioception innervation to the wrist joint. 

Ulnar nerve

Figure E1.38.  The anatomy of the sensory nerves of the palm (left view) and dorsum of the hand (right view).

Median nerve Ulnar nerve

Proper palmar digital branches

Palmar digital branches

Ulnar nerve Proper palmar digital branches

Palmar cutaneous branches

Palmar digital branches

Dorsal branch and dorsal digital branches Superficial branch

Palmar branches

Palm

Posterior antebrachial cutaneous nerve

Dorsum

Radial nerve

Radial Median Ulnar Figure E1.39.  The sensory distribution of the median, ulnar, and radial nerves in the hand.

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

Median Nerve The median nerve is formed by branches of the medial and lateral cords of the brachial plexus (C5-T1) and branches into the anterior interosseous nerve (AIN), palmar cutaneous branch, recurrent motor branch, and the digital nerves to the thumb, index, middle, and radial aspect of the ring finger. The median nerve enters the forearm on the medial side of the biceps tendon lateral to the brachial artery. The nerve travels deep to the lacertus fibrosus, between the two heads of the pronator teres muscle (which it directly innervates), and then continues deep to the FDS muscle belly. The lacertus fibrosus, pronator teres, and FDS are key structures that can cause a compression neuropathy of the median nerve at the elbow or proximal forearm. The nerve continues between the FDS and FDP muscles, where it provides innervation to the entire FDS muscle. In the proximal third of the forearm the median nerve gives off the AIN, which innervates the FDP muscles to the index and middle fingers and the FPL and PQ. The AIN has special clinical importance because it lies in the deep compartment of the flexor tendons. It is frequently the first nerve involved in compartment syndrome of the forearm or in proximal fracture-dislocations of the forearm and elbow. In the distal forearm, 4 cm proximal to the distal wrist crease, the median nerve becomes more superficial, passing just beneath the flexor retinaculum. At this level, the palmar cutaneous nerve branches from the radial side of the median nerve and lies along the sheath of the FCR on the ulnar side of the tendon. This branch usually perforates the palmar fascia and provides sensation to a critical area near the base of the thenar eminence. Injury to this nerve results in persistent paresthesias in the region of the thenar eminence, which will make gripping difficult. For this reason, most surgical incisions around the volar wrist are planned either ulnar to the PL (ie, carpal tunnel release) or radial to the FCR (eg, the common volar approach to the distal radius). The median nerve passes into the hand via the carpal tunnel by running directly beneath the transverse carpal ligament. The motor branch to the thenar eminence takes off on the radial aspect of the nerve, either within the carpal tunnel by piercing the transverse carpal ligament or just distal to the ligament by traveling distally as a recurrent nerve to innervate the thenar muscles: the APB, OP, and superficial head of the FPB. The median nerve then separates into four branches, forming the common digital nerve to the thumb (which quickly divides into the radial and ulnar digital nerve to the thumb), proper digital nerve to the index finger (which becomes the radial digital nerve to the index finger), common digital nerve to the second web space (which becomes the ulnar digital nerve to the index finger and the radial digital nerve to the middle finger), and common digital nerve to the third web space (which becomes the ulnar digital nerve to the middle finger and the radial digital nerve to the ring finger) (see Fig. E1.38). The four branches travel deep or dorsal to the superficial palmar arterial arch but at the distal palm become superficial or palmar to the arteries. As a result of this pattern of innervation the median nerve supplies sensation to the palmar surface of the thumb and index finger, middle finger, and radial half of the ring finger (see Fig. E1.39). The common digital nerves also provide branches to supply the lumbrical muscles to the index and middle finger. A recommended mnemonic for remembering the median nerve innervation within the hand is LOAF (lumbricals to the index and middle finger, opponens policis, abductor pollicis, and superficial head of the flexor pollicis brevis). In the volar forearm the ulnar nerve innervates the FCU and the FDP to the middle, ring, and small fingers; the median nerve innervates all the other forearm flexor muscles. 

Ulnar Nerve The ulnar nerve is a terminal branch of the medial cord (C8T1) of the brachial plexus, and in the wrist area, it divides into

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the dorsal sensory branch, deep motor branch, and the superficial sensory branch, which terminates as the digital nerves to the small finger and ulnar nerve to the ring finger. The ulnar nerve perforates the medial intermuscular septum approximately 8 cm proximal to the medial epicondyle. The arcade of Struthers is an aponeurotic band between the medial intermuscular septum and medial head of the triceps that lies superficial to nerve and can cause its compression at this level. The ulnar nerve enters the forearm via the cubital tunnel, which is formed by the medial epicondyle of the humerus and the medial wall of the olecranon. The tunnel’s roof is formed by a band of fibrous tissue (Osborne’s ligament), which is superficial to the FCU aponeurosis. The nerve passes deep to the two heads of the FCU, giving off its first motor branches, to innervate the FCU. The ulnar nerve continues deep (dorsal) and radial to the FCU muscle. The nerve gives off branches to the FDP muscle of the, ring, and small fingers. There is a great deal of overlap between the ulnar and median innervation of the FDP middle finger. In the proximal forearm, between 5 and 11 cm from the medial epicondyle, the nerve of Henle (also called the palmar cutaneous branch) separates from the main ulnar nerve. The nerve of Henle travels in close proximity to the ulnar artery and gives off multiple branches that provide sympathetic input to the vessel. Distally it supplies sensation to the hypothenar area.11 In the distal half of the forearm, the dorsal sensory branch of the ulnar nerve separates from the main nerve but continues to travel in proximity to it. Two to three centimeters proximal to the wrist crease, the sensory branch passes dorsal to the FCU tendon, over the ulnar head to provide sensory innervation to the dorsum of the small and ring fingers, approximately to the level of their DIP joints. The main portion of the ulnar nerve enters the hand via the Guyon canal ulnar to the artery. The Guyon canal is a fibroosseous tunnel that begins at the proximal edge of the palmar carpal ligament and is approximately 4 cm long. From proximal to distal the tunnel is bordered by the FCU, pisiform, and ADM on the ulnar side and extrinsic digital flexors and the hook of the hamate on the radial side. The roof is composed of the palmar carpal ligament, the pisohamate arcade, and the palmaris brevis distally. The floor is formed by the transverse carpal ligament and the hypothenar muscles (see Fig. E1.23). Within or just after leaving the Guyon canal, the ulnar nerve divides into the motor (or deep) branch and the sensory (or superficial branch). The motor branch passes close and distal to the hook of the hamate and innervates the hypothenar muscles (ADM, FDM, and ODM) and all of the interosseous muscles. It is accompanied across the hand by the deep palmar arterial arch. The last muscles innervated by the motor branch of the ulnar nerve are the AdP and the deep head of the FPB. The sensory portion of the ulnar nerve branches into the proper digital nerve to the small finger (which becomes the ulnar digital nerve to the small finger) and the common digital nerve to the fourth web space (which becomes the radial digital nerve to the small finger and the ulnar digital nerve to the ring finger) (Figs. E1.38 and E1.39). The superficial branch also innervates the palmaris brevis muscle. 

Anomalous Innervation Anatomic variations in communication between the ulnar and median nerves have been described separately by Martin and Gruber and have become known as the Martin-Gruber interconnection. In this anomaly, nerve fibers that were destined to be within the ulnar nerve instead stay within the median nerve as it is formed by contributions from the lateral and medial cords. In the forearm these fibers finally join the ulnar nerve through an anomalous interconnection between the ulnar and median nerves. Six variations on this anomaly have been

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

described, which are mainly anomalous motor innervation of the thenar, hypothenar, or dorsal interosseous muscles by the proximal portion of the median nerve. This nerve interconnection explains why patients with high ulnar nerve lesions may retain function in areas that are typically innervated by the ulnar nerve. Another group of anomalies was described originally and simultaneously by Riche and Cannieu. These Riche-Cannieu anastomoses occur within the hand between the motor branch of the ulnar nerve and the recurrent motor branch of the median nerve. Although these anomalies are rarely of clinical or electrophysiologic significance, anatomic studies have found interconnections to be common.12 

Digital Nerves The terminal radial and ulnar digital nerves provide sensory function to the volar aspect of their respective digits, as well as the dorsal aspect distal to the DIP joints. They lie just volar to the mid-lateral line of the digit and are always superficial (palmar) to the artery within the digit (remember: “it always hurts before it bleeds”). The neurovascular bundles travel within a fascial sheath, which is composed of Grayson ligament on the palmar surface, Cleland’s ligament on the dorsal surface, and the Gosset lateral digital sheet laterally. 

Arterial Anatomy The brachial artery travels through the cubital fossa, anterior to the brachialis muscle, between the median nerve and the biceps tendon, and passes under the bicipital aponeurosis. At this point it divides into its two main branches, the ulnar and radial arteries. In the proximal forearm the common interosseous artery branches off the ulnar artery and divides into the posterior and anterior interosseous arteries. These arteries pass on either side of the interosseous membrane between the forearm bones. They anastomose proximal to the wrist joint. The arterial anatomy of the hand is one of the areas of greatest variability. The ulnar artery enters the hand through the Guyon canal and forms the superficial palmar arterial arch (see Fig. E1.23). The superficial palmar arch is joined by a smaller branch from the radial artery in 80% of individuals (Fig. E1.40). The ulnar artery also gives off a contribution to the deep palmar arch, which is joined by another terminal branch of the radial artery in more than 95% of cases. The common digital arteries to the second, third, and fourth web spaces branch from the superficial palmar arch. The digital arteries to the radial aspect of the index finger and the ulnar aspect of the small finger are variable. The radial digital artery to the index finger originates either from Radial digital artery to index finger

Radial digital artery Ulnar digital artery Common digital artery

Superficial palmar arch

Deep palmar arch

Princeps pollicis artery Radial artery

Ulnar artery

Figure E1.40.  The superficial and deep palmar arches and the arterial branches to the fingers.

the superficial palmar arch or as a branch of the princeps pollicis artery (to the thumb). The ulnar digital artery to the small finger is usually a branch of the superficial arch. The radial artery bifurcates at the level of the wrist to form a palmar branch, which is usually a minor contributor to the deep palmar arch, and a dorsal branch that travels deep to the tendons in the first compartment, around the thumb metacarpal, pierces the first dorsal interosseous muscle, and enters the palm by passing between the transverse and oblique heads of the AdP muscle. There it forms the princeps pollicis artery, which sends digital arteries to the thumb, as well as to the radial digital artery of the index finger and the deep palmar arch. The continuation of the radial artery becomes the dominant artery in the deep palmar arch, joining with a branch from the ulnar artery to provide blood supply to the interosseous muscles of the hand. 

EXAMINATION OF THE HAND AND UPPER EXTREMITY Where knowledge of anatomy is the science required to evaluate a patient with hand pathology, a good examination of the hand is definitely an art and requires practice. An examination in the emergency department or office will often focus in on the patient’s symptoms or injuries, but young hand surgeons are encouraged to practice a full hand examination when appropriate to get a sense of a “normal exam.” This text will provide some general principles, specific maneuvers, and clinical pearls, but more detailed discussions of specific aspects of a hand examination will be covered in other chapters.

Patient History An outline for a patient history can be obtained as summarized in Box E1.2. The history will be brief for an acute trauma and may be longer for a nontraumatic complaint. When a patient is presenting with a complaint of “pain,” ask additional questions to get the patient to describe the pain more specifically (eg, sharp, burning, aching, electric shocks). The patient should also be asked to

BOX E1.2   Taking a History GENERAL INFORMATION   Determine the patient’s age, occupation, and important activities and hobbies (eg, playing instruments). Determine the dominant hand. Does the patient have a preexisting condition or injury affecting hand function? Determine significant medical conditions (eg, diabetes mellitus). Important information to determine in patients sustaining upper extremity trauma How long ago did the injury occur? Was the injury sustained in a tidy or untidy environment, such as a farm injury? Was the mechanism of injury sharp or crushing? What type of treatment did the patient receive? Is the injury work related? What is the date of the patient’s last tetanus vaccination? Important information to determine in patients with nontraumatic upper extremity problems When did the patient’s symptoms (eg, pain, numbness, stiffness) begin and what activities provoke them? Have the symptoms been progressive? Are there other areas with similar problems either in the hand or elsewhere (ie, in a patient with systemic arthritis)? Are the symptoms nocturnal (eg, night pain or numbness)? Any distant history of trauma to the area?  

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

pinpoint the location of any symptoms (eg, pain or paresthesias) as much as possible; asking them to point to a location with a single finger or move their hand or fingers into the inciting position can be helpful to focus the subsequent examination. When describing the location of a patient’s symptoms or examination findings, referencing the relationship (eg, proximal or distal) to identifiable anatomic bony landmarks (eg, PIP joint, radial styloid, lateral epicondyle) is helpful. Because of the ability to pronate and supinate the forearm, the terms medial and lateral may cause confusion when describing a location in the hand. Symptoms or findings in the hand should be described as palmar (volar) or dorsal and on the ulnar or radial aspect. 

Examination of the Extremity Before manipulating the patient’s extremity, a visual inspection should evaluate the overall appearance and resting posture of the arm and hand. The skin should be evaluated for its texture, color, integrity, and previous scars. Any surface landmarks should be noticed and referenced during the examination (Figs. E1.19C). Any areas of swelling, soft tissue compromise, or deformity, as with a malaligned fracture or with arthritis, should be identified and compared with the opposite side. Manipulation of the extremity should be tailored to the patient’s injuries or symptoms, with the general principle to perform any maneuvers likely to cause the patient pain.

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when there is decreased active and passive ROM, structural abnormalities, ligament tightness, and tendon/muscle/nerve dysfunction may be involved. The following maneuvers to evaluate muscle and tendon function as they relate to joint ROM should be noted. The same tests can be used to determine tendon integrity after acute trauma. Elbow.  ROM of the elbow is measured as degrees of flexion or extension, where full extension is 0 degrees or neutral. Assessment of the stability of the elbow will be covered in Chapter 36. As an important flexor of the elbow and supinator of the forearm, the integrity of the biceps tendon can be checked with the hook test; the patient is asked to maximally flex the elbow, and the examiner pushes his or her thumb into the tissue of the flexion crease from the lateral side. The thumb should be able to hook underneath the tight band of the taut biceps tendon. Lack of a “hook” indicates likely distal biceps rupture.  Forearm.  Forearm motion is measured as the degrees of pronation or supination from the neutral position (see Fig. E1.19) with the elbow flexed to 90 degrees and held against the torso. It is difficult to differentiate the action of the supinator and the

Vascularity Skin color, temperature, and turgor of the digits can provide important information on the vascular status of the extremity. Cool and pale digits may indicate lack of adequate arterial supply, whereas swollen, purple digits may indicate venous compromise. Capillary refill of the nail bed, assessed after releasing manual pressure to this area, provides further information; refill time of more than 2 seconds is considered slow and a sign of poor perfusion. When there is concern for a vascular injury or after revascularization of the arm, hand, or digit, more objective measures of arterial flow should be used. A handheld Doppler ultrasound machine can be used to assess for arterial perfusion in the pulp of the digits; presence of an arterial signal indicates adequate perfusion to that finger. Alternatively a disposable oxygen saturation probe placed on a finger is a good substitute. Decreased oxygen saturation relative to an unaffected digit or extremity, or more importantly lack of an arterial waveform or heart rate reading, indicates possible arterial compromise. The Allen test examines the integrity of the palmar arches and their supply from the radial and ulnar arteries (Fig. E1.41). With the hand elevated, the patient opens and closes his or her fist several times to exsanguinate the blood out of his hand. Both arteries are occluded with manual pressure over each side of the palmar wrist. The patient relaxes the hand, which should appear blanched. The pressure is released from one artery. Brisk return of color to the fingers and capillary refill should be noted in the fingernails within 5 to 7 seconds. Lack of rapid capillary refill to all digits after releasing the pressure from one of the arteries indicates that the patient has a vessel occlusion or an incomplete arch. 

Assessing Range of Motion and Tendon Function Problems with ROM of any joint can be due to pathologies of the involved bones, joint surfaces, ligaments, overlying soft tissue and skin, or appropriate tendons and muscles and their nerves. Both active and passive ROM, as well as joint stability, should be assessed. In general, when a joint has full passive ROM but decreased active ROM, this indicates a problem limited to the tendons and muscles or nerves that power the joint. However,

A

B

C

Figure E1.41.  Allen test to evaluate patency of the radial and ulnar arteries and their communications. (A) With the hand elevated, the patient opens and closes his fist several times to exsanguinate the blood out of his hand. Both arteries are occluded with manual pressure over each side of the palmar wrist. The patient relaxes his hand, which should appear blanched. (B) The pressure is released from the radial artery. Failure to achieve rapid capillary refill to all digits indicates that the patient has a radial artery occlusion or an incomplete arch. (C) The pressure is released from the ulnar artery. Failure to achieve rapid capillary refill to all digits indicates that the patient has an ulnar artery occlusion or an incomplete arch.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

biceps in forearm supination, though the supinator may provide the majority of supination strength in full elbow flexion. In contrast, the PQ is the main pronator of the forearm with the elbow fully flexed. Any problems with pronation and supination should include an assessment of DRUJ stability and the TFCC.  Wrist.  Wrist motion is measured as the degrees of flexion or extension and radial or ulnar deviation from the neutral wrist position. The ulnar wrist flexors and extensors are capable of ulnar deviation and the radial tendons the opposite. To test function of the ECRB and ECRL, ask the patient to extend and radially deviate the wrist with the hand in a fist position (to prevent assistance in wrist extension by EDC); palpate the taut tendons on the dorsoradial side of the wrist (see Fig. E1.14). The ECU tendon can similarly be evaluated by asking the patient to extend and ulnarly deviate the wrist while palpating the taut tendon. Of note, the ECRB attaches centrally to the base of the third metacarpal. When acting alone, the ECRL produces some radial deviation with wrist extension, whereas the ECRB produces only extension, which makes it an optimal choice for tendon transfers to restore wrist extension. The wrist flexors (FCR and FCU) are more superficial and can easily be palpated in the distal forearm with wrist flexion and radial or ulnar deviation, respectively. For the extensors and flexors, when asking a patient to extend or flex the wrist in a neutral position, deviation to the ulnar or radial side indicates lack of function in the opposite tendons. An examination for carpal instability and its effect on ROM will be presented in Chapters 4 and 5. 

will not be using the lateral bands for extension and will have a floppy, easily flexed DIP joint. A patient with central slip injury will need to recruit the intrinsics for PIP extension and will have tight lateral bands pulling tension down to the terminal tendon. This will result in a taut, extended DIP joint that cannot be passively moved by the examiner, in addition to a positive Elson test.  Extrinsic Flexor Tendons.  Each finger should be examined separately for function of both the FDP and FDS tendons, although a hypoplastic or absent small finger FDS is a normal variant. Examination of the FDS is performed with active flexion of the PIP joint for each finger separately while holding the other three fingers in full extension. Holding the other digits in extension will neutralize the FDP, which has a common muscle to the digits, isolating the malfunctioning FDS (Fig. E1.42). Lack of PIP flexion indicates FDS injury, though this does not exclude a partial injury to the tendon. The FDP can be tested by blocking the PIP joint in extension and asking the patient to flex the DIP joint (Fig. E1.43). Lack of DIP flexion indicates FDP injury or muscle denervation. Patients with weakness of active flexion but intact FDP and FDS tendons on examination should be assessed for stenosing flexor tenosynovitis (or trigger finger). The A1 pulley over the MCP joint can be palpated at the level of the distal palmar crease. Pain in this area with a palpable nodule felt with active or passive finger flexion is indicative of this condition even without active triggering of the digit.

Fingers.  Finger motion can be measured in terms of the difference between the degree of maximal extension and degree of maximal flexion. Hyperextension is recorded as a negative number so that the total range of digit motion can be determined by the following formula: FDS

Degrees of Flexion − Degrees of Extension/Hyperextension = Total Joint Motion

Abduction and adduction of the fingers are rarely measured, but they may be recorded as a means of determining the function of the interosseous muscles of the hand. Thumb motion is recorded as flexion and hyperextension, with the total motion equaling flexion minus hyperextension. The thumb motion also includes palmar and radial abduction, opposition, and retropulsion. Evaluation of problems with finger ROM requires examination of the appropriate joints and soft tissue, as well as the extrinsic extensors, extrinsic flexors, and the intrinsics. Extrinsic Extensor Tendons.  It is important to remember that the extrinsic extensors to the fingers are the only extensors of the MCP joint. To evaluate the fourth compartment, including the EDC, ask the patient to straighten the fingers while observing MCP joint extension. Asking the patient to extend the index finger or small finger with the other digits flexed can isolate the EIP and EDM, respectively (see Fig. E1.27). Due to the junctura tendinae, laceration of a single tendon of the EDC proximal to this structure can still result in extension of that digit, though it will likely be weaker than surrounding digits. The central slip of the extensor mechanism extends the PIP joint of the fingers along with the radial and ulnar lateral bands. Elson test is used to evaluate for central slip injury. In this test the patient’s hand is placed on the edge of a table, and the PIP joints of the fingers are flexed to 90 degrees over the edge. The examiner provides resistance over the dorsum of the middle phalanx, and the patient is then asked to extend their PIP joint. While holding resistance, the examiner then uses the other hand to passively flex the DIP joint. A patient with an intact central slip

Figure E1.42.  Testing the FDS is performed by asking the patient to flex the digits while holding the adjacent digits in extension to block the action of the FDP.

FDP

Figure E1.43.  Testing the FDP is performed by blocking the PIP joint in full extension.

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

In patients who are unconscious or uncooperative or in children requiring sedation, integrity of the flexor and extensor tendons can be evaluated using the tenodesis effect (Fig. E1.44). This is a useful examination which is due to the normal interplay between the flexors, extensors, and intrinsic tendons. In the tenodesis effect the fingers will extend or flex when the wrist is passively flexed or extended, respectively. Furthermore, in wrist extension the fingers will take on a cascade of a gradual increase in the degree of flexion in the direction of radial to ulnar digits (see Fig. E1.44). Lack of tenodesis or lack of a cascade indicates likely tendon injury on the side of failed motion; for example, lack of extension with wrist flexion indicates extensor tendon injury to that digit.  Intrinsic Muscle Evaluation.  The lumbrical muscles are the key in producing MCP joint flexion and PIP/DIP joint extension. With chronic lumbrical dysfunction, clawing of the fingers (as described in the anatomy section above) can occur with hyperextension of the MCP joints and flexion of the IP joints. Isolated tightness of a lumbrical (from lengthening of FDP with too long of a tendon graft) or retraction of FDP on adjacent finger (middle, ring, small—causing proximal “pull” on common belly) can also cause characteristic changes in finger ROM. In this case flexion of the fingers will cause MCP flexion and a paradoxical extension of the finger IP joints due to pull of lumbrical on MCP (flexion) and the lateral bands (PIP and DIP extension). This is called the lumbrical-plus phenomenon. Tightness of any of the interosseous muscles and lumbricals causes poor IP joint flexion with the MCP extended (intrinsic-plus finger) and should be differentiated from the lumbrical-plus finger. Intrinsic tightness is confirmed with the Bunnell test. In this test, PIP joint flexion is passively or actively compared with the MCP joint held in extension or flexion by the examiner. In a positive test, flexion of the MCP joints will relax the intrinsic muscle tension, allowing more flexion of the PIP joint (Fig. E1.45).  Thumb Range of Motion.  Stability of the thumb joints should be assessed. The TM can be tested by placing a thumb over the TM joint and providing an adduction force on the distal metacarpal. With laxity of the TM joint, the base of the metacarpal will subluxate from the trapezium and be felt pushing against the examiners thumb. Loading the metacarpal into the trapezium and adducting or flexing the metacarpal may

A

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elicit pain and palpable crepitus indicative of TM arthritis. The ligaments of the MCP joint should be tested by placing ulnar and radial stress on the proximal phalanx while bracing the metacarpal. A lack of an end point to stress or laxity relative to the contralateral side may indicate an ulnar collateral or radial collateral ligament injury. The EPB and APL both contribute to abduction of the thumb. Ask the patient to radially abduct, “bring the thumb away from the index finger.” Palpate the taut tendons (see Fig. E1.12). Because the EPL extends

Tight fibers

Loose fibers

Figure E1.45.  In the intrinsic tightness (or Bunnell) test, PIP joint flexion is compared with the MCP joint flexed or extended. In a positive test, with hyperextension of the MCP joint, passive flexion of the PIP joint is limited.

B Figure E1.44.  The tenodesis effect is demonstrated. (A) Flexion of the wrist causes extension of the fingers. (B) Extension of the wrist causes flexion of the fingers.

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Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

responsive to changes in sensibility and should be used to evaluate nerve recovery after trauma and nerve repair.13 In general, sensibility of the entire hand should be evaluated in the radial and ulnar aspects of each digit assessed separately. This requires the prongs of a 2PD device to be placed longitudinally and not transversely. Motor function is assessed and graded on a six-point scale (0-5) of muscle strength: 0 is complete paralysis, 1 is palpable or visible muscle contraction only, 2 is active movement through the entire arc of motion with gravity eliminated, 3 is active movement against gravity, 4 is active but weak movement against some additional resistance, and 5 is normal strength against resistance. It is helpful to compare strength with the unaffected hand or with adjacent but uninvolved muscles. Specific examination of peripheral nerves in compression syndromes will be covered in Chapter 20. FPL

Figure E1.46.  Testing the FPL is performed by blocking the MCP joint in extension.

both the thumb MCP and IP joints, it is very difficult to confirm an EPB laceration. Tenosynovitis involving the APL and EPB tendons within the first dorsal compartment is a common cause of pain and limited thumb ROM. To test for this, have the patient grip their thumb with it flexed into their palm and then ulnarly deviate their wrist. Significant pain over the radial styloid is a positive Finkelstein sign. The EPL can be evaluated by checking resistance to extension of the thumb IP joint. However, the EPL is also the only tendon to cause retropulsion of the thumb. To test this, have the patient place the hand flat on a table and lift only the thumb off the table (see Fig. E1.22). The FPL can be tested by having the patient flex the thumb IP joint against resistance (Fig. E1.46). It is difficult to obtain angular measurements for opposition and abduction. Opposition can be evaluated when the thumb is brought from the position of adduction directly over the third metacarpal; it is measured as the absolute number of centimeters from the flexion crease of the thumb IP joint to the distal palmar crease. Thumb abduction can be measured as the absolute distance from the thumb IP joint flexion crease to the distal palmar crease at the base of the small finger. This may be performed either for palmar or radial abduction. For additional information regarding the examination of tendon function and digital ROM, review Video E1-4, “General Examination of Hand and Wrist Tendon Function.” 

Neurologic Evaluation Examination of the innervation of the hand and wrist includes evaluation of the median, radial, and ulnar nerves’ sensory and motor functions. Absence of sensory function can be assessed by loss of sensibility to light touch in a particular nerve distribution. The use of more objective tools to measure sensibility includes two-point discrimination (2PD) and Semmes-Weinstein monofilament tests. In general, 2PD ≤ 5 mm and sensibility to the 2.83 monofilament is normal for the fingertips. In an acute trauma situation, sensibility at the fingertips should not be assessed solely by light touch because patients often can “feel” the proprioceptive movement of a finger with touch. In these cases, construction of a 2PD device with a paper clip provides better evaluation of loss of sensibility. A Semmes-Weinstein monofilament test is more

Median Nerve.  The palmar surface of the distal pad of the index finger has exclusive sensory innervation by the median nerve and is useful to quickly evaluate a proximal median nerve injury. The thenar eminence should be examined for sensory innervation by the palmar cutaneous branch. Decreased sensibility in the radial digits but not in the thenar eminence indicates median nerve dysfunction distal to the take-off of the palmar cutaneous branch, as in compression of the median nerve in carpal tunnel syndrome. For motor testing of the distal median nerve, the APB muscle is examined by asking the patient to palmarly abduct and extend the thumb in line with the index finger and resist pressure applied by the examiner pushing the thumb away from the index finger. The examiner can simultaneously feel the APB to see if in contracts and observe any signs of atrophy. AIN motor function can quickly be evaluated by asking the patient to flex the thumb IP joint against resistance.  Ulnar Nerve.  The ulnar nerve exclusively innervates the digital pad of the small finger. Sensibility in the distribution of the dorsal sensory branch can differentiate between a lesion in the nerve proximal or distal to the wrist (normal sensibility distal to wrist). To test for ulnar nerve motor function, the examiner can test the first dorsal interosseous muscle by having the patient abducted the index finger against resistance. Another test of intrinsic function is the cross-finger test, in which the patient is asked to cross the middle finger over the index finger. The AdP can be tested by having the patient pinch a piece of paper between the thumb and proximal phalanx of the index finger with both hands. When the AdP is paralyzed or weak, the patient will compensate by using the FPL, resulting in more flexion of the thumb IP joint (Froment paper sign) (Fig. E1.47). Chronic denervation and atrophy of the ulnar-supplied intrinsic muscles result in characteristic loss of dorsal soft tissue mass between the metacarpals and the first web space. Testing the strength of flexion of the distal phalanx during grip can assess ulnar nerve innervation of the FDP muscle. Weak flexion of the ring and small fingers relative to the index and middle fingers indicates a proximal ulnar nerve lesion.  Radial Nerve.  Sensory function should be tested over the dorsum of the thumb-index web space because this area is exclusively innervated by the radial nerve. Motor function is evaluated by checking the strength of wrist and digital extension. Testing the EPL by asking the patient to extend the thumb IP joint against resistance is an easy test for distal function. Evaluating radial nerve function in finger extension requires evaluation of MCP joint extension with the wrist extended (to eliminate the tenodesis effect). In addition, the intrinsic muscles will produce PIP extension if the MCP joints are flexed; this can mislead examiners who do not test for IP extension with the MCP fully extended.

Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow

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REFERENCES Normal

FPL

Ulnar nerve palsy

FPL

Figure E1.47.  With a positive Froment paper test the thumb IP joint hyperflexion compensates for AdP muscle weakness by tightening the FPL, which can act as a secondary adductor and indicates a low ulnar nerve palsy. FPL, Flexor pollicis longus.

ACKNOWLEDGMENTS In writing the third version of this chapter, much of the credit must go to the authors of the previous version: Shai Luria, MD, Jay T. Bridgeman, MD, DDS, and Thomas E. Trumble, MD. The anatomy and examination of the hand have not changed in the interval and much of their work is included in this version.

1. Rongieres M, Akhavan M, Mansat P, et al. Functional anatomy of the medial ligamentous complex of the elbow. Its role in anterior posterior instability. Surg Radiol Anat. 2001;23(5):301–305. 2. Dunning CE, Zarzour ZD, Patterson SD, et al. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 2001;83-A(12):1823–1828. 3. Weaver L, Tencer AF, Trumble TE. Tensions in the palmar ligaments of the wrist. I. The normal wrist. J Hand Surg [Am]. 1994;19(3):464–474. 4. Mayfield JK, Johnson RP, Kilcoyne RF. Ligaments of the wrist and their functional significance. Anat Rec. 1976;183(3):417–428. 5. Pulos N, Bozentka DJ. Carpal ligament anatomy and biomechanics. Hand Clin. 2015;31:381–387. 6. Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg [Am]. 1990;15(6):847–854. 7. Townley WA, Swan MC, Dunn RIR. Congenital absence of flexor digitorum superficialis: implications for assessment of little finger lacerations. J Hand Surg [Eu]. 2010;35E(5):417–418. 8. Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg [Am]. 2011;36(1):170–182. 9. Smith RJ. Balance and kinetics of the fingers under normal and pathological conditions. Clin Orthop Relat Res. 1974;104:92–111. 10. Schweitzer TP, Rayan GM. The terminal tendon of the digital extensor mechanism: part 1, anatomic study. J Hand Surg [Am]. 2004;29(5):898–902. 11. Balogh B, Valenchak J, Vesely M, et al. The nerve of Henle: an anatomic and immunohistochemical study. J Hand Surg [Am]. 1999;24(5):1103–1108. 12. Unver Dogan N, Uysal II , Seker M. The communications between the ulnar and median nerves in upper limb. Neuroanatomy. 2009;8:15–19. 13. Jerosch-Herold C. Assessment of sensibility after nerve injury and repair: a systematic review of evidence for validity, reliability and responsiveness of tests. J Hand Surg [Br]. 2005;30B(3):252–264.

Regional Anesthesia for the Upper Extremity Adam H. Dalgleish, CRNA, MSN, Robin King, CRNA, MSN

GENERAL CONSIDERATIONS Historical Perspective William Morton performed the first successful public demonstration of ether inhalation anesthesia in 1846 at the Massachusetts General Hospital in Boston. Forty years later, Karl Koller discovered the local anesthetic properties of cocaine; within a year of this discovery surgeons were performing regional brachial plexus anesthesia with cocaine for surgery of the upper extremity.1 Regional anesthesia performed by surgeons eliminated the need for an individual dedicated to administering inhalational anesthesia and the consequences of toxic effects of the early anesthetic agents. The original technique involved anesthetizing the skin with cocaine; the trunks of the brachial plexus were dissected out surgically and then individually anesthetized.2 With the advent of nonexplosive halogenated anesthetics and specialty training of physicians dedicated to the delivery of these agents, regional anesthesia performed by surgeons rapidly declined. Other factors that contributed to this decline were adverse events related to the relatively crude equipment used to perform regional anesthesia and local anesthetic impurities and the lack of understanding of the pharmacology and toxicity of local anesthetics. In recent years, both regional and general anesthesia have experienced parallel improvements. The ability to safely perform ambulatory general anesthesia for upper extremity surgery was enhanced with the introduction of better intraoperative monitoring, improved inhalational agents, the laryngeal mask airway (LMA), and advancements in the treatment and prevention of postoperative nausea and vomiting. For regional anesthesia, the peripheral nerve stimulator was introduced in the 1970s; real-time visualization of nerves and the spread of local anesthetic through the use of ultrasound guidance were introduced in the past 20 years. 

Regional Anesthesia for Ambulatory Surgery Meta-analyses comparing regional and general anesthesia suggest that there is no significant difference between these techniques with regard to mortality and major morbidity.3 This is primarily due to the uncommon occurrence of these outcomes in modern perioperative care. However, studies comparing general and regional anesthesia have demonstrated an improved recovery profile with regard to pain and postoperative nausea and ­ vomiting, enhanced patient satisfaction, and a reduction in unscheduled hospital admissions when regional anesthetic techniques are used.4-11 The selection of an optimal anesthetic for a specific upper extremity procedure in a particular patient does not necessarily dichotomize to a choice between regional and general anesthesia.5 By taking into consideration the patient and procedure, the anesthesia provider and surgeon can decide when it is optimal to use an individual technique and when both techniques could be combined, with a nerve block being used primarily for opioid sparing and postoperative pain relief. The improved safety with available techniques has changed the focus from decreasing anesthetic morbidity and mortality to issues such as improving anesthesia turnover time and returning the patient quickly to baseline function.

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Preoperative anesthesia clinics are an effective means of screening for concurrent medical illnesses, determining patients’ wishes for a specific anesthetic technique, discussing these techniques, and selecting a method of anesthesia to satisfy the requirements of the surgeon and patient. Patients classified as physical status III and IV by the American Society of Anesthesiologists (ASA) classification system (Box E2.1) and those with severe systemic diseases are particularly attractive potential candidates for regional anesthesia because their medical conditions may increase the risks of general anesthesia. Although these patients may benefit most from regional anesthesia, they also may present the greatest challenges for the safe application of these techniques. For example, a patient with a difficult airway and obstructive sleep apnea or a patient with severe pulmonary hypertension is less easily rescued from a partially effective block or tourniquet pain by simply deepening sedation. These patients require more planning and resources for safe conversion to general anesthesia in the event of a failed block. Important criteria for selection of regional anesthesia are the degree of patient acceptance and the skill of the anesthesia provider. Overly anxious patients, those with a history of psychiatric disease, the very young, and the very old may be poor candidates for regional anesthesia. Obesity not only increases the associated risks of general anesthesia but also presents technical challenges that may preclude regional anesthesia. A second consideration is the anesthesia provider’s familiarity and facility with specific block techniques. Surgeons and anesthesia providers must cooperate to reach the goals of a safe, pleasant, and cost-effective experience for the patient. This begins by relaying expectations and surgical ­considerations to the anesthesia provider in advance of a selected case. A survey of orthopedic surgeons by Oldman and colleagues12 indicated that the main reason for not favoring regional anesthesia was delay in the surgical schedule. Realistic expectations with regard to the performance and onset times for regional techniques will result in a more satisfactory perioperative partnership. Chan and colleagues13 demonstrated, in a randomized trial ­comparing infraclavicular block with sedation to general anesthesia, that the nonoperative time was longer by 5 to 10 minutes in patients receiving an infraclavicular block. A review of multiple trials and case series for brachial plexus anesthesia indicate block performance times of 8 to 10 minutes and onset times of 15 to 25 minutes. The ­recognition of the fact that even in the best hands regional techniques may take more nonoperative time than general anesthesia emphasizes the importance of developing a system for parallel

BOX E2.1   American Society of Anesthesiologists Physical Status Classification System ASA 1: Normal healthy patient ASA 2: Patient with mild systemic disease ASA 3: Patient with severe systemic disease ASA 4: Patient with severe systemic disease that is a constant threat to life ASA 5: Moribund patient who is not expected to survive without the operation

Regional Anesthesia for the Upper Extremity

rather than serial care of patients by using block rooms or early entry into the operating room (OR). This can allow patient care to safely move forward during the time that a block is “setting up.”13 Partially successful regional anesthesia techniques can be rescued by a surgeon with knowledge of peripheral nerve block techniques proximal to the intended site of surgery, obviating the need for excessively heavy sedation or general anesthesia. Cooperation by peripheral nerve supplementation in this situation may circumvent the need for a prolonged recovery room stay, prolonged drowsiness, nausea and vomiting, or an unscheduled hospital admission. 

PHARMACOLOGY Local Anesthetics Local anesthetics in current clinical use consist of unsaturated benzene rings joined to tertiary amines by an ester or amide linkage. The ester or amide component of a local anesthetic determines both its classification and route of metabolism. The ester local anesthetics are rapidly metabolized (and thus inactivated) by plasma cholinesterases. All other local anesthetics are amides and are metabolized into both active and inactive substances by the liver. Substitutions on the benzene ring or tertiary amine portion of the local anesthetic molecule alter its ionization (dissociation) constant (pKa), lipid solubility, and protein binding, determining the rapidity of onset, potency, and duration of action of local anesthetics, respectively.14 

Mechanism of Action Local anesthetics are water insoluble and are thus marketed as water-soluble hydrochloride salts. In an aqueous solution the local anesthetic’s fixed dissociation constant (pKa) determines the equilibrium between the charged local anesthetic cation and the uncharged base. The uncharged base freely diffuses through the lipid bilayer of neurons. After crossing a neuron’s lipid bilayer, the local anesthetic molecule again dissociates into its basic and cationic forms, with the cation entering the protein-based sodium channel. The presence of the local anesthetic molecule within the sodium channel renders the channel impermeable to sodium, thus preventing the propagation of action potentials and impulse conduction. With time, the local anesthetic diffuses out of neurons, rendering the neurons once again susceptible to depolarization.15 

Additives Sodium Bicarbonate Because the free base form of most local anesthetics is poorly soluble in water, they are prepared as hydrochloride salts, with commercial solutions having a pH in the range of 4.4 to 6.4. Addition of bicarbonate can increase the rate of onset of some local anesthetics by shifting the equilibrium to the uncharged base form, which can more readily penetrate into neural tissue. Neutralizing the pH of a local anesthetic solution may also decrease the associated pain of injection. Using an 8.4% sodium bicarbonate solution, 3 mL can be added to a lidocaine 30-mL vial or 0.3 mL to a bupivacaine 30-mL vial. Attempts to add further bicarbonate will result in precipitation of the local anesthetic from its solution. 

Preservatives Antimicrobial preservatives are added to multidose vials of local anesthetics. Preservative-containing local anesthetic solutions should not be used in spinal, epidural, or intravenous (IV) regional anesthesia because of their potentially cytotoxic effects. The most frequently used antimicrobials are methylparaben, ethylparaben, and propylparaben.

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Antioxidants or ion-chelating agents, such as sodium ethylenediaminetetraacetic acid, are added to commercially available local anesthetics to prevent oxidation or to scavenge divalent cations and thus retard their degradation. Preservative-free preparations are available for patients suspected of having allergies to any of these preservatives. 

Epinephrine Low concentrations of epinephrine can be added to local anesthetics to retard their absorption and act as a vascular marker to detect accidental intravascular injection. Epinephrine has the effect of decreasing local anesthesia plasma levels, thus minimizing toxic reactions and prolonging the duration of anesthesia. The range of concentrations typically used is 1:200,000 (5 μg/mL) to 1:800,000 (1.25 μg/mL). Caution should be used in patients with cardiovascular disease. Although there is some dissenting opinion on the matter, due to the potential for soft-tissue necrosis, epinephrinecontaining solutions should not be injected into areas with poor collateral circulation. These areas include the fingers, toes, ears, penis, and nose. 

Sedation Premedication Certain patients will suffer from anxiety for days before an anticipated surgical procedure. Excessive anxiety may preclude surgery performed under regional anesthesia. Small doses of premedications taken orally the evening before or the morning of scheduled surgery may provide adequate anxiolysis. The degree of sedation and memory impairment associated with these medications is highly variable and needs to be considered for matters such as obtaining informed consent, providing perioperative care instructions, and determining mode of transport to and from the surgical facility. Particular caution should always be used in the elderly, the very young, and those patients with concurrent medical illnesses. Consultation with an anesthesia provider in the preanesthesia clinic may help in addressing anxiety and choosing an appropriate anxiolytic agent. Antihistamines will produce anxiolysis and sedation and also have an antiemetic effect. They may be appropriate as a premedication for patients who describe nausea as a particularly bothersome component of previous anesthetic use. Finally, opioids may provide some sedation but are primarily useful in patients with painful conditions of their extremities and in particular if the extremity will be manipulated before anesthesia. Patients should be cautioned against operating a motor vehicle after receiving these medications. 

Intraoperative Sedation The short-acting benzodiazepine midazolam (Versed) is well suited for short procedures and has largely replaced the ­longer-acting, previous standard treatment, diazepam (Valium). Midazolam is water soluble and thus is prepared in an aqueous solution that does not cause phlebitis. As with all benzodiazepines, midazolam produces sedation, anxiolysis, amnesia, and respiratory depression. It is approximately 2 to 3 times as potent as diazepam, has an IV onset time of 1 to 2 minutes, and has a terminal elimination half-life of 2 to 4 hours. Small IV doses of 0.015 to 0.05 mg/kg can be slowly titrated to the desired effect, usually requiring 0.5 to 3 mg total dose in the average healthy adult. IV opioid analgesia is also appropriate as a means of supplementing regional anesthesia and in particular for providing analgesia for tourniquet discomfort. Most patients will note onset of tourniquet discomfort within 30 minutes of cuff inflation and ­suffer from intolerable pain within 1 to 1.5 hours. Fentanyl can be

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Regional Anesthesia for the Upper Extremity

titrated in IV doses of 0.3 to 0.5 μg/kg to the desired effect, with doses commonly ranging from 25 to 100 μg in a healthy adult. Adequate exsanguination of the upper extremity prior to inflating the tourniquet will minimize discomfort related to its use. The use of premedication with intraoperative analgesics or combination of opioids and benzodiazepines will have synergistic effects; thus doses should be properly tailored in these situations. Excessive sedation or respiratory depression from either benzodiazepines or opioids can be reversed with the use of proper antagonists. Flumazenil (Romazicon) in 0.2-mg increments up to 3 mg will reverse the effects of benzodiazepines. Naloxone (Narcan) in 0.04-mg increments up to 0.4 mg will reverse the effects of opioids. Both flumazenil and naloxone have durations of action of approximately 45 minutes. After the effect of the antagonist has dissipated, patients may once again experience oversedation and respiratory depression due to the longer half-lives of opioids and benzodiazepines, as compared with their respective antagonists. Patients experiencing excessive sedation or respiratory depression must be closely monitored until they become stable. The use of sedation requires proper monitoring, protocols for discharge, and availability of resuscitation drugs and equipment. Pulse oximetry and electrocardiogram (ECG) are minimal standards for monitoring during sedation for office procedures. Supplemental oxygen should be placed by facemask or nasal prongs. Levels of sedation at which patients can maintain their airway reflexes and communicate without excessive verbal prompting are generally safe for procedures performed outside the OR. In the OR setting, anesthesiologists have a host of potent short-acting agents available with greater potential for respiratory depression; thus sedation in the OR is best left in their domain. 

COMPLICATIONS Nerve Injury After Regional Anesthesia Although uncommon, the possibility of long-term nerve injury due to regional anesthetic techniques needs to be addressed as part of the consent process for anesthesia. The causation of nerve injury due to regional anesthesia may be multifactorial; the r­elevant associated factors include mechanical needle trauma, neural ischemia due to injected volume-induced hydrostatic pressure compromise, neurotoxicity of local anesthetics, and intraneural injection.16-19 The estimated incidence of injury due to regional anesthetic techniques vary by the anatomic block sites used and the type of studies exploring this problem.16,19,20 Larger prospective studies of patients who received interscalene blocks identified a short-term (days to weeks) incidence of nerve injury between 4% and 10%.20 These injuries were primarily sensory in nature; by 6 months the incidence of persistent injury was 0.2%. Similar incidences of injury and patterns of recovery were found in studies of patients with axillary brachial plexus block.16,19 However, case reports have documented the rare, potentially devastating occurrence of permanent motor and sensory deficits.21

Mechanism of Injury In high concentrations, local anesthetics are neurotoxic. In clinical practice, injected doses are frequently much higher than necessary to produce neurotoxicity; however, the perineurium acts as a diffusion barrier to prevent excessively high concentrations of local anesthetic from reaching intraneural structures. Neurotoxicity is likely to occur with intraneural injection. Thus caution must be used when performing nerve blocks on anesthetized patients or when supplementing a preexisting nerve block. Intraneural injection is usually heralded by intense pain upon injection. Patients who are excessively sedated or anesthetized may not be able to communicate the symptoms of an intraneural injection.21

Studies have concluded that all local anesthetics are neurotoxic to some degree, with lidocaine and tetracaine more so than others. Focal demyelination, edema, and wallerian degeneration can occur. The extent of the damage depends on the concentration of local anesthetic present and the length of time it is in contact with the nerve.22 The addition of epinephrine to local anesthetics is well established for the detection of intravascular injection. However, the resulting vasoconstriction can produce ischemia and toxicity. Hematoma formation may produce nerve ischemia via compression. Prompt surgical intervention in the event of a hematoma formation is recommended.22 

Prevention and Treatment of Nerve Injury Prevention of nerve injury begins with appropriate patient selection. Known risk factors include obesity, diabetes, and patients receiving anticoagulants.23 Avoiding heavy sedation enables the practitioner to maintain verbal contact with the patient and allows for the identification of sharp pain, which may indicate an intraneural injection.24 The management of suspected perioperative nerve injury should involve a team approach. This collaborative effort will serve to reassure the patient and provide the best opportunity to address the causes of nerve injury, which may require early intervention rather than supportive observation. Including the anesthesia provider in the evaluation of any problem that may be block related promotes continuous quality improvement. A thorough neurologic assessment will help to localize the anatomic site of the nerve lesion and identify potential etiologic factors. The pattern of sensory deficit and the finding of ­differential function of muscles innervated by the same nerve root but different peripheral nerves should be the focus of a physical examination. Careful history taking may reveal previously overlooked, mild neurologic symptoms associated with preexisting conditions, such as carpal and cubital tunnel syndrome, that may have been exacerbated by perioperative factors. Electromyogram (EMG) and nerve conduction studies have a role in diagnosis and prognosis.25 The decision on the timing of these studies and the possible need to repeat them should be determined by the evolution of the nerve injury and by the expert judgment of the hand surgeon and, if necessary, a neurologist. Nerve conduction studies are particularly informative when the response to stimulation can be evaluated at sites both distal and proximal to the lesion. With an entirely new onset of nerve dysfunction, EMG findings, such as denervation potentials, may not appear for 10 to 14 days. Their presence before this time suggests an element of preoperative neuropathy. The amount of abnormal spontaneous activity associated with denervation will decrease as reinnervation occurs, providing a prognostic indicator. 

Anaphylaxis Allergic reactions to amide local anesthetics are extremely rare. Type I, immunoglobulin E–mediated anaphylaxis presents as urticaria, shortness of breath, bronchospasm, and cardiovascular collapse (CC). Careful history elicited from those with a history of an allergic reaction to amides usually demonstrates symptoms of tachycardia, chest tightness, and light-headedness as a result of an intravascular injection of an epinephrine-containing local anesthetic mixture. Nevertheless, allergies to amides may crossreact within this group. Thus when a true allergy is suspected, all amides should be avoided. Ester local anesthetics are metabolized to para-aminobenzoic acid (PABA). PABA exists in sunscreen lotions and preservatives of the paraben group. Ester local anesthetics should be avoided in individuals with allergies to PABA. There is no evidence for cross-reactivity between amides and ester local anesthetics.14 

Regional Anesthesia for the Upper Extremity

Local Anesthesia Systemic Toxicity Incidence The incidence of local anesthesia systemic toxicity (LAST) is reportedly less than 1%.26 Progression to CC and death is even more unlikely. However, failing to recognize and treat the early symptoms of toxicity can result in devastating outcomes. Toxicity resulting from peripheral placement of local anesthetic occurs from either direct intravascular injection or rapid absorption. 

Recognition Central nervous system (CNS) toxicity is dose- and time-dependent, with initial symptoms being tinnitus, metallic taste, difficulty focusing, light-headedness, circumoral numbness, and confusion. If brain tissue levels continue to rise, the patient will experience muscle twitching and tremors, often leading to generalized tonic-clonic convulsions resulting in loss of consciousness, generalized CNS depression, and respiratory arrest. Local anesthetics prolong conduction time in the heart (ie, PR and QRS intervals). Increasing plasma levels will suppress the sinoatrial and atrioventricular nodes, causing sinus bradycardia, conduction block, electrical inexcitability, and cardiac arrest. Bupivacaine’s action makes the heart vulnerable to malignant reentry cardiac arrhythmias. The ratio of the dosage required for irreversible CC and dosage that will produce CNS toxicity (CC/ CNS ratio) is approximately 7:1 for lidocaine and 3.7:1 for bupivacaine, indicating that bupivacaine has greater cardiovascular toxicity than lidocaine.14 

Prevention Measures aimed at preventing high blood levels, such as using the lowest dose and weakest concentration, minimizing absorption with a vasoconstricting agent, and injecting local anesthetic in small aliquots with repeated aspiration, can help to reduce the incidence of systemic reactions. Most systemic reactions occur as a result of inadvertent intravascular injection or injection into a highly vascular tissue bed, with resultant rapid local anesthetic uptake into the systemic circulation. Addition of a low concentration of epinephrine (1:200,000 to 1:800,000) delays systemic absorption and can warn of an impending intravascular injection by eliciting tachycardia on the ECG or a pressor response in patients receiving beta-adrenergic blocking agents. Judicious use of sedation allows continuous verbal contact with the patient during injection and enables the anesthesia provider to abort the procedure at the first sign of toxicity. The maximum recommended safe doses of commonly used local anesthetics are listed in Table E2.1. Using less of the recommended dose does not ensure that

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a systemic reaction will not occur. According to a multicenter prospective study published in 2013, the incident of LAST was decreased when ultrasound was used for placement of peripheral nerve blocks.26 Ropivacaine, which is less lipophilic than bupivacaine, results in a decrease in central nervous and cardiovascular toxicity.27 However, the practitioner needs to be aware that equipotent doses of ropivacaine can still produce a significant degree of cardiotoxicity. 

Treatment of Local Anesthesia Systemic Toxicity Initial treatment of LAST includes securing the airway, treating lethal arrhythmias, and ensuring prevention of respiratory and metabolic acidosis. Ventilation, oxygenation, and treatment of seizure are paramount. Small doses of benzodiazepines administered before the block will lower the threshold for CNS excitation but will potentially limit the ability of the patient to report unusual symptoms that may be early signs of toxicity. Larger doses of benzodiazepine may be used to terminate a seizure. Advancement of LAST to CC necessitates initiation of an advanced cardiovascular life support (ACLS) protocol with some modifications. Decreased dosing of epinephrine to less than 1 μg/ kg and avoiding vasopressin is recommended.28 Performing highquality cardiopulmonary resuscitation (CPR) for an extended period of time should be expected. Notifying a nearby medical center for potential use of cardiopulmonary bypass is recommended. Case reports and animal studies have established a role for a 20% lipid emulsion (Intralipid) 1.5 mL/kg IV bolus followed by an infusion of 0.25 mL/kg per minute for 10 minutes as a rescue treatment for LAST.29,30 Controversy remains regarding the most appropriate time for Intralipid initiation. Delivering lipid emulsion after development of CNS signs of toxicity may prevent the progression of LAST to CC; however, not all patients with LAST will show CNS signs before advancing to CC. Prudently the practitioner is advised to consider the rate of progression and severity of initial symptoms for timing of lipids.28 The bolus dose could be repeated every 5 minutes, 2 or 3 times if needed. A 20% lipid emulsion stores easily in a regional anesthesia supply area and should be available when local anesthetics are in use. In extreme situations, cardiopulmonary bypass may be implemented until the effects of the local anesthetic have dissipated. If oxygenation and perfusion can be maintained effectively until local anesthetic levels diminish, the patient may recover fully. It is not unusual for these resuscitative efforts to last more than an hour. 

REGIONAL ANESTHESIA TECHNIQUES In many centers, peripheral nerve blocks are the mainstay of anesthesia for the upper extremity. Contraindications are few and primarily involve patient refusal and coagulopathies. Relative

TABLE E2.1   Commonly Used Local Anesthetics Local Anesthetic

Onset of Action

Potency

Duration of Action (h)*

Maximum Dose (mg/kg)†

Procaine (ester) Chloroprocaine (ester) Lidocaine (amide) Prilocaine (ester) Mepivacaine (amide) Ropivacaine (amide) Levobupivacaine (amide) Bupivacaine (amide)

Rapid Rapid Moderate Rapid Moderate Slow Slow Slow

Weak Intermediate Intermediate Intermediate Intermediate Potent Potent Potent

0.5-1.5 0.5-1 1-2 1-2 1.5-3 4-12 4-12 4-12

15 15 5 7 5 3 3 2.5

*Durations of action are approximate times for infiltrative anesthesia. Duration of action and maximum dose are increased by addition of epinephrine 1:200,000-400,000. †Maximum dosages are for infiltrative anesthesia. Inadvertent intravascular injection will produce toxicity at much lower than the above-recommended dosages.

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Regional Anesthesia for the Upper Extremity

contraindications are considered when the risks of regional anesthesia outweigh the potential benefits. When properly performed, nerve blocks can provide excellent anesthesia intraoperatively and good analgesia postoperatively. Regional anesthesia for upper extremity surgery may involve blocking the entire brachial plexus, performing selective nerve blocks, or providing IV regional anesthesia.

Brachial Plexus Blocks The brachial plexus is responsible for the innervation of the entire upper extremity deriving its nerve roots from C5 to T1 (Fig. E2.1). For shoulder surgery, C4 will also have to be blocked, as should T2 for upper arm surgery on the medial side of the arm and axilla (Fig. E2.2). Brachial plexus blocks became popular in the 1960s when Alon Winnie first advocated the use of single-injection techniques.31 Prior to this, anesthesia providers performed brachial plexus blocks by attempting to elicit numerous paresthesias corresponding to the multiple branches of the brachial plexus, injecting local anesthetic with each paresthesia. This undoubtedly can be unpleasant for the patient. From cadaveric studies, Winnie hypothesized that the brachial plexus was invested in a fibrous sheath that could contain the spread of local anesthetic to the brachial plexus if a large-volume, single-injection technique were used. However, Winnie’s single-injection technique did not always prove itself reliable clinically, with lack of or delayed onset of block in one or more nerve distributions. A set of cadaveric and image-contrast studies performed by Thompson and Rorie, as well as recent studies with ultrasound, have demonstrated compartmentalization of the brachial plexus sheath.32,33 If brachial plexus block is attempted but there is no clinical evidence of anesthesia, the general implication is that injection was not made within the brachial plexus sheath; a partial block generally suggests that the performing anesthesia provider is at the mercy of anatomic compartmentalization. Not uncommonly, if one has the luxury to wait 30 to 40 minutes, local anesthetic will redistribute itself within the brachial plexus sheath by either diffusing through septa or spreading longitudinally up and down compartments to eventually reach nerves within an isolated compartment. Multiple methods can be used to ensure that one has positioned a block needle within the brachial plexus sheath: feeling

the characteristic “click” as the needle pops through the sheath, eliciting paresthesias, performing nerve stimulation techniques using insulated block needles, and making use of the most recent innovation—ultrasound guidance. Paresthesia techniques have the disadvantages of not being applicable to all block sites, requiring purposefully eliciting an uncomfortable sensation, and relying on the patient’s subjective location of the paresthesia site for their success. The ability to observe the spread of local anesthetic in real time with ultrasound may offer a safety advantage. A 2011 meta-analysis by Gelfand et al. reported that ultrasound-guided peripheral nerve blocks were associated with an increase in the overall success rate when compared with nerve stimulation or other methods.34 As compared with other techniques, ultrasoundguided approaches have the advantage of directly visualizing the nerves, surrounding structures, and spread of local anesthesia.35 Ultrasound visualization can be combined with nerve stimulation to take advantage of the best features of both technologies, although it has not been shown to be additive in terms of its success rate.36 Discussion continues in the anesthesia literature over the use of nerve blocks in heavily sedated or anesthetized patients. There is no overwhelming scientific evidence to suggest that nerve blocks performed in patients who are incapacitated by heavy sedation or general anesthesia (and thus unable to communicate pain as a result of nerve trauma) have any higher incidence of nerve injury. However, a dramatic case series by Benumof outlined severe spinal cord injuries occurring with interscalene blocks performed for patients under general anesthesia.21 Brachial plexus blocks are divided into those performed above and below the clavicle and those performed in the arm. A description of some of the common techniques follows, as well as a ­discussion of the advantages and disadvantages of each technique (Fig. E2.2). All patients must have ECG, pulse oximetry, and blood pressure monitoring. If sedation is being used, supplemental oxygen is placed via facemask or nasal cannula. In each ­situation the patient is placed supine with the arm resting comfortably by their side or abducted to 90 degrees. The skin is prepared with an antiseptic solution and sterile towels or drapes placed on the periphery of the field. A fine-gauge needle is used to raise a lidocaine skin wheal at the intended block site. Middle scalene Subclavian perivascular

Sympathetic trunk

Anterior scalene

Middle scalene C4 Anterior scalene

C5

C6 Phrenic nerve

lnterscalene

Supraclavicular

C7

C5 C6

C7 T1

T1

Subclavian artery and vein

Brachial plexus

Axillary Subclavian artery and vein Figure E2.1.  The anatomy of the brachial plexus.

lnfraclavicular

Figure E2.2.  Common approaches to brachial plexus anesthesia are demonstrated.

Regional Anesthesia for the Upper Extremity

Interscalene

Indications.  The most common indications for an interscalene brachial plexus block include surgery of the shoulder and upper arm. Lower nerve roots (C8,T1) forming the ulnar nerve are unreliably blocked at this level, often leading to “ulnar sparing,” thus limiting its use in hand and elbow surgery.  Considerations.  Interscalene brachial plexus blocks consistently block the ipsilateral phrenic nerve, although this phenomenon may be decreased when comparing ultrasound-guided approaches to peripheral nerve stimulation techniques.37 Regardless, a careful consideration should be shown to patients with severe pulmonary disease or preexisting phrenic nerve palsy. Interscalene blocks frequently involve the cervicothoracic ganglion, causing a temporary ipsilateral Horner syndrome (myosis, ptosis, and anhidrosis), which is usually transient and of no medical consequence but may be disturbing to the patient. Vocal hoarseness may be produced from involvement of the recurrent laryngeal nerve. Due to the large number of blood vessels in the neck, there is added potential for intraarterial or IV injection with all its consequences. Injection into dural cuffs or nerve roots may produce an excessively high epidural or spinal block with cardiorespiratory collapse. There are case reports of the block needle entering the intervertebral foramen with injection into the spinal cord and consequent permanent spinal cord injury.21  Technique.  The patient is positioned supine with the arm resting comfortably by the side and the head turned away from the side being blocked. The cricoid cartilage is palpated, and a line is then drawn laterally delineating the level of the C6 vertebral body. Next the posterior border of the sternocleidomastoid muscle is palpated. Rolling the index finger posteriorly from the sternocleidomastoid muscle, the operator will feel the muscle bellies of the anterior and middle scalene muscles. The interscalene block is performed by entering the groove between the anterior and middle scalene muscles. Once the appropriate needle proximity to the brachial plexus has been verified by peripheral nerve stimulation and/or ultrasound visualization, the syringe containing local anesthetic is aspirated for evidence of blood or cerebrospinal fluid. If the aspiration is negative, local anesthetic is incrementally injected while continuously monitoring for evidence of intravascular injection. The ultrasound approach can be performed out of plane, resulting in an entry point similar to the traditional approach, or in-plane, with the probe with a needle entry point posterolateral to the plexus (Figs. E2.3 and E2.4). 

Figure E2.3.  The in-plane approach for an ultrasound-guided interscalene block.

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Supraclavicular

Indications.  Supraclavicular brachial plexus blocks are indicated for surgery distal to the shoulder. This includes the upper arm and elbow, in addition to the forearm, wrist, and hand.  Considerations.  Due to the compactness of the brachial plexus at this site, this block has a rapid onset and extends to all components of the brachial plexus, with infrequent need for peripheral nerve supplementation. However, as with other brachial plexus blocks, the intercostobrachial nerve is not blocked, and an additional injection may be required if the medial upper arm needs coverage. The incidence of pneumothorax ranges between 0.5% and 6%, depending on the skill and experience of the operator. Complete hemidiaphragmatic paralysis reportedly occurs in ­ approximately one third of cases.38 Recurrent laryngeal nerve and cervical ­sympathetic nerve block may also occur.  Technique.  The midpoint of the clavicle is marked. The lateral border of the sternocleidomastoid muscle is identified, and the interscalene groove is palpated by rolling the fingers back from the muscle border over the anterior scalene muscle. A mark is then made 1.5 to 2 cm posterior to the clavicle at its midpoint. This mark should be within the interscalene groove. Palpation of the subclavian artery may also be possible at this point in thin individuals. Imaging of the brachial plexus begins with placement of the ultrasound linear probe at the supraclavicular fossa. Initial scanning involves identifying the subclavian artery as it passes over the first rib. The brachial plexus is most compact where it crosses over the first rib and under the clavicle lying superolateral to the subclavian artery. Immediately below the first rib is the cupola of the pleura. At this level the brachial plexus is located between the anterior and middle scalene muscles. By slightly repositioning the probe, the hypoechoic trunks and divisions can be identified at a depth of 1 to 3 cm. 

Infraclavicular

Indications.  Infraclavicular brachial plexus blocks are administered at the level of the cords and provide reliable anesthesia for procedures at or distal to the elbow. Similar in outcome to the supraclavicular block, either approach may be considered based on patient anatomy. 

Figure E2.4.  The ultrasound appearance of the interscalene brachial plexus anatomy.

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Regional Anesthesia for the Upper Extremity

Considerations.  The brachial plexus is deeper from the skin than other upper extremity blocks, making the block potentially more uncomfortable for the patient and resulting in potentially more difficulty in accurately visualizing the needle tip when ultrasound guidance is used. An arterial puncture at this level is less compressible and more difficult to monitor for the occurrence of an expanding hematoma (Figs. E2.5 and E2.6). The infraclavicular block offers a clean, nonmobile site that is well suited to placing and anchoring continuous brachial plexus catheters. Pneumothorax has been reported but is less of a risk than with the supraclavicular approach. The incidence of phrenic nerve block is unknown but is believed to be very uncommon, which can be considered when evaluating patients with severe pulmonary disease. Sparing of the musculocutaneous nerve and tourniquet pain are much less frequent occurrences than with the axillary approach. Infraclavicular nerve blocks should be avoided in patients with ipsilateral subclavian venous catheters or pacemakers. 

Technique.  There are at least two different approaches to the infraclavicular brachial plexus block. A midclavicular needle insertion point can be used, directing the needle laterally toward the arterial pulse in the axilla. A paracoracoid approach, with an insertion point 2 cm inferior and 2 cm medial to the coracoid process, with a vertical needle insertion path, has also been described. The ultrasound assistance uses a transverse view of the brachial plexus at the coracoid process and real-time guidance of the needle to the individual cords of the brachial plexus adjacent to the axillary artery. 

Axillary

Indications.  Axillary brachial plexus blocks occur at the level of the terminal branches, including the median, radial, and ulnar nerves, and provides excellent anesthesia of the hand and ­forearm. The axillary, musculocutaneous, and medial brachial cutaneous nerves have already branched proximally and therefore are spared with this approach.  Considerations.  The axillary approach is commonly taught and is a simple approach to use. Complications are rare and generally attributable to intravascular injection, nerve injury, and hematoma. This approach is also amenable to ultrasound guidance because the perivascular proximity of the median, ulnar, and radial nerves can be identified and the musculocutaneous nerve can be localized in the coracobrachialis muscle as a separate injection. 

Figure E2.5.  The in-plane approach for an ultrasound-guided infraclavicular brachial plexus block.

Figure E2.6.  The appearance of the infraclavicular brachial plexus anatomy on ultrasound.

Technique.  The axillary block is performed by placing the patient supine with the arm supinated and abducted 90 degrees. The axillary artery is palpated and followed proximally to a point high in the axilla, where it should be marked. Because the terminal nerves are often separated by fascia at this level, multiple injections around the axillary artery may be needed to produce reliable anesthesia of the lower arm, wrist, and hand. The transarterial technique has grown less popular as the use of ultrasound and peripheral nerve stimulation have become widespread. Nerve stimulation can elicit distinct characteristic twitches of the muscles innervated by the median, ulnar, and radial nerves, thereby allowing for selective nerve blockade, if desired. The ultrasoundguided approach has revealed several variations of the proximity of nerves around the axillary artery, thereby also allowing for a targeted approach to each nerve (Figs. E2.7 and E2.8). The mus-

Figure E2.7.  The in-plane approach for an ultrasound-guided axillary brachial plexus block.

Regional Anesthesia for the Upper Extremity

culocutaneous nerve exits from the brachial plexus sheath above the shoulder and thus is blocked in the axillary approach only when it is specifically sought with a separate injection. A separate ring injection of local anesthetic in the upper arm will likely be required for tourniquet coverage. 

LOCAL ANESTHETIC CHOICE Different local anesthetics will provide varying duration of surgical anesthesia and postoperative analgesia. The utility of a block as the sole anesthetic may still be limited by tourniquet pain, the mechanism of which is still not fully elucidated. Surgical anesthetic times for brachial plexus blocks are within the range of 2 hours; times may be shorter in the axillary approach because the upper arm is not extensively anesthetized. Chloroprocaine (Nesacaine) will produce approximately 1 hour of surgical anesthesia, lidocaine and mepivacaine (Carbocaine) 4 to 6 hours, and bupivacaine 12 to 18 hours of analgesia. Studies of the effects of mixing shorter-acting and longeracting local anesthetics to take advantage of the rapid onset of the former and the duration of analgesia of the latter have had mixed results. Specifically, most studies were unable to demonstrate significantly faster onset of anesthesia; however, the mixtures were accompanied by a substantially shorter duration of analgesia.14 Patients should be forewarned of the surgical discomfort that may occur with recession of the block. Some patients with prolonged anesthesia from a long-acting local anesthetic may awaken later at night fearing a surgical catastrophe is occurring with the onset of discomfort from a receding block. Outpatients should be encouraged to begin oral analgesics, anticipating the onset of block recession; inpatients may need bridging IV analgesia.

Continuous Brachial Plexus Anesthesia Continuous brachial plexus techniques have several useful applications. They can provide for prolonged postoperative analgesia in patients undergoing painful procedures or those with chronic pain syndromes. They are also useful in patients who are tolerant of opioids, suffer significant adverse effects from opioids, or have medical conditions that preclude the use of opioids (ie, sleep apnea, severe pulmonary disease, previous narcotic addiction). Another very useful role for continuous brachial plexus catheters is in replant and free-flap graft surgery. Continuous brachial plexus block without epinephrine interrupts sympathetic nerve

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function, producing the vasodilation necessary for replant and free-flap survival. Most continuous brachial plexus blocks will use a catheterthrough-needle insertion technique. Once the catheter is p ­ ositioned correctly, it can be used to establish surgical anesthesia or be combined with general anesthesia. Postoperative management is best conducted by a dedicated anesthesiology-based pain management service that will generally infuse dilute solutions of local anesthetics. With careful patient selection and appropriate expertise and resources, increasingly patients are being discharged home with continuous catheter infusions of local anesthetic via disposable programmable pumps.39-42 

Peripheral Nerve Blocks Peripheral nerve blocks are useful when there is an anticipated limited surgical field, brachial plexus blocks are contraindicated or technically challenging, bilateral surgical procedures of the upper extremity are contemplated, or when inadequate brachial plexus blocks require supplementation.43 Peripheral nerve blocks of the upper extremity can be performed at the elbow or wrist or in the hand. Innervation of the forearm arises from cutaneous nerves in the upper arm; therefore the forearm will not be anesthetized by blocks at the elbow. Thus peripheral nerve blocks at the elbow or wrist are useful only for procedures of the wrist and hand. Peripheral nerve blocks will not provide anesthesia for tourniquet discomfort and thus will generally limit surgical time to less than 1 hour. (Adequate exsanguination will help tourniquet time tolerance.)

Blocks at the Elbow The radial nerve can be blocked at two sites at the elbow. The first is at a point 4 cm proximal to the lateral epicondyle, where the nerve wraps laterally around the humerus on its course from a posterior position along the humeral shaft to its anterior destination at the elbow. A 25-gauge needle is used to enter the skin 4 cm proximal to the lateral epicondyle and advanced until the humerus is contacted. The needle is then withdrawn 5 mm, and a field block fanning both cephalad and caudad is performed using 5 mL of local anesthetic. In the elbow crease the radial nerve lies lateral and deep to the biceps tendon and can be blocked by passing a 25-gauge needle lateral to the biceps tendon and injecting 5 mL of local anesthetic at a depth of approximately 2 to 3 cm (Fig. E2.9). Biceps

Radial nerve

Brachial artery

Median nerve Radial artery

Figure E2.8.  The ultrasound appearance of the axillary brachial plexus block.

Figure E2.9.  Peripheral blocks of radial and median nerves at the elbow.

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Regional Anesthesia for the Upper Extremity

At the elbow the median nerve lies medial and superficial to the brachial artery. The brachial artery is palpated with the index finger of the left hand, and a 25-gauge needle is inserted medially to the brachial arterial pulse, taking precautions not to enter the artery. After negative aspiration 5 mL of local anesthetic is injected. The ulnar nerve passes through the ulnar groove on the posteromedial aspect of the distal humerus and is easily blocked in this location. One should not inject directly into the ulnar groove because this is a tight anatomic space; elevated hydrostatic pressure may result, potentially increasing the risk of nerve injury. 

proximal to the web spaces and advanced until its tip can be felt just beneath the dermis by the operator’s index finger. Very slowly, a small amount of local anesthetic (0.25 mL) is injected; the needle is then withdrawn to a midpoint between the two metacarpals, and 2 to 3 mL of local anesthetic is injected. Alternatively, one may elect to have the patient hold the hand with fingers extended and advance the needle dorsally between the web spaces of two fingers, keeping the needle in line with the metacarpals. A volume of 2 to 3 mL will anesthetize the common digital nerves running between the metacarpals (Fig. E2.12).

Blocks at the Wrist At the level of the wrist the radial nerve exists from beneath the brachioradialis muscle as the superficial radial nerve, a pure sensory branch innervating the dorsal surface of the hand, thumb, index finger, middle finger, and radial half of the ring finger. Block of this nerve at the wrist is a field block fanning around the radial border of the wrist 2 cm proximal to the tip of the radial styloid (Fig. E2.10). The median nerve is blocked by inserting a needle into the volar crease of the wrist at the ulnar border of the palmaris longus tendon or in line with the ring finger axis because the palmaris longus may be absent. The needle is advanced distally deep into the hand toward the carpal tunnel. Firm injection of 3 to 5 mL of local anesthetic may help to displace the median nerve from the path of the advancing needle, lowering the risk of nerve injury (Fig. E2.11). The ulnar nerve can be blocked by inserting a needle just radial to the flexor carpi ulnaris (FCU) tendon or can be injected transversely by placing the needle underneath the FCU tendon. The ulnar artery is radial to the nerve; if blood is aspirated from the needle, it is necessary to replace the needle slightly to the ulnar side of the ulnar artery. 

Metacarpal Blocks

Transverse carpal ligament Ulnar artery

Palmar carpal ligament FCR

Ulnar nerve

Radial nerve FCU Ulnar blocks

Median nerve Palmaris longus

Median block Figure E2.11.  Regional blocks for both the median and ulnar nerves at the wrist. FCR, Flexor carpi radialis; FCU, flexor carpi ulnaris tendons.

The common digital nerves are derived from the median and ulnar nerves and divide in the distal palm of the hand into the proper digital nerves to supply adjacent sides of the fingers, palmar aspect, tip, and nail bed area. Digital vessels accompany the digital nerves and travel on the palmolateral aspect of the finger beside the flexor tendon sheath. Small dorsal digital nerves derived from the radial and ulnar nerves supply the dorsum of the fingers as far distally as the proximal interphalangeal joint. These travel on the dorsolateral aspect of the finger. The operator grasps the patient’s hand to be anesthetized with the left thumb and index fingers, placing them on the dorsal and palmar surfaces, respectively, between the two metacarpal heads of the digit to be blocked. A 25-gauge needle is then inserted through the skin on the dorsal surface between two metacarpals Extensor pollicis longus

Radial nerve Figure E2.10.  A radial nerve block at the wrist.

Figure E2.12.  Two approaches to metacarpal blocks of the common digital nerves.

Regional Anesthesia for the Upper Extremity

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Advantages.  Blocks performed at the base of the metacarpal will anesthetize the distal metacarpal and entire digit, allowing the surgeon to operate distal to the metacarpal phalangeal joint or finger. The small amount of local anesthetic used poses little risk of cardiovascular or CNS toxicity. 

Disadvantages

Disadvantages.  Common digital nerves provide innervation to two adjacent finger surfaces; thus two metacarpal blocks must be performed to provide complete anesthesia of one digit. 

Intravenous Regional Anesthesia: The Bier Block

Digital Nerve Blocks The neurovascular bundles containing the digital nerves travel along the ulnar and radial borders of the digits 2 to 3 mm deep to the palmar surfaces of the digits. Needle punctures of the skin of the dorsal surface of the fingers are less painful than those of the palmar surface; thus it is recommended to inject on the dorsal surface. This is performed by directing the needle toward the nerve bundle on either side, forming a wheal of local anesthetic across the dorsal surface of the digit if anesthesia is required over the dorsal digit. The dorsal skin surrounding the nail bed is anesthetized by blocking branches of the digital nerves along the palmar aspects of the digits. Care should be taken to inject less than 2 mL at each digital nerve, ensuring excessive fluid does not result in a digital compartment syndrome (Fig. E2.13).

Advantages Digital blocks are extremely safe and effective. Tourniquet control can be obtained by wrapping a sterile Penrose drain around the digit. 

The area of surgery must be limited to the digit, especially the pulp. Digital nerve blocks do not provide sufficient anesthesia to place traction on flexor or extensor tendons. 

In 1908 the German surgeon August Bier first performed IV regional anesthesia.44 The technique is very simple to perform, with the major technical skill being placement of an IV cannula. A detailed knowledge of the anatomy of the upper extremity is not necessary; however, meticulous attention to detail must be provided during both initiation and maintenance of the block because inadvertent loss of local anesthetic into the central circulation may produce lifethreatening sequelae. The person performing the anesthetic block should dedicate his or her full attention to the anesthetic and preferably should not perform the surgery. The mechanism of action of Bier blocks is not fully agreed upon but is believed to be a combination of retrograde flow of local anesthetic through the vasavenosum to large peripheral nerves and diffusion of local anesthetic through venous channels to peripheral nerve endings.44

Indications and Contraindications Indications for IV regional include short procedures on the hand, wrist, and forearm. Contraindications include compartment syndrome, infection in the involved extremity, allergy to local anesthetic, situations in which local anesthetics may affect preexisting cardiac conditions, and situations in which the use of a tourniquet is contraindicated. 

Considerations Bier blocks are safe, reliable (96% to 100% reported success rates), easy to learn, acceptable to patients, produce good muscle relaxation for fracture reductions, and have rapid recovery of function. Painful conditions of the extremity or external fracture fixators may preclude exsanguination of the extremity. Tourniquet pain limits the duration of patient tolerance, and there is no provision for postoperative analgesia. Reported complications related to Bier blocks are uncommon but include pain on injection, inadequate anesthesia, tourniquet failure with local anesthetic toxicity of varying severity, temporary discoloration of the distal extremity, and tourniquetrelated nerve injury. Obese patients may have a poor “tourniquet fit” with problems with adequate exsanguination. Sometimes leaving both tourniquets inflated can solve this problem. If the tourniquet seems inadequate, the Esmarch bandage can be reapplied and secured with a clamp while still leaving the tourniquet in place. 

Palmar digital nerves 2 1

3

4 5

1

6 Figure E2.13.  Digital nerve blocks are safe and effective. Step 1, Raise a skin wheal at the base of the proximal phalanx. Step 2, Inject as the needle is advanced toward the digital nerve. Step 3, Withdraw the needle, leaving the tip just below the skin. Step 4, Redirect the needle so the tip is directed across the dorsum of the digit. Step 5, Inject as the needle is advanced across the dorsum of the digit to the opposite side. Step 6, Insert the needle through the previously anesthetized skin on the other side of the digit; repeat step 2 on this side.

Technique An IV cannula is first placed in the contralateral extremity. This IV line may be used to deliver medications for sedation or for resuscitation. An IV cannula is inserted into a vein on the surgical extremity and then secured with a minimal amount of adhesive tape. One layer of soft material (eg, Webril) is wrapped around the intended tourniquet site to prevent petechiae or other superficial skin damage. A double pneumatic tourniquet is securely placed on the upper arm and inflated and deflated once to test for functioning of all components. After the tourniquet has been tested, the arm is elevated and a 3- to 5-inch Esmarch bandage is used to exsanguinate all blood from the arm. After adequate exsanguination, the distal cuff is inflated first, followed by the proximal cuff. The distal cuff is then deflated, and the Esmarch bandage removed. It is recommended that the tourniquet should be inflated to 50 to 100 mm Hg above the systolic blood pressure.45 At this point the extremity should be blanched and without a pulse. Failure of either of these

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Regional Anesthesia for the Upper Extremity

to occur should alert the anesthesia provider to possible technical malfunctioning of the tourniquet. After ensuring proper tourniquet inflation, 30 to 50 cc of 0.5% lidocaine is injected and the IV cannula removed. Alternatively, 12 to 15 cc of 2% lidocaine can be used for injection. Lidocaine’s short duration does not provide for analgesia following the surgical procedure. A 2002 study found that 0.4 mL/kg up to 25 mL of 0.375% ropivacaine provided significant pain relief for the first 90 minutes after the surgical procedure in comparison with 0.5% lidocaine.46 The addition of ketorolac to the local anesthetic solution has been found to decrease operative pain and increase the time to first opioid request.47 Bupivacaine is not recommended due to the potential for cardiac toxicity. We recommend leaving the IV in place until the arm is prepped with surgical solution. As the person prepares to apply the surgical antiseptic solution, they apply pressure over the venipuncture site to prevent hematoma formation. 

Tourniquet Management It is very important to position the OR table before inflating the tourniquet because, if the table rolls over the tourniquet lines, the cuff will rapidly deflate, releasing a large bolus of anesthetic. Most patients will experience tourniquet pain within 20 to 30 minutes. To alleviate tourniquet pain, inflate the distal cuff and deflate the proximal cuff. Extreme caution must be taken not to deflate one cuff before inflating the second cuff. Upper arm tourniquets should be kept inflated for at least 30 minutes. The tourniquet should be clearly labeled. For example, the red cuff lines are used for the proximal and the blue cuff lines are used for the distal cuff. After this time, enough local anesthetic will have bound to tissues, thus preventing a rapid rise in plasma local anesthetic concentration after tourniquet release. Upon surgical completion, deflating and then reinflating the tourniquet several times can avoid sudden washout of the local anesthetic and can prevent systemic toxicity. 

Practical Tips for Facilitating Regional Anesthesia When a regional anesthetic technique is being used as the primary anesthetic, realistic expectations for block performance and onset times for local anesthetics must be kept in mind, with 25 minutes being an approximate guideline for complete “set-up” of a block. OR turnover is facilitated by a preoperative block area or early entry into the OR. Regional anesthetics for postoperative analgesia in conjunction with a general anesthetic are most appropriate for longer procedures involving osteotomies and in patients with opioid intolerance or sensitivity. The sedation used with a block or the general anesthetic portion of a combined technique should be tailored for rapid emergence and avoidance of postoperative nausea and vomiting. For prophylaxis of postoperative nausea and vomiting, the use of dexamethasone 4 to 8 mg IV and serotonin 5-HT3 receptor antagonists, such as ondansetron (Zofran), should be considered, particularly for ambulatory surgery patients. Regional anesthesia works best as one component of multimodal analgesia. When there are no procedural or patient-specific contraindications, the intraoperative or immediate postoperative use of ketorolac (Toradol) improves analgesia and may minimize opioid-induced side effects. The advantages of multimodal analgesia can be extended further in the postoperative period by the use of nonsteroidal antiinflammatory drugs, such as ibuprofen or naproxen, or the cyclooxygenase-2 inhibitor celecoxib.

ACKNOWLEDGMENTS We give full acknowledgement to Christopher Kent, MD, who authored the previous edition of this chapter. Dr. Kent’s previous chapter was the foundation of this chapter. We have maintained much of the original text he authored, revising it only as it seemed relevant in light of an updated literature review.

REFERENCES 1. Brown D, Fink B. The history of neural blockade and pain management. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in ­ Clinical Anesthesia and Management of Pain. Philadelphia, PA: ­Lippincott-Raven; 1998:3–34. 2. Halsted WS. Practical comments on the use and abuse of cocaine: suggested by its invariably successful employment in more than a thousand minor surgical operations. NY Med J. 1885;42:294. 3. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101(6):1634–1642. 4. D’Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth. 1995;20(1):62–68. 5. Gohl MR, Moeller RK, Olson RL, Vacchiano CA. The addition of interscalene block to general anesthesia for patients undergoing open shoulder procedures. AANA J. 2001;69(2):105–109. 6. Greek R, Maurer P, Torjman M, Schieren H. Effect of general anesthesia versus interscalene block for shoulder surgery: postoperative pain and neuroendocrine responses. Anesthesiology. 1993;79:814. 7. Hadzic A, Arliss J, Kerimoglu B, et al. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004;101(1):127–132. 8. Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology. 2005;102(5):1001–1007. 9. McCartney CJ, Brull R, Chan VWS, et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology. 2004;101(2):461–467. 10. Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth. 1994;19(3):175–182. 11. Wu CL, Rouse LM, Chen JM, Miller RJ. Comparison of postoperative pain in patients receiving interscalene block or general anesthesia for shoulder surgery. Orthopedics. 2002;25(1):45–48. 12. Oldman M, McCartney CJ, Leung A, et al. A survey of orthopedic surgeons’ attitudes and knowledge regarding regional anesthesia. Anesth Analg. 2004;98(5):1486–1490. 13. Chan VW, Peng PW, Kaszas Z, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesth Analg. 2001;93(5):1181–1184. 14. Covino B, Wildsmith J. Clinical pharmacology of local anesthetic agents. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA: ­Lippincott-Raven; 1998:97–128. 15. Strichartz G. Neural physiology and local anesthetic action. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA: Lippincott-Raven; 1998:35–54. 16. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104(4):965–974. 17. Myers RR, Heckman HM. Effects of local anesthesia on nerve blood flow: studies using lidocaine with and without epinephrine. Anesthesiology. 1989;71(5):757–762. 18. Selander D, Brattsand R, Lundborg G, et al. Local anesthetics: ­importance of mode of application, concentration and adrenaline for the appearance of nerve lesions. An experimental study of ­axonal degeneration and barrier damage after intrafascicular injection or topical application of bupivacaine (Marcain). Acta Anaesthesiol Scand. 1979;23(2):127–136. 19. Auroy Y, Benhamou D, Bargues L, et al. Major complications of ­regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002;97(5):1274–1280. 20. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and n ­ onacute complications associated with interscalene block and shoulder ­surgery: a prospective study. Anesthesiology. 2001;95(4):875–880. 21. Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 2000;93(6):1541–1544. 22. Kim HJ, Park SH, Shin HY, Choi YS. Brachial plexus injury as a complication after nerve block or vessel puncture. Korean J Pain. 2014;27(3):210–218.

Regional Anesthesia for the Upper Extremity 23. Brull R, McCarney C, Chen V, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104(4):965–974. 24. Hardman D. Nerve injury after peripheral nerve block: best practices and medical-legal protection strategies. Anesthesiology News. July 2015:1–8. 25. Aminoff MJ. Electrophysiologic testing for the diagnosis of peripheral nerve injuries. Anesthesiology. 2004;100(5):1298–1303. 26. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38(4):289–297. 27. Kuthiala G, Chaudhary G. Ropivacaine: a review of its pharmacology and clinical use. Indian J Anaesth. 2011;55(2):104–110. 28. Checklist for treatment of local anesthetic systemic toxicity. America Society of Regional Anesthesia and Pain Medicine. < http://www.asra.com/ content/documents/asra_last_checklist.2011.pdf>. Accessed August 8, 2016. 29. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anaesthesia. 2006;61(8):800–801. 30. Rosenblatt MA, Abel M, Fischer GW, et al. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacainerelated cardiac arrest. Anesthesiology. 2006;105(1):217–218. 31. Winnie AP, Collins VJ. The subclavian perivascular technique of brachial plexus anesthesia. Anesthesiology. May-June 1964;25:353–363. 32. Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology. 1983;59(2):117–122. 33. Neal JM, Hebl JR, Gerancher JC, Hogan QH. Brachial plexus anesthesia: essentials of our current understanding. Reg Anesth Pain Med. 2002;27(4):402–428. 34. Gelfand HJ, Ouanes JP, Lesley MR, et al. Analgesic efficacy of ­ultrasound-guided regional anesthesia: a meta-analysis. J Clin Anesth. 2011;23(2):90–96. 35. Neal JM, Brull R, Chan V, et al. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine executive summary. Reg Anesth Pain Med. 2010;35(2):S1–S9. 36. Hopkins PM. Ultrasound guidance as a gold standard in regional ­anaesthesia. Br J Anaesth. 2007;98(3):299. 37. Yuan JM, Yang XH, Fu SK, et al. Ultrasound guidance for brachial plexus block decreases the indicence of complete hemi-diaphragmatic

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paresis or vascular punctures and improves success rate of brachial plexus nerve block compared with peripheral nerve stimulator in adults. Chin Med J (Engl). 2012;125(10):1811–1816. 38. Petrar SD, Seltenrich ME, et al. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular ­ brachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med. 2015;40(2):133–138. 39. Ilfeld BM, Enneking FK. A portable mechanical pump providing over four days of patient-controlled analgesia by perineural infusion at home. Reg Anesth Pain Med. 2002;27(1):100–104. 40. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesiology. 2002;96(6):1297–1304. 41. Ilfeld BM, Morey TE, Wright TW, et al. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesth Analg. 2003;96(4):1089–1095. 42. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a ­ ­disposable infusion pump. Anesth Analg. 2000;91(6):1473–1478. 43. Brown D, Bridenbaugh L. The upper extremity somatic block. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA: Lippincott-Raven; 1998:345–372. 44. Holmes C. Intravenous regional neural blockade. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and M ­ anagement of Pain. Philadelphia, PA: Lippincott-Raven; 1998:395–410. 45. Hadzic A. Hadzic’s Peripheral Nerve Blocks and Anatomy for UltrasoundGuided Regional Anesthesia (New York School of Regional Anesthesia). New York, NY: McGraw-Hill; 2012. 46. Peng PW, Coleman MM, McCartney CJ, et al. Comparison of ­anesthetic effect between 0.375% ropivacaine versus 0.5% lidocaine in forearm intravenous regional anesthesia. Reg Anesth Pain Med. 2002;27(6):595–599. 47. Rivera JJ, Villecco DJ, Dehner BK, Burkard JF, Osborne LA, ­Pellegrini JE. The efficacy of ketorolac as an adjunct to the Bier block for controlling postoperative pain following nontraumatic hand and wrist surgery. AANA J. 2008;76(5):341–345.

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Fractures and Ligament Injuries of the Thumb and Metacarpals Thomas P. Lehman, MD, PT, Ghazi M. Rayan, MD

KEY SURGICAL VIDEOS Video 1-1 Screw Fixation of Bennett Fracture The Bennett fracture is approached using a curvilinear incision near the volar and radial aspect of the base of the thumb. The interval between the EPB and APB tendons is used. A capsuleotomy is performed. The dental pick is used to deliver the volar beak of the base of the metacarpal into a reduced position. Kirschner wires provide provisional fixation. When the fracture fragments are large enough, the wires are exchanged for lag screws. When the fracture fragments are smaller, Kirschner wire fixation alone may be sufficient. It is important to securely repair the capsule and APL back to the base of the thumb metacarpal. In this case a bone anchor is used to help to reattach the APL and capsule. Video 1-2 Buttress Plate Fixation of Bennett Fracture A volar radial incision is made to approach the base of the thumb metacarpal. The sensory nerve branches are identified and protected prior to reflecting the APL and EPB tendons exposing the fracture. Fragments are reduced with dental picks and provisionally stabilized with Kirshner wires. If the size of fracture fragments allows, a buttress T plate may be applied using locking and nonlocking screws. The APL tendon is reattached to the metacarpal base using the holes in the plate as needed. Video 1-3 Dorsoradial Capsulodesis Instability of the trapeziometacarpal joint may be treated with capsulodesis of the dorsal radial ligament. Instability of the joint is first confirmed with the rotation shear test. A C-shaped incision is made at the base of the thumb. Through the interval between the APL and EPB tendons the capsule is exposed and a transverse capsulotomy is performed. The trapeziometacarpal joint is then reduced with pronation and abduction. With the thumb maintained in this position the distal capsular flap is repaired and dorsal radial ligament is repaired with 3-0 suture. A Kirshner wire is placed across the joint prior to wound closure and placement in a thumb spica splint. The wire is removed at 4 weeks.

ANATOMY Each metacarpal bone has four regions, from proximal to distal: the base, shaft, neck, and head. The base articulates with the corresponding carpal bones at the carpal metacarpal (CMC) joint. The index and middle fingers’ metacarpals are anchored firmly at their base to provide stability for pinch and grasp, whereas the ring and small fingers’ metacarpals are more mobile, which facilitates grasp and power grip. The ring and small metacarpals also tolerate a greater degree of angulation following injury because of this motion. With the exception of the thumb metacarpal, all other metacarpal bases articulate with one another. The index metacarpal is usually the longest and has the largest base. Moving ulnarly, the metacarpals’ lengths decrease, ending

Video 1-4 Thumb MCP Joint Ulnar Collateral Ligament Repair The UCL in this patient has avulsed directly from the base of the thumb proximal phalanx, as demonstrated by MRI. The patient had presented late and the examination was equivocal, but the swelling suggested the need for an MRI. A linear incision is made along the ulnar aspect of the thumb MCP joint. The adductor aponeurosis is split after the small sensory branch of the radial sensory nerve has been retracted with a Ragnell. The ligament that has been avulsed and retracted can be identified and has been repaired using a bone anchor. In this case a bioabsorbable anchor is used. A horizontal mattress suture through the distal stump of the ligament securely anchors the ligament to the bone. The adductor aponeurosis is repaired with a running suture. The TM joint is approached using a curvilinear incision at the base of the thumb. Dissection is performed between the APL and EPB to expose the capsule. A transverse incision is made in the capsule in line with the joint. The redundant capsule is then imbricated and repaired with suture to stabilize the joint. A transarticular Kirschner wire is then placed for stabilization while the soft tissues heal. The thumb is immobilized until the Kirschner wire is removed at 4 weeks. Gentle range of motion is initiated at that time, with continued removable splint use for 2 more weeks. Full use of the hand is permitted at 8 weeks. (Acknowledgment: Special thanks to Brian Chenowith, MD, for production of this video.) Video 1-5 ORIF Metacarpal Shaft Although many nondisplaced and minimally displaced fractures of the metacarpal can be treated with cast and immobilization alone, this severally displaced and rotated fracture is stabilized using a combination of lag screw and plate fixation. The third metacarpal fracture is approached using a linear incision directly over the metacarpal. The tendons are retracted. The fracture can be stabilized and reduced with clamps and stabilized with a lag screw fixation. Because this is a short oblique fracture, it was reinforced with plate fixation. A rectangular plate was chosen because it can be placed around the lag screw that was inserted to provide the original stabilization

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with the thin small finger metacarpal. Each metacarpal shaft consists primarily of cortical bone, whereas the base and head consist mostly of cancellous bone. Each metacarpal has an intramedullary canal, and the shafts curve longitudinally with slight dorsal convexity and a volar concavity (Fig. 1.1). The metacarpal head articulates with the proximal phalanx to form the metacarpal phalangeal (MCP) joint. These joints are stabilized by the strong palmar plate, which may occasionally contain sesamoid bones, and radial and ulnar collateral ligaments (UCLs). The palmar plates of adjacent digits are connected by the three inter palmar plate ligaments (radial, central, and ulnar),1 which provide lateral metacarpal stability. The collateral ligaments are divided into proper and accessory components. The accessory part is thinner and has more vertically oriented fibers

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CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

that are tighter in extension. The proper collateral ligament is stronger and tighter in flexion. The cam shape of the metacarpal head contributes to this mutable ligament tension (Fig. 1.2). The increased proper collateral ligament tension results in decreased abduction and adduction during MCP joint flexion and is the reason that MCP joints should be immobilized in flexion (ie, the intrinsic-plus position). The shorter thumb and its location permit its opposition to the other digits. The unique motion of the thumb is due to the mechanics of the trapeziometacarpal (TM) joint. The shape of

each articular surface of the TM joint is similar to the seat of two saddles with their axes 90 degrees to one another. This configuration allows a wide range of flexion, extension, abduction, adduction, and rotation, which are all necessary for thumb function. Multiple ligaments around the TM joint contribute to its stability. The dorsoradial ligament is emerging as an important stabilizer to this joint. The anterior oblique or “beak” ligament also anchors the ulnar portion of the joint, preventing dorsal or radial subluxation of the metacarpal base. The thumb metacarpal head is variable in its shape. It may be round as other digits, but occasionally it is flatter. This shape correlates to the amount of motion available at the MCP joint, with more rounded joints having a greater range of motion. Stability of the MCP joint is provided by the palmar plate and the radial and UCLs. The palmar plate often contains paired sesamoid bones, which may be subjected to fracture or other pathology. The collateral ligaments are composed of cordlike proper collateral ligaments and broader flatter accessory collateral ligaments that extend from the palmar plate dorsally to the proper collateral ligament. The thumb interphalangeal (IP) joint is similar to the distal interphalangeal (DIP) joints of other digits and is stabilized by a palmar plate and collateral ligaments. The thenar muscles add bulk to the radial side of the hand and insert in the proximal phalanx and extensor hood. 

PHYSICAL EXAMINATION

Section through metacarpals Figure 1.1.  The metacarpals form the distal arch of the hand. (From Trumble TE, Sack JT. Orthopaedic Trauma Protocols. New York, NY: Raven Press; 1993:157.)

Assessment of the injured hand includes obtaining an adequate history with special attention to the mechanism of injury. The evaluation should be performed in a controlled environment with adequate lightning. Digital or other regional anesthesia may facilitate examination and improve the patient’s comfort. These techniques should be used only after the sensory function in the hand and digits is defined and documented in order to rule out associated peripheral nerve injuries. Inspection requires the hand to be cleaned of blood or debris to identify the presence and extent of wounds. Hydrogen peroxide removes any dried blood around lacerations and ensures thorough examination. Inspection is performed for ecchymosis, swelling, deformities, and lacerations. Any wound near a joint should be inspected for possible intraarticular extension. Skin lacerations may be associated with tendon and/or neurovascular injury. The integrity of these structures should be confirmed. Each metacarpal base, shaft, and head should be palpated for crepitus or tenderness. This is facilitated by their subcutaneous location dorsally. Rotational alignment should be confirmed by inspecting the plane of each nail for asymmetry and the flexed fingers, which should all point to the scaphoid tubercle. Similar to other digits, evaluating the injured thumb should rule out ligament injury. Special attention should be given to the stability of the TM and MCP joints because these ligament injures are more common than in the fingers. Rotational malalignment of the thumb is difficult to quantify but is better tolerated than in the other digits. 

RADIOGRAPHIC EXAMINATION 70-degree maximum length and tension of ligaments Figure 1.2.  The metacarpal heads are shaped like a cam with a longer palmar diameter as compared with the dorsal portion. The cam shape of the MCP joint results in tightening of the collateral ligaments when the joints are in flexion to provide stability. (From Trumble TE, Sack JT. Orthopaedic Trauma Protocols. New York, NY: Raven Press; 1993:157.)

Radiographic evaluation of the metacarpals requires posteroanterior (PA), oblique, and lateral views of the hand. A 60-degree, supinated oblique view from a forearm neutral position provides adequate visualization of the index and long metacarpal shafts and the ring and small metacarpal bases. A 60-degree, pronated oblique view offers detailed assessment of the ring and small metacarpal shafts and the index and middle metacarpal bases. Minimizing discomfort during examination after acute trauma requires gentle positioning of the hand. Splints and dressings should be removed prior to imaging, unless there is gross instability or uncontrolled bleeding. Comparison films of the contralateral hand are occasionally helpful.

CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

Figure 1.3.  Dislocations of the CMC joints can often be missed on routine radiographs. A slight widening between the base of the third and fourth metacarpals in this radiograph provides a clue to the dislocation of the fourth and fifth CMC joints. CMC, Carpometacarpal.

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Additional special views are sometimes indicated. Skyline and Brewerton views provide better visualization of the metacarpal heads. A skyline view is obtained with the wrist hyperextended on a foam wedge while the digits are partially flexed at the MCP and IP joints. The beam is directed parallel to the dorsal surface of the proximal phalanx. The Brewerton view is more useful and obtained with the MCP joints flexed 65 degrees. The hand is placed with the dorsal aspect of the digits resting on the cassette. The beam is directed 15 degrees from ulnar to radial. When a CMC joint dislocation is suspected, the 60-degrees oblique views are particularly useful. A gap between adjacent metacarpals on a PA view should raise suspicion of a CMC joint dislocation (Fig. 1.3). Obtaining quality radiographs of the injured thumb is challenging because subtle injuries may be missed if positioning is inappropriate. A Robert view, taken with the forearm fully pronated, dorsum of the thumb on the cassette, and x-ray beam aimed at the TM joint, allows visualization of abnormalities around four articulations of the thumb basal (Fig. 1.4).2 Computerized tomography (CT) is helpful in evaluating the proximal thumb and metacarpals if plain radiography does not provide adequate information (Fig. 1.5A and B). CT may also be helpful in evaluating periarticular injuries associated with the TM joint or other CMC instability. Magnetic resonance imaging (MRI) is rarely indicated in the evaluation of acute injuries. 

FRACTURES, DISLOCATIONS, AND LIGAMENT INJURIES OF THE THUMB Thumb Fractures

15°

Treatment of fractures and dislocations of the thumb ray is often guided by the same principles as for the other digits. However, its unique anatomy, location, and function may require treatment modalities that are different from other digits. Because of the thumb’s increased mobility at the TM joint, a modest amount of malalignment may not result in a functional deficit following thumb fractures, and this malalignment is better tolerated than in the other digits.

Thumb Metacarpal Base Fractures Figure 1.4.  A Robert view is obtained with the hand fully pronated and the x-ray beam angled 15 degrees from distal to proximal.

Figure 1.5.  (A) An oblique view obtained in plaster demonstrates the thumb TM joint dislocation. (B) The dislocation of the TM joint is better visualized on CT.

A

Fracture dislocations of the thumb TM joint are more common than isolated dislocations. The most common injury pattern is an avulsion fracture of the beak ligament insertion with displacement of the metacarpal dorsoradially and proximally. This

B

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CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

instability pattern has traditionally been termed a “Bennett fracture” (Fig. 1.6). A better term is “Bennett fracture subluxation.” More complex injuries with two or more major articular fragments are called “Rolando fractures” (Fig. 1.7). The mechanism of injury is forced abduction of the thumb combined with axial loading, which results in an intraarticular

fracture of the palmar rim of the proximal metacarpal. This site is the insertion of the palmar oblique ligament, which is one stabilizer of the TM joint during pinch and grasp. Without this restraint the remainder of the metacarpal subluxates or dislocates dorsoradially due to the pull of the abductor pollicis longus (APL) tendon, while the metacarpal head adducts due to pull of the adductor pollicis muscle (Fig. 1.8). Treatment.  Attempted closed manipulation may rarely anatomically align the fracture subluxation. If this can be obtained, thumb spica cast or splint immobilization is appropriate as a definitive treatment, and radiographs should be repeated in the first 1 to 2 weeks to ensure that the reduction is maintained within the cast. The intraarticular fracture dislocations of the thumb metacarpal base are very unstable and almost always require surgical stabilization. Fractures that are missed or are inadequately treated are likely to displace and result in functionally significant malunion (Fig. 1.9). Treatment Closed reduction   Pin fixation Open reduction   Pin fixation   Screw fixation   Plate fixation External fixation

Figure 1.6.  Bennett fracture dislocation of the thumb metacarpal.

Relative Indications If manipulation achieves anatomic reduction Articular displacement >2 mm Instability with or without communication (often) One large fragment (seldom) Buttressing comminuted fragments (rare) Comminuted, unstable fractures with soft tissue trauma

Closed Reduction and Percutaneous Pinning.  Closed reduction is obtained by longitudinal traction combined with ab-

Palmar oblique ligament

Adductor pollicis

MC III

MC II

MC I MC II

MC I

TCL

APL

Rolando fracture Figure 1.7.  Rolando fracture involves the base of the thumb metacarpal with either a T or Y fracture pattern that splits the articular surface of the base of the metacarpal.

Figure 1.8.  The deforming forces in Bennett fracture are the pull of the APL and the adductor pollicis. APL, Abductor pollicis longus; TCL, transverse carpal ligament.

CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

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Figure 1.9.  (A) Bennett fracture was minimally displaced on initial presentation. (B) The fracture was missed and eventually displaced, resulting in malunion.

A

Figure 1.10.  When closed reduction of a Bennett fracture is successful, percutaneous pinning to stabilize the fracture, as well as to stabilize the thumb metacarpal to the trapezium, is the satisfactory method of treating this injury. (From Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg Am. 1996;21(5):804.)

duction and pronation of the thumb metacarpal. These injuries have considerable instability of the TM joint, which necessitates some type of fixation even if concentric reduction is achieved after manipulation. Pin fixation is recommended when anatomic reduction can be obtained by closed means. Two 0.045-inch, parallel Kirschner wires are recommended for fixation. Many patterns of fixation have been described, and the exact technique is probably less important than assuring that the pins maintain anatomic alignment of the TM joint. One pin can stabilize the thumb metacarpal to the adjacent index metacarpal while an additional pin may stabilize the base of the thumb metacar-

B pal directly to the trapezium (Fig. 1.10). It is not necessary to cross the fracture site with the Kirschner wire directly into the avulsed articular fragment. Because this fragment retains its strong ligamentous attachment, it does not displace, and the unstable metacarpal shaft must be reduced but not necessarily fixed to it. Patients with high-energy injuries and considerable comminution may also be candidates for percutaneous fixation. When the joint surface is severely comminuted, it may not be possible to restore articular congruity with traditional open techniques. Pin fixation of the major shaft fragment may be used with or without external fixation to maintain alignment for a few weeks as healing occurs. Skeletal traction has been advocated in extremely comminuted fractures if ligamentotaxis does not result in anatomic alignment. In addition, a limited open approach may allow the surgeon to improve articular congruity even if comminuted fragments are too small to accept internal fixation.  Open Reduction and Internal Fixation.  Closed manipulation may fail to restore anatomic alignment of the TM joint. This is an indication for open reduction if the articular fragments are large enough to accept fixation. Exposure is through a curvilinear Wagner incision along the proximal and radial border of the thenar muscles (Fig. 1.11). Care is taken to protect the sensory branches of the radial nerve. The abductor pollicis brevis (APB) and opponens pollicis muscles are reflected off the thumb metacarpal. The APL tendon insertion onto the base of the metacarpal is then elevated off the palmar aspect of the TM joint using sharp dissection. Supinating or radially abducting the thumb exposes the fracture site (Fig. 1.12). When present, hematoma or interposed soft tissue is removed from the fracture site to facilitate reduction. In less comminuted Bennett fractures, screw fixation can be used if the avulsed fragment is of sufficient size and good quality (Fig. 1.13). Bony fragments are usually small, and fixation using Kirschner wires is preferred (Fig. 1.14). The optimal placement of the Kirschner wires is percutaneously along the radial border of the thumb. The thumb is pronated to align the articular surface, and the pins are advanced to stabilize the fracture. Pins may be placed directly into the small avulsed fragment if feasible; however, transfixing the TM joint is usually sufficient. In high-energy injuries the joint fragments are first manually reduced and fixed with Kirschner wires. Autogenous bone

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CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

Incision

graft from the distal radius or less often the olecranon may be used when necessary to fill large periarticular voids. Small T-shaped plates may be used to stabilize the shaft to the articular segment (Fig. 1.15). Kirschner wires may be placed in a retrograde direction through the fracture and out the radial and ulnar aspects of the metacarpal. The fracture is reduced, and the pins are then advanced through the proximal fragments and across the TM joint, as described for closed reduction and

Thenar muscles reflected proximally

TM joint ligament incised, flaps elevated Figure 1.11.  Open reduction of Bennett or three-part Rolando fracture subluxation is performed using an incision based over the palmar aspect of the thumb TM joint. TM, Trapeziometacarpal. (From Trumble TE, Sack JT. Orthopaedic Trauma Protocols. New York, NY: Raven Press; 1993:154.)

Figure 1.13.  Bennett fracture subluxation usually occurs with a small avulsion and fragment; some fragments are large enough to accommodate screw fixation. Placement of Kirschner wires across the TM joint can be avoided.

MC II

Incision

Kirschner wire APB

MC I

Superficial branch of radial nerve

APL Figure 1.12.  The fracture surfaces in a Bennett fracture can be exposed by supinating the thumb. The fracture is then reduced by pronating the thumb. APB, Abductor pollicis brevis; APL, abductor pollicis longus.

Figure 1.14.  The optimal site for placement of Kirschner wires to stabilize the fracture is from a site that is radial to the skin incision.

CHAPTER 1  Fractures and Ligament Injuries of the Thumb and Metacarpals

pinning (Fig. 1.16A). In severe Rolando fractures that have required distraction to protect the reconstructed articular surface, a technique that uses internal distraction with a plate spanning the trapezium to the metacarpal can be used, with the internal plate removed 8 to 10 weeks after the initial surgery (Fig. 1.16B to E).  Rehabilitation.  Pins that cross are removed at 6 to 8 weeks. Because fixation crosses the TM joint, cast immobilization should be maintained until pin removal. Immobilization should be maintained for an additional 3 to 6 weeks in a removable splint while a program of progressive range of motion exercises is initiated. Heavy gripping and pinching activities are avoided for 3 months. For additional information regarding open reduction and internal fixation of Bennett fracture, see Video 1-1, “Screw Fixation of Bennett Fracture,” with description and key points at the beginning of the chapter. For additional information regarding open reduction and internal fixation of an intraarticular base of thumb metacarpal fracture, see Video 1-2, “Buttress Plate Fixation of Bennett Fracture,” with description and key points at the beginning of the chapter. 

Thumb Metacarpal Shaft Fractures The thumb metacarpal shaft is relatively protected from injury by its generous soft tissue envelope, strong cortical bone, mobility, and short lever arm as compared with finger metacarpals. Fractures at the metadiaphyseal junction tend to be transverse, whereas shaft fractures may be transverse but are usually oblique or spiral. When displacement occurs, the thenar muscle insertion flexes and adducts the distal fragment while the APL abducts and extends the proximal fragment, resulting in an apex dorsal deformity.

Figure 1.15.  Bone grafting can be used if necessary to elevate the fracture fragments; it is followed by internal fixation with plate and screws to reconstruct the articular surface and to stabilize the metacarpal shaft to the reconstructed articular surface.

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Treatment  Treatment

Relative Indications

Nonoperative management

Apposition >50% Angulation