BOOK
Principles of Hand Surgery and Therapy E-Book
Thomas E. Trumble | Ghazi M. Rayan | Mark E. Baratz | Jeffrey E. Budoff | David J. Slutsky
(2016)
Additional Information
Book Details
Abstract
Ideal for hand surgeons, residents in a hand surgery rotation, and therapists interested in a review of surgical principles, Principles of Hand Surgery and Therapy, 3rd Edition, by Drs. Thomas E. Trumble, Ghazi M. Rayan, Mark E. Baratz, Jeffrey E. Budoff, and David J. Slutsky, is a practical source of essential, up-to-date information in this specialized area. This single-volume, highly illustrated manual covers all areas of adult and pediatric hand surgery and therapy, including the elbow. You’ll find state-of-the-art basic science combined with step-by-step techniques and therapeutic protocols, helping you hone your skills and prescribe effective long-term care for every patient.
- An expanded therapy section with more than 50 diagnosis-specific rehabilitation protocols and more than 100 full-color photographs.
- New chapters on pediatric fractures; expanded coverage of carpal injuries, including fractures and ligament injuries and perilunate instability; a new chapter on diagnostic and therapeutic arthroscopy for wrist injuries; and expanded treatment of arthritis.
- New information on pediatric surgery with detailed surgical images.
- The latest information on pain management, as well as nerve physiology and nerve transfers.
- Core knowledge needed for the boards—including tumors, free tissue transfer, and thumb reconstruction.
- Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| IFC | ES1 | ||
| Principles of Hand Surgery and Therapy | i | ||
| Principles of Hand Surgery and Therapy | iii | ||
| Copyright | iv | ||
| Contributors | v | ||
| Preface | ix | ||
| Acknowledgments | x | ||
| Contents | xi | ||
| Video Contents | xiii | ||
| Principles of Hand Surgery and Therapy | xvii | ||
| Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow | e1 | ||
| INTRODUCTION | e1 | ||
| Elbow Anatomy | e1 | ||
| Ligaments | e1 | ||
| Ligaments | e3 | ||
| Musculature | e3 | ||
| Carpus | e4 | ||
| Ligaments | e4 | ||
| Extrinsic Extensor Tendons and Muscles | e5 | ||
| Extrinsic Flexor Tendons and Muscles | e6 | ||
| Ligaments | e8 | ||
| Hypothenar Muscles | e11 | ||
| Finger Flexors | e11 | ||
| Metacarpal-Phalangeal Joint | e15 | ||
| Proximal Interphalangeal Joint | e16 | ||
| Distal Interphalangeal Joint | e16 | ||
| Coordinated Grip | e16 | ||
| Peripheral Nerves | e16 | ||
| Cutaneous Innervation of the Forearm | e17 | ||
| Radial Nerve | e17 | ||
| Median Nerve | e19 | ||
| Ulnar Nerve | e19 | ||
| Anomalous Innervation | e19 | ||
| EXAMINATION OF THE HAND AND UPPER EXTREM | e20 | ||
| Patient History | e20 | ||
| Examination of the Extremity | e21 | ||
| Vascularity | e21 | ||
| Assessing Range of Motion and Tendon Fun | e21 | ||
| Neurologic Evaluation | e24 | ||
| Regional Anesthesia for the Upper Extremity | e26 | ||
| 1 - Fractures and Ligament Injuries of the Thumb and Metacarpals | 1 | ||
| ANATOMY | 1 | ||
| PHYSICAL EXAMINATION | 2 | ||
| RADIOGRAPHIC EXAMINATION | 2 | ||
| Thumb Fractures | 3 | ||
| Thumb Metacarpal Base Fractures | 3 | ||
| Treatment. Attempted closed manipulation may rarely anatomically align the fracture subluxation. If this can be obtained, thumb ... | 4 | ||
| Closed Reduction and Percutaneous Pinning. Closed reduction is obtained by longitudinal traction combined with abduction and pro... | 4 | ||
| Open Reduction and Internal Fixation. Closed manipulation may fail to restore anatomic alignment of the TM joint. This is an ind... | 5 | ||
| Rehabilitation. Pins that cross are removed at 6 to 8 weeks. Because fixation crosses the TM joint, cast immobilization should b... | 7 | ||
| Thumb Metacarpal Shaft Fractures | 7 | ||
| Treatment | 7 | ||
| Closed Reduction and Immobilization. Nondisplaced metacarpal shaft fractures can be effectively managed by a period of cast immo... | 7 | ||
| Surgical Treatment. Because of its mobility, indications for surgical treatment of thumb metacarpal fractures differ considerabl... | 7 | ||
| Rehabilitation. Pins should be protected with a cast or splint immobilization until their removal. This period may vary from 3 t... | 7 | ||
| Thumb Metacarpal Head Fractures | 8 | ||
| Thumb Proximal Phalanx Fractures | 8 | ||
| Thumb Distal Phalanx Fractures | 9 | ||
| Thumb Dislocations and Ligament Injuries | 9 | ||
| Thumb Trapeziometacarpal Joint Dislocations | 9 | ||
| Treatment. Stable injuries and those with anatomic alignment after closed reduction may be immobilized in a thumb spica splint i... | 9 | ||
| Rehabilitation. The thumb is immobilized in a cast or splint for 4 weeks. The Kirschner wire is removed at 4 weeks. Range of mot... | 10 | ||
| Thumb Metacarpal Phalangeal Joint Ligament Injuries | 10 | ||
| Complete Collateral Ligaments Injuries. Acute, complete UCL injuries in the presence of Stener lesions must be repaired surgical... | 11 | ||
| Chronic Thumb Metacarpal Phalangeal Collateral Ligament Injuries. Chronic instability is usually the result of an improperly tre... | 12 | ||
| Rehabilitation. Thumb spica splint or cast immobilization with the IP free to move is used for 3 weeks. Thereafter the thumb is ... | 13 | ||
| Thumb Metacarpal Phalangeal Joint Dislocation | 13 | ||
| Treatment. Closed reduction should be attempted by traction, hyperextension, and pressure at the base of the proximal phalanx, f... | 14 | ||
| Rehabilitation. Following closed or open treatment of dorsal MCP dislocation, the joint should be immobilized with an extension ... | 14 | ||
| Thumb Interphalangeal Joint Injuries | 14 | ||
| Metacarpal Fractures | 14 | ||
| Intraarticular Base Fractures With or Without Carpal Metacarpal Joint Instability. Intraarticular injuries of the metacarpal bas... | 15 | ||
| Avulsion Base Fractures. These injuries are not typically associated with instability of the CMC joint. Avulsion fractures are u... | 16 | ||
| Treatment | 16 | ||
| Nonoperative Management. Nondisplaced fractures and transverse fractures that are stable after closed reduction may be treated w... | 16 | ||
| Open Reduction and Internal Fixation. Open reduction is indicated whenever closed reduction does not result in anatomic alignmen... | 16 | ||
| Primary Arthrodesis. Some authors advocate primary arthrodesis in the setting of severe fracture-dislocations in the CMC joints ... | 16 | ||
| Rehabilitation. Following surgery the patient’s hand should be placed into an intrinsic-plus splint, as described for nonoperati... | 16 | ||
| Metacarpal Shaft Fractures | 17 | ||
| Treatment | 17 | ||
| Nonoperative Management. Hematoma and/or wrist block provide adequate anesthesia to perform closed reduction. Transverse fractur... | 17 | ||
| Intramedullary Fixation. Intramedullary fixation has evolved as an extension of percutaneous pinning. Standard Kirschner wires c... | 17 | ||
| Open Reduction and Internal Fixation. Open reduction and internal fixation are indicated when closed reduction does not successf... | 18 | ||
| External Fixation. The principal indications for external fixation have been open fractures with potential for infection and com... | 19 | ||
| Rehabilitation. Following surgery, the patient’s hand should be placed in an intrinsic-plus splint as described above. DIP and P... | 19 | ||
| Metacarpal Neck Fractures | 19 | ||
| Treatment | 20 | ||
| Nonoperative Management. Anesthesia for closed reduction can be performed as for metacarpal shaft fractures. Improving and maint... | 20 | ||
| Surgical Management. Indications for surgical treatment of metacarpal neck fractures are not well established. Rotational deform... | 20 | ||
| Closed Reduction and Percutaneous Pin Fixation. After a closed reduction is performed as described above, it is maintained with ... | 21 | ||
| Open Reduction and Internal Fixation. Open reduction and internal fixation are indicated when closed reduction is not successful... | 21 | ||
| Rehabilitation. Following surgery, the extremity should be placed into an intrinsic-plus position, as described above. DIP and P... | 21 | ||
| Metacarpal Head Fractures | 21 | ||
| Treatment | 21 | ||
| Open Reduction With Internal Fixation. Displaced fractures require reduction and fixation. Occasionally a nondisplaced fracture ... | 21 | ||
| Salvage Techniques. The MCP joint is vital to hand function. Restoration of its anatomy is always the primary goal following inj... | 21 | ||
| Rehabilitation. The timing of postoperative mobilization depends on the severity of the injury and type of fixation used. Injuri... | 22 | ||
| Carpal Metacarpal Dislocations | 22 | ||
| Rehabilitation. Following surgery, the patient’s arm should be placed into an intrinsic-plus immobilizing splint as described fo... | 22 | ||
| Surgical Treatment. Open reduction of a complex dislocation can be performed through a dorsal or volar approach. Unless the disl... | 23 | ||
| Rehabilitation. Following closed reduction, most MCP dislocations are stable. A dorsal extension blocking splint that maintains ... | 23 | ||
| SPECIAL CONSIDERATIONS | 23 | ||
| Open Fractures | 23 | ||
| Segmental Bone Loss | 24 | ||
| Pediatric Fractures | 24 | ||
| FRACTURE COMPLICATIONS | 24 | ||
| Compartment Syndrome | 24 | ||
| Fight Bite Infection | 25 | ||
| Malunions | 25 | ||
| Nonunions | 25 | ||
| ACKNOWLEDGMENT | 25 | ||
| REFERENCES | 25 | ||
| 2 - Phalangeal Fractures and Interphalangeal Joint Injuries | 27 | ||
| PROXIMAL PHALANGEAL FRACTURES | 27 | ||
| Anatomy | 27 | ||
| Physical Examination | 27 | ||
| Radiographic Evaluation | 27 | ||
| Treatment | 28 | ||
| Closed Reduction | 28 | ||
| Open Fracture Treatment | 28 | ||
| Intraarticular Base Fractures. Nondisplaced, comminuted, intraarticular fractures have a propensity to settle and displace. Perc... | 29 | ||
| Rehabilitation. Therapy is initiated based on the fracture stability. An initial period of immobilization is typically used for ... | 32 | ||
| Transverse Shaft Fractures. Transverse fractures with minimal comminution are usually stable after reduction and can tolerate ap... | 32 | ||
| Rehabilitation. With rigid internal fixation, early range-of-motion exercises are started within a few days to a week of surgery... | 32 | ||
| Comminuted Fractures With Extensive Bone Loss. Extensive comminution may preclude stabilization with internal fixation devices a... | 32 | ||
| Rehabilitation. Range-of-motion exercises at uninvolved joints, while securely stabilizing around the fracture, minimize stiffne... | 32 | ||
| Condylar Fractures | 32 | ||
| T- and Y-Shaped Bicondylar Fractures. T- or Y-shaped fracture patterns require exposure of both sides of the joint to obtain ana... | 37 | ||
| Rehabilitation. Active exercises in a removable intrinsic-plus splint are started immediately if stable fixation is obtained. In... | 37 | ||
| Mechanism of Injury | 38 | ||
| Anatomy | 38 | ||
| Physical Examination | 38 | ||
| Diagnostic Imaging Evaluation | 39 | ||
| Treatment | 39 | ||
| Dorsal Subluxation and Dislocation | 39 | ||
| Simple Dislocation. Simple dislocations are defined as injuries that hyperextend past the joint’s normal range, but the base of ... | 39 | ||
| Rehabilitation. Passive and active finger flexion exercises are started with the goal of finger flexion to the distal palmar cre... | 39 | ||
| Complex Dislocation. Unlike simple dislocations, in complex dislocations the base of the middle phalanx is no longer in contact ... | 39 | ||
| Rehabilitation. If the joint is stable to passive extension, buddy-taping alone will be sufficient. If the joint is not stable t... | 39 | ||
| Irreducible Dislocation. When the joint cannot be reduced by closed manipulation, an open reduction is required using a dorsal a... | 39 | ||
| Subluxation and Dislocation With Avulsion Fractures of the Base of the Middle Phalanx. The narrow insertion of the volar plate o... | 39 | ||
| Rehabilitation. At 5 to 6 weeks, active PIP flexion exercises with a dynamic extension splint are started. Night extension splin... | 41 | ||
| Avulsion of the Central Slip With Fracture. Avulsion fractures displaced less than 1 mm are treated similar to tendon avulsion w... | 41 | ||
| Rehabilitation. Postoperatively the hand is immobilized in a PIP extension, Bunnell splint, or a transarticular Kirschner wire f... | 41 | ||
| Complex Volar Dislocations. Volar PIP dislocations without an associated fracture are rare. Closed reduction is attempted but no... | 41 | ||
| Rehabilitation. When a closed reduction is successful, the patient must be tested for the competence of the central slip. If an ... | 41 | ||
| Rehabilitation. The digit is started on early active and passive motion to achieve full flexion, which is most limited due to th... | 44 | ||
| Ligamentous Injuries With Avulsion Fractures. An avulsion fracture involving less than 25% of the joint can often be treated in ... | 44 | ||
| Rehabilitation. Rehabilitation after repair is the same as described for injuries without avulsion fractures | 44 | ||
| Pediatric Injuries. Although dislocations are exceedingly rare in children, radiographic evaluation should be performed to rule ... | 44 | ||
| MIDDLE PHALANGEAL FRACTURES | 44 | ||
| Middle Phalangeal Shaft Fractures Without Comminution | 44 | ||
| Middle Phalangeal Shaft Fractures With Comminution | 45 | ||
| Condylar Fractures | 45 | ||
| DISTAL PHALANGEAL FRACTURES | 45 | ||
| Mechanism of Injury | 45 | ||
| Anatomy | 45 | ||
| Physical Examination | 45 | ||
| Radiographic Evaluation | 45 | ||
| Treatment | 45 | ||
| Bony Mallet Finger Injuries | 48 | ||
| Rehabilitation. Six to eight weeks of full-time splinting is recommended followed by gentle progressive DIP flexion exercises, i... | 48 | ||
| Rehabilitation. Skeletal fixation with Kirschner wires can maintain the alignment of the digit without requiring tight splints o... | 48 | ||
| Tuft Fractures | 48 | ||
| Distal Interphalangeal Joint Subluxation and Dislocation | 48 | ||
| Rehabilitation. The Kirschner wires can generally be removed within 4 weeks, and the patient can be started on gentle active ran... | 48 | ||
| Joint Contractures | 48 | ||
| Nonunions | 54 | ||
| Malunions | 54 | ||
| ACKNOWLEDGMENTS | 55 | ||
| REFERENCES | 55 | ||
| 3 - Pediatric Fractures | 56 | ||
| INTRODUCTION | 56 | ||
| HAND FRACTURES | 56 | ||
| SCAPHOID FRACTURES | 58 | ||
| DISTAL RADIUS FRACTURES | 60 | ||
| FOREARM FRACTURES | 62 | ||
| PEDIATRIC ELBOW FRACTURES | 66 | ||
| REFERENCES | 69 | ||
| 4 - Carpal Instability | 70 | ||
| 5 - Scaphoid Fractures | 100 | ||
| MECHANISM OF INJURY AND CLASSIFICATION OF ACUTE SCAPHOID FRACTURES | 100 | ||
| ANATOMY | 100 | ||
| BIOMECHANICS | 100 | ||
| ACUTE FRACTURES | 100 | ||
| Physical Examination | 100 | ||
| Diagnostic Imaging of the Scaphoid | 101 | ||
| Early Management | 103 | ||
| Definitive Management | 103 | ||
| Nonoperative Management of Acute Scaphoid Fractures | 104 | ||
| Operative Management of Scaphoid Fractures | 104 | ||
| SCAPHOID NONUNIONS | 105 | ||
| Factors in Treating Scaphoid Nonunions | 106 | ||
| Limited Approach for Percutaneous Cannulated Headless Screw Fixation With or Without Arthroscopic Manipulation | 107 | ||
| Volar Percutaneous Scaphoid Fixation | 107 | ||
| Dorsal Percutaneous Scaphoid Fixation | 108 | ||
| Open Volar Approach for Acute Scaphoid Waist Fractures | 109 | ||
| Volar Approach for Scaphoid Waist Nonunion With a Viable Proximal Pole | 110 | ||
| Open Dorsal Approach to the Scaphoid | 111 | ||
| Dorsal Approach for Scaphoid Nonunion With a Viable Proximal Pole | 111 | ||
| OUTCOME | 115 | ||
| Complications and Pitfalls | 115 | ||
| Salvage Procedures | 115 | ||
| REFERENCES | 115 | ||
| 6 - The Distal Radioulnar Joint and Triangular Fibrocartilage Complex | 117 | ||
| ANATOMY | 118 | ||
| Ligamentous Structures | 118 | ||
| Interosseous Membrane | 118 | ||
| Distal Radioulnar Joint Capsule | 118 | ||
| Triangular Fibrocartilage Complex | 118 | ||
| BIOMECHANICS | 119 | ||
| MECHANISM OF INJURY | 119 | ||
| PHYSICAL EXAMINATION | 120 | ||
| IMAGING STUDIES | 121 | ||
| Radiographs | 121 | ||
| Computerized Tomography | 121 | ||
| Arthrography | 121 | ||
| Magnetic Resonance Imaging | 122 | ||
| Arthroscopy | 122 | ||
| Acute Dislocation | 122 | ||
| Fractures of the Ulnar Head and Sigmoid Notch | 123 | ||
| Galeazzi Fracture-Dislocations | 125 | ||
| Essex-Lopresti Injuries | 126 | ||
| Ulnar Styloid Fracture | 126 | ||
| Class 1A Tear | 126 | ||
| Class 1B Tear | 127 | ||
| Class 1C | 127 | ||
| Class 1D Tear | 127 | ||
| Repair of Peripheral Triangular Fibrocartilage Complex Tears Open Repair. Incise the skin longitudinally between the fifth and s... | 127 | ||
| Chronic Distal Radioulnar Joint Instability | 128 | ||
| Radioulnar Ligament Reconstruction8 | 130 | ||
| Degenerative Triangular Fibrocartilage Complex Tears (Palmer Class 2), Ulnar Impaction Syndrome | 131 | ||
| Ulnar Shortening Osteotomy | 132 | ||
| Wafer Resection | 133 | ||
| Distal Radioulnar Joint Arthritis | 133 | ||
| Management of Failed Distal Ulna Excision | 138 | ||
| Extensor Carpi Ulnaris Tendonitis and Subluxation | 139 | ||
| Distal Radioulnar Joint Contracture | 139 | ||
| REFERENCES | 142 | ||
| 7 - Diagnostic and Therapeutic Arthroscopy for Wrist Injuries | 144 | ||
| SPECIFIC TECHNIQUES | 145 | ||
| Dry Wrist Arthroscopy | 145 | ||
| Other Tips | 147 | ||
| Ganglion Cyst Excision | 147 | ||
| Triangular Fibrocartilage Complex Debridement or Repair | 148 | ||
| SCAPHOLUNATE LIGAMENT INJURY: ASSESSMENT AND TREATMENT | 148 | ||
| ARTHROSCOPIC DEBRIDEMENT FOR ARTHRITIS | 148 | ||
| ARTHROSCOPIC MANAGEMENT OF WRIST STIFFNESS | 149 | ||
| REFERENCES | 150 | ||
| 8 - Fractures and Malunions of the Distal Radius | 151 | ||
| Anatomy | 151 | ||
| Mechanism of Injury | 151 | ||
| CLASSIFICATION OF DISTAL RADIUS FRACTURES | 151 | ||
| AO-ASIF (Association for Study of Internal Fixation) Classification | 153 | ||
| Fernandez and Jupiter Classification | 153 | ||
| Associated Injuries | 153 | ||
| INITIAL ASSESSMENT | 153 | ||
| Radiographic Studies | 155 | ||
| TREATMENT OF DISTAL RADIUS FRACTURES | 155 | ||
| Percutaneous Pinning | 156 | ||
| Extrafocal Pinning | 156 | ||
| Intrafocal Pinning (Kapandji Technique) | 156 | ||
| External Fixation | 156 | ||
| Approaches for Open Reduction and Internal Fixation | 158 | ||
| Dorsal Approach | 160 | ||
| Volar Radial Approach | 160 | ||
| Volar-Ulnar (Extended Carpal Tunnel) Approach | 163 | ||
| Combined Volar and Dorsal Approach | 164 | ||
| Carpal Tunnel Syndrome | 164 | ||
| Volar Locking Plate | 164 | ||
| Volar Plate Application | 165 | ||
| Fragment Specific Fixation Devices | 167 | ||
| Arthroscopically Assisted Open Reduction and Internal Fixation | 167 | ||
| Distraction Plating for Fractures With Extensive Comminution | 169 | ||
| Distal Radial Ulnar Joint | 171 | ||
| Rehabilitation After Distal Radius Fracture | 171 | ||
| Outcomes of Treatment | 172 | ||
| MALUNIONS OF THE DISTAL RADIUS | 172 | ||
| Surgical Technique | 174 | ||
| Postoperative Rehabilitation | 174 | ||
| ACKNOWLEDGMENTS | 174 | ||
| REFERENCES | 179 | ||
| 9 - Compartment Syndrome and Volkmann Ischemic Contracture | 180 | ||
| HISTORY | 180 | ||
| ACUTE COMPARTMENT SYNDROME | 180 | ||
| Anatomy | 180 | ||
| Compartments of the Hand | 180 | ||
| Evaluation | 181 | ||
| History | 181 | ||
| Examination | 181 | ||
| Diagnostics | 181 | ||
| Treatment | 183 | ||
| Reduction of Risk Factors | 183 | ||
| Surgical Compartment Release: Volar | 184 | ||
| Surgical Compartment Release: Dorsal | 185 | ||
| Finger Compartment Syndromes | 186 | ||
| Postoperative Care and Rehabilitation | 186 | ||
| NEONATAL COMPARTMENT SYNDROME | 187 | ||
| CHRONIC COMPARTMENT SYNDROME | 188 | ||
| Diagnosis of Chronic Compartment Syndrome | 188 | ||
| Treatment of Chronic Compartment Syndrome | 188 | ||
| VOLKMANN ISCHEMIC CONTRACTURE | 188 | ||
| Treatment of Volkmann Ischemic Contractures | 189 | ||
| Mild Contractures | 189 | ||
| Moderate Contractures | 189 | ||
| Severe Contractures and Salvage | 191 | ||
| CONCLUSION | 192 | ||
| REFERENCES | 192 | ||
| 10 - Nail Bed and Fingertip Injuries | 193 | ||
| CORE KNOWLEDGE | 193 | ||
| Sensory Organelles in the Fingertip | 193 | ||
| Nail Bed Anatomy | 193 | ||
| Finger Pulp Anatomy | 195 | ||
| EVALUATION AND TREATMENT OF FINGERTIP INJURIES | 195 | ||
| Evaluation | 195 | ||
| Classification | 195 | ||
| Repair. Nail bed lacerations typically result from crushing injuries that lead to ragged, stellate lacerations. Sufficient nail ... | 196 | ||
| Nail Bed Grafts. Split-thickness grafts from the nail bed can successfully take when used for nail bed defects. Grafts from the ... | 196 | ||
| Partial Fingertip Amputations | 196 | ||
| Examination | 196 | ||
| Classification | 196 | ||
| Expected Outcomes. Complete reepithelialization with restoration of some protective sensibility can occur with conservative trea... | 197 | ||
| Technical Tips. Even if a small amount of bone is exposed, this “open” technique may still be effective. The bone should not ext... | 197 | ||
| Type 2. In these injuries with more than 50% of the nail damaged along with loss of its underlying supportive distal phalanx, it... | 197 | ||
| Technical Tips. Nail bed ablation is easily performed with tangential dissection just under the nail fold, leaving the overlying... | 197 | ||
| 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... | 197 | ||
| Type 4 (Amputations at the Distal Interphalangeal Joint). In sharp amputations, replantation can be considered. This may be most... | 197 | ||
| Technical Tips. Revision of amputations at the DIP joint level should be performed in the operating room, where attention can be... | 198 | ||
| Management of Specific Structures | 198 | ||
| Nail | 198 | ||
| Nerve | 198 | ||
| Technical Tips. It is important to separate the artery from the nerve before performing neurectomy because inadvertently dividin... | 198 | ||
| Tendon | 198 | ||
| Bone and Cartilage | 198 | ||
| Local and Regional Flap Options | 199 | ||
| Description (Fig. 10.9). This flap can be executed either as a single proximally based flap or a double H flap. When designed as... | 199 | ||
| Description (Fig. 10.10). After the recipient site (the fingertip defect) has been properly debrided, a paper or cloth template ... | 199 | ||
| 11 - Amputations and Prosthetics | 206 | ||
| CORE KNOWLEDGE | 206 | ||
| Functional Patterns of Digital Amputations | 206 | ||
| GENERAL PRINCIPLES | 206 | ||
| Nerves | 206 | ||
| Tendons | 206 | ||
| Bone | 206 | ||
| Soft Tissue | 207 | ||
| Thumb | 207 | ||
| Phantom Limb Pain | 207 | ||
| TREATMENT OF SPECIFIC UPPER EXTREMITY AMPUTATIONS | 207 | ||
| Digital Level Amputations | 207 | ||
| Amputations Through the Distal Phalanx and Distal Interphalangeal Joint | 207 | ||
| Amputations Through the Middle Phalanx | 208 | ||
| Rehabilitation of Digital Level Amputations | 208 | ||
| Ray Amputations | 208 | ||
| Ray Amputation of the Index Finger | 209 | ||
| Ray Amputation of the Middle Finger | 209 | ||
| Middle Finger Gap Closure Versus Transposition | 212 | ||
| Ring Finger Ray Amputations | 212 | ||
| Small Finger Ray Amputation | 212 | ||
| Management of Multiple Digits Amputations | 212 | ||
| Below-the-Elbow Amputations | 212 | ||
| Amputations Through the Carpus | 212 | ||
| Technique for Below-the-Elbow Amputation | 217 | ||
| Krukenberg Operation | 217 | ||
| Elbow Disarticulation and Above-the-Elbow Amputation | 217 | ||
| Surgical Technique | 217 | ||
| Shoulder Disarticulations and Forequarter Amputations | 217 | ||
| Prosthetics | 219 | ||
| General Types | 219 | ||
| External Prostheses: Signal Sources | 220 | ||
| Targeted Muscle Reinnervation | 220 | ||
| External Prostheses: Sensory Feedback | 224 | ||
| Indications for Prosthetic Prescription | 224 | ||
| Digital Prosthesis | 226 | ||
| REFERENCES | 226 | ||
| 12 - HAND INFECTIONS, INJECTION INJURIES, SNAKE BITES, AND EXTRAVASATION INJURIES | 227 | ||
| Urgency | 227 | ||
| History | 227 | ||
| Tetanus | 227 | ||
| Cultures and Stains | 227 | ||
| Exam | 227 | ||
| Imaging | 227 | ||
| Treatment | 227 | ||
| CLINICAL PRESENTATION (SPECIFIC INFECTIONS) | 228 | ||
| Human Bites (Clenched-Fist Injuries) and Septic Arthritis | 228 | ||
| Animal Bites and Scratches | 228 | ||
| Insect Bites | 228 | ||
| Necrotizing Fasciitis | 228 | ||
| Paronychia | 230 | ||
| Acute Presentation | 230 | ||
| Chronic Paronychia Infections | 230 | ||
| Felons | 230 | ||
| Flexor Tendon Sheath Infections | 231 | ||
| Flexor Tendon Sheath Infections Without an Abscess | 231 | ||
| Flexor Tendon Sheath Infections With an Abscess | 231 | ||
| Deep Space Infections | 232 | ||
| Web Space Abscesses | 232 | ||
| Parona Space Infection | 233 | ||
| Midpalmar, Thenar, and Hypothenar Space Abscesses | 233 | ||
| Horseshoe Abscesses | 233 | ||
| SPECIFIC INFECTIOUS ORGANISMS | 233 | ||
| Methicillin-Resistant Staphylococcus aureus | 233 | ||
| Mycobacterial Infections | 233 | ||
| Fungal Infections | 234 | ||
| Candida | 234 | ||
| Sporothrichosis | 234 | ||
| Histoplasmosis | 234 | ||
| Coccidioidomycosis | 234 | ||
| Viral Infections | 234 | ||
| Herpetic Whitlow | 234 | ||
| Orf Virus | 234 | ||
| Human Immunodeficiency Virus | 234 | ||
| Occupational Bloodborne Pathogen Exposure | 235 | ||
| High-Pressure Injection | 235 | ||
| Surgical-Site Infection | 235 | ||
| Extravasation | 235 | ||
| Snake Bites | 236 | ||
| REFERENCES | 236 | ||
| 13 - Burns and Frostbite of the Hand | 237 | ||
| INTRODUCTION AND EPIDEMIOLOGY | 237 | ||
| SKIN ANATOMY | 237 | ||
| THERMAL BURNS | 237 | ||
| Classification of Burns | 237 | ||
| Acute Burn Management | 237 | ||
| Initial Evaluation | 237 | ||
| Escharotomy | 239 | ||
| Fasciotomy | 239 | ||
| Wound Care | 240 | ||
| Occupational Therapy and Hand Therapy | 240 | ||
| Excision and Skin Grafting | 240 | ||
| Skin Substitutes | 242 | ||
| Cultured Epithelial (Epidermal) Autografts. These grafts are generated from the patient’s own keratinocytes by culture expansion... | 242 | ||
| Integra. Integra Dermal Regeneration Template (Integra Life Sciences) is a two-layer construct consisting of bovine tendon colla... | 242 | ||
| Human Acellular Dermal Matrix. Acellular dermal matrix (ADM) is a processed human dermis with the cellular components removed to... | 243 | ||
| MatriDerm. MatriDerm (MedSkin Solutions) is similar to human ADM but from a bovine source. The bovine collagen matrix is cross-l... | 243 | ||
| Coverage of Deep Burns | 243 | ||
| Reverse Radial Forearm Flap. Many modifications of the reverse radial forearm flap have been described. Traditionally it is harv... | 243 | ||
| Reverse Posterior Interosseous Flap. This fasciocutaneous flap is harvested from the dorsal aspect of the forearm and can provid... | 243 | ||
| Abdominal and Groin Flaps. When local or regional flaps are not feasible due to the extent of injury, the abdomen or groin may p... | 243 | ||
| Free Flaps. With the expansion of flap selections and refinement of microsurgical techniques, free flaps are becoming more commo... | 243 | ||
| Pinning of Hand Joints | 244 | ||
| Amputation | 244 | ||
| Secondary Reconstructive Surgery | 244 | ||
| Scar Contracture Release | 244 | ||
| Laser Treatments | 245 | ||
| ELECTRICAL BURNS | 245 | ||
| CHEMICAL BURNS | 246 | ||
| Hydrofluoric Acid | 246 | ||
| Phenol (Carbolic Acid) | 247 | ||
| Lye (Sodium Hydroxide) | 247 | ||
| White Phosphorus | 247 | ||
| Elemental Sodium, Potassium, and Lithium | 247 | ||
| COLD INJURY | 247 | ||
| Pathophysiology | 247 | ||
| Classification | 247 | ||
| Treatment | 248 | ||
| REFERENCES | 249 | ||
| 14 - Flexor Tendon Injuries | 251 | ||
| HISTORY AND EPIDEMIOLOGY | 251 | ||
| TENDON INJURY AND REPAIR | 251 | ||
| What Key Information Is Required for Surgeons Performing Tendon Repair? | 251 | ||
| What Is the Ideal Research Model for Studying Flexor Tendon Injuries? | 251 | ||
| What Is the Best Way to Determine the Strength of Tendon Repair? | 251 | ||
| Can the Flexor Tendon Repair Increase Tendon Friction (Work of Flexion) During Digital Flexion? | 252 | ||
| How Strong Are Flexor Tendon Repairs? | 252 | ||
| Does Suture Locking Increase Time-Zero Tendon Repair Strength? | 253 | ||
| Does the Knot Location of the Core Sutures Affect Tendon Strength and Tendon Healing? | 253 | ||
| Should the Core Sutures Be Placed in the Dorsal or the Palmar Segment of the Tendon? | 254 | ||
| Does the Epitenon Suture Improve the Strength and Quality of the Tendon Repair? | 254 | ||
| Should One or Two Tendons Be Repaired in Zone II? | 254 | ||
| Does the Surface Area of the Tendon Repair Affect the Strength of Repair? | 255 | ||
| Does the Timing of Tendon Repair Affect the Quality of the Patient’s Functional Result? | 256 | ||
| Do Partial Tendon Lacerations Need to Be Repaired, and If So, When? | 256 | ||
| What Is the Role of Tendon Sheath Repair Following Repair of Lacerated Flexor Tendons? | 256 | ||
| Intrinsic Versus Extrinsic Tendon Healing | 256 | ||
| What Type of Rehabilitation Will Optimize the Functional Result? | 256 | ||
| Is the Lack of Vascularity of Tendon Grafts a Problem? | 260 | ||
| Physiology of Tendon Injury and Repair | 260 | ||
| Cytokines and Growth Factors | 260 | ||
| Tendon Nutrition and Blood Supply | 261 | ||
| Tendon Structure and Biomechanics | 261 | ||
| FLEXOR TENDON ANATOMY | 261 | ||
| Zone I | 262 | ||
| Zone II (No Man’s Land) | 262 | ||
| Zone III | 263 | ||
| Zone IV | 263 | ||
| Zone V | 263 | ||
| EXAMINATION | 263 | ||
| ACUTE TENDON REPAIR | 263 | ||
| Zone I | 263 | ||
| Zone II (No Man’s Land) | 265 | ||
| Zone III Injuries | 265 | ||
| Zone IV Injuries | 265 | ||
| Zone V Injuries | 265 | ||
| Flexor Pollicis Longus Injuries | 265 | ||
| REHABILITATION OF FLEXOR TENDON INJURIES | 266 | ||
| Description | 266 | ||
| Initial 24 to 48 Hours Postoperative | 266 | ||
| Twenty-Four to 72 Hours Postoperative to 4 Weeks | 267 | ||
| Four Weeks Postoperative | 267 | ||
| Four Weeks | 267 | ||
| Five Weeks | 267 | ||
| Six Weeks | 267 | ||
| Seven Weeks | 267 | ||
| Eight Weeks | 267 | ||
| Nine Weeks | 267 | ||
| Ten to 14 Weeks | 268 | ||
| Adhesions | 268 | ||
| Treatment. Hand therapy is necessary to maximize digital PROM. Surgical treatment of stiffness should be delayed until all the s... | 268 | ||
| Bowstringing | 269 | ||
| The Plantaris Tendon. A longitudinal incision is made parallel and medial to the Achilles tendon. The incision is carried down t... | 269 | ||
| Ring-Toe Extensor. Because of the toe extension from the short toe extensors, this graft can be harvested without any deleteriou... | 271 | ||
| Long Toe Flexor (Intrasynovial Tendon Graft).72 The second toe flexor is the best choice of intrasynovial tendon graft given its... | 272 | ||
| Tendon Allografts. As a last option, tendon allografts can be useful when the supply of available autografts has been exhausted.... | 272 | ||
| Prerequisites for Two-Stage Flexor Tendon Reconstruction | 272 | ||
| First Stage | 272 | ||
| Second Stage. Incisions are made distally at the level of the DIP joint to identify the distal end of the tendon. Sutures anchor... | 273 | ||
| Postoperative Rehabilitation. This is similar to zone II flexor tendon rehabilitation (passive protocol) in the acute setting, b... | 273 | ||
| Pedicled Intrasynovial Graft. In chronic lacerations in which both the FDP and FDS tendons have been lacerated, use of a pedicle... | 273 | ||
| Stage III Flexor Tendon Reconstruction (Tenolysis of Adhesions). In our experience, tenolysis is frequently necessary. Flexor te... | 274 | ||
| Assessment. Evaluate PROM, AROM, and muscle strength of the extrinsic finger flexors and extensors | 275 | ||
| 15 - Extensor Tendon Injuries | 278 | ||
| ACUTE EXTENSOR TENDON INJURIES | 278 | ||
| Anatomy | 278 | ||
| Classification of Extensor Tendon Injuries | 279 | ||
| Clinical Presentation | 280 | ||
| Treatment | 280 | ||
| Zone 1 | 280 | ||
| Zone 2 | 282 | ||
| Rehabilitation Protocol for Zone 1 and 2 Injuries | 282 | ||
| Zone 3 | 282 | ||
| Elson Test | 282 | ||
| Zone 4 | 283 | ||
| Zones 3 and 4 Rehabilitation Protocols | 283 | ||
| Zone 5 | 283 | ||
| Zone 6 | 283 | ||
| Zone 7 | 284 | ||
| Zone 8 | 284 | ||
| Zone 9 | 284 | ||
| Zone 5 to 9 Rehabilitation Protocols | 286 | ||
| Outcomes of Extensor Tendon Repairs | 286 | ||
| LATE EXTENSOR TENDON RECONSTRUCTION | 287 | ||
| 16 - Nerve Repair and Nerve Transfers | 293 | ||
| INTRODUCTION | 293 | ||
| Anatomy of Peripheral Nerves | 293 | ||
| Physiology of Peripheral Nerves | 293 | ||
| Basic Electrophysiology2,3 | 293 | ||
| Neuromuscular Junction Transmission | 295 | ||
| Axonal Transport | 295 | ||
| Sensory Receptors | 295 | ||
| Distal Axon. The distal axon cannot survive without its connection to the cell body and disintegrates (ie, wallerian degeneratio... | 296 | ||
| Proximal Axon. Following transection, there is demyelination of the distal stump. The axons degenerate to one or more proximal i... | 296 | ||
| Axon Regeneration | 296 | ||
| Role of Schwann Cells. Following nerve transection the Schwann cell removes the axonal and myelin debris in both the severed ner... | 297 | ||
| Nerve Biomechanics. A normal nerve has longitudinal excursion, which subjects it to a certain amount of stress and strain in sit... | 297 | ||
| Clinical Assessment | 297 | ||
| Laboratory Assessment | 298 | ||
| Nerve Conduction Studies2,3 | 298 | ||
| Lumbrical-Interosseous Latency Differences. A recording electrode is placed over the second palmar interspace at the distal palm... | 298 | ||
| 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... | 299 | ||
| 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 pe... | 300 | ||
| Electromyography | 300 | ||
| Axonotmesis and Neurotmesis. The axons are disrupted but the surrounding stroma is intact. This cannot initially be distinguishe... | 300 | ||
| Partial Lesions. Partial lesions usually represent axonotmesis, in which recovery depends on axonal sprouting and regeneration. ... | 300 | ||
| Complete Lesions. When the nerve is divided completely, recovery is dependent solely on axonal regeneration. The EMG is initiall... | 300 | ||
| Magnetic Resonance Imaging | 300 | ||
| TREATMENT OF NERVE INJURIES | 300 | ||
| Nerve Repair | 300 | ||
| Group Fascicular Suture. The motor and sensory groups of fascicles are identified as described. In a major nerve, such as the me... | 301 | ||
| External Epineurial Splint. Jabaley has used the external epineurium as a splinting device.31 The external epineurium is incised... | 301 | ||
| Nerve Repair: Secondary | 301 | ||
| Repair at the Elbow. The median nerve is located through an S-shaped anteromedial incision at the cubital fossa. The lacertus fi... | 301 | ||
| Repair in the Forearm. The median nerve is approached through a volar incision. The nerve is identified on the undersurface of t... | 302 | ||
| Repair at the Wrist. The median nerve at the wrist has approximately 30 fascicles. The motor recurrent branch often consists of ... | 302 | ||
| Repair in the Hand. The median nerve is approached through an extensile carpal tunnel approach, with division of the TCL. The re... | 302 | ||
| Digital Nerve Repair. There are often two fascicles in the typical digital nerve. An external epineurial repair gives the same r... | 303 | ||
| Repair in the Forearm. The motor fascicles lie dorsal and slightly ulnarly to the sensory fascicles at the wrist level and usual... | 304 | ||
| Repair at the Wrist. The ulnar nerve has 15 to 25 fascicles at the wrist. It can be clearly divided into a volar sensory compone... | 304 | ||
| Repair in the Hand. The nerve is approached through a volar ulnar incision in line with the ring finger. The deep motor and more... | 304 | ||
| Digital Nerve Repair. Repair or grafting in the digits is similar to the median nerve (Fig. 16.22) | 304 | ||
| Repair in the Forearm and Wrist. The PIN nerve is approached through a dorsolateral approach, developing the plane between the e... | 304 | ||
| Postoperative Rehabilitation. After nerve repair the rehabilitation focuses on three areas: initial immobilization to protect th... | 304 | ||
| Outcomes Following Repair and Graft. Most series report the results of nerve repair using the BMRC grading system, which has bee... | 304 | ||
| Alternate Methods of Nerve Reconstruction | 308 | ||
| Nerve Conduits | 308 | ||
| Indications. Conduits are indicated for reconstruction of small-diameter, noncritical sensory nerves with a gap of less than 3 c... | 308 | ||
| Contraindications. These include uncertainty about the viability of the nerve ends, especially with avulsion injuries, blast inj... | 308 | ||
| Autogenous Vein Grafts. The use of autologous veins as a biologic tube to reconstruct a nerve gap has been well described over t... | 309 | ||
| Postoperative Rehabilitation. Repair of other tendon or muscle injuries will influence the rehabilitation. With an isolated nerv... | 309 | ||
| Outcomes. The use of conduits for mixed nerves is still experimental and cannot be considered a standard of treatment as yet, al... | 310 | ||
| Processed Nerve Allografts. Taras et al.52 reported the outcomes of 14 patients with an average age of 39 years (range, 18 to 76... | 311 | ||
| End-to-Side Repairs | 312 | ||
| Neurotization | 312 | ||
| Nerve Transfers | 312 | ||
| Nerve Transfers to Restore Wrist and Finger Extension | 312 | ||
| Median Nerve. Just distal to the cubital fossa, the motor branches of the median nerve consistently collect into three fascicula... | 313 | ||
| Posterior Interosseous Nerve Palsy. In a PIN palsy the presenting symptoms are weakness and/or paralysis of the extensor muscles... | 314 | ||
| Electrodiagnostic Studies. PIN lesions do not affect the superficial radial SNAP, which should be normal. The compound motor act... | 314 | ||
| Indications. The time for reinnervation must take the distance from the injury to the motor end plate into account. As a general... | 314 | ||
| Contraindications. Contraindications include nerve palsies that may recover spontaneously, such as proximal radial nerve lesions... | 314 | ||
| Radial Nerve Exposure. The radial nerve is isolated through the same incision. It can be found between the BR and brachialis as ... | 314 | ||
| Nerve Transfer. MacKinnon recommends coapting the FDS motor fascicles with the ECRB branch because this can reproduce the tenode... | 314 | ||
| Postoperative Rehabilitation. An above-elbow splint is applied with the elbow at 90 degrees and the shoulder, wrist, and fingers... | 315 | ||
| Outcomes. In Mackinnon’s series, 17 of 19 patients had complete radial nerve palsy, whereas two had intact wrist extension with ... | 315 | ||
| Contraindications. The absolute contraindication for this nerve transfer is a global brachial plexus palsy with no recovery of u... | 316 | ||
| Relevant Anatomy. The musculocutaneous nerve (MCN) is the terminal branch of the lateral cord of the brachial plexus, containing... | 316 | ||
| Surgical Technique. The patient is placed supine on the operating table, with the arm placed out on a hand table. The entire ext... | 316 | ||
| Outcomes. A total of 100 cases can be identified in the English literature.68 Eighty percent of patients recovered ≥M4 motor str... | 317 | ||
| Double Fascicular Transfer | 317 | ||
| Indications. The most common indication for this procedure is a proximal ulnar nerve injury to restore function to the ulnar inn... | 317 | ||
| Contraindications. An AIN transfer should be performed within 6 months of injury, with an upper limit of 12 months.73 Damage to ... | 317 | ||
| Surgical Technique.73 The patient is positioned supine with the arm abducted to 90 degrees on a hand table, with use of a tourni... | 317 | ||
| Outcomes. Despite the enthusiasm with this procedure, there is a paucity of published outcomes. Pace and Wood74 describe a case ... | 318 | ||
| Sensory Nerve Transfers | 318 | ||
| Indications. Sensory nerve transfers can be performed for areas requiring critical sensation in cases in which a proximal nerve ... | 319 | ||
| Contraindications. The main contraindication for nerve transfer is when a direct end-to-end nerve repair is possible or in the c... | 319 | ||
| Surgical Technique. The patient is positioned supine with the arm abducted on a hand table under general anesthesia. Tourniquet ... | 319 | ||
| Nerve Transfer for Median Nerve Injury. The ulnar sensory fascicles to the fourth web space can be transferred to the median inn... | 319 | ||
| Nerve Transfer for Ulnar Nerve Injury. A sensory nerve transfer can be performed using the median sensory fascicles to the third... | 319 | ||
| Outcomes. Despite the number of technical reports, published outcomes following sensory nerve transfers are lacking. Most of the... | 319 | ||
| REFERENCES | 320 | ||
| 17 - Brachial Plexus Injuries | 322 | ||
| CORE KNOWLEDGE | 322 | ||
| Anatomy | 322 | ||
| Epidemiology of Adult Brachial Plexus Injuries | 322 | ||
| Mechanism of Injury in Adult Brachial Plexus Injuries | 322 | ||
| Brachial Plexus Injury During Birth | 323 | ||
| Classification of Brachial Plexus Injuries | 323 | ||
| Preganglionic Injuries | 323 | ||
| Postganglionic Injuries | 324 | ||
| C5 and C6 or Upper Trunk (Erb-Duchenne) Paralysis. These injuries produce paralysis of the deltoid, supraspinatus, infraspinatus... | 324 | ||
| C5, C6, and C7 Injury. This combination of neural injuries features all the deficits of Erb-Duchenne paralysis plus paralysis of... | 324 | ||
| Entire Brachial Plexus Injury. This results in an initial flail and anesthetic arm. Frequently there is a combination of pregang... | 325 | ||
| C8 and T1 (Klumpke Palsy). These injuries are extremely rare in both birth injuries and adults and may be nonexistent as an isol... | 325 | ||
| EVALUATION | 326 | ||
| History and Examination | 326 | ||
| Magnetic Resonance Imaging. With the ability to highlight the resonance of nerve tissue and adjust the plane of the images to co... | 326 | ||
| Myelography and Myelo-Computerized Topography Scans. When traction from the injury is applied to the intradural portion of the s... | 326 | ||
| Angiography. Angiography is rarely indicated, usually when there is clinical evidence to suggest a closed, hemodynamically stabl... | 326 | ||
| 18 - Management of Chronic Upper Extremity Pain and Factitious Syndromes | 339 | ||
| CORE KNOWLEDGE | 339 | ||
| Classification of Pain: Complex Regional Pain Syndrome | 339 | ||
| Synonyms | 339 | ||
| Physiology of Pain | 339 | ||
| Descending Pain Pathways and Gate Theory. The pairing of ascending and descending pain pathways provides a mechanism to modulate... | 340 | ||
| Norepinephrine as the Sympathetic Neurotransmitter. The sympathetic response to certain stimuli is processed by the sympathetic ... | 340 | ||
| Innervation Changes in Complex Regional Pain Syndrome. The physiologic changes that correspond to CRPS suggest altered innervati... | 340 | ||
| Changes in the Sympathetic Nervous System in Complex Regional Pain Syndrome. There appears to be an abnormal coupling (sympatho-... | 341 | ||
| Diagnostic Criteria for Complex Regional Pain Syndrome | 341 | ||
| Staging and Phases of Complex Regional Pain Syndrome | 341 | ||
| Incidence, Prevalence, Genetics, and Natural History of Complex Regional Pain Syndrome | 341 | ||
| EVALUATION: DIAGNOSIS | 342 | ||
| Clinical Evaluation | 342 | ||
| Blood Tests | 342 | ||
| Testing for Sympathetically Maintained Pain | 343 | ||
| Imaging | 343 | ||
| Extremity Vascular Laboratory Testing | 343 | ||
| Psychological Tests | 343 | ||
| Depression, Stress, and Anxiety | 343 | ||
| MANAGEMENT | 343 | ||
| Timing | 343 | ||
| Hand Therapy | 343 | ||
| Oral Medications | 343 | ||
| Parenteral Medications | 344 | ||
| Surgical and Ablative Therapies | 345 | ||
| Correction of the Nociceptive Focus | 345 | ||
| Sympathectomy | 345 | ||
| Late Surgical Intervention | 345 | ||
| Outcomes | 345 | ||
| PRACTICAL PAIN MANAGEMENT | 345 | ||
| FACTITIOUS INJURY AND SELF-ABUSE SYNDROMES | 345 | ||
| Conversion Reaction | 346 | ||
| Malingering | 346 | ||
| Posttraumatic Stress Disorder | 346 | ||
| Focal Dystonias | 346 | ||
| Fibromyalgia and Myofascial Pain Syndromes | 347 | ||
| REFERENCES | 347 | ||
| 19 - Management of Upper Extremity Vascular Disorders and Injuries | 348 | ||
| CORE KNOWLEDGE | 348 | ||
| Significance | 348 | ||
| Components of Peripheral Blood Flow | 348 | ||
| Control of Blood Flow | 348 | ||
| Anatomy | 348 | ||
| DIAGNOSIS AND EVALUATION | 348 | ||
| History | 348 | ||
| Physical Examination | 348 | ||
| Laboratory Testing | 349 | ||
| Medical Testing | 349 | ||
| Noninvasive Testing | 349 | ||
| Invasive and Structural Testing | 350 | ||
| TYPES OF VASCULAR PATHOBIOLOGY, WORK-UP AND TREATMENT | 350 | ||
| Raynaud Disease and Raynaud Phenomenon | 351 | ||
| Work-Up | 351 | ||
| Oral Pharmacologic Intervention. Oral medications are used to reduce vasospasm and pain and prevent thrombosis. Most medications... | 351 | ||
| Botulinum Toxin Type A (Botox) Injections. Over 80% of patients can improve with a single injection of botox therapy with 50 to ... | 351 | ||
| Peripheral Sympathectomy. Peripheral sympathectomy in the palm or digits is effective in maximizing nutritional digital flow. As... | 351 | ||
| Cervicothoracic Sympathectomy. This procedure is discussed here primarily to discourage its use. The permanent interruption of t... | 352 | ||
| Thrombolytic Therapy. An alternative to surgery is the use of intraarterial anticoagulants for acute upper extremity thrombotic-... | 352 | ||
| Prevention of Thrombosis. Several drugs that alter platelet function and coagulation pathways can be used over the long term, in... | 352 | ||
| Embolectomy. An embolectomy is employed less frequently in the upper extremity than the lower extremity. However, this procedure... | 352 | ||
| Technique. After verifying the extent and location of embolic events, an arteriotomy is performed at either the wrist or elbow. ... | 352 | ||
| Arterial Reconstruction. Reconstruction options include end-to-end repair, interposition grafting, and bypass grafting | 352 | ||
| Technique. Veins may be harvested through a simple longitudinal incision, multiple short longitudinal incisions, transverse inci... | 353 | ||
| Arterialization. If the patient presents with unreconstructable distal vasculature, a salvage procedure may be performed consist... | 354 | ||
| Peripheral Vascular Small Vessel Disease | 354 | ||
| 20 - Compressive Neuropathies | 362 | ||
| PATHOPHYSIOLOGY | 362 | ||
| Basic Science | 362 | ||
| Systemic Disorders | 362 | ||
| Electrodiagnostic Studies | 362 | ||
| AREAS OF COMPRESSION | 362 | ||
| Epidemiology | 363 | ||
| Anatomy and Pathology | 363 | ||
| Symptoms | 363 | ||
| Examination | 364 | ||
| Diagnostic Tests | 364 | ||
| Treatment | 364 | ||
| Carpal Tunnel Release. CTR surgery can be divided into open and endoscopic procedures. Endoscopic CTR offers the advantage of de... | 364 | ||
| Open CTR. An incision is made in line with the radial border of the ring finger from the distal volar wrist crease toward the pr... | 365 | ||
| Single Portal Versus Two Portal Endoscopic Release. The single portal technique was designed by John Agee, MD, to minimize the s... | 365 | ||
| Complications | 366 | ||
| Postoperative Rehabilitation | 366 | ||
| Anatomy and Pathology | 367 | ||
| History | 367 | ||
| Examination | 367 | ||
| Diagnostic Tests | 367 | ||
| Treatment | 368 | ||
| ULNAR-SIDED HAND NUMBNESS | 368 | ||
| Differential Diagnosis | 368 | ||
| Epidemiology | 368 | ||
| Anatomy | 368 | ||
| Symptoms | 368 | ||
| Examination | 369 | ||
| Diagnostic Tests | 370 | ||
| Treatment | 370 | ||
| In Situ Release. The authors use this procedure for most cases of uncomplicated cubital tunnel syndrome, except in cases of nerv... | 370 | ||
| Endoscopically Assisted Cubital Tunnel Release. There are several products to assist in cubital tunnel release and the nerve can... | 370 | ||
| Anterior Submuscular Ulnar Nerve Transposition. This technique is appropriate for patients with nerve subluxation or recurrent s... | 370 | ||
| Anterior Subcutaneous Transfer of the Ulnar Nerve. This procedure (Fig. 20.17) is well suited for elderly patients or patients r... | 372 | ||
| Medial Epicondylectomy. This procedure has the advantage of not disturbing the vascular supply of the ulnar nerve (Fig. 20.18). ... | 372 | ||
| Complications | 372 | ||
| Epidemiology | 373 | ||
| Anatomy and Pathology (Figs. 20.20 and 20.21) | 373 | ||
| Symptoms | 374 | ||
| Examination | 374 | ||
| Diagnostic Tests | 374 | ||
| Treatment | 374 | ||
| Complications | 374 | ||
| Thoracic Outlet Syndrome | 374 | ||
| Epidemiology | 374 | ||
| Anatomy | 374 | ||
| Symptoms | 375 | ||
| Examination | 375 | ||
| Diagnostic Studies | 375 | ||
| Treatment | 375 | ||
| Supraclavicular Approach. The surgery is performed with the patient in the beach chair position. An incision is made 1 cm above ... | 376 | ||
| Transaxillary First Rib Resection. The incision for this procedure is more cosmetically appealing than the supraclavicular appro... | 376 | ||
| Results | 377 | ||
| Complications | 377 | ||
| Radial Nerve Compression | 377 | ||
| Epidemiology | 377 | ||
| Anatomy and Pathology | 377 | ||
| Symptoms | 377 | ||
| Examination | 377 | ||
| Diagnostic Studies | 377 | ||
| Treatment | 377 | ||
| Anterior Approach. This approach gives the widest exposure. The incision begins proximal to the antecubital fossa between the br... | 377 | ||
| Transmuscular Approach. A curvilinear incision is made directly over the mobile wad. Distal branches of the lateral antebrachial... | 378 | ||
| Posterior Approach. The posterior approach uses an incision along the posterior border of the extensor origin using a line drawn... | 378 | ||
| Rehabilitation. For either approach, the arm is postoperatively bandaged in a long-arm splint. Range-of-motion exercises of the ... | 379 | ||
| Release of Wartenberg’s Syndrome. At the level of the wrist, the sensory branch of the radial nerve exits between the tendon of ... | 379 | ||
| REFERENCES | 379 | ||
| ADDITIONAL READING | 379 | ||
| 21 - The Paralytic Hand and Tendon Transfers | 380 | ||
| CORE KNOWLEDGE | 380 | ||
| Principles of Tendon Transfer | 380 | ||
| Muscle Physiology | 380 | ||
| Muscle Tension | 381 | ||
| Functional Anatomy | 381 | ||
| Rehabilitation | 381 | ||
| RADIAL NERVE PALSY | 382 | ||
| Rehabilitation | 384 | ||
| MEDIAN NERVE PALSY | 384 | ||
| Low Median Nerve Palsy | 385 | ||
| High Median Nerve Palsy | 386 | ||
| Rehabilitation | 387 | ||
| ULNAR NERVE PALSY | 388 | ||
| Low Ulnar Nerve Palsy | 388 | ||
| High Ulnar Nerve Palsy | 390 | ||
| Rehabilitation | 391 | ||
| COMBINED NERVE PALSIES | 391 | ||
| ACKNOWLEDGMENT | 393 | ||
| REFERENCES | 393 | ||
| 22 - Cerebral Palsy, Stroke, and Traumatic Brain Injury | 394 | ||
| OVERVIEW | 394 | ||
| CEREBRAL PALSY | 394 | ||
| Core Knowledge | 394 | ||
| Clinical Evaluation | 394 | ||
| Motor Evaluation | 394 | ||
| Cognition | 394 | ||
| Voluntary Control of Hand Placement | 394 | ||
| Sensibility and Stereognosis | 394 | ||
| Dynamic Electromyography | 394 | ||
| Splints and Therapy | 394 | ||
| Surgical Treatment | 395 | ||
| Elbow Flexion Deformity | 395 | ||
| Surgical Technique. Elbow contractures can be released with an S-shaped incision centered over the antecubital fossa, with the p... | 395 | ||
| Rehabilitation. The elbow is splinted for 2 weeks in the position of maximal extension that was achieved during surgery. The pos... | 395 | ||
| Complications. Wound problems, such as hematomas, can occur with these large surgical releases. It is advisable to place suction... | 396 | ||
| Wrist Flexion Deformity | 396 | ||
| Surgical Technique for Flexor Carpi Ulnaris Lengthening. A simple step-cut lengthening of the FCU is recommended. An incision al... | 396 | ||
| Surgical Technique for Flexor Pronator Slide. The flexor-pronator slide is performed using the incision along the medial midaxia... | 396 | ||
| Surgical Technique for Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis Tendon Transfer. The FCU is exposed using two inci... | 397 | ||
| Rehabilitation. Patients with the Green tendon transfer are casted in wrist extension for 4 weeks before starting active wrist e... | 397 | ||
| Surgical Technique: Dorsal Wrist Approach With Proximal Row Carpectomy and Dorsal Plate Fixation. An oblique dorsal wrist incisi... | 397 | ||
| Rehabilitation. Patients are treated after surgery in a short-arm cast for 6 weeks, followed by a removable orthosis, until unio... | 397 | ||
| Complications. Wrist arthrodesis can improve appearance, hygiene, function, and overall satisfaction in those suffering with a s... | 397 | ||
| Surgical Technique for Fractional Tendon Lengthening. A finger flexor fractional lengthening is performed using an incision on t... | 398 | ||
| Surgical Technique for Step-Cut Lengthening. This surgery is performed using the same type of incision as a fractional lengtheni... | 398 | ||
| Rehabilitation. Patients with fractional lengthening are allowed to start active finger and wrist flexion and extension while us... | 398 | ||
| Surgical Technique for Flexor Carpi Ulnaris to Extensor Digitorum Communis Tendon Transfer. A longitudinal incision is made on t... | 398 | ||
| Swan Neck Deformities of the Fingers Secondary to Contractures of Intrinsic Muscles. Spasticity and contractures of the intrinsi... | 399 | ||
| Surgical Technique for Central Slip Tenotomy.16. Central slip tenotomy is performed using a transverse incision 1 cm proximal to... | 399 | ||
| Rehabilitation. After central slip tenotomy, the PIP joint is pinned for 4 weeks. After removal of the pins in the office, activ... | 399 | ||
| Rehabilitation. Postoperatively the patients are splinted in the intrinsic-minus position with the MCP joints extended and the P... | 399 | ||
| Surgical Technique for Superficialis Tenodesis to Correct Swan Neck Deformity. For patients with moderate-to-severe swan neck de... | 399 | ||
| Surgical Technique for Release of Nerve/Nerve Block of the Adductor Pollicis and Flexor Pollicis Brevis. A carpal tunnel approac... | 399 | ||
| Surgical Technique for Release of the Adductor Pollicis and Flexor Pollicis Brevis. Mild contractures of the AddP can be release... | 400 | ||
| Surgical Technique for FPL Lengthening. A step-cut lengthening technique can be very successful (Fig. 22.14). After surgery the ... | 401 | ||
| Surgical Technique for Transferring the Thumb FPL to the APB. The FPL is identified and released via a radial midaxial exposure ... | 401 | ||
| Surgical Technique for Extensor Pollicis Longus Rerouting. The EPL tendon is exposed using a curved incision over the proximal p... | 401 | ||
| Surgical Outcomes | 401 | ||
| STROKE AND TRAUMATIC BRAIN INJURY | 402 | ||
| Stroke | 402 | ||
| Sensory Impairment. The sensory impairment can vary in individuals but usually results in a profound loss of discrimination, usi... | 402 | ||
| Motor Impairment. In the first several days to weeks following the stroke the patient has flaccid paralysis followed by graduall... | 402 | ||
| Cognitive Impairment. Memory loss, decreased learning ability, and decreased mentation can all complicate the rehabilitation of ... | 402 | ||
| Traumatic Brain Injury | 402 | ||
| Treatment of Stroke and Traumatic Brain Injury | 402 | ||
| Upper Extremity Involvement | 402 | ||
| Spasticity | 402 | ||
| Wrist and Finger Flexion Contracture. Wrist and finger flexion deformities are considered together because the finger muscles ar... | 403 | ||
| Individual Step-Cut Tendon Lengthening. This surgery is performed using the same type of incision as the FDS to FDP transfer. Pa... | 403 | ||
| Fractional Tendon Lengthening. When the finger can be passively extended several centimeters from the palm in patients who have ... | 403 | ||
| Rehabilitation. The patients with fractional lengthening are allowed to start active finger and wrist flexion and extension whil... | 404 | ||
| Complications Following Correction of Finger Flexion Contractures. Loss of grip strength is a common problem, especially followi... | 404 | ||
| Lengthening of Wrist Flexor Tendons. For mild deformities in patients who can actively extend to within 30 degrees of neutral wr... | 404 | ||
| Rehabilitation. The wrist is splinted in 30 degrees of wrist extension after surgery for 6 weeks on a full-time basis. Nighttime... | 404 | ||
| Complications. Recurrence of the deformity may be a problem for patients who do not follow through with their postoperative spli... | 404 | ||
| Thumb-in-Palm Deformity. This deformity can occur in adults with stroke or TBI, although it does not usually require surgical tr... | 404 | ||
| REFERENCES | 404 | ||
| 23 - UPPER LIMB RECONSTRUCTION IN PERSONS WITH TETRAPLEGIA | 405 | ||
| INTRODUCTION | 405 | ||
| DEMOGRAPHICS OF SPINAL CORD INJURY | 405 | ||
| NERVE INJURY IN TETRAPLEGIA | 406 | ||
| TIMING OF SURGERY | 406 | ||
| HIGH-LEVEL TETRAPLEGIA | 406 | ||
| Shoulder Girdle | 408 | ||
| Functional Electrical Stimulation | 409 | ||
| MID-LEVEL CERVICAL TETRAPLEGIA | 409 | ||
| CLASSIFICATION | 409 | ||
| TREATMENT | 410 | ||
| Elbow | 410 | ||
| Forearm | 412 | ||
| Technique: Biceps Tendon Rerouting | 413 | ||
| Technique: One-Bone Forearm | 414 | ||
| Wrist and Hand | 416 | ||
| REHABILITATION AND OUTCOME | 418 | ||
| SUMMARY | 419 | ||
| REFERENCES | 420 | ||
| 24 - Tendinopathies of the Hand, Wrist, and Elbow | 422 | ||
| ADULT TRIGGER FINGER | 422 | ||
| Anatomy | 422 | ||
| Clinical Presentation | 422 | ||
| Nonoperative Treatment | 423 | ||
| Surgical Treatment | 423 | ||
| Percutaneous Trigger Finger Release | 423 | ||
| Open Trigger Finger Release | 424 | ||
| Trigger Thumb Release | 425 | ||
| Trigger Digit Postoperative Rehabilitation | 425 | ||
| Complication | 425 | ||
| LOCKING METACARPAL PHALANGEAL JOINT | 425 | ||
| Anatomy | 426 | ||
| Clinical Presentation | 426 | ||
| Nonoperative Treatment | 426 | ||
| Surgical Treatment | 427 | ||
| Release of the First Dorsal Compartment With Fascial Reconstruction | 427 | ||
| Complications | 428 | ||
| Anatomy | 429 | ||
| Clinical Presentation | 429 | ||
| Nonoperative Treatment | 429 | ||
| Surgical Treatment | 429 | ||
| Rehabilitation After Second Dorsal Compartment Release | 429 | ||
| Complications | 429 | ||
| FLEXOR CARPI RADIALIS STENOSING TENOSYNOVITIS | 429 | ||
| 25 - Osteoarthritis | 441 | ||
| OSTEOARTHRITIS AND POSTTRAUMATIC ARTHRITIS | 441 | ||
| Clinical Presentation and Medical Management | 441 | ||
| Treatment Principles | 442 | ||
| Arthroplasty | 443 | ||
| Arthrodesis | 443 | ||
| OSTEOARTHRITIS OR DEGENERATIVE ARTHRITIS | 444 | ||
| Clinical Presentation | 444 | ||
| Distal Interphalangeal Joint (Heberden Node and Mucous Cyst) | 444 | ||
| Proximal Interphalangeal Joint | 445 | ||
| Proximal Interphalangeal Joint Arthrodesis | 446 | ||
| Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthrodesis. Initially the finger is immobilized in a splint a... | 446 | ||
| Proximal Interphalangeal Joint Arthroplasty | 446 | ||
| Dorsal Approach. One dorsal approach for PIP arthroplasty is similar to that used for arthrodesis, with the key distinction bein... | 446 | ||
| Lateral Approach. In the lateral approach (best for the index finger with ular approach to preserve the PIP radial collateral li... | 447 | ||
| Volar Approach. The volar approach is the author’s preferred approach for a primary arthroplasty. In some cases of revision surg... | 447 | ||
| Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthroplasty. Postoperative rehabilitation for PIP joint arthr... | 449 | ||
| Carpometacarpal Joint Arthritis of the Thumb | 449 | ||
| Nonoperative Treatment of Basal Joint Arthritis | 450 | ||
| Surgical Treatment of Basal Joint Arthritis | 450 | ||
| Surgical Procedure for Ligament Reconstruction and Tendon Interposition. A Wagner incision is used beginning just dorsal to the ... | 451 | ||
| Suspensionplasty Using the Abductor Pollicis Longus. This approach to the basal joint is similar to the ligament reconstruction ... | 452 | ||
| Costochondral Interposition Hemiarthroplasty or Complete Trapezial Arthroplasty. Costochondral allograft has been suggested as a... | 452 | ||
| Carpometacarpal Implant Arthroplasty. A multitude of implants have been proposed and attempted. Several different Silastic impla... | 452 | ||
| Tightrope Ligament Reconstruction With or Without Implant Arthroplasty. A major breakthrough and basal joint arthroplasty for th... | 453 | ||
| Abduction Osteotomy of Thumb Metacarpal. In young patients who do manual labor, an abduction osteotomy can delay or prevent the ... | 456 | ||
| Arthrodesis of the Thumb Carpometacarpal Joint. Isolated trapeziometacarpal arthritis can be effectively treated with a number o... | 456 | ||
| Postoperative Rehabilitation After Thumb Carpometacarpal Arthrodesis. A short-arm, thumb-spica splint is used until radiographic... | 457 | ||
| SCAPHOTRAPEZIOTRAPEZOID ARTHRITIS | 457 | ||
| Scapholunate and Scaphoid Nonunion Advanced Collapse Pattern Arthritis | 457 | ||
| Scaphoid Excision and Capsulorraphy | 457 | ||
| Four-Bone Fusion | 457 | ||
| Postoperative Rehabilitation After Four-Bone Arthrodesis. Postoperatively, the wrist is immobilized for 6 weeks. Patients are th... | 457 | ||
| Proximal Row Carpectomy | 461 | ||
| Postoperative Rehabilitation After Proximal Row Carpectomy. The wrist is immobilized for 4 weeks, at which time active range-of-... | 461 | ||
| Total Wrist Arthrodesis | 461 | ||
| Total Wrist Arthroplasty | 461 | ||
| REFERENCES | 465 | ||
| 26 - RHEUMATOID ARTHRITIS | 466 | ||
| OVERVIEW | 466 | ||
| INFLAMMATORY ARTHRITIS | 466 | ||
| Clinical Presentation | 466 | ||
| Pathophysiology | 466 | ||
| Laboratory Studies | 466 | ||
| Histology | 467 | ||
| Radiographic Findings in Rheumatoid Arthritis | 467 | ||
| Medical Management | 468 | ||
| Disease-Modifying Antirheumatic Drugs and Surgery | 468 | ||
| Juvenile Rheumatoid Arthritis | 468 | ||
| Other Inflammatory Arthritis | 469 | ||
| Systemic Lupus Erythematosus | 469 | ||
| Scleroderma | 469 | ||
| Fingertip Ulcerations | 470 | ||
| Psoriatic Arthritis | 470 | ||
| Crystalline Arthropathy | 471 | ||
| Gout. Gout results from hyperuricemia and the deposition of sodium urate crystals. It occurs commonly in males in the fifth and ... | 471 | ||
| Chondrocalcinosis (Pseudogout). In contrast to gout, pseudogout is a less aggressive form of crystalline arthropathy and is also... | 472 | ||
| Diagnostic Joint Aspirates | 472 | ||
| PATTERNS AND COMMON TREATMENT MEASURES | 472 | ||
| Rheumatoid Arthritis | 472 | ||
| Synovitis and Tenosynovitis | 472 | ||
| Extensor Compartment Synovitis. Synovitis of the distal radioulnar joint (DRUJ) and dorsal extensor compartment may coexist. Swe... | 472 | ||
| Procedure for Distal Ulna Resection and Dorsal Tenosynovectomy. A modified Darrach procedure is performed with or without the ad... | 473 | ||
| Ruptured Extensor Tendons. Extensor tendon ruptures can be quite debilitating and are treated with either tendon transfer or an ... | 473 | ||
| Postoperative Rehabilitation After Extensor Tendon Repairs and Transfers. The wrist is immobilized in 20 degrees of extension an... | 475 | ||
| Flexor Tenosynovitis. Fingers with greater passive than active motion may be affected by tenosynovitis, which can be refractory ... | 475 | ||
| Postoperative Rehabilitation for Flexor Tenosynovectomy. Patients are typically started on active and passive flexion exercises ... | 475 | ||
| Flexor Pollicis Longus Tendon Rupture. Flexor pollicis longus (FPL) tendon rupture in the setting of RA has been called Mannerfe... | 475 | ||
| Note on Concomitant Carpometacarpal Joint Arthritis. It is fairly common to find the thumb affected by some amount of carpometac... | 477 | ||
| Swan Neck Deformity of the Thumb. This deformity often exists in patients without inflammatory arthritis. It is believed to be a... | 477 | ||
| Swan Neck Deformity With Flexible Metacarpal Phalangeal Joint. In this setting the MCP joint position can be corrected by releas... | 478 | ||
| Ulnar Collateral Ligament Instability. In the setting of rheumatoid disease, UCL instability is the result of synovitis and repe... | 478 | ||
| Silicone Implant Arthroplasty for Reconstruction of the Metacarpal Phalangeal Joint. These implants are preferred when the patie... | 479 | ||
| Postoperative Rehabilitation for Metacarpal Phalangeal Joint Silicone Implant Arthroplasty. The splint and dressing are changed ... | 481 | ||
| Overall Functional Outcomes of Silicone Metacarpal Phalangeal Arthroplasty. In general, silicone arthroplasty of the MCP joint p... | 481 | ||
| Swan Neck Deformity. The etiology of swan neck deformity in rheumatoid patients is multifactorial. In addition to intrinsic tigh... | 482 | ||
| Flexible (Supple) Swan Neck Deformity. Surgical management of swan neck deformities can be frustrating, with frequent recurrence... | 482 | ||
| Postoperative Rehabilitation After Swan Neck Correction. A hand-based splint is used that block the PIP in 30 degrees of flexion... | 483 | ||
| Rigid Swan Neck Deformity. For rigid swan neck deformity, PIP joint arthrodesis in a functional position is recommended. PIP joi... | 484 | ||
| Boutonnière Deformity. Boutonnière deformity is nearly always secondary to PIP joint swelling and synovitis. The central tendon ... | 484 | ||
| Fixed Boutonnière Deformity. It is rare that a fixed boutonnière deformity requires extensive treatment because the finger is of... | 484 | ||
| Postoperative Rehabilitation for Proximal Interphalangeal Fusion. The guidelines for postoperative management of small joint fus... | 485 | ||
| WRIST ARTHRITIS | 485 | ||
| Rheumatoid Pattern of Wrist Degeneration | 485 | ||
| Radiolunate Arthrodesis for Ulnar Translocation | 485 | ||
| Postoperative Rehabilitation for Partial Wrist Fusion. The wrist is immobilized for 6 to 8 weeks. After radiographs have confirm... | 486 | ||
| Involvement of the Midcarpal and Radiocarpal Joints | 486 | ||
| Wrist Arthrodesis | 486 | ||
| Postoperative Rehabilitation After Wrist Arthrodesis. Total wrist arthrodesis has a high fusion rate and relatively few major co... | 487 | ||
| Total Wrist Arthroplasty | 487 | ||
| Postoperative Rehabilitation After Total Wrist Arthroplasty. On average, the wrist is splinted for 3 weeks before allowing wrist... | 489 | ||
| REFERENCES | 489 | ||
| 27 - Carpal Avascular Necrosis: Kienböck Disease and Preiser Disease | 490 | ||
| KIENBÖCK DISEASE | 490 | ||
| Core Knowledge | 490 | ||
| Historical Background | 490 | ||
| Etiology | 490 | ||
| Vascular Anatomy. The vascular anatomy of the lunate and its vulnerability to disruption have long been suspected as causes for ... | 490 | ||
| Load Distribution. Osseous anatomy and the load borne through the lunate may also be significant factors in the development of l... | 491 | ||
| Epidemiology | 491 | ||
| Evaluation and Treatment | 491 | ||
| Diagnostic Studies. Initially, any patient with suspected Kienböck disease should be evaluated with plain radiographs (Fig. 27.3... | 491 | ||
| Staging. The most common method for staging Kienböck disease was first developed by Stahl in 1947. Lichtman et al. modified this... | 492 | ||
| Treatment | 493 | ||
| Stage I. The appropriate treatment for stage I disease remains controversial. Some authors have argued that patients in this sta... | 495 | ||
| Stages I, II, or IIIA With Ulnar-Negative Variance. In these three stages the carpus has not collapsed into an instability patte... | 495 | ||
| Surgical Technique for Radial Shortening (Dorsal Approach). The distal radius may be approached either dorsally or palmarly. The... | 497 | ||
| Surgical Technique for Radial Shortening (Volar Approach). An 8-cm longitudinal incision is made over the radial border of the f... | 497 | ||
| Vascularized Bone Graft. The use of a VBG may be combined with lunate unloading procedures or used as an alternative to other pr... | 497 | ||
| Surgical Technique for Vascularized Bone Graft From the Radius. The incision curves from the dorsal wrist, centered over the lun... | 498 | ||
| Surgical Technique for Vascularized Bone Graft From the Base of the Second or Third Metacarpal. This technique takes advantage o... | 498 | ||
| Stages I, II, or IIIA With Ulnar-Positive or Neutral Variance. In this situation the radius is as short as or shorter than the u... | 498 | ||
| Surgical Technique for Capitate Shortening. The capitate is approached using a straight midline dorsal incision. The tendons of ... | 499 | ||
| Stages I, II, or IIIA (Other Techniques). In 2001 Illarramendi et al. described their technique of coring out the metaphyseal re... | 499 | ||
| Stage IIIB. If the disease has progressed to stage IIIB, salvage procedures must be considered. In this stage, carpal instabilit... | 500 | ||
| Surgical Technique for Scaphotrapeziotrapezoid Arthrodesis. An incision is made along the dorsoradial aspect of the wrist, begin... | 501 | ||
| Surgical Technique for Scaphocapitate Arthrodesis. This technique may be used as an alternative to the STT fusion in stage IIIB ... | 501 | ||
| Rehabilitation After Osteotomies or Arthrodeses for Kienböck Disease. In general, patients are splinted for 2 weeks after surger... | 502 | ||
| Stage IV. In stage IV, there is significant collapse of the lunate combined with perilunate arthritis. These degenerative change... | 502 | ||
| Surgical Technique for Wrist Arthrodesis. A longitudinal incision is made over the dorsum of the wrist just ulnar to Lister tube... | 502 | ||
| Rehabilitation After Wrist Arthrodesis. A splint is worn for 2 weeks. Patients are started on immediate finger range-of-motion e... | 505 | ||
| PEDIATRIC KIENBÖCK DISEASE | 505 | ||
| PREISER DISEASE | 505 | ||
| Core Knowledge | 505 | ||
| Diagnosis | 505 | ||
| Diagnostic Imaging | 505 | ||
| Treatment | 505 | ||
| Summary | 507 | ||
| REFERENCES | 507 | ||
| 28 - Dupuytren Disease | 509 | ||
| HISTORY | 509 | ||
| EPIDEMIOLOGY | 509 | ||
| PREDISPOSING FACTORS | 509 | ||
| ETIOLOGY | 509 | ||
| PATHOPHYSIOLOGY | 509 | ||
| ANATOMY | 509 | ||
| PATHOLOGY | 511 | ||
| Microcords | 512 | ||
| Palmar Cords | 512 | ||
| Palmodigital Cords | 513 | ||
| Digital Cords | 513 | ||
| Thumb Diseased Tissue | 513 | ||
| CLINICAL PRESENTATION | 514 | ||
| CLINICAL TYPES | 515 | ||
| DIFFERENTIAL DIAGNOSIS | 515 | ||
| TREATMENT | 515 | ||
| Nonoperative Treatment | 515 | ||
| Surgical Treatment | 516 | ||
| Methods of Skin Management | 519 | ||
| REHABILITATION | 519 | ||
| COMPLICATIONS | 521 | ||
| Intraoperative Complications | 521 | ||
| Early Postoperative Complications | 522 | ||
| Late Postoperative Complications | 522 | ||
| SUMMARY | 522 | ||
| REFERENCES | 522 | ||
| 29 - Ganglion, Mucous Cyst, and Carpal Boss | 524 | ||
| GANGLIONS | 524 | ||
| Core Knowledge | 524 | ||
| Pathology | 524 | ||
| Diagnosis | 524 | ||
| Treatment | 524 | ||
| Dorsal Wrist Ganglion | 525 | ||
| Volar Wrist Ganglion | 526 | ||
| Occult Wrist Ganglions | 526 | ||
| Surgical Technique | 526 | ||
| Ganglion of Tendon Sheath | 526 | ||
| Surgical Technique | 527 | ||
| Rehabilitation | 528 | ||
| Complications | 528 | ||
| MUCOUS CYST | 528 | ||
| Diagnosis | 528 | ||
| Treatment | 528 | ||
| Surgical Technique | 528 | ||
| GANGLION CYST OF THE PROXIMAL INTERPHALANGEAL JOINT | 529 | ||
| Surgical Technique | 529 | ||
| Postoperative Rehabilitation | 529 | ||
| CARPAL BOSS | 529 | ||
| Treatment | 530 | ||
| Surgical Technique | 530 | ||
| Postoperative Rehabilitation | 530 | ||
| Complications | 530 | ||
| REFERENCES | 530 | ||
| 30 - REPLANTATION | 531 | ||
| INTRODUCTION | 531 | ||
| ASSESSMENT AND SURGICAL PREPARATION | 531 | ||
| Classification | 531 | ||
| Surgical Anatomy | 531 | ||
| Indications and Contraindications | 531 | ||
| Transport and Care of the Patient and Amputated Part | 534 | ||
| Preparation of the Part and Stump | 534 | ||
| SURGICAL TECHNIQUE | 537 | ||
| Surgical Sequence | 537 | ||
| Major Limb Replantation | 540 | ||
| Ring Avulsion Injuries | 540 | ||
| POSTOPERATIVE CARE | 540 | ||
| Postoperative Complications: Immediate | 542 | ||
| Postoperative Complications: Late | 542 | ||
| SECONDARY SURGERY | 542 | ||
| OUTCOMES OF REPLANTATION | 542 | ||
| REFERENCES | 543 | ||
| 31 - Thumb Reconstruction Following Partial or Complete Amputation | 545 | ||
| CORE KNOWLEDGE | 545 | ||
| History | 545 | ||
| Classification of the Thumb Injuries | 545 | ||
| Reconstruction of Level A Amputations | 545 | ||
| Postoperative Rehabilitation. The thumb is immobilized for 2 weeks and then range of motion is initiated at the IP and MCP joint... | 545 | ||
| Advantages and Disadvantages. The advantage of the Moberg flap is that it provides sensate coverage with no additional donor sit... | 545 | ||
| Surgical Technique. The skin over the dorsal aspect of the index finger proximal phalanx is elevated as a radially based flap, l... | 545 | ||
| Postoperative Rehabilitation. Thumb adduction and flexion contractures may develop following index-to-thumb cross-finger flaps. ... | 546 | ||
| Advantages and Disadvantages. The advantage to this technique is that it provides a greater area of soft-tissue coverage than is... | 546 | ||
| Additional Options for Large Palmar Soft-Tissue Deficits | 546 | ||
| Reversed Dorsal Digital Island Flap. The use of an innervated reverse dorsal digital island flap for palmar coverage has been re... | 547 | ||
| Venous Flaps | 547 | ||
| Retrograde Arterialized Free Venous Flaps for the Reconstruction of the Thumb. These flaps provide thin flexible cutaneous flaps... | 548 | ||
| Postoperative Rehabilitation. The hand, forearm, and elbow were wrapped in a bulky dressing and were elevated for 5 days while t... | 548 | ||
| Advantages. For reconstruction of the hand, retrograde arterialized free venous flaps offer a custom-made, thin, and pliable fla... | 548 | ||
| Disadvantages. They require microsurgery, which increases the surgical time, effort, and cost compared with local flaps. Postope... | 548 | ||
| Great Toe Pulp Neurovascular Free Flap | 548 | ||
| Dorsal Soft-Tissue Deficits of the Thumb Measuring 3 cm2 or Less Treated With Dorsal Rotation Flap From the Index Finger | 548 | ||
| Technique for Dorsal Rotation Flap From the Index Finger to the Thumb. The flap is elevated in a similar manner as the cross-fin... | 548 | ||
| Postoperative Rehabilitation. This is identical to that of the volar cross-finger flap | 549 | ||
| Advantages and Disadvantages of the Dorsal Rotation Flap. The advantage of the dorsal rotation flap is that it does not require ... | 549 | ||
| Surgical Technique: Reversed Radial Forearm Flap and | 550 | ||
| Surgical Technique: Radial Artery Preserving Forearm Fascial Flap. The radial forearm fascia may also be harvested without sacri... | 550 | ||
| Postoperative Rehabilitation. A protective splint is applied that is designed to avoid compression of the vascular pedicle. Post... | 552 | ||
| Advantages and Disadvantages for Reverse Radial Forearm Flaps. The advantage of these flaps is that substantial soft tissue cove... | 553 | ||
| The Posterior Interosseous Flap. The axis of the flap is the line drawn from the lateral epicondyle of the humerus to the ulnar ... | 553 | ||
| Postoperative Rehabilitation Following Posterior Interosseous Flap. The patients are splinted and required to elevate their arms... | 555 | ||
| Advantages of Posterior Interosseous Flaps. They can be harvested without sacrificing a major artery, and they provide a regiona... | 556 | ||
| Disadvantages. The flaps often have some flap necrosis, and they are challenging to raise. Posterior interosseus nerve (PIN) inj... | 556 | ||
| Metacarpal Lengthening | 556 | ||
| Surgical Technique. The skin overlying the planned osteotomy site is retracted toward the osteotomy at the time of incision to m... | 557 | ||
| Postoperative Rehabilitation Following Thumb Metacarpal Lengthening. After surgery the patient is maintained in a thumb spica sp... | 558 | ||
| Advantages and Disadvantages for Thumb Metacarpal Lengthening. One advantage of thumb metacarpal lengthening is that the donor s... | 558 | ||
| Web Space Enlargement | 558 | ||
| Postoperative Rehabilitation. A palmer abduction night splint is used for 4 to 6 weeks after surgery | 559 | ||
| Toe-to-Thumb Transplantation | 559 | ||
| Vascular Anatomy of the Great and Second Toe. Arterial supply to the foot is conveyed through a dorsal system from the dorsalis ... | 559 | ||
| Great Toe Transplant | 559 | ||
| Surgical Technique: Great Toe Harvest. Dissection is begun after placement and inflation of a sterile high thigh tourniquet. The... | 560 | ||
| Surgical Technique: Great Toe Wraparound Flap. The use of a filleted composite tissue flap of skin, neurovascular pedicle, and n... | 560 | ||
| Second Toe Transplant | 560 | ||
| Surgical Technique. The course of the dorsalis pedis artery and proximal veins are identified and outlined as with the great toe... | 560 | ||
| Postoperative Rehabilitation. The transplanted digit is monitored for viability after surgery. Monitoring can be aided with the ... | 561 | ||
| Advantages and Disadvantages of Toe-to-Thumb Transplant. The advantage of toe transplant is that it can provide reconstruction o... | 561 | ||
| Osteoplastic Thumb Reconstruction | 562 | ||
| 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 b... | 563 | ||
| Stage 3: Providing Sensation With a Neurovascular Island Flap. The neurovascular island flap is outlined on the ulnar aspect of ... | 563 | ||
| Postoperative Rehabilitation. A splint is worn until there is evidence of healing at the bone graft site. Patients are encourage... | 563 | ||
| Advantages and Disadvantages. The donor sites for osteoplastic thumb reconstruction are well tolerated and concealed. Advantages... | 564 | ||
| Surgical Technique. Use of the reverse radial forearm flap requires the existence of a complete palmar arch, and its dissection ... | 564 | ||
| Postoperative Rehabilitation. A thumb spica splint is used for 3 to 4 weeks to protect the reconstructed thumb. When radiographi... | 564 | ||
| Advantages and Disadvantages. The primary advantage of this technique is the single-stage nature of the reconstruction and attac... | 564 | ||
| Dorsal Rotation Flap | 565 | ||
| Surgical Technique. The dorsal rotational flap is elevated using an incision that extends dorsally from the level of the CMC joi... | 565 | ||
| Postoperative Rehabilitation. The skin graft is protected until its incorporation is apparent. The transfixation wires between t... | 566 | ||
| Advantages and Disadvantages. The advantage of the dorsal rotation flap is that it provides a single-stage procedure with sensat... | 566 | ||
| Dorsal Rotation Flap for Phalangization of the Metacarpal Hand. Various techniques are available to improve the pinch function b... | 566 | ||
| Surgical Technique. The dorsal rotation flap is elevated as previously described. The index ray remnant is removed along with th... | 566 | ||
| Postoperative Rehabilitation. The dressings are removed in 2 to 3 weeks to assess skin graft incorporation and the patient begin... | 566 | ||
| Advantages and Disadvantages. The advantages of this technique are its simplicity and the opportunity to avoid an additional don... | 566 | ||
| Reconstruction of Level D Amputations at the Base of the Thumb Metacarpal and Trapezium | 566 | ||
| Pollicization | 566 | ||
| Surgical Technique. Various incisions have been described using modifications of an apex-proximal V that extends to the proximal... | 567 | ||
| Postoperative Rehabilitation. The hand is protected with a spica splint and the pollicized digit is evaluated for vascular insuf... | 567 | ||
| Advantages and Disadvantages. Pollicization of the index finger provides satisfactory treatment for the proximally amputated thu... | 568 | ||
| Staged Multiflap Total Thumb Reconstruction | 568 | ||
| Surgical Technique. Planning is of paramount importance in total thumb reconstruction with multiple flaps. Goals include stabili... | 568 | ||
| Stage 1: Stabilization of the Soft-Tissue Envelope. Adequate and supple soft tissue can be supplied by the pedicled groin flap o... | 568 | ||
| Stage 2: Reconstruction of the CMC Joint and Metacarpal. Free fibula harvest is detailed in Chapter 32. A skin paddle based on p... | 568 | ||
| Stage 3: Reconstruction of the Phalanges. Toe-to-thumb transplant is performed as described earlier in this chapter. Osteosynthe... | 568 | ||
| Stage 4: Opponensplasty, Tenolyses and Revision of the CMC Joint. Multiple techniques for opponensplasty have been described, in... | 568 | ||
| Postoperative Rehabilitation. Standard monitoring for free tissue transplantation is used in the immediate postoperative period.... | 570 | ||
| Advantages and Disadvantages. Multiflap reconstruction of the thumb can provide an aesthetic and functional result that arguably... | 570 | ||
| REFERENCES | 570 | ||
| 32 - Soft-Tissue Coverage of the Hand | 571 | ||
| CORE KNOWLEDGE | 571 | ||
| Goals for Reconstruction | 571 | ||
| Preparation of the Wound Bed | 571 | ||
| Choosing the Right Flap | 571 | ||
| PEDICLED FLAPS (RANDOM VERSUS AXIAL) | 572 | ||
| Random Pattern Flaps | 572 | ||
| Axial Pattern Flaps | 572 | ||
| Staging of Pedicle Flaps | 573 | ||
| TECHNIQUES FOR TISSUE TRANSFER | 573 | ||
| 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 ... | 573 | ||
| Double-Opposing Z-Plasties. This flap is well suited for discrete linear contractures in the first web space, when the scar line... | 573 | ||
| Rhomboid Flaps. In this flap design, all sides of the defect are of equal length including the transverse diagonal of the defect... | 573 | ||
| Dorsal Hand Flap. This flap is well suited for cutaneous defects at the radial or ulnar aspects of the dorsum of the hand. The f... | 573 | ||
| Pedicle Flaps | 574 | ||
| Random Pedicle Flaps | 574 | ||
| Abdominal Flap. The abdominal flap is useful for soft-tissue coverage in the region of the wrist or forearm. A flap can be raise... | 574 | ||
| Abdominal Pocket Flaps. This flap is extremely useful for burn injuries when there has been a substantial area of skin loss on t... | 574 | ||
| Axial Pedicle Flaps | 575 | ||
| Groin Flap. McGregor and Jackson introduced the groin flap in 1972.5 In its heyday, the pedicled groin flap was the mainstay for... | 575 | ||
| Anatomy. The vascular pedicle for the flap is based on the SCIA. While the SCIA provides an axial blood supply to the area of th... | 575 | ||
| Surgical Technique. It is important to inspect the patient for previous incisions from hernia repairs or lymph node biopsies or ... | 575 | ||
| Reversed Radial Forearm Flap. The radial forearm flap was initially described in 1978 for the reconstruction of burn injuries to... | 576 | ||
| Anatomy. A full description of the vascular anatomy of the radial forearm flap is presented in the free flap reconstruction sect... | 576 | ||
| Surgical Technique. A line drawn from the mid-antecubital fossa to the tubercle of the scaphoid marks the axis of the radial art... | 577 | ||
| Posterior Interosseous Flap. The posterior interosseous flap was initially described in the 1980s and has been a good alternativ... | 577 | ||
| Anatomy. As the name describes, this flap is based on the posterior interosseous artery. When used in reverse fashion, it requir... | 577 | ||
| Surgical Technique. With the forearm pronated, the flap is centered on a line between the lateral epicondyle and the ulnar head ... | 577 | ||
| Microvascular Transplantation | 577 | ||
| Fasciocutaneous Free Flaps | 578 | ||
| Lateral Arm Flap. The lateral arm flap is ideal for upper extremity reconstruction because it can be harvested within the same l... | 578 | ||
| Anatomy. The blood supply to the lateral arm flap is via the posterior radial collateral artery (PRCA), which arises from the pr... | 578 | ||
| Surgical Technique. The entire arm and shoulder are prepped and draped out free, and a sterile tourniquet is applied high on the... | 578 | ||
| Advantages and Disadvantages. Advantages: The flap can be harvested from the ipsilateral arm to avoid another donor site in anot... | 579 | ||
| Radial Forearm Free Flap. We use the free radial forearm flap for coverage of small soft-tissue defects over exposed joints or t... | 579 | ||
| Anatomy. Branches of the radial artery perfuse skin along the entire volar forearm. The flap is usually designed along the longi... | 579 | ||
| Surgical Technique. It is important to perform an Allen test to ensure the patency of an ulnar artery that will become the sole ... | 580 | ||
| Advantages and Disadvantages. Advantages: The advantages of the flap are that it is thin with relatively little subcutaneous fat... | 581 | ||
| Anterolateral Thigh Flap. The anterolateral thigh (ALT) flap is an axial fasciocutaneous or fascia-only flap, based on perforato... | 581 | ||
| Anatomy. The vascular pedicle of the ALT flap is the descending branch of the lateral circumflex femoral artery, which in turn a... | 581 | ||
| Surgical Technique. A line is marked from the ASIS to the superolateral patella. The main perforator enters the flap at around t... | 581 | ||
| Advantages and Disadvantages. Advantages: There is minimal functional deficit, especially when harvested as a fascial flap. A la... | 582 | ||
| Scapular Flap. The scapular and parascapular flaps provide a large surface area of skin with a pedicle that is based on the circ... | 582 | ||
| Anatomy. The subscapular artery is 3 mm in diameter and takes its origin from the axillary artery. The subscapular artery then b... | 583 | ||
| Surgical Technique. The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest ... | 583 | ||
| Advantages and Disadvantages. Advantages: The donor site defect from the scapular flap leaves no functional impairment and can b... | 584 | ||
| Muscle Free Flaps | 584 | ||
| Anatomy. The latissimus dorsi is a fan-shaped muscle that originates from the thoracolumbar fascia, the lower six thoracic verte... | 585 | ||
| Surgical Technique. The contralateral latissimus dorsi muscle is usually chosen to perform the surgery without any position chan... | 585 | ||
| Advantages and Disadvantages. Advantages: This is a workhorse flap with a long pedicle of good diameter and it can include the s... | 585 | ||
| Partial Superior Latissimus Muscle Flap. We find this option very useful for hand coverage because a full latissimus flap is rar... | 585 | ||
| Surgical Technique. The patient is positioned as per the latissimus dorsi flap described above. The landmarks of the latissimus ... | 585 | ||
| Advantages and Disadvantages. Advantages: The PSL flap leaves behind part of the latissimus that will still be functional and pr... | 587 | ||
| 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... | 587 | ||
| Anatomy. The gracilis muscle lies medially underneath the deep fascia of the medial portion of the thigh. It arises as a thin ap... | 587 | ||
| Surgical Technique. With the patient lying supine, the leg is prepared circumferentially from the groin to the toes. The hip is ... | 588 | ||
| Functional Muscle Transplantation. Functional muscle transplantation is indicated in cases of major functional loss for which th... | 588 | ||
| Advantages and Disadvantages. Advantages: The gracilis muscle is expendable and leaves no functional loss. It is thin and long a... | 590 | ||
| Rectus Abdominis Muscle Flap. The rectus abdominis muscle is supplied by the superior epigastric artery (SEA) and the deep infer... | 590 | ||
| Anatomy. The rectus abdominis muscle is a long strap muscle interrupted by three to five tendinous intersections or inscriptions... | 590 | ||
| Surgical Technique. Patients who have had prior abdominal surgery, particularly incisions in the groin or lower abdomen, may not... | 591 | ||
| Fascial Flaps | 591 | ||
| Dorsal Thoracic Fascia Flap. For a detailed description of the landmarks and anatomy of the DTF flap, please refer to the scapul... | 591 | ||
| Surgical Technique. The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest ... | 591 | ||
| Anatomy. The fibula has a slender shaft with thick cortices and it is the only expendable long bone in the body that is strong e... | 592 | ||
| Surgical Technique. The patient is prepared in the supine position with the hip flexed and abducted and the knee flexed. The inc... | 592 | ||
| FLAP INSETTING | 593 | ||
| POSTOPERATIVE CARE AND MONITORING | 593 | ||
| REFERENCES | 594 | ||
| 33 - Benign and Malignant Neoplasms of the Upper Extremity | 596 | ||
| CORE KNOWLEDGE | 596 | ||
| History | 596 | ||
| Examination | 596 | ||
| Laboratory Tests | 596 | ||
| Imaging Studies | 596 | ||
| Tumor Growth | 596 | ||
| Staging Tumors | 597 | ||
| Biopsy | 597 | ||
| MANAGEMENT OF BENIGN AND MALIGNANT NEOPLASMS OF THE UPPER EXTREMITY | 598 | ||
| Location. The cyst is typically located within the dermis, although it can be deposited in any subcutaneous tissue, including bo... | 599 | ||
| Imaging. Although not typically needed, an ultrasound or MRI will show a well-circumscribed oval lesion without internal enhance... | 599 | ||
| Histology. Keratin debris forms a thick gelatinous material that extrudes from the cyst. The wall of the cyst is lined by epithe... | 599 | ||
| Treatment. A marginal excision of the cyst is usually curative because recurrence is rare.17 | 599 | ||
| Location. These lesions are commonly located near the proximal and distal interphalangeal joints.17 | 600 | ||
| Imaging. If longstanding, the mass may cause pressure changes in the bone that can be seen radiographically. Alternatively, ultr... | 600 | ||
| Histology. The tumors have abundant histiocyte-like cells and multinucleated giant cells (Fig. 33.6A). The cells may have a surr... | 600 | ||
| Differential Diagnosis. GCT of the tendon sheath can present similar to malignant soft-tissue masses, such as synovial sarcoma o... | 600 | ||
| Treatment. Marginal excision is the mainstay of therapy (see Fig. 33.6B). However, recurrence has been a concern. Historically, ... | 600 | ||
| Location. These lesions can occur anywhere, but in the upper extremity the most common location is in the forearm.19 | 601 | ||
| Imaging. Plain radiographs may show a soft-tissue shadow of the lipoma | 601 | ||
| Histology. These tumors consist of a capsule with mature adipose tissue (Fig. 33.8A).19 | 601 | ||
| Differential Diagnosis. The differential diagnosis for these lesions includes atypical lipomatous tumor (ALT) or liposarcoma. Su... | 601 | ||
| Treatment. Treatment is symptomatic with excision of a lipoma only with symptoms. If a lipoma is removed, typically it can be sh... | 601 | ||
| Imaging. MRI, although illustrative, often cannot definitively distinguish neurilemomas from malignant peripheral nerve sheath t... | 602 | ||
| Histology. The schwannoma, or neurilemoma, is of Schwann cell origin and histologically is composed of a cellular component with... | 603 | ||
| Treatment. Preoperative evaluation with nerve conduction studies and MRI will help to determine whether the lesion is on the sur... | 603 | ||
| Benign Aggressive Fibrous Tissue Lesions | 604 | ||
| Imaging. Desmoid tumors are soft-tissue lesions and as such do not typically involve the bone. Radiographs may demonstrate disru... | 604 | ||
| Histology. Histologically, these are clonal lesions of connective tissue. They have densely packed collagen with well-differenti... | 604 | ||
| Treatment. Surgery remains the primary mode of therapy for patients with desmoid tumors.33,36 Historically, up to a 68% recurren... | 605 | ||
| Vascular Lesions | 605 | ||
| Imaging. Radiographic features depend on the involvement of the underlying bone. If the AVM is located within the bone, cortical... | 605 | ||
| Histology. Lakes of vessels are noted without evidence of hypercellularity or abnormal mitoses in the endothelium (Fig. 33.14A) | 605 | ||
| Treatment. This lesion can be very difficult to completely eradicate.40 AVMs that are stable or adjacent to critical structures ... | 605 | ||
| Imaging. MRI enhanced with gadolinium can differentiate these lesions from sarcomas and vascular malformations, eliminating the ... | 605 | ||
| Treatment. Hemangiomas during the neonatal period and childhood are treated nonoperatively because most eventually involute. Spl... | 605 | ||
| Malignant Soft-Tissue Lesions | 605 | ||
| Location. Fibrosarcomas involve the upper extremity in 30% of cases and the lower extremity in 60%.45 | 606 | ||
| Imaging. MRI is the most useful imaging modality for this type of lesion. Plain radiographs may show soft-tissue density changes... | 606 | ||
| Histology. Histologically, fibrosarcomas are often described as composed of spindle cells arranged in a herringbone pattern (Fig... | 606 | ||
| Treatment. Wide surgical excision with limb salvage, when feasible, is the preferred treatment. Using this approach with the add... | 606 | ||
| Location. Although synovial sarcomas most frequently involve the lower extremities, Brien et al. reported they are the most comm... | 606 | ||
| Imaging. On plain radiographs a soft-tissue density may be observed at the location of the mass, and 15% to 30% will have calcif... | 607 | ||
| Histology. Synovial cell sarcomas are histologically composed of epithelial cells (that form glandular structures) and spindle c... | 607 | ||
| Treatment. Treatment consists of wide surgical excision with chemotherapy and radiation.3 Results of limb salvage are compromise... | 607 | ||
| Location. These are rare malignant lesions of the upper extremity. When the tumor is present, it is most likely to be identified... | 607 | ||
| Imaging. Although pleomorphic sarcomas can occur in bone, they usually occur in the soft tissues. MRI is the imaging modality of... | 609 | ||
| Histology. The tissue consists of spindled and pleomorphic cells. The pleomorphic elements may be bizarre, multinucleated, or “h... | 609 | ||
| Treatment. Treatment remains wide or radical excision with limb salvage as the goal. The decision to use chemotherapy and radiat... | 609 | ||
| Imaging. MRI is useful to clearly show the extent of the tumor because these have a tendency to spread along soft-tissue planes ... | 609 | ||
| Histology. The tumor is composed of epithelioid cells surrounding a central area of necrosis.3 Nuclei are relatively bland with ... | 609 | ||
| Differential Diagnosis. When these lesions ulcerate, they may mistakenly be diagnosed as an infection. They may also be diagnose... | 609 | ||
| Treatment. Wide excision is the recommended treatment for epithelioid sarcoma. When the digits are involved, a ray amputation ma... | 609 | ||
| Location. Angiosarcoma often involves the skin and subcutaneous tissue. It rarely involves the bone, but when it does, it typica... | 611 | ||
| Histology. Histologically, they are typically composed of epithelioid cells with vascular channels (Fig. 33.20).60 | 611 | ||
| Differential Diagnosis. When it occurs at the site of previous radiation for breast cancer, the mass may be confused for recurre... | 611 | ||
| Treatment. Five-year survival is dismal and estimated at 15%.62 The tumor is poorly responsive to chemotherapy or radiation, and... | 611 | ||
| Benign Bone Tumors | 611 | ||
| Age. The average age at presentation for solitary enchondromas is typically in the fourth decade of life. In one study, patients... | 611 | ||
| Location. The most frequent locations in the hand are the proximal phalanges, followed by the middle phalanges and metacarpals.1... | 611 | ||
| Imaging. Plain radiographs are usually sufficient for diagnosis. Typical findings include cortical expansion or endosteal scallo... | 611 | ||
| Histology. Enchondromas contain well-differentiated areas of hyaline cartilage within lamellar bone. In the hand, more cellular ... | 612 | ||
| Differential Diagnosis. The differential diagnosis includes GCTs, fibrous dysplasia, unicameral bone cyst (UBC), chondroblastoma... | 612 | ||
| Treatment. Treatment is largely symptomatic. Painless lesions may be observed with serial plain radiographs. In a review by O’Co... | 612 | ||
| Location. UBCs have a propensity to involve the long bones, typically the proximal femur and proximal humeral metaphysis.75,76 | 614 | ||
| Imaging. The lesions are benign, causing slight expansion of the surrounding bone. They are often well marginated with a thin, s... | 614 | ||
| Histology. The cavity of the lesion is entirely cystic. A thin fibrous membrane lines the cavity. The fluid within the cavity is... | 614 | ||
| Differential Diagnosis. The differential diagnosis should include such entities as an aneurysmal bone cyst (ABC), fibrous dyspla... | 614 | ||
| Treatment. Although there are several described treatment options for UBCs, all typically begin with aspiration of the cyst. Thi... | 614 | ||
| Location. These lesions mostly occur in the metaphysis of long bones. They typically lie in an eccentric location within the bon... | 615 | ||
| Imaging. Plain radiographs will demonstrate an expansile lesion that is often located in the metaphysis of long bones. The lesio... | 615 | ||
| Histology. Macroscopically, these lesions are composed of a cavitary lesion that is divided with multiple fibrous septations. Th... | 615 | ||
| Differential Diagnosis. The differential diagnosis includes UBC, GCT, telangiectatic osteosarcoma, and osteoblastoma. Biopsy is ... | 615 | ||
| Treatment. The type of treatment is dependent on the location of the lesion. In most circumstances, curettage and bone grafting ... | 615 | ||
| Location. Osteochondromas of the hand and wrist are rare, occurring only 4% of the time, according to one study. The proximal ph... | 616 | ||
| Imaging. These lesions may be sessile (broad based) or pedunculated (narrow stalk). They have a cartilage cap that is not apprec... | 616 | ||
| Histology. The stalk is composed of cortical bone with a medullary canal. The cartilage cap is hyaline cartilage (see Fig. 33.34... | 616 | ||
| Differential Diagnosis. The differential diagnosis includes parosteal osteosarcoma and periosteal chondroma | 616 | ||
| Treatment. Excision is reserved for symptomatic lesions or lesions with a rapidly expanding cartilage cap. For most lesions a ma... | 617 | ||
| Location. The lesion is most frequently found in the small tubular bones of the hands and feet | 617 | ||
| Imaging. Radiographs demonstrate a well-circumscribed bony mass arising from the cortical surface (Fig. 33.35A and B). A CT scan... | 617 | ||
| Histology. The lesion demonstrates areas of cartilage and bone. The hypercellular fibrocartilage and hyaline cartilage is haphaz... | 617 | ||
| Differential Diagnosis. The key differential diagnosis is with osteochodroma.2 In contrast to osteochondroma, BPOP typically lac... | 617 | ||
| Treatment. Although no difference in recurrence rates has been reported between intralesional and marginal excision, some series... | 617 | ||
| Location. This unusual tumor presents in the diaphysis or in the junction between the diaphysis and the metaphysis. Although mos... | 617 | ||
| Imaging. Plain radiographs demonstrate a small lucent zone surrounded by dense sclerosis (Fig. 33.36). They are usually less tha... | 617 | ||
| Histology. There is a vascular cellular nidus composed of benign osteoblasts and osteoclasts forming irregular seams of | 617 | ||
| Differential Diagnosis. The differential diagnosis includes osteoblastoma, infection, and fracture. A contrast-enhanced CT has b... | 619 | ||
| Treatment. Most patients have a trial of nonoperative management with NSAIDs.1,92 There are reports that these lesions will spon... | 619 | ||
| Location. The most common locations for osteoblastomas are the diaphysis of long bones or the pedicles of the spine. Although on... | 619 | ||
| Imaging. Radiographically, these lesions may appear similar to osteoid osteomas but are typically larger (>1.5 cm) and have less... | 619 | ||
| Histology. There remains ongoing debate as to whether osteoid osteomas and osteoblastomas represent singular or separate entitie... | 619 | ||
| Differential Diagnosis. The differential diagnosis is wide because these lesions may be confused with osteoid osteoma, ABC, infe... | 619 | ||
| Treatment. Recurrence rates up to 20% have been reported following intralesional curettage and bone grafting. Due to these high ... | 619 | ||
| Location. Approximately half of all cases occur around the knee. The distal radius is the third most common site of presentation... | 619 | ||
| Imaging. Plain radiographs demonstrate an eccentric, lytic lesion without bone formation or calcification (Fig. 33.39). The lesi... | 619 | ||
| Histology. Large numbers of giant cells and nuclei are present. The nuclei within the giant cells appear identical to the nuclei... | 620 | ||
| Differential Diagnosis. The differential diagnosis includes ABC, osteosarcoma, and brown tumor of hyperparathyroidism | 620 | ||
| Treatment. Treatment recommendations for GCTs of bone vary widely, from intralesional resection to amputation, with the primary ... | 620 | ||
| Location. The disease can occur in almost any bone, but the most common locations include the skull, ribs, and femur. The metaca... | 620 | ||
| Imaging. The bone marrow appears to be expanded with matrix of ground-glass opacity on plain radiographs. The lesion is usually ... | 621 | ||
| Histology. The marrow cavity is filled with nonossified osteoid that displaces the normal marrow. A histologic hallmark is lack ... | 621 | ||
| Differential Diagnosis. The differential diagnosis includes UBC, ABC, GCT, infection, Paget disease, osteosarcoma, hemangioma, a... | 621 | ||
| Treatment. There is a role for nonsurgical management. Activity modification or administration of bisphosphonates may be helpful... | 621 | ||
| Location. The proximal humerus is the most frequent site affected. In the hand, chondroblastoma is incredibly rare and may prese... | 623 | ||
| Imaging. Plain radiographs show a well-circumscribed lucent lesion, frequently with stippled calcification (Fig. 33.48) | 623 | ||
| Histology. Microscopically the tissue has a chicken-wire calcification appearance because of ovoid or fried egg–appearing chondr... | 623 | ||
| Differential Diagnosis. The differential diagnosis includes GCT, enchondroma, fibrous dysplasia, degenerative cyst, and chondrom... | 623 | ||
| Treatment. Curettage or local excision and bone grafting is the recommended treatment. The historic recurrence rate is approxima... | 623 | ||
| Malignant Tumors of Bone | 623 | ||
| Location. An estimated 10% to 15% of cases of osteosarcoma arise in the humerus, making this the third most common location in t... | 623 | ||
| Imaging. Radiographically, classic osteosarcoma will present as a region of bone destruction with scattered areas of calcificati... | 623 | ||
| Histology. Osteosarcoma is a malignant tumor derived from osteoblastic cells.1 As such, bizarre nuclei undergoing mitosis are no... | 624 | ||
| Differential Diagnosis. The differential diagnosis for osteosarcoma in the hand includes such entities as a subungual exostosis,... | 624 | ||
| Treatment. Wide excision with adjuvant multiagent chemotherapy is the standard of care to help to improve survival. No significa... | 624 | ||
| Location. Although chondrosarcomas are the most common malignant primary bone tumor of the hand, they occur in the hand and wris... | 625 | ||
| Imaging. Cortical destruction and the presence of a soft-tissue mass are typical of a chondrosarcoma (Fig. 33.54). Radiographs m... | 625 | ||
| Histology. Microscopic features of an enchondroma and chondrosarcoma may be similar. The cartilage cells in chondrosarcoma show ... | 625 | ||
| Differential Diagnosis. As previously stated, it may be very difficult to differentiate a chondrosarcoma from a benign enchondro... | 625 | ||
| Treatment. Chondrosarcoma is a surgical disease. Radiation therapy and chemotherapy are ineffective. In most instances the goal ... | 625 | ||
| Round Cell Tumors of Bone | 625 | ||
| Location. The disease occurs in the major long bones (femur, tibia, and humerus). An estimated 1.4% of Ewing sarcomas occur in t... | 625 | ||
| Imaging. Ewing sarcoma classically presents as a lytic lesion with a periosteal reaction and a soft-tissue mass. The expansion o... | 625 | ||
| Histology. Biopsy of a Ewing sarcoma often shows a liquefied gray-white appearance, which can be mistaken for the purulent exuda... | 626 | ||
| Differential Diagnosis. Osteomyelitis may be confused with Ewing sarcoma, based on a presentation of fevers and elevated inflamm... | 626 | ||
| Treatment. Prior to any operative treatment a complete workup must be performed because an estimated 25% of patients have metast... | 626 | ||
| Location. This lesion typically affects the diaphysis of long bones with a predilection for the femur | 628 | ||
| Imaging. A moth-eaten appearance without a periosteal reaction usually occurs on plain radiographs. MRI identifies a large soft-... | 628 | ||
| Histology. Densely packed round cells are noted, with the tumor invading bone without regard for cortical margins | 630 | ||
| Differential Diagnosis. Metastatic disease and myeloma should be included in the differential diagnosis for this group of patien... | 630 | ||
| Treatment. Chemotherapy and irradiation provide the best initial treatment. Surgery is reserved for prophylactic stabilization o... | 630 | ||
| Location. The tumor typically occurs in bones with the greatest hematopoietic potential | 630 | ||
| Imaging. The lesion is similar to lymphoma of bone, but the MRI does not show as significant a soft-tissue reaction (see Fig. 33... | 630 | ||
| Histology. The tumor consists of densely packed plasma cells with a cartwheel pattern to the nuclear material. Immunohistochemic... | 630 | ||
| Differential Diagnosis. Lymphoma and metastatic disease should be considered in the differential diagnosis | 630 | ||
| Treatment. Bisphosphonate therapy is effective at improving quality of life and the amount of bone pain. Bone pain can also be a... | 630 | ||
| Location. Skeletal metastases to the hand and wrist comprise approximately 0.1% of all metastatic skeletal lesions. Although any... | 630 | ||
| Imaging. Radiographically, lesions appear aggressive, with either purely lytic or mixed lytic-blastic changes. CT or MRI may be ... | 630 | ||
| Histology. The primary site of tumor origin dictates histologic appearance | 630 | ||
| Treatment. An individualized approach is necessary. A thorough medical oncology evaluation is suggested to determine the need fo... | 630 | ||
| Benign Pigmented Lesions of Skin | 631 | ||
| Benign Nevi | 631 | ||
| Nevus. Less common on the hand than elsewhere, nevi usually arise in late childhood, adolescence, or young adulthood. They can m... | 631 | ||
| Blue Nevus. These are uncommon and present as a blue macule or papule, usually less than 6 mm in diameter. They represent a beni... | 631 | ||
| Histology. Histologically, they represent epidermal cell (keratinocyte) proliferations. There is no dermal component to these le... | 631 | ||
| Treatment. Before treatment (usually for cosmetic reasons), one must be sure that melanoma has been ruled out clinically or hist... | 631 | ||
| Histology. Histologically, lentigines represent an increased number of pigment cells (melanocytes) at the base of the epidermis | 632 | ||
| Treatment. Effective cosmetic removal may be achieved with topical bleaching creams, liquid nitrogen, or lasers, including Q-swi... | 633 | ||
| Histology. Caused by local infection with the fungus Hortaea werneckii (formerly Exophiala werneckii), it is diagnosed by cultur... | 633 | ||
| Treatment. This lesion is more common in the coastal southeastern United States; suspicion for this lesion should lead to a smal... | 633 | ||
| Benign Nonpigmented Skin and Nail Lesions | 633 | ||
| Imaging. Radiographs, if taken, may show cortical scalloping from the compression of the soft-tissue mass.19 | 633 | ||
| Histology. Small, round, basophilic cells in clusters surrounding small vessels are noted with glomus cell tumors (Fig. 33.63) | 633 | ||
| Treatment. Surgical excision is the primary mode of treatment. Recurrence occurred in 41% of patients in one study. All of the r... | 634 | ||
| Histology. Histologically, pyogenic granulomas represent an uncontrolled proliferation of granulation tissue and are inflammator... | 634 | ||
| Differential Diagnosis. A nodular melanoma can rarely mimic this condition, and therefore a biopsy is recommended to confirm the... | 634 | ||
| Treatment. Nonsurgical treatment with silver nitrate application is sometimes effective, but surgical excision is a more definit... | 634 | ||
| Histology. Although certain features of the histologic architecture suggest a keratoacanthoma, it may be difficult to distinguis... | 634 | ||
| Treatment. Because of the difficulty in distinguishing keratoacanthoma from SCC, observation is not usually recommended. Rather,... | 634 | ||
| Location. Warts are common on the hands and periungual areas | 634 | ||
| Histology. Verrucae are epidermal proliferations similar to seborrheic keratoses. However, unlike seborrheic keratoses, they oft... | 634 | ||
| Treatment. Due to possible difficulty in ruling out squamous or verrucous carcinoma, any large, refractory, or clinically unusua... | 634 | ||
| Malignant Skin Lesions | 635 | ||
| Location. The most common areas for these to occur are areas that are exposed to the sun, such as the face, hands, and back. Cut... | 636 | ||
| Histology. Histologically, tumors originate in the epidermis and are seen to invade into the dermis or deeper. The tumor nests a... | 636 | ||
| Differential Diagnosis. Precursor lesions to SCC include actinic keratosis and SCC in situ (Bowen disease). Actinic keratoses ar... | 636 | ||
| Treatment. The risk of malignant progression to SCC of an individual actinic keratosis is felt to be low. Nevertheless, in one s... | 636 | ||
| Location. BCC is thought to occur in the hand in only 10% of cases (see Fig. 33.72C).17 | 637 | ||
| Histology. Histologically, there are large islands of basaloid cells with peripheral palisading and cleft artifacts | 637 | ||
| Differential Diagnosis. The differential diagnosis includes ulcerations, actinic keratosis, fungal infections, or psoriasis.156 | 638 | ||
| Treatment. Prognosis with complete removal is excellent because these tumors are usually slow growing (over months to years) wit... | 638 | ||
| Subtypes of Melanoma | 638 | ||
| Nodular Melanoma. Nodular melanoma accounts for 15% to 30% of reported melanomas. The nodular variety is a more aggressive tumor... | 638 | ||
| Lentigo Maligna Melanoma. This entity presents as a slowly enlarging pigmented patch on the sun-exposed skin (usually face) of e... | 640 | ||
| Acral-Lentiginous Melanoma. These lesions are most commonly found on the soles of the feet, but they can occur on the palms and ... | 640 | ||
| Histology. The malignant melanocytes can spread radially and vertically beneath the epidermis. Vertical growth occurs in the mos... | 643 | ||
| Treatment. Excisional biopsy with a 1- to 2-mm margin to obtain staging pathologic information is the recommended biopsy techniq... | 643 | ||
| ACKNOWLEDGMENTS | 644 | ||
| REFERENCES | 644 | ||
| 34 - Congenital Hand Anomalies | 648 | ||
| CORE KNOWLEDGE | 648 | ||
| History | 648 | ||
| Limb Development and Staging | 648 | ||
| The Pediatric Hand | 648 | ||
| Classification | 649 | ||
| Incidence and Etiology | 650 | ||
| Timing of Treatment | 651 | ||
| Principles of Treatment | 652 | ||
| COMMON CONGENITAL HAND DIFFERENCES | 652 | ||
| Shoulder and Arm | 652 | ||
| Clinical Presentation. In total phocomelia, there is at birth, a hypoplastic hand with a variable number of digital remnants att... | 652 | ||
| Treatment. These are generally managed without surgery and are referred to an upper limb prosthetist and/or mechanical engineer.... | 652 | ||
| Clinical Presentation. These are classified into four groups by their degree of hypoplasia,20 and many indices have been establi... | 652 | ||
| Treatment. The presence of a mild deformity with minimal restriction of movement does not require surgery (Fig. 34.6). Many surg... | 652 | ||
| Elbow | 652 | ||
| Presentation. Young patients often do not complain of elbow pain but may have a lateral palpable click, a bony prominence, and s... | 652 | ||
| Treatment. Attempts at surgical reduction and reconstruction of the annular ligament in young children are not predictable. Radi... | 653 | ||
| Clinical Presentation. Males and females are affected equally. Almost 60% have bilateral involvement. Adaptive hypermobility of ... | 653 | ||
| Treatment. Unilateral synostosis or bilateral conditions with less than 30 degrees of fixed pronation do not cause major functio... | 654 | ||
| Clinical Presentation. The entire upper limb is dysplastic with shoulders elevated and atrophic musculature. The arm is longer t... | 654 | ||
| Treatment. Treatment is similar to that for proximal radioulnar synostosis. These are usually effective helping limbs. Osteotomy... | 655 | ||
| Forearm | 655 | ||
| Clinical Presentation. The shoulder is well developed, and there is usually excellent elbow motion despite occasional radial hea... | 655 | ||
| Treatment. Surgery is performed in less than 10% of these children and consists of excision of nubbins, soft-tissue contouring o... | 657 | ||
| Clinical Presentation. Onset of symptoms is usually during late childhood or early adolescence. Females are affected 4:1 over ma... | 657 | ||
| Treatment. Most patients are treated conservatively when they present, often as adolescents or young adults (Fig. 34.13). In you... | 657 | ||
| Clinical Presentation. The presence of a skin lesion on the dorsal forearm is the key to diagnosis. Flexed wrists and digits wit... | 657 | ||
| Treatment. Early recognition and fasciotomy are crucial to decompress all muscle groups in the volar and sometimes dorsal forear... | 657 | ||
| Clinical Presentation. The entire limb may be affected, the shoulders are narrow and rounded, and the supporting musculature is ... | 661 | ||
| Treatment. Passive stretching and splinting is recommended for correction of the hand and wrist deviation. Most surgeons agree t... | 661 | ||
| Clinical Presentation. This condition usually involves the entire upper limb. The shoulder is hypoplastic with limited active ex... | 662 | ||
| Treatment. Treatment must be individualized. Very little is necessary for the hypoplastic shoulder, other than soft-tissue stabi... | 662 | ||
| Clinical Presentation. The size of the radius has become the practical criterion for classification (see Fig. 34.20). There is a... | 666 | ||
| Treatment. Treatment depends on the severity of the deformity. The surgical techniques to correct these deformities are beyond t... | 667 | ||
| Hand | 668 | ||
| Clinical Presentation. In the stiff type the affected joints have normal cartilage but contracted capsules and ligaments. In add... | 668 | ||
| Treatment. Contractures are initially addressed with splinting, stretching, and serial casting. The surgical team should not off... | 669 | ||
| Clinical Presentation. The hands and feet are primarily involved, and at birth many of these children look like AMC patients. Ha... | 669 | ||
| Treatment. In contrast to AMC, surgical treatment carries a more predictable outcome. Initial goals are to release soft-tissue c... | 669 | ||
| Clinical Presentation. The typical cleft hand has a V-shaped, central cleft that can be unilateral or bilateral. The depth of th... | 670 | ||
| Treatment. Flatt has aptly described these hands as “functional triumphs and aesthetic disasters.” The major goals for reconstru... | 671 | ||
| Clinical Presentation. The arm and forearm may be shorter than the opposite limb, and the hand is smaller than the unaffected si... | 673 | ||
| Treatment. Some of these do not require treatment. For the short finger-type symbrachydactyly, web space release and later stabi... | 673 | ||
| Clinical Presentation. The patterns of hand involvement vary, and there is often lipomatous overgrowth within the subcutaneous t... | 674 | ||
| Treatment. Early consultation by the family and expeditious treatment is required. There is initially a desire to retain the ove... | 674 | ||
| Thumb | 676 | ||
| Clinical Presentation. There is a delayed appearance of normal ossification centers. The thumb is best analyzed by a systematic ... | 676 | ||
| Treatment. Prior to any surgery it is important for the hand surgeon to become coordinated with treatment of associated anomalie... | 678 | ||
| Clinical Presentation. The thumbs appear at birth longer and narrow and often have a deficient first web space. Bilateral cases ... | 679 | ||
| Treatment. The goals are to preserve a mobile, independent ray with an adequate web space on the radial border of the hand. A lo... | 679 | ||
| Clinical Presentation. The clinical presentation of thumb polydactyly is variable, with no two thumbs alike. The radial of the t... | 685 | ||
| Treatment. The goals are to create a satisfactory web space, maintain motion in at least two of the three joints, and create the... | 686 | ||
| Clinical Presentation. Trigger thumbs are not present at birth and are usually discovered by babysitters, grandparents, or paren... | 687 | ||
| Treatment. Conservative watchful waiting is recommended for children under 1 year of age. Surgery should is recommended earlier ... | 687 | ||
| Clinical Presentation. The thumb at birth or during infancy lies in varying degrees of flexion below the digits, depending upon ... | 687 | ||
| Treatment. In children with passively correctable thumbs, initial splinting is the mainstay of treatment. Night splinting plus p... | 689 | ||
| Digits | 691 | ||
| Presentation. The affected finger or thumb will be deviated and in severe cases flexed and possibly also rotated. Many variation... | 691 | ||
| Treatment. Although some authors have recommended splinting for clinodactyly, this is a developmental skeletal disorder, which w... | 691 | ||
| Clinical Presentation. Most PIP flexion contractures are slight and ignored, and patients compensate by hyperextending the MCP j... | 691 | ||
| Treatment. Initial passive stretching and splinting is the hallmark of many cases. The majority of type I cases with isolated fi... | 693 | ||
| Clinical Presentation. Most small digital nubbins with a hypoplastic nail are attached along the base of the proximal phalanx. T... | 693 | ||
| Treatment. The treatment varies from simple to complex. Ligation in the nursery has been reported to be associated with complica... | 695 | ||
| Clinical Presentation. These are complex anomalies, which make surgical correction difficult.7,101-103 The spectrum varies treme... | 696 | ||
| Treatment. The same principles for syndactyly release are observed, but correction involves more than separation of the conjoine... | 696 | ||
| Clinical Presentation. These digits and thumbs are shorter than normal and may have associated syndactyly (complete or incomplet... | 701 | ||
| Treatment. The management of brachydactyly runs the entire gamut of hand surgery, and each case must be individualized. Short di... | 702 | ||
| Clinical Presentation. The PIP joint is most frequently involved. Distal joint fusions are unusual but seen in symbrachydactyly,... | 702 | ||
| Treatment. There is no standardized treatment for these digits, which are not usually surgically released. Distraction lengtheni... | 702 | ||
| Clinical Presentation. There are many presentations, and the webbing may involve one or more of the four interdigital web spaces... | 704 | ||
| Treatment. The history of syndactyly correction has been well documented over the past century and appropriately reflects the in... | 704 | ||
| Apert Hand | 708 | ||
| Clinical Presentation. These deformities are always present at birth. One or all extremities may be affected. Deformities are as... | 710 | ||
| Treatment. Management of these digital and thumb deformities should be individualized. At birth the goal is early liberation of ... | 712 | ||
| REFERENCES | 715 | ||
| 35 - Fractures of the Forearm and Elbow | 717 | ||
| FOREARM FRACTURES | 717 | ||
| Kinematic and Mechanical Considerations | 717 | ||
| Treatment Principles | 717 | ||
| Isolated Radius Fractures | 718 | ||
| Isolated Ulna Fractures | 720 | ||
| Monteggia Fracture-Dislocations | 720 | ||
| Essex-Lopresti Injuries | 720 | ||
| FRACTURES OF THE DISTAL HUMERUS | 720 | ||
| Preoperative Evaluation | 720 | ||
| Operative Treatment | 725 | ||
| Operative Exposure | 725 | ||
| Olecranon Osteotomy. The patient is placed in a lateral decubitus position with the arm supported over a bolster. A prior incisi... | 725 | ||
| Extensile Lateral Exposure. A midline posterior or a lateral skin incision can be used. The patient is positioned supine with th... | 725 | ||
| Capitellar and Complex Shear Fractures of the Distal Humerus. Apparent capitellar fractures are often more complex fractures of ... | 731 | ||
| Optimizing Outcome | 732 | ||
| Complications | 732 | ||
| EPICONDYLAR FRACTURES WITH AND WITHOUT INCARCERATION | 736 | ||
| RADIAL HEAD FRACTURES | 737 | ||
| Preoperative Evaluation | 740 | ||
| Operative Approach | 742 | ||
| Operative Exposures | 742 | ||
| Open Reduction and Internal Fixation | 742 | ||
| Prosthetic Replacement | 744 | ||
| Optimizing Outcomes | 744 | ||
| Complications | 746 | ||
| TRAUMATIC ELBOW INSTABILITY | 746 | ||
| Indications and Contraindications | 746 | ||
| Preoperative Evaluation | 747 | ||
| Operative Techniques | 750 | ||
| Intraoperative Testing of Elbow Stability | 752 | ||
| Unstable Simple Elbow Dislocations | 752 | ||
| Posterior Dislocation and Fracture of the Radial Head | 753 | ||
| Terrible Triad Fracture-Dislocations | 753 | ||
| Surgical Procedure: Internal Fixation of a Tip Fracture of the Coronoid. Exposure and fixation of the small transverse fractures... | 753 | ||
| Varus Posteromedial Rotational Instability Injuries | 753 | ||
| Surgical Procedure: Anteromedial Coronoid Facet Fracture. A medial skin flap is elevated with care taken to protect the medial a... | 753 | ||
| Optimizing Outcomes | 755 | ||
| OLECRANON AND PROXIMAL ULNA FRACTURES | 755 | ||
| Indications and Contraindications | 755 | ||
| Preoperative Evaluation | 755 | ||
| Operative Techniques | 756 | ||
| Skin Incision | 756 | ||
| Tension Band Wiring | 756 | ||
| Kirschner Wire Technique | 756 | ||
| Screw Technique | 756 | ||
| Plate and Screw Fixation | 756 | ||
| Operative Technique for Fracture-Dislocations | 758 | ||
| Distal Humeral Shaft Fractures | 758 | ||
| Optimizing Outcomes | 761 | ||
| Rehabilitation of Elbow Injuries | 761 | ||
| Complications of Elbow Injuries | 761 | ||
| REFERENCES | 761 | ||
| 36 - ELBOW ARTHROSCOPY AND INSTABILITY | 763 | ||
| Proximal Anteromedial Portal | 763 | ||
| Anteromedial Portal | 763 | ||
| Proximal Anterolateral Portal | 763 | ||
| Anterior Superolateral Portal | 763 | ||
| Anterolateral Portal | 763 | ||
| Soft Spot Portal | 763 | ||
| Posterolateral Portals | 763 | ||
| Posterior Central Portal | 763 | ||
| EQUIPMENT AND SETUP | 763 | ||
| Prone Position | 763 | ||
| Lateral Position | 764 | ||
| Arthroscopes | 764 | ||
| Infusion Pumps | 764 | ||
| Capsular Capacity | 764 | ||
| Fluid Extravasation | 764 | ||
| ARTHROSCOPIC ELBOW PROCEDURES | 765 | ||
| Plica Syndrome | 765 | ||
| 37 - Elbow Arthritis | 784 | ||
| Rheumatoid Arthritis | 784 | ||
| Posttraumatic Arthritis/Contracture | 784 | ||
| Primary Osteoarthritis | 784 | ||
| EVALUATION | 785 | ||
| History | 785 | ||
| Physical Examination | 785 | ||
| Radiographic Assessment | 785 | ||
| TREATMENT | 785 | ||
| Nonsurgical Management | 785 | ||
| Surgical Management | 786 | ||
| Technique. The patient is placed supine with the elbow on an arm table. A lateral incision is made proximally along the supracon... | 786 | ||
| Medial Column Approach. The medial column procedure is used for the same basic indications as the lateral column procedure, allo... | 788 | ||
| Technique. A medial incision is centered just posterior to the medial epicondyle and extends proximally posterior to the medial ... | 788 | ||
| Management With Elbow Arthroscopy | 788 | ||
| Technique. General anesthesia with or without regional nerve block is used. Supine, prone, and lateral decubitus patient positio... | 788 | ||
| Surgical Management of Rheumatoid Arthritis | 790 | ||
| Technique. The patient is placed in the lateral decubitus position with a beanbag. A posterior midline incision is used, and the... | 791 | ||
| Surgical Management of Osteochondral Lesions | 793 | ||
| REFERENCES | 795 | ||
| HAND THERAPY | 796.e1 | ||
| CERTIFIED HAND THERAPIST | 796.e1 | ||
| ESTABLISHING TREATMENT PROTOCOLS | 796.e1 | ||
| ORDERING HAND THERAPY | 796.e1 | ||
| PATIENT EVALUATION | 796.e1 | ||
| Grip Strength Testing | 796.e1 | ||
| Five Handle-Position Testing | 796.e1 | ||
| Rapid Exchange Testing | 796.e1 | ||
| Pinch Strength Testing | 796.e2 | ||
| Lateral Pinch (Key Pinch) | 796.e2 | ||
| Three-Point Pinch (Chuck, Three-Fingered Pinch) | 796.e2 | ||
| Tip Pinch (Two-Point Pinch) | 796.e2 | ||
| Sensibility Testing | 796.e2 | ||
| Semmes-Weinstein Monofilament Testing | 796.e2 | ||
| Static Two-Point Discrimination | 796.e3 | ||
| Range-of-Motion Measurements | 796.e3 | ||
| Edema Measurement | 796.e3 | ||
| Dexterity Functional Testing | 796.e4 | ||
| CUSTOM ORTHOSES | 796.e4 | ||
| Static Orthoses | 796.e4 | ||
| Dynamic Orthoses | 796.e4 | ||
| Serial Casting/Serial Static Orthosis | 796.e5 | ||
| Static-Progressive Orthoses | 796.e5 | ||
| Resting (Intrinsic-Plus) Hand Orthosis | 796.e5 | ||
| Wrist Orthosis | 796.e5 | ||
| Forearm Based Thumb Spica Orthosis | 796.e5 | ||
| Forearm Based Thumb Spica Orthosis (Radially Based) | 796.e5 | ||
| Dorsal Extension Block Orthosis | 796.e5 | ||
| Tenodesis Orthosis | 796.e7 | ||
| Dynamic Metacarpal Phalangeal Extension Orthosis | 796.e7 | ||
| Muenster Orthosis | 796.e7 | ||
| Posterior Elbow Orthosis | 796.e7 | ||
| Anterior Elbow Orthosis | 796.e7 | ||
| Elbow Flexion Block Orthosis | 796.e7 | ||
| Short Opponens or Hand Based Thumb-Spica Orthosis | 796.e8 | ||
| Carpometacarpal Orthosis | 796.e8 | ||
| Mallet Orthosis | 796.e8 | ||
| Serial Casting | 796.e8 | ||
| Web Spacer Orthosis | 796.e9 | ||
| Ulnar Nerve Palsy Orthosis | 796.e9 | ||
| Static-Progressive Orthoses | 796.e9 | ||
| THERAPEUTIC MODALITIES | 796.e10 | ||
| Therapeutic Heat and Cold Modalities | 796.e10 | ||
| Superficial Heat Modalities | 796.e11 | ||
| Deep Heat Modalities | 796.e11 | ||
| Cold Modalities | 796.e12 | ||
| Electrical Stimulation | 796.e12 | ||
| Continuous Passive Motion | 796.e13 | ||
| BIOFEEDBACK | 796.e13 | ||
| TREATMENT TECHNIQUES | 796.e13 | ||
| Active Range of Motion and Passive Range of Motion | 796.e13 | ||
| Strengthening | 796.e13 | ||
| Heat and Stretch | 796.e13 | ||
| Joint Mobilization | 796.e14 | ||
| Wound Care | 796.e14 | ||
| Edema Control | 796.e14 | ||
| Scar Massage | 796.e15 | ||
| Sensory Reeducation | 796.e15 | ||
| Computerized Exercise Equipment | 796.e15 | ||
| Postsurgical Considerations for Ligamentous Injuries to the Carpus | 796.e15 | ||
| Scapholunate Repair Protocol | 796.e15 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e16 | ||
| Postsurgical Considerations for Collateral Ligament Injuries to the Digits | 796.e16 | ||
| Thumb MCP Collateral Ligament Repair Protocol | 796.e16 | ||
| Index Through Small Finger (SF) MCP Collateral Ligament Protocol | 796.e16 | ||
| Proximal Interphalangeal Collateral Ligament | 796.e17 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e17 | ||
| Postsurgical Considerations for Fractured Metacarpals and Phalanges | 796.e17 | ||
| Metacarpal ORIF Protocol | 796.e17 | ||
| Phalanx ORIF Protocols | 796.e18 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e18 | ||
| Postsurgical Considerations for Distal Radius Fractures | 796.e18 | ||
| Distal Radius ORIF Protocol | 796.e18 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e19 | ||
| Postsurgical Considerations for Flexor Tendon Repairs | 796.e19 | ||
| Flexor Tendon Zone 1 to 4 Early Active Protocol | 796.e19 | ||
| Flexor Tendon Zone 1 to 4 Passive Motion Protocol | 796.e20 | ||
| Zone 5 and FPL Flexor Tendon Protocol | 796.e21 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e21 | ||
| Postsurgical Considerations for Extensor Tendon Injuries | 796.e21 | ||
| Zone 1 or 2 Protocol | 796.e22 | ||
| Zone 3 Central Slip Injuries Postoperative Protocol | 796.e23 | ||
| Zone 4 Through 7 Immediate Controlled Active Motion | 796.e24 | ||
| Zone 4 Through 7 Standard Early Motion Protocol | 796.e25 | ||
| Extensor Pollicis Longus (EPL) Repair Protocol | 796.e26 | ||
| Frayed or Weak Flexor Tendon Tenolysis Protocol. Three days postsurgery the rigid plaster postoperative dressing is removed and ... | 796.e26 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e27 | ||
| Considerations for Digit Amputations/Replantation | 796.e27 | ||
| Digit Replantation Protocol | 796.e27 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e28 | ||
| Considerations for Complex Regional Pain Syndrome | 796.e28 | ||
| Pain Assessment. A thorough pain assessment will include documentation of the location and distribution of the pain and a descri... | 796.e28 | ||
| Sensory Testing. Perform a thorough sensory assessment using objective measures such as the Semmes-Weinstein monofilament (thres... | 796.e28 | ||
| Edema. Include volumetric measurements and baseline circumferential measurements, as appropriate. Include descriptions of the ty... | 796.e28 | ||
| Functional Outcomes Measure. Improving function and participation in meaningful activity is the goal of therapy; therefore an ac... | 796.e28 | ||
| Treatment | 796.e28 | ||
| Pain Management. Pain must be addressed first. Pain must be managed so that the patient is able to participate in therapy and us... | 796.e29 | ||
| Desensitization. This may include the use of textures, pressure, percussion, and vibration. Avoid cyclic stimulation by maintain... | 796.e29 | ||
| Edema Management. Treat edema with light compression wraps or garments, active motion, and elevation. Brawny edema associated wi... | 796.e29 | ||
| Range of Motion and Strengthening Program. Prevent stiffness and improve functional use of the UE in I/ADLs. Follow protocol for... | 796.e29 | ||
| Mirror Visual Feedback. MVF was originally developed in 1995 by V. S. Ramachandran for the treatment of phantom limb symptoms.54... | 796.e29 | ||
| Graded Motor Imaging Program. GMI is a three-step program used to treat pain and movement problems, including CRPS. It is believ... | 796.e29 | ||
| Orthotic Positioning or Casting. Static orthoses, dynamic orthoses, and casts may be used for the protection of healing tissues;... | 796.e29 | ||
| Activity Modification and Adaptive Equipment. This will need to be addressed based upon individual needs. In particular, instruc... | 796.e29 | ||
| Discharge | 796.e29 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e29 | ||
| Considerations for Nonsympathetically Maintained Chronic Pain | 796.e29 | ||
| Setting the Baseline. The baseline is the level to which the patient feels increased pain, weakness, and fatigue with a certain ... | 796.e30 | ||
| The Exercise Program. Exercises should be tailored for the specific diagnoses, along with general aerobic and conditioning exerc... | 796.e30 | ||
| The Discharge Evaluation. On completion of the prescribed duration of outpatient therapy, a discharge evaluation is completed. T... | 796.e30 | ||
| OPTIMIZING HAND REHABILITATION OUTCOMES | 796.e30 | ||
| Postsurgical Considerations for Compressive Neuropathies in the Upper Extremity | 796.e30 | ||
| Endoscopic Cubital Tunnel Release Protocol | 796.e30 | ||
| Carpal Tunnel Release (Endoscopic or Open) Protocol | 796.e31 | ||
| Radial Tunnel Release Protocol | 796.e31 | ||
| Trigger Finger Release Protocol | 796.e32 | ||
| Conservative and Postsurgical Considerations for Tendinopathy of Medial and Lateral Elbow. Tennis elbow, lateral epicondylitis, ... | 796.e32 | ||
| What Is the Best Treatment? No one specific protocol has been shown to be the best treatment for elbow epicondylosis. Such a wid... | 796.e32 | ||
| Suggested Treatment Protocol. Apply ultrasound to the medial or lateral epicondyle with parameters of 3.3 MgHz, 10% to 20%, 1.0 ... | 796.e32 | ||
| Postsurgical Considerations for Total Joint Arthroplasties of the Hand | 796.e34 | ||
| Metacarpal Phalangeal Arthroplasty (Pyrocarbon) Protocol | 796.e34 | ||
| Thumb Carpometacarpal Joint Arthroplasty Protocol | 796.e36 | ||
| Total Wrist Arthroplasty Protocol | 796.e36 | ||
| Postsurgical Considerations for Dupuytren’s Disease | 796.e37 | ||
| Postsurgical Considerations for Ganglion, Carpal Boss, and DIP Mucous Cyst Excision | 796.e37 | ||
| Wrist Ganglion Excision Protocol | 796.e37 | ||
| Mucous Cyst Excision at the DIP Protocol | 796.e37 | ||
| Postsurgical Considerations for DRUJ and Triangular Fibrocartilage Complex (TFCC) Injuries | 796.e38 | ||
| TFCC/DRUJ Repair Protocol | 796.e38 | ||
| TFCC Debridement Protocol | 796.e39 | ||
| Ulnar Osteotomy Protocol | 796.e39 | ||
| Postsurgical Considerations for Elbow Instability | 796.e39 | ||
| Simple Dislocation Protocol | 796.e40 | ||
| Complex Dislocation Postoperative Protocol | 796.e40 | ||
| Postsurgical Considerations for Elbow Fractures | 796.e40 | ||
| Olecranon Fracture ORIF Protocol | 796.e41 | ||
| Postsurgical Considerations for Elbow Arthritis | 796.e43 | ||
| Arthroscopic/Open Debridement Protocol | 796.e43 | ||
| Total Elbow Arthroplasty Protocol | 796.e43 | ||
| Postsurgical Considerations for Nerve Repair or Transfers | 796.e43 | ||
| Digital Nerve Repair Protocol | 796.e44 | ||
| Isolated Median Nerve Repair Protocol Distal to Anterior Interosseous Nerve (AIN) | 796.e44 | ||
| Radial Nerve Repair Protocol | 796.e45 | ||
| Ulnar Nerve Repair at Forearm and Wrist Protocol | 796.e45 | ||
| Postsurgical Considerations for Brachial Plexus/Tendon Transfer | 796.e46 | ||
| REFERENCES | 796.e47 | ||
| Index | 797 | ||
| A | 797 | ||
| B | 798 | ||
| C | 799 | ||
| D | 801 | ||
| E | 802 | ||
| F | 804 | ||
| G | 806 | ||
| H | 806 | ||
| I | 806 | ||
| J | 807 | ||
| K | 807 | ||
| L | 808 | ||
| M | 808 | ||
| N | 810 | ||
| O | 810 | ||
| P | 811 | ||
| Q | 813 | ||
| R | 813 | ||
| S | 814 | ||
| T | 816 | ||
| U | 818 | ||
| V | 819 | ||
| W | 819 | ||
| X | 820 | ||
| Y | 820 | ||
| Z | 820 | ||
| IBC | ES2 |