Back to Contents CHAPTER 42 - Surgery of the Hand Clayton A. Pei er Philoso!

hically and anato ically" the hand and #rain uni$uely identify Ho o sa!iens. Throughout history hu ankind%s !rogress is easured through the e&olution of a strong and o#ile u!!er li # 'ith an inde!endently o!!osa#le thu # and the cogniti&e !o'ers to use the . The #alance" !recision" and s!eciali(ation of the hand gi&e it a central role. The goal of surgical treat ent of the hand is to retain a)i u useful !art length" inde!endent" sta#le otion" and uni !aired o#ility of sensate !arts. *E+ERA, C-+S./ERAT.-+S E)a ination Prior records and diagnostic i ages ay !recisely define the e)tent" li itations" and duration of the !atient%s disorder" and the clinical course. The history should include infor ation of rele&ant syste ic disease such as dia#etes" atherosclerosis" neurologic and !sychiatric disorders" and other serious diseases or chronic diseases. The e)a iner should use the !atient%s nor al anato y0the contralateral" unin&ol&ed li #0to o#ser&e for differences in align ent" contour" and sy etry. -#ser&ing the hand and forear at rest in !ronation and in su!ination" should re&eal any s'elling" asses" erythe a" ulceration" atro!hy" anhidrosis" or e)coriation 12ig. 42-34. The re!roduci#ility of the !atient%s acti&e !artici!ation in the e)a ination !rocess is i !ortant. Res!onses should #e consistent5 re!eated efforts" such as in gri! testing" should !roduce si ilar &alues. Accurate recording of infor ation #y the e)a iner is i !ortant 12ig. 42-24. ,ight !al!ation !ro&ides infor ation concerning e)cessi&e or a#sent s'eating associated 'ith an)iety or insensi#ility in !articular (ones" ner&e distri#utions" der ato es" or #ody !arts. 6ariations in skin contour" te)ture" color" te !erature" ca!illary refill" and hair characteristics offer infor ation regarding circulation" ner&e su!!ly" asses" and 7oint s'elling. A#nor al" in7ured" and scarred soft tissues can restrain 7oint otion" !roduce skin #lanching 'ith atte !ted acti&e function" or cause &isi#le 8di !ling9 of adherent dee! structures" such as in7ured" re!aired" or adherent tendons. The nails and e!onychial and !aronychial cuticular tissues often irror syste ic disease as 'ell as acute and chronic in7ury. +ails ha&e a li ited range of #iologic res!onses. S!litting and fissuring" onycholysis" and onychorrhe)is ay reflect loss of nail adherence to the #ed atri) after trau a" aging" or alnutrition. The trans&erse !osttrau atic nail crease that !arallels the !ro)i al nail fold and ad&ances 'ith gro'th 1Beau%s line4 re!resents a single alteration of nail eta#olis at the ti e of trau a. .t is co on after in7ury #ut does not offer a !oor !rognosis. :ulti!le trans&erse groo&es 1:ee%s lines4 can occur 'ith diseases such as Hodgkin%s disease" alaria" and !soriasis and are nor al in the latter !art of !regnancy. Pig ented longitudinal #ands ay occur in elano a" glo us tu or" and car!al tunnel syndro e. +ail #ed !ig entation can #e found 'ith syste ic se!sis" su#ungual infection" and #enign and alignant tu ors 12ig. 42-;4.

:otion should #e recorded 'ith a s all gonio eter and strength 'ith a dyna o eter. Si !le line sketches record sites of in7ury" s'elling" !art loss" or dysfunction and can !recisely record and co unicate findings 12ig. 42-44. . aging Studies /iagnostic i aging includes traditional roentgenogra!hy" single- and ulti!le-!hase technetiu #one scans" co !uted to ogra!hy 1CT4" and agnetic resonance i aging 1:R.4. :ost !atients should recei&e !lain radiogra!hs in !osteroanterior lateral and one or #oth o#li$ue !ro7ections. Radiogra!hs !ro&ide infor ation 'ith relati&ely inter ediate sensiti&ity" high s!ecificity" and reasona#le cost. /iagnoses can #e issed if only s!eciali(ed and e)!ensi&e e&aluations such as tris!iral or CT" :R." or #one scans are used. The )-ray #ea ust #e centered on the !art in $uestion. Re$uesting an )-ray of the hand ay #e too general for diagnosing a !ro#le in a s!ecific finger. The !hysician e&aluating the i aging studies should recei&e the history" !hysical findings" and a 'orking differential diagnosis 12ig. 42-<4.

TRAUMA
.t is esti ated that one-third of usculoskeletal trau a occurs to the u!!er li #. The annual econo ic i !act fro di inished and lost hand and u!!er e)tre ity function runs into the #illions of dollars in the =nited States. The #est care is deli&ered initially" 'hen tissues are fresh and !otentially can #e sal&aged" re&asculari(ed" and directly re!aired" 'ithout the #urdens of secondary scar tissue after delayed healing" osteoarticular degeneration" or infection. .t is in the acute situation that success is greatest in achie&ing a !otentially functional and aesthetically satisfactory result.

Skeletal Trauma
2orear and >rist
The forear is a t'o-#one usculotendinous unit 'ith co !le) #io echanical interactions. The osteoarticular and liga entous connections of radius" ulna" interosseous e #rane" and !ro)i al and distal radioulnar 7oints allo' the &ariety of hand !lace ent and force transfers. The disru!tion of any one !art of this anato ic and echanical construct should cause the !hysician to search also for less o#&ious in7uries else'here. :ost su#o!ti al outco es after forear fractures can #e related to failure to recogni(e in7ury to a !ro)i al or distal region" often at the radioulnar 7oint" or failure to a!!reciate !rogressi&e loss of initial reduction after treat ent. Se&ere neuro&ascular !ro#le s are unco on" #ut" 'hen !resent" they ay #e related to acute &ascular co !ro ise fro trau a" i o#ili(ation" or co !art ent syndro e. The distal radius for s a #iconca&e articular surface to seat the !ro)i al ro' of car!al #ones" sca!hoid" lunate" and tri$uetru . The radius articulates distally not only 'ith the car!als #ut also 'ith the ulna. The length and relationshi!s of these se&eral

#ones ust #e considered after trau a. The trau ati(ed li # usually can #e co !ared to a !rein7ury state #y radiogra!hs of the o!!osite side 12igs. 42-? and 42@4. /istal radius fractures ha&e #een &ariously classified" #ut a guide that integrates assess ent of fracture !atterns and treat ent is useful 1Ta#le 42-34. Because there are any &ariations of fracture !atterns in the distal radius" this syste si !lifies co on characteristics and suggests treat ent for each generic ty!e of fracture. The treat ent for a s!ecific !atient should #e #ased not only on the !attern #ut also on age" hand do inance" occu!ation" social needs" cogniti&e and !sychosocial factors" and li&ing arrange ents. Radiogra!hically" radius fractures are sta#le or unsta#le" dis!laced or nondis!laced" and 'ith or 'ithout in&ol&e ent of the radiocar!al or radioulnar articular surfaces. The condition of surrounding soft tissues and the !resence of associated in7ury in other regions of the hand" forear " and el#o' are !art of the decision- aking !rocess. Because these fractures ost co only occur fro a fall on an outstretched hand" they result in a #ending o ent 'ith the a)ial load through the radial eta!hysis" and transient or co !lete associated neuro&ascular in7uries" !articularly to the edian ner&e at the car!al canal" are co on. There ay #e an associated a&ulsion fracture of the ulnar styloid !rocess. The radius is ore co only dis!laced dorsally" as in Colles% fracture" 'ith i !action" !ro)i al dis!lace ent" and dorsal angulation of its distal articular surface. .n such cases" the dorsal corte) of the distal frag ent is co inuted and has significant !rognostic i !lications for !ostreduction #one sta#ility 'hen anaged entirely #y e)ternal ani!ulation and cast or s!lint fi)ation 12ig. 42-A4. ,ess fre$uently" a fle)ion or #ending occurs in a fall" creating !al ar dis!lace ent 1S ith%s fracture4. >hen intraarticular" either of these fracture !atterns ay ha&e associated radiocar!al su#lu)ation" #ut this !ro#le is ore often associated 'ith the &olar li! &ariant" S ith Ty!e ; or Barton%s fracture !attern. E&en nondis!laced fractures can !otentially dis!lace during the healing !rocess as resor!tion and #one re odeling occur at the fracture site. :aintaining a satisfactory degree of length and align ent during healing is i !ortant" and !atients should #e o#ser&ed e&ery 3B to 3< days 'ith e)a ination and )-rays. This in7ury ay #e associated 'ith significant s'elling" and circular cast i o#ili(ation should not #e used initially5 cast i o#ili(ation should #e delayed until initial s'elling has su#sided. A sugar-tongs forear and 'rist s!lint ay #e a!!lied that aintains #one length and align ent 'hile si ultaneously controlling forear rotation 'ithout a rigid circu ferential shell 12ig. 42-C4. The dis!laced dorsal frag ent can #e reduced co forta#ly under fracture #lock anesthesia" 'ith or 'ithout addition of intra&enous or intra uscular sedation. After sterile skin !re!aration a 22-gauge needle is introduced o#li$uely into the fracture site &ia o&erlying skin. As!iration 'ill re&eal 'hen the needle is 'ithin the fracture he ato a5 ? to A , 3D e!i&acaine hydrochloride 1Car#ocaine4 or lidocaine hydrochloride 1Eylocaine4 'ithout e!ine!hrine can #e in7ected to !roduce anesthesia in 3B to 3< in. The ty!ical fracture" 'ith dorsal dis!lace ent and angulation fro an e)tension &ector" can #e reduced #y distraction a!!lied #y allo'ing the ar to hang

fro finger tra!s !laced on the inde) and iddle fingers" 'ith the ar itself ser&ing as a counter'eight. A dorsal-to-!al ar force is a!!lied o&er the area of dis!lace ent after the frag ents ha&e #een disi !acted. The 'rist is i o#ili(ed in neutral forear rotation 'ith only slight 'rist fle)ion or ulnar de&iation to a&oid causing secondary co !ression of the edian ner&e. The sugar-tongs s!lint is a!!lied. The 'idth of the !laster should allo' ade$uate s!ace for tissue s'elling. The dorsal and !al ar edges of the s!lint should not touch each other. 2or ost adults" a ;-inch !laster 'idth is ade$uate" #ut in large indi&iduals 4-inch !laster ay #e needed" 'hich is a!!lied o&er generous soft-tissue !adding. After reduction and s!lint a!!lication" )rays are o#tained to record the reduction. .f fracture realign ent is inco !lete" or if significant intraarticular dis!lace ent 13 or ore4 osteoarticular incongruity re ains" re!eated ani!ulati&e reduction or an alternate ethod of treat ent should #e considered. Patients should ha&e a neuro&ascular e)a ination #efore ani!ulati&e reduction" and their edian ner&e sensory status should #e assessed again after the a!!lication of the !laster s!lint. 2racture !osition and neuro&ascular status ust #e follo'ed carefully. After @ to 3B days" the !atient has re!eat )-rays. Ele&ation and digital otion 'ill ha&e di inished s'elling significantly in any cases" and the s!lint ay #e re!laced 'ith a circular cast. So e circu stances ay dictate snugging the s!lint 'ith a re!lace ent circular gau(e o&er'ra! and delaying cast a!!lication an additional 'eek or t'o. .n young !atients" a long ar cast ay #e !refera#le5 in the older indi&idual" the risk of el#o' stiffness is significant" and !rolonged i o#ili(ation of that 7oint is not ad&isa#le. Ele&ation of the hand !lus finger o#ili(ation and a thera!y !rogra that is directed to the entire u!!er li #" including the shoulder" is started at this ti e. >hen the s!lint is changed into a cast" )-rays are o#tained after cast a!!lication. Radiogra!hs are re!eated e&ery 2 'eeks to onitor healing and o#ser&e for colla!se" angulation" and dis!lace ent 12ig. 42-3B4. :ost casts can #e re o&ed ? 'eeks after trau a" 'hen radiogra!hs de onstrate o#&ious ne' #one for ation and the fracture region is relati&ely nontender. .f no otion or significant !ain is elicited at the fracture site" cast i o#ili(ation ay #e discontinued. Thera!ists can fa#ricate a custo ther o!lastic restingF!rotecti&e s!lint and acti&e otion e)ercises can #egin 12ig. 42-334. The custo s!lint can generally #e discontinued after another 2 to 4 'eeks" de!ending on !atient co fort and !rogress in reha#ilitation. :otion e)ercises for the hand and 'rist are follo'ed #y !rogressi&e strengthening" increasing acti&ities of daily li&ing" and return to function. =nsta#le fractures of the distal radius are treated 'ith !ercutaneous or o!en fracture !inning under fluorosco!ic onitoring. :any of these fractures re$uire an e)ternal fi)ation de&ice to !re&ent !rogressi&e colla!se and loss of align ent at the co inuted fracture line. >hen fractures are significantly i !acted" areas of o#&ious #one loss 'ithin the su# eta!hyseal region after reduction ay re$uire #one graft or #one su#stitute to !re&ent delayed union or nonunion. :anage ent #y o!en reduction" 'ith the co #ination of e)ternal and internal fi)ation 'ith !lates and scre's" is a!!ro!riate for the ore se&ere su#grou!" ost often those of younger age 'hose in7uries are the result of high-i !act trau a" such as those sustained in &ehicular accidents and isha!s 'ith hea&y achinery 12igs. 42-32" 42-3;" and 42344.

Carpal Bone Fractures

The eight car!al #ones ha&e a large !ro!ortion of their surfaces co&ered 'ith articular cartilage" a fact that has t'o clinical i !lications. 2irst" the li ited !eriosteal attach ent offers a tenuous #lood su!!ly5 after fracture one of the frag ents is !otentially at risk for a&ascular necrosis. Second" ost car!al fractures are intraarticular in7uries. The dis!laced fracture often needs surgical re!air to a&oid secondary arthritis fro 7oint surface incongruity. The !attern of car!al fracture or fracture dissociation ay not #e clearly discerni#le on standard !osteroanterior and lateral radiogra!hs" and o#li$ue &ie's" car!al tunnel !ro7ection" and other &ie's ay #e necessary. .f results are still e$ui&ocal" tris!iral to ogra!hy or CT should de onstrate the fracture !atterns and frag ent !ositions. >hen the $uestion of 'hether or not a fracture is !resent" a fre$uent !ro#le 'ith in7uries a#out the radial side of the car!us" es!ecially the sca!hoid" the use of technetiu #one scan @2 h after trau a is diagnostic.

Scaphoid Fracture
+early t'o-thirds of all car!al fractures are of the sca!hoid. This in7ury occurs ost often in ales aged 3< to ;B years. Sca!hoid fractures occur ost co only through the iddle third of the 'aist or at the 7uncture of the iddle and !ro)i al !oles. /iagnosis re$uires clinical and i aging infor ation. After a fall on the outstretched hand" the !atient%s 'rist is tender at the anato ic snuff #o)" the hollo' #et'een the thu # e)tensor tendons on the radial as!ect of the 'rist" 7ust dorsal and distal to the styloid !rocess of the radius. Pain is elicited and sy !to s re!roduced 'ith direct !ressure o&er the tu#erosity of the sca!hoid at the #ase of the thenar e inence and 'ith !assi&e 'rist otion. Routine radiogra!hs in !osteroanterior" lateral" and o#li$ue &ie's along 'ith a !osteroanterior !ro7ection in ulnar de&iation to elongate the sca!hoid hel!s to &isuali(e the fracture. .f initial radiogra!hs are nor al #ut the history and !hysical e)a ination suggest the !ossi#ility of sca!hoid fracture" continuous i o#ili(ation in a thu # s!ica s!lint or cast is ad&ised. Re!eat radiogra!hs in 2 to ; 'eeks or technetiu #one scan after @2 h 'ill ake the diagnosis. 2racture configuration 12ig. 42-3<4 and location affect sta#ility and la#ility of the #lood su!!ly. The !ro)i al !ole of the sca!hoid is su!!lied fro &essels entering the distal t'o-thirds. 2racture of the !ro)i al third or a s aller frag ent risks a&ascularity in the s all !ro)i al frag ent" resulting in nonunion and secondary arthrosis. +ondis!laced sca!hoid fractures treated 'ith ade$uate i o#ili(ation ha&e a union rate of CB to C< !ercent. /is!laced fractures" defined as dis!lace ent of 3.B or ore" are associated 'ith a&ascular necrosis in one-half and nonunion in onehalf of !atients if not reduced and sta#ili(ed o!erati&ely. Sca!hoid fracture frag ent dis!lace ent of 2.B or ore should raise sus!icion of an associated intercar!al liga ent in7ury" such as transsca!hoid !erilunate insta#ility or su#lu)ation. .n the treat ent of the nondis!laced" sta#le sca!hoid fracture" one study de onstrated decreased ti e to union and decreased incidence of delayed and nonunion 'hen long ar " a#o&e-el#o' thu # s!ica casts 'ere used for ? 'eeks" follo'ed #y short ar s!ica cast for a!!ro)i ately ? 'eeks. . o#ili(ation of the 'rist in slight fle)ion and radial de&iation rela)es the &olar radiosca!hoid liga ent. The thu # eta!halangeal 7oint should #e included in the cast" at least during the initial ? 'eeks. -!en reduction

and internal fi)ation can #e done effecti&ely 'ith an interfrag entary lag co !ression scre' or 'ith Girschner 'ires for all dis!laced fractures. The scre' techni$ue is ore sta#le and allo's earlier o#ili(ation. The use of !ercutaneous co !ression scre's for i ediate internal sta#ili(ation of the acute #ut nondis!laced fracture is increasingly !o!ular outside the =nited States. ,i ited e)!erience suggests a ore ra!id course 'ith decreased acute and long-ter disa#ility 'ithout significant increase in co !lications. .nterfrag entary scre' techni$ue for this #one is technically de anding. >hen i ediate !ostin7ury i aging does not clearly de onstrate the !resence of fracture" i o#ili(ation and additional i aging infor ation #y standard radiogra!hs in 2 'eeks or #one scan after ; days are necessary to ake the diagnosis. 2racture dis!lace ent is unacce!ta#le" and 3 to 2 of al!osition" angulation" or any intercar!al colla!se should !ro !t o!en re!air. ,ess than < !ercent of nondis!laced fractures result in nonunion" 'hich is defined as a#sent )-ray e&idence of healing 4 to ? onths after in7ury" 'hile a <B !ercent nonunion rate for dis!laced fractures occurs.

Other Carpal Fractures

The lunate ost co only fractures secondary to idio!athic a&ascular necrosis or lunato alacia 1Gien#Hck%s disease4 'ithout a history of acute trau a. The lunate is ore radiodense on !osteroanterior !ro7ection radiogra!hs. :ild radiodensity is not unco on after car!al in7uries and should not #e confused 'ith Gien#Hck%s disease. Si !le" acute lunate fractures are not co on. They should #e treated 'ith i o#ili(ation 'hen nondis!laced5 o!en treat ent rarely is re$uired. 2ractures of the ca!itate are unco on. The !ro)i al !ole" like that of the sca!hoid" recei&es its #lood su!!ly fro &essels that enter distally. Ca!itate neck fractures are at !otential risk for a&ascular necrosis. >hen a&ascular necrosis occurs" usually it is inco !lete" that is" te !orary. Ca!itate head colla!se is unco on. .solated fractures of the tra!e(iu and tra!e(oid are unco on. .n7uries to these #ones are often associated 'ith intraarticular fractures of the #ase of the first etacar!al. -!en reduction is often necessary" 'ith internal fi)ation #y Girschner 'ires or co !ression scre's. 2ractures of the !isifor usually are secondary to a direct #lo' to the hy!othenar e inence. The fractured !isifor is #est seen in car!al tunnel !ro7ection radiogra!hs or CT i aging. E)cision ay #e re$uired for dis!laced fractures" nonunion" alunion" and secondary arthritis. There are t'o ty!es of fracture of the ha ateI those in&ol&ing the #ody and those of the ha ulus 1hook4. 2ractures of the #ody of the ha ate are difficult to diagnose on !lain radiogra!hs5 i aging ay re$uire se&eral o#li$ue !ro7ections or CT scan. The !atient ay ha&e !ain referred to the dorsal 'rist 'ith fractures of the #ody or hook. 2ractures of the #ody of the ha ate heal 'ith i o#ili(ation for 4 to ? 'eeks. 2ractures of the ha ulus are ore co on and usually are the result of a direct force trans itted into the #ase of the !al fro a gras!ed o#7ect. The !al is tender to direct !ressure o&er the ha ate5 so eti es the disco fort is re!orted as dorsal. Secondary ulnar neuro!athy at *uyon%s canal also ay #e !resent. ,ate fle)or tendon ru!tures ha&e #een re!orted" es!ecially in those 'hose undiagnosed !al ar !ain syndro e is treated 'ith re!eated steroid in7ections.

Routine radiogra!hs and car!al tunnel &ie's ay #e negati&e5 CT scan can ake the diagnosis. The acute hook fracture should heal in a short ar cast5 dis!laced fractures and sy !to atic nonunions are ost efficiently treated 'ith e)cision of the ha ulus and s oothing of the fracture #ase.

Carpal Dislocations and Instabilities

The radiocar!al and intercar!al articulations are not inherently sta#le on the #asis of their osseous anato y5 it is the integration of osteoliga entous anato y that secures the co !le) kine atics of 'rist function 12ig. 42- 3?4. :ost car!al dislocations are caused #y an acute a)ial load 'ith 'rist hy!ere)tension. The !ri ary dislocation occurs at the idcar!al 7oint 'ith dorsal dis!lace ent of the ca!itate. >hen the ca!itate dis!laces" the sca!hoid ust fracture or its liga ents 'ill tear" allo'ing it to rotate fro a relati&ely hori(ontal !osition to one of &ertical alalign ent 'ith the !ro)i al !ole rotating dorsally. This configuration is called dorsal !erilunate dislocation 12igs. 42-3@" 42-3A" and 42-3C4. These serious and unsta#le intraarticular in7uries" 'ith or 'ithout sca!hoid fracture or tri$uetral #reak" re$uire careful reduction and internal fi)ation. The a7ority re$uire o!en reduction. /irect trau a to the edian ner&e fro i !act" #y secondary stretching resulting fro dorsal dis!lace ent of the car!us" or fro acute #leeding and s'elling 'ithin the car!al tunnel" should #e elucidated #y neuro&ascular e)a ination. Car!al insta#ilities of all ty!es should #e treated aggressi&ely to !re&ent chronic insta#ility and dysfunction 12ig. 42- 2B4.

Metacarpal Fractures
Because of their su#cutaneous location and relati&ely rigid !ro)i al articulations" the etacar!als re!resent one-third of hand and 'rist fractures. 2ailure to reconstitute the etacar!als ay lead to !er anent functional deficit. Co !lication rates after e)tensi&e e)!osure for !late fi)ation can #e high" and the risk of additional in7ury ust #e 'eighed against outco es e)!ected 'ith conser&ati&e easures. The goal is early restoration of hand function to !re&ent stiffness. >hether internal or e)ternal i o#ili(ation is used is i aterial" as long as #one length and articular relationshi!s are !reser&ed and soft-tissue anage ent and thera!y techni$ues can #e instituted ra!idly. The etacar!als for a rigid longitudinal arch #ecause of their con&e)ity dorsally. There also is a dyna ic trans&erse arch #ased on the sta#le and o#ile car!o etacar!al articulations of the thu # and those of the ring and little fingers. The thenar and hy!othenar uscles o#ili(e these arches" allo'ing !recision and strength in hand use. Because of sta#le !ro)i al and distal liga entous su!!ort" isolated fractures of the central third and fourth etacar!als0the iddle and ring fingers0 are less likely to shorten" rotate" and angulate. S!iral and o#li$ue fractures that dis!lace do so 'ith shortening and rotation. :etacar!al shortening also ay occur #y direct #one loss or angular defor ity. :idshaft angulation !roduces a ore serious defor ity 12ig. 42-234. Pain and s'elling are the hall arks of etacar!al fractures" as the loose dorsal tissues allo' large a ounts of ede a fluid and fracture he ato a to accu ulate. The #ony

!ro inence of an angulated fracture a!e) is al'ays located dorsally #ecause of the !ull of the interosseous intrinsic uscles. A skin laceration often connotes an o!en fracture and andates surgical treat ent. This is i !ortant in etacar!al fractures caused #y a tooth i !act" as in a fight5 this results in a conta inated !uncture 'ound at the fracture site or at the etacar!o!halangeal 7oint. Patients 'ith hu an or ani al #ites re$uire surgical irrigation of the fracture site or 7oint !lus high-dose anti#iotics. Rotational align ent of a etacar!al fracture is #est assessed 'ith the fingers fle)ed at the etacar!o!halangeal 7oint. >ith an uncoo!erati&e 7u&enile !atient or an unconscious !atient" the 'rist can #e !assi&ely fle)ed and e)tended" 'ith the resulting e)trinsic fle)or and e)tensor effect on digital align ent o#ser&ed. :alrotation or acti&e fle)ion !roduces a degree of &isi#le digital o&erla!. :alrotation and radialulnar angulation interferes 'ith hand function and should #e corrected. 2ractures of the etacar!al heads are less co on" usually the result of direct trau a. The second and fifth etacar!als are ost co only trau ati(ed" 'ith a ;I3 ale !redo inance. As these are intraarticular in7uries" a ste!-off of 3.B or ore is significant. =nsta#le fractures are fi)ed 'ith !ins" scre's" or !lates. The etacar!al neck is the ost co on fracture site. As 'ith dis!laced and angulated fractures" the corte) on the angulated side usually is co inuted. The nor al !ull of the intrinsic uscles further fle)es the head frag ent" aking it difficult to aintain reduction. The degree of angulation and the etacar!al in&ol&ed deter ines the #est treat ent for the s!ecific fracture. Because the second and third car!o etacar!al 7oints are rigid" no ore than 3B to 3< degrees of !al ar angulation of the distal frag ent is acce!ta#le. Considera#ly ore angulation 1;B to <B degrees4 ay #e acce!ta#le in the neck region of the fourth and fifth etacar!als. Closed reduction ay #e achie&ed through the co #ination of direct and counter!ressure a!!lied 'ith the finger fle)ed 12ig. 42-224. The hand should not #e i o#ili(ed in the !osition de!icted for ani!ulation. -!en reduction usually is not necessary" #ut 'hen the fracture is unsta#le and residual or recurring angulation is not acce!ta#le" then internal fi)ation is re$uired. :etacar!al shaft fractures should #e !rotected 'hen !osition and angulation are acce!ta#le" #ut re!aired 'hen they are not. S!iral and o#li$ue fractures undergo alrotation and dis!lace ent #ecause of the nor al forces of the fle)or and e)tensor tendons and hand intrinsics. Those that are not initially dis!laced or rotated ust #e carefully o#ser&ed. .nternal fi)ation allo's ore ra!id soft-tissue o#ili(ation and often can #e treated 'ith !ercutaneous inter etacar!al !in techni$ue" local #lock anesthesia" and fluorosco!ic onitoring. So e of these fractures re$uire o!en reduction for fi)ation 12igs. 42-2;" 42-24" and 42-2<4. .ntraarticular car!o etacar!al fracture-dislocations are of functional significance in the o#ile fourth and fifth etacar!al-ha ate saddle 7oints. These o#ile 7oints ha&e tendon insertions around the #ases of the etacar!al and !eriarticular tissue that allo' dis!lace ent 12igs. 42-2? and 42-2@4. Reduction is #est aintained 'ith internal fi)ation. So e re$uire o!en reduction and fi)ation to restore accurate osteoarticular align ent. /elayed union and nonunion of closed etacar!al in7uries are unco on. Bone consolidation should #e discerni#le #y radiogra!h 'ithin 32 to 3? 'eeks. . o#ili(ation of the hand for se&eral onths seriously risks co !ro ising function.

+onunion ay #e associated 'ith inade$uate i o#ili(ation" loss of #one su#stance" infection" or disru!tion of #lood su!!ly. /igital i !air ent ay result fro tendon adhesions directly o&er a fracture site" secondary s all-7oint contracture fro !rolonged i o#ili(ation" or scarring of trau ati(ed intrinsic uscles. Si ultaneous skeletal sta#ili(ation and s all-7oint o#ili(ation should #e achie&ed.

Phalan eal Fractures

The goal of !halangeal fracture treat ent is restoration of anato y" #one healing" and full functional reco&ery. /ysfunctional angulation and rotation are not acce!ta#le. Sta#ili(ed fracture anato y ust allo' ra!id o#ili(ation. Each ethod of fracture care has relati&e ad&antages and risks. ,ess in&asi&e ethods ay offer less sta#ility" #ut they inflict less soft-tissue da age. An algorith for care is outlined in 2ig. 422A. >hen o!eration is re$uired" the least trau atic ethod should #e used to a&oid &iolation of gliding structures 'hen !ossi#le. The !atient%s acti&e !artici!ation in a reha#ilitation !rogra enco !assing su!er&ised thera!y" custo s!linting" and ho e e)ercises is critical for reco&ery of function. Pro)i al inter!halangeal 7oint otion" !articularly e)tension" can #e difficult to regain if an in7ured" s'ollen finger is i o#ili(ed in fle)ion. Scar can tether the e)tensor tendons or !re&ent the fle)ors fro gliding" i !airing gras! and ani!ulation and !re&enting return to !rein7ury e !loy ent. >hen Girschner 'ires are used" they ay #e #uried" and they ay then #e retrie&ed in the out!atient setting under local anesthesia after 4 'eeks. Sufficient fracture healing usually has occurred #y then des!ite the delayed a!!earance of significant interfrag entary callus on radiogra!hs. >hen Girschner 'ires are left e)ternal to the skin" as in 7u&eniles" !ins ust #e ca!!ed and cared for eticulously. Scre's and !lates usually are not re o&ed until at least ? to 32 onths after fracture healing. S all #one !lates and scre's need not #e re o&ed e)ce!t to treat sy !to s fro the hard'are.

Fin er !i ament In"uries

:etacar!o!halangeal 1:P4 Joint :P 7oint dislocations can #e anaged #y closed eans through gentle reduction and s!linting under local anesthesia. .f significant residual collateral liga ent insta#ility in a !articular finger is !resent" surgical re!air is necessary. The s all su#grou! of irreduci#le fractures re$uires o!erati&e re!air. Patients 'ith acute collateral in7uries ay ha&e a alrotated finger 12ig. 42-2C4 #ecause of rotation a#out the intact liga ent. The ru!tured liga ent region is s'ollen and tender. E&aluation #y gentle !assi&e stress should #e done 'ith the :P 7oint in fle)ion" a !osition in 'hich the collateral liga ents are nor ally tight. So e !erfor si ultaneous radiogra!hic e&aluation during this !assi&e stress. Patients 'ith !articular disco fort 'ho cannot tolerate soft-tissue stress in order to e&aluate 7oint sta#ility can #e e)a ined after 3.B , of local anesthetic agent is in7ected into the 7oint. /orsal dislocations that are irreduci#le are characteri(ed #y di !ling of the !al ar skin o&er a !ro inent etacar!al head. .nter!osed soft tissues can !re&ent 7oint reduction. .n these cases surgical treat ent is re$uired 12ig. 42-;B4. Thu # :P 7oint in7uries result fro a)ial load and angular dis!lace ent. These in7uries often occur 'hen the !atient 7a s the thu # into an o#7ect 'hile falling.

/isru!tion of the ulnar collateral liga ent of the thu # is called ga ekee!er%s thu #" although the ter 'as originally a!!lied only to chronic ulnar collateral insta#ility. A larger !ercentage of the in7uries are caused #y 7a ing the thu # into sno' in a fall 'hile skiing. Collateral la)ity at the thu # :P 7oint is dysfunctional and !ainful and ay lead to late arthritis. After !lain radiogra!hs fail to detect the !resence of intraarticular fractures" the thu # is carefully e)a ined in a#out ;B degrees of :P fle)ion" gently and !rogressi&ely stressing the sus!ect collateral liga ent 12ig. 42;34. Radiogra!hs ay #e o#tained si ultaneously 12ig. 42-;245 the stress radiogra!h is #est !erfor ed #y the e)a ining !hysician. Treat ent of inco !lete collateral liga ent in7uries 'ithout associated insta#ility is #est done closed" 'ith cast i o#ili(ation for a!!ro)i ately 4 'eeks" follo'ed #y custo -s!lint i o#ili(ation. Soreness ay !ersist for se&eral onths. Co !lete disru!tion of the ulnar or radial collateral liga ent of the thu # :P 7oint should #e re!aired and !rotected #y te !orary !in fi)ation of the 7oint" 'hich is ost likely to gi&e a #etter result and shorter !eriod of disa#ility than secondary reconstruction.

Pro#imal Interphalan eal $PIP% &oint

The tightly congruent osteoarticular contours of the !ro)i al inter!halangeal 7oint ake restoration of sta#le align ent of disru!ted or dis!laced structures essential" allo'ing safe institution of early o#ili(ation. Stiffness" rather than insta#ility" is the outco e that ust #e a&oided after trau a in the region of the P.P 7oint. :ost dorsal and lateral P.P dislocations can #e treated #y closed reduction and should #e sta#le. . o#ili(ation for 3B to 3< days allo's the !atient to reco&er fro the acute !osttrau atic effects #efore a !rotected o#ili(ation !rogra is started" 'ith #uddy ta!es to an ad7acent finger. Joints 'ithout an actual history of dis!lace ent" defor ity" or reduction #y !atient" coach" trainer" or !hysician ay ha&e considera#le s'elling and stiffness if not o#ili(ed early. /islocations 'ith fractures are ore likely unsta#le 12igs. 42-;; and 42-;44. Posto!erati&e i o#ili(ation that inad&ertently stresses an osteoarticular frag ent results in !osttrau atic insta#ility 12ig. 42-;<4. The co #ination of 7oint surface i !action and liga ent disru!tion ha&e the 'orst !rognosis 12ig. 42-;?4. These fracture-dislocations ha&e an ulti ate outco e that is often unsatisfactory.

Palmar $'olar% PIP Dislocations

.n &olar P.P dislocations the iddle !halan) is dis!laced !al ar'ard" so eti es resulting in serious insta#ility. This P.P dislocation results fro the co #ination of a)ial load and !al ar &ector force" ost often during s!orts acti&ities 12ig. 42-;@4. -ften unrecogni(ed is that this trau a has an associated disru!tion of the central sli! of the e)tensor tendon and one collateral liga ent. Closed reduction and !inning" or o!en reduction for the irreduci#le &ariant" 'ith !rolonged !osto!erati&e thera!y is the rule.

Distal Interphalan eal $DIP% &oint

The /.P 7oint ust #e co forta#le and sta#le for !recision !inch and !o'er gri!. .deally" reha#ilitation after /.P 7oint trau a restores a !ain-free and sta#le arc of otion" #ut this is not al'ays !ossi#le. So e co !ro ise #et'een sta#ility" otion" and sy !to s ay #e necessary5 functional !osition" near e)tension" and /.P 7oint sta#ility are the ost critical to regaining a useful hand. Collateral liga ent in7uries and dorsal or !al ar dislocations ay occur at this le&el. Sta#le 7oints for 'hich

closed reduction is !ossi#le need not #e !inned. Percutaneous fi)ation under fluorosco!ic guidance" 'ith aintenance of !in fi)ation for 4 to < 'eeks" is a useful ad7unct" #ecause it allo's the rest of the hand to #e ra!idly o#ili(ed. .t is !refera#le to #ury !ins in adults and to re o&e the in an out!atient setting using local anesthesia. S'elling and disco fort !ersist after /.P and P.P in7ury for ; to ? onths in ost !atients. 2unctional reco&ery of o#ility and !o'er occurs slo'ly. Protection during s!orts and si ilar acti&ities ay #e needed for ? onths or ore. .t should #e e)!lained early to !atients that the 7oint is likely to #e sore or s'ollen for so e ti e5 the sooner !atients understand this" the ore likely they are to acce!t their role in reco&ery.

Fin ertip In"uries

Conser&ati&e treat ent" such as healing #y secondary intention of fingerti! a !utations" often results in !ainful scarring and defor ity. There are se&eral re$uire ents for a satisfactory outco e after fingerti! a !utationI 134 -!ti u functional finger length ust #e aintained" and additional shortening during or as a co !lication of treat ent ust #e a&oided. 124 The residual ti!F!ul! re$uires a resistant and resilient character like nor al skin. 1;4 E)cellent fingerti! sensi#ility should #e aintained to a&oid 8#linding9 the finger. 144 2inally" #one su!!ort for the nail is needed to ini i(e #eaking defor ity. Achie&ing all of these targets si ultaneously ay #e i !ossi#le" and choices ay #e necessary. Anato y and function in con7unction 'ith the ty!e and le&el of in7ury in each !atient should #e considered 12igs. 42-;A and 42-;C4. >hich finger is in7ured and ho' it 'as in7ured influence treat ent. 2or the thu #" e&ery reasona#le effort ust #e ade to restore a sensate and dura#le !ul!. Re$uire ents for sensi#ility are ore critical in the inde) and iddle fingers" #ut they are also significant in the ulnar !ul! of the s all finger. A !utations can #e clean and shar!" #ut the co on a&ulsion ay ha&e a co !onent of a&ulsion" crush" #last" and #urn" as in e)!losions. E)!losions cause e)tensi&e trau a to surrounding skin" soft tissue" and neuro&ascular tissue that re$uires de#ride ent and" in so e cases" staging of the closure. Treat ent of !artial a !utations" crush in7uries" and !artial de&asculari(ing in7uries should #e directed to'ard !reser&ing soft tissues. /istal !halangeal fractures" including #ursting or tuft fractures" are fre$uently associated 'ith crush trau a and nail #ed disru!tion or lacerations. +ail #ed in7uries are not al'ays o#&ious" and su#ungual he ato a ay #e the only sign of nail #ed in7ury. +ail #ed in7uries should #e re!aired to !re&ent !er anent late nail defor ity. +ail #ed re!airs usually are done 'ith fine ?-B a#sor#a#le suture. After re!air" the nail that 'as re o&ed is re!laced #eneath the cuticle to s!lint the #ed 12igs. 42-4B and 42434.

Sur ical treatments used to treat (in ertip amputations

include the follo'ingI Bone Shortenin and Primar) Closure

This is !erfor ed under local or regional anesthesia and consists of de#riding enough #one so that the skin can #e closed 'ith a fe' <-B sutures" 'ithout tension. Thorough de#ride ent of conta inated or de&itali(ed hard and soft tissues is re$uired. This ethod affords co&erage 'ith soft tissues of nor al sensi#ility" and this 'ell-!added fingerti! is not !ainful" #ut the cost is so e length and at least a !ortion of the fingernail. .nade$uate #one resection !roduces a fingerti! 'ith un!added #one" resulting in !ain during gras!ing. Composite Pulp Reattachment Rea!!lication of the 8co !osite9 of skin and !ul!" or skin" !ul!" and #one" can #e done 'hen the ass of the a !utated !art is &ery s all. This choice should #e reser&ed for young children. .t is #est to de#ride any residual #one. Su!erficial necrosis of the rea!!lied !art should #e e)!ected. .n ost situations" this is a te !orary #iologic dressing. Skin *ra(tin *rafts are a eans of co&erage for skin defects5 they are not ti e consu ing and theoretically could #e a!!lied to a 'ide range of fingerti! a !utations. The a7or dra'#acks are sensory loss in the graft area and the inade$uate !adding if graft is a!!lied o&er un!added #one and !eriosteu on !rehensile surfaces. The aesthetics of the graft are affected #y the donor site. The #est cos etic result for the !ul! surface is achie&ed in all races 'ith s!lit- thickness or full-thickness skin graft taken fro the gla#rous skin at the hy!othenar e inence under local anesthesia. The defect co&ered 'ith skin graft should #e a skin defect" and the reci!ient #ed ust ha&e ade$uate nati&e !adding. Skin graft 'ill not satisfactorily !rotect #one" no atter 'hat the skin donor source. Skin graft to the !al fro any area other than gla#rous skin !roduces a result that is relati&ely hy!er!ig ented. S!lit grafts usually are inade$uate for !ressure and friction surfaces. Toe- to-finger and foot inste!-to-hand !ul! skin grafting can #e !erfor ed" #ut the short-ter disad&antages are o#&ious as co !ared to full-thickness hy!othenar skin as the donor. !ocal Flaps ,ocal tissue transfer fro ore !ro)i ally on the in7ured finger affords &asculari(ed" !added" and ost often sensate tissue. Ad&ance ent is #y trans!osition or rotation 12igs. 42-42 and 42-4;4. Re ional and Distant Flaps Cross-finger" thenar" and other heterodigital fla!s ha&e #een used since the early !art of the t'entieth century" generally for ore e)tensi&e !ul! loss and other'ise unco&era#le #one and tendon 12ig. 42-444. These fla!s ha&e the ad&antage of retaining finger length #ut carry the risk of !osttrau atic defor ity or dysfunction in an ad7acent donor finger. Care ust #e taken to a&oid dysfunction fro i o#ili(ation of the in7ured or the donor !art #ecause of non!hysiologic !ositioning during fla! healing and #efore !edicle detach ent. Such fla!s usually are not sensate. Re!lantation and :icro&ascular +eurosensory 2la!s :icrosurgical ad&ances ha&e ade finger- and hand-!art reattach ent !ossi#le and allo'ed reconstruction #y co !osite neuro&ascular !ul! tissue fro toes" 'ith or 'ithout 7oints and tendons. The isolated single digit a !utation in the adult usually is

not suita#le for re!lantation" es!ecially if !ro)i al to the P.P 7oint" #ecause the functional and aesthetic reco&ery usually does not 7ustify the or#idity and costs of the re!lantation !rocedure. :ulti!le digit a !utations" su#total hand a !utations" a !utations throughout the u!!er li # !ro)i al to the hand" and ost !ediatric a !utations should #e e&aluated for re!lantation or !ri ary co !osite icro&ascular reconstruction 12ig. 42-4<4. So(t+Tissue Trauma

Tendon In"uries
Fle#or Tendons 2le)or echanis in7uries in the hand and fingers are no longer treated #y late reconstruction in ost !atients" #ecause direct !ri ary and delayed !ri ary re!airs offer good to e)cellent results" e&en 'hen done in the iddle of the digits. Satisfactory results are re!orted in @< to CA !ercent of !atients in &arious series. 2le)or tendon re!air and functional reha#ilitation is a challenge. 2le)or tendons are not difficult to re!air" #ut achie&ing good function of re!aired tendons is difficult" !articularly in (ones in 'hich ulti!le tendons of different e)cursion are in 7u)ta!osition. Tendons ust glide" and si ultaneously they are restrained #y liga ents" such as 'ithin the digital sheath and 'ithin the car!al canal. *etting fle)or tendons to glide after re!air re ains the !ro#le . The critical o!erati&e !rinci!le in tendon re!air is to achie&e near-!erfect anato ic align ent of the tendon ends. There should #e no ga!s at the re!air site" and 8#unching9 of the re!air (one should #e a&oided to !er it the re!aired tendon1s4 to glide 'ithin a sheath or !ulley syste . The (ones of fle)or tendons are defined #y the nu #er of tendons" restraints" and !ulleys and the !resence or a#sence of syno&ial e #rane at that s!ecific anato ic le&el 12igs. 42-4? and 42-4@4. .n the diagnosis of tendon disru!tion" the !atient often !resents 'ith an o!en 'ound and loss of acti&e otion. -#ser&ing the !art at rest 12ig. 42- 4A4 along 'ith acti&e" se!arate e&aluation of the fle)or digitoru !rofundus and fle)or digitoru su!erficialis tendons 12ig. 42-4C4 akes the diagnosis. A high le&el of sus!icion should #e aintained 'ith in7uries that ha&e loss of acti&e fle)ion or e)tension 'hen )-rays do not sho' skeletal disru!tion. Tendon a&ulsions ay occur 'ithout attached #one and can #e diagnosed only if the e)a iner is sus!icious. Closed" isolated fle)or !rofundus a&ulsion is ost co on in the ring finger5 the /.P 7oint 'ill not fle)" #ut the P.P 7oint does" ho'e&er !ainful. 2or !ri ary or delayed !ri ary re!air to #e effecti&e" early diagnosis is essential 12igs. 42-<B and 42-<34. Partial tendon lacerations" a!!ro)i ately u! to one-third of the tendon%s crosssectional area" do not !resent serious risk of ru!ture" #ut the lacerated edge ay catch on a near#y !ulley" !roducing !osttrau atic triggering. ,acerations in&ol&ing ;B to <B !ercent of the tendon%s cross- sectional area ay #e treated #y e!itendinous suture alone. /i&ision of <B !ercent or ore of cross-sectional area should #e treated surgically as though di&ision 'ere co !lete. 2le)or echanis sal&age #y graft and staged reconstruction" or #y !osttrau atic tenolysis or grafting" is #eyond the sco!e of this te)t. Secondary tenolysis should #e reser&ed for those !atients 'hose fingers ha&e achie&ed a sta#le #iologic state ore than 4 onths after trau a. Soft tissues are no longer ede atous" a)i u acti&e and !assi&e 7oint o#ili(ation has #een achie&ed

#efore secondary o!eration" and the !atient o!eration for additional reco&ery.

ust #e 'illing to undergo a second

,#tensor Tendons The su!erficial location of the e)tensor tendons on the dorsu of the fingers and hand ake the &ulnera#le to in7ury" es!ecially 'hen the fingers are fle)ed. Trau a co es fro lacerations" crush i !acts" a#rasions" and #ites. E)tensor tendon in7uries are ore co on than those of fle)or in7uries and are often treated casually in the e ergency de!art ent. E)tensor dysfunction ay result in loss of acti&e fle)ion fro scar tattering and in di inished acti&e e)tension. The e)tensor syste is ore intricate and co !le) than the fle)or syste . The interconnections of the e)trinsic digital e)tensor tendons fro the uscles in the forear and tendons in the hand" and the intrinsic tendons in 'hich uscles and tendons are in the hand" are co !le). The t'o sets of tendons colla#orate to fle) the etacar!o!halangeal 7oints and e)tend the inter!halangeal 7oints. Because e)cursion of the e)tensor echanis is li ited o&er the finger 7oints" !reser&ation of tendon length is ore critical to aintain and restore tendon #alance than 'ith fle)or tendon in7ury. The fle)or tendons are thick" round" cordlike structures 'ith s!iraling fi#ers. The e)tensor tendons are thin and flat" and the longitudinal fi#ers of the e)tensors do not hold sutures 'ell. The li ited a ount of soft tissues a#out these tendons also akes re!airs !rone to adherence and scarring. The e)trinsic e)tensors of the forear " i.e." #rachioradialis and e)tensor car!i radialis longus" are inner&ated #y the radial ner&e" and the e)tensor car!i radialis #re&is uscle #y the dee! #ranch of the radial ner&e. The !osterior interosseous #ranch of the radial ner&e inner&ates the e)tensor car!i ulnaris uscle and all !ro!er and co on thu # and digital e)tensors. The tendons cross the 'rist through si) !ulley co !art ents" ser&ing to e)tend the 'rist and the :P and inter!halangeal 1.P4 7oints. These si) tendon tunnels are defined #y reflections of the e)tensor retinaculu into the dorsal corte) of the radius and 'rist ca!sule and ser&e to li it the tendon &ector effect of the digital e)tensors at the 'rist 7oint #y aintaining their !ro)i ity to the center of a)is of 'rist otion. E)trinsic digital e)tensor tendons ele&ate the !ro)i al !halan). That is" they e)tend the :P 7oint &ia the a!oneurotic sagittal fi#ers that reach around the lateral sides of the !halan) to insert on the !al ar argin of the #one and &olar !late" there#y lifting the etacar!al fro a #road !al ar attach ent rather than a single !oint dorsally. The e)trinsic e)tensor tendon is the only :P 7oint e)tensor. /istally" the function of the intrinsic and e)trinsic tendons together for the dorsal tendon a!!aratus in the fingers 12ig. 42-<24. The intrinsic tendons arise fro the four dorsal and three !al ar interosseous uscles. There also are three thenar" three hy!othenar" and four lu #rical uscles. The grou! ser&es as the !ri ary inde!endent etacar!o!halangeal 7oint fle)ors and as inter!halangeal 7oint e)tensors. The :P 7oint fle)or fi#ers course distally fro a !al ar !osition" sending u! the trans&erse a!oneurosis dorsally to insert on the lateral edges of the e)trinsic e)tensor tendon in the !ro)i al third of the !ro)i al !halan) 1see 2ig. 42-<24. The direct distal continuation of the intrinsic tendon is the lateral #and that continues distally to reach a !osition dorsal to the center of a)is of P.P otion #efore crossing o&er the distal third of the !ro)i al !halan)" there#y aking it an e)tensor tendon for #oth

inter!halangeal 7oints. At the eta!hysis of the !ro)i al !halan) and the #ase of the iddle !halan)" the e)trinsic and intrinsic tendons con&erge to #eco e con7oined e)tensors. The central sli! inserts into the dorsal li! of the iddle !halan) as its direct e)tensor" #ut the con7oined lateral #ands run along the dorsal lateral edge of the P.P 7oint and con&erge distally o&er the iddle !halan) to #eco e the ter inal tendon that inserts into the dorsal li! of the distal !halan)" functioning as this last 7oint%s only e)tensor. Because of the nor al dorsolateral !osition of the lateral #ands" in certain direct in7uries to the dorsu of the finger at the P.P 7oint the lateral #ands ay su#lu)ate &olarly" hy!ere)tending the ter inal 7oint. This is called the #outonni Kre defor ity. >hen the ter inal tendon insertion at the distal inter!halangeal 7oint is a&ulsed or transected" the distal 7oint droo!s and the secondary !ro)i al and dorsal retraction of the lateral #ands !roduces gradual hy!ere)tension at !ro)i al inter!halangeal le&el. This defor ity is kno'n as allet or #ase#all finger5 it !rogresses to the s'an-neck defor ity 'hen the P.P hy!ere)tension is added. The ty!e of in7ury and the results of surgery &ary #ecause of the structural and functional differences in the e)tensor syste fro fingerti! to forear . E)tensor tendon characteristics ha&e #een categori(ed #y eight anato ical (ones5 the four 'ith odd nu #ers o&erlie the 7oints" and the four 'ith e&en nu #ers are the tendon seg ents #et'een the 7oints 12ig. 42-<;4. *eneric reco endations for re!air ethods are illustrated in 2ig. 42-<4. Lone 3 1:allet 2inger and Secondary S'an-+eck4 Ter inal tendon in7ury ay occur #y a&ulsion 'ith or 'ithout attached #one frag ent" and #y transection fro laceration or crush 12igs. 42-<< and 42-<?4. Closed in7uries can #e successfully treated #y closed eans5 o!en in7uries also ay #e treated #y e)tension s!linting. -!en or closed in7uries that include fracture of the 7oint surface 'ith secondary !al ar su#lu)ation of the distal !halan) re$uire reduction and internal fi)ation in neutral e)tension to restore /.P 7oint congruence and !ro!er tendon relationshi!s. This !er its al ost i ediate 7oint !lus hand reha#ilitation 'hile !rotecting the re!aired tendon and 7oint and aking 'ound care easier. -ther'ise" the ter inal 7oint is rarely !inned. S!lints that i o#ili(e the /.P articulation in e)tension 1? to A 'eeks4 #ut lea&e the P.P 7oint unrestrained usually are !referred 12ig. 42-<@4. Lone 2 Lone 2 is the area o&er the iddle !halan) 'here the lateral #ands fuse to for the ter inal tendon. The lateral #ands are connected !ro)i ally #y the thin triangular liga ent. .n7uries in this area usually are fro laceration 'ith resultant allet defor ity. /irect re!air and ter inal 7oint !inning for ? to A 'eeks is a!!ro!riate for o!en cases5 closed s!linting for closed in7uries 'ithout significant fracture is effecti&e. Lone ; 1BoutonniKre4 Lone ; is the area o&er the P.P 7oint 'here the central sli! and lateral #ands interconnect. .n7ury ay #e closed or o!en and ay include a&ulsion of the central sli!" 'ith or 'ithout a dorsal #one frag ent. The latter in7uries re$uire accurate reduction of the 7oint" #one" and contiguous tendon echanis . Pinning the P.P 7oint

in e)tension allo's early reha#ilitation of the other 7oints. =ntreated" this #outonniKre defor ity !rogresses to a fi)ed P.P 7oint fle)ion contracture 'ith secondary hy!ere)tension of the ter inal 7oint. Closed s!lint or !ercutaneous !in anage ent ay #e e$ually effecti&e for the !ure tendon in7uries 12ig. 42-<A4. Lone 4 The dorsu of the !ro)i al !halan) is co&ered entirely #y the confluent e)trinsic e)tensor tendon and #y the t'o lateral #ands arising fro tendons of intrinsic uscles. Because of this local anato y" ost tendon in7uries in (one 4 are !artial and the cut tendon ends do not retract significantly. -nly direct ins!ection can confir this diagnosis. .f inter!halangeal 7oint e)tension is nor al" a !artial tendon in7ury need not #e re!aired. S!linting the P.P 7oint for ; to 4 'eeks usually is ade$uate. Lone < ,acerations and #ite 'ounds are co on at the etacar!o!halangeal 7oint. >ith o!en in7uries in this region" a hu an or ani al #ite should #e sus!ected until other'ise dis!ro&ed. Bite 'ounds are serious conta inated in7uries re$uiring !ri ary surgical de#ride ent" irrigation of the 'ound and 7oint" and aggressi&e intra&enous anti#iotics for 24 to 4A h. Patients ay #e reluctant to seek treat ent early" and any deny the echanis of in7ury. The incidence of co !lications is directly related to the delay in treat ent. Radiogra!hs are taken to rule out the !resence of a foreign #ody such as a !iece of tooth" an intraarticular fracture" or air in the 7oint" !ro&ing conta ination. >hen caused #y a #ite" the 'ound is left o!en and tendon re!air is !erfor ed secondarily after healing #y secondary intention. .n a si !le laceration" the tendon can #e re!aired directly. The ore dorsal e)trinsic e)tensor tendon and the sagittal #and echanis should #e re!aired to !re&ent su#lu)ation of the e)tensor into the inter etacar!al &alley. Closed e)tensor tendon dislocation is al ost al'ays to the ulnar side of the 7oint and re$uires tendon and sagittal fi#er reconstruction. >here direct re!air is !ossi#le" !ri ary and delayed !ri ary re!airs are !refera#le" using suture techni$ues descri#ed in 2ig. 42-<4. The 'rist is i o#ili(ed in ;B degrees or less of e)tension" and the :P 7oint is s!linted at ?B to @B degrees or treated 'ith a custo dyna ic :P e)tension s!lint for early !assi&e otion. The P.P and /.P 7oints are left free. Lone ? Lone ? co&ers the dorsu of the hand" 'hich includes the etacar!als and distal car!als" 'here there are four co on e)tensor tendons to the fingers and t'o !ro!er tendons" one to the inde) and one to the little finger. The three 'rist e)tensors insert in this regionI e)tensor car!i radialis longus into the dorsoradial #ase of the second etacar!al" e)tensor car!i radialis #re&is into the dorsoradial #ase of the third etacar!al" and e)tensor car!i ulnaris into the ulnar dorsal edge of the fifth etacar!al. The e)tensor !ollicis longus tendon crosses fro !ro)i al to distal in a radial to ulnar line. Single or !artial tendon laceration ay not !roduce etacar!o!halangeal e)tension loss" #ecause forces are trans itted through the tendinous interconnections e)tending fro ad7acent e)tensors" such as the 7uncturae tendinu . .n ost cases" ho'e&er" the in&ol&ed finger lies slightly ore fle)ed or is less a#le to e)tend than the others. Parado)ically" the affected finger ay fle) at the :P and e)tend at the .P 7oints 'hen the !atient atte !ts acti&e e)tension #ecause of loss of the e)trinsic e)tensor tendon 'ithout disru!tion of the intrinsics. The tendons

are o&al in cross-section and thicker here than distally. Core sutures of the ty!e used in fle)or re!airs are reco ended 1see 2ig. 42- <44. Con&entional !ostre!air treat ent 'as i o#ili(ation 'ith the 'rist in 4< degrees or ore of e)tension and the fingers in ild :P fle)ion for a#out 4 to ? 'eeks. This is discouraged" ho'e&er" #ecause !atients can #eco e significantly stiff 'ith this !rotocol. .nstead" the 'rist should #e ke!t in a#out ;B degrees of e)tension and the etacar!o!halangeal 7oints fitted 'ith !ro)i al !halangeal e)tensor cuffs 'ith the inter!halangeal 7oints free" allo'ing acti&e fle)ion and !assi&e e)tension. :oti&ated !atients ay #egin this !rogra on the se&enth to tenth !osto!erati&e day5 others are i o#ili(ed for dou#le that ti e. At least one ad7acent finger ust #e included in the s!lint. :ulti!le tendon in7uries ay necessitate including all fingers in s!lints throughout the reha#ilitation !rotocol. Lone @ Lone @ is the !ro)i al 'rist region under the e)tensor retinaculu in 'hich the e)tensors tra&erse the fi#ro-osseous tunnel in si) syno&ial co !art ents. =nlike for the fle)or !ulleys" re!air of the e)tensor retinaculu is relati&ely easy to !erfor " #ut retinacular release should #e a&oided 'hen !ossi#le. To !re&ent e)tensor tendon #o'stringing" !reser&ation or reconstruction of so e !ortion 14B !ercent or ore4 of the !ro)i al or distal retinaculu is critical. Ste!-cut retinaculu release ore easily allo's closure 'ithout !roducing a s!ace too tight to allo' gliding of re!aired tendon1s4. Tendon lacerations in this area often are associated 'ith in7uries to the near#y radial or ulnar sensory ner&e #ranches" 'hich should #e considered at e)a ination and surgery. Closed ru!ture of e)tensor tendons" usually the e)tensor !ollicis longus tendon" is not rare" es!ecially after Colles% fracture and other in7uries to the distal radius. :any e)tensor !ollicis longus ru!tures occur se&eral 'eeks or onths after nondis!laced Colles% fractures. .t is !ostulated that fracture he ato a reduces the li ited #lood su!!ly in the e)tensor !ollicis longus tendon" leading to the attrition ru!ture. Syste ic connecti&e tissue diseases" such as rheu atoid arthritis" and !athologic conditions that !roduce a shar! #one edge" chronic tenosyno&itis" or #oth" also ay contri#ute to this !ro#le . Attrition ru!tures should #e re!aired #y tendon transfer or grafting. /irect re!air is al ost ne&er !ossi#le #ecause of the 'ide (one of tendon trau a that occurs #efore #reakage. Lone A Trau a to the radial sensory or !osterior interosseous ner&e #ranches ay occur conco itantly 'ith e)tensor in7uries in the forear in (one A. :ulti!le ad7acent uscles or tendons ake it difficult to identify indi&idual tendons. The !riority of re!air is to restore inde!endent 'rist and thu # e)tension and grou! e)tension of the fingers. >ith lacerations at the usculotendinous 7unctions" the tendons ay #e seen distally" #ut !ro)i ally their fi#rous se!ta retract into the uscle #ellies. 2or re!air at this le&el" the suture line ust include fascia or the intra uscular tendinous se!ta to !re&ent !ullout and failure of o!eration. >ith in7uries in the !ro)i al forear " di&ision of the !osterior interosseous ner&e alone ay !roduce loss of e)tensor function #y dener&ation" or it ay occur in co #ination 'ith in7ury to so e or all of the uscles and tendons. After re!air" el#o' fle)ion and 'rist e)tension ay #e needed to reduce tension at the suture line. Thu # e)tensor in7uries are dealt 'ith in anner si ilar to in7uries to the finger.

Tendon Trans(ers Tendon transfer is a reconstructi&e !rocedure that antedates the t'entieth century. Transfers in the u!!er li # are designed to restore otion in a nonfunctioning !art. Tendon transfers are used in isolated !eri!heral ner&e !aralysis" for irre!ara#le tendon da age after e)tensi&e seg ental loss fro de&astating trau a or in destructi&e connecti&e tissue diseases such as rheu atoid arthritis" and to re#alance the hand or !ro&ide o&e ent to a s!astic or !araly(ed li # after central ner&ous syste in7ury or disease. =!!er e)tre ity reconstruction #y tendon transfer re$uires careful !atient selection and e)tended thera!y su!er&ision" often 'ith !reo!erati&e and !osto!erati&e reha#ilitation !rotocols.

-er.e In"ur)
The u!!er e)tre ity is inner&ated #y the #rachial !le)us and se&eral sensory #ranches arising fro the !le)us and intercostal ner&es 12ig. 42- <C4. .nner&ation !atterns &ary" 'ith interco unications and fi#er e)changes 'ithin and #et'een ner&es. +er&es are co !osed of a)ons and associated Sch'ann cells enclosed in a #ase ent e #rane. Thin collagen fi#ers called endoneuriu are i ediately outside this #ase ent e #rane5 the ter endoneurial tu#e refers to the a)on and Sch'ann cell co !osite. Endoneurial tu#es are grou!ed together to for a &aria#le nu #er of fascicles. Perineuriu surrounds each fascicle" co !osed of concentric layers of flattened cells and collagen fi#ers. The !erineuriu creates a diffusion #arrier against the surrounding en&iron ent" !ro&iding the !eri!heral ner&e the e$ui&alent of a #lood#rain #arrier 12ig. 42-?B4. Surrounding the layers of !erineuriu is e!ineuriu . E!ineuriu that fills the s!ace #et'een fascicles is called internal and that surrounding the ner&e itself is ter ed e)ternal or outer. The outer layer is co !osed of collagen and so e elastin fi#ers. The fascicular organi(ation and internal anato y of the ner&e is not constant o&er its length. The to!ogra!hic fascicular organi(ation of the ner&e rearranges as #ranches co e off these fascicles. The fascicles o&e to the !eri eter 'ithin the ner&e as the ner&e courses to'ard the !eri!hery. The internal organi(ation of the ner&e reflects the location and !osition of those final #ranches. 2or nor al ner&e function to #e aintained" the !eri!heral ner&e ust glide. 2ocused tension or co !ression induces local in7ury" ner&e dysfunction" and sy !to s. Co !ression and traction neuro!athies result 'hen a ner&e is tethered" es!ecially at or near a 7oint. The ulnar ner&e" for e)a !le" has a longitudinal e)cursion of 3B or ore !ro)i al to the el#o'5 the edian and ulnar ner&es glide nearly 3< at the 'rist. After in7ury to a ner&e" the ner&e is at risk for local scar for ation adhesions and secondary traction neuritis fro tension focused at the site of adherence. Classification of ner&e in7uries" as descri#ed #y Seddon" is as follo'sI +eura!ra)ia descri#es !aralysisFdysfunction in the a#sence of ner&e degeneration. This dysfunction is often of so e duration" though reco&ery is al'ays achie&ed in a shorter ti e than 'ould #e re$uired after co !lete transection and ner&e degeneration and regeneration. Reco&ery #y definition is in&aria#ly co !lete. A)onot esis includes da age to the ner&e fi#ers of a se&erity that causes co !lete ner&e degeneration. The e!ineuriu and other su!!orting structures of the ner&e are

not disru!ted" so the internal architecture is relati&ely 'ell !reser&ed. S!ontaneous reco&ery is the rule" and generally it is of &ery good $uality #ecause the regenerating fascicles are guided into their !aths &ia the intact sheaths. Reco&ery takes longer than for neura!ra)ia. +eurot esis is 'hen all ner&e structures ha&e #een di&ided. ,aceration !roduces neurot esis" #ut !hysical ga!s in the ner&e ay occur e&en though the e!ineurial sheath a!!ears in continuity" such as after traction or crush. At the site of da age the ner&e 'ill #e co !letely re!laced #y fi#rous tissue" and there is co !lete loss of anato ic continuity. Reco&ery after ner&e in7ury de!ends on successful reinner&ation of sensory or otor end-organs. After dener&ation" uscles #egin to lose their #ulk5 a loss of crosssectional area 'ithout any loss in uscle fi#er count #egins 'ithin 3 'eek of dener&ation. Connecti&e tissue surrounding the uscle undergoes degeneration and thickening. .nterstitial fi#rosis !redo inates o&er ti e" #ut !assi&e e)ercises ay delay or !re&ent this !heno enon. 2or function to #e resu ed" otor end-!lates ust #e reinner&ated 'ithin 3A onths of trau a. Sensory end-organs ay #e usefully reinner&ated long after initial in7ury" #ut the $uality of reco&ery di inishes 'ith the !assage of ti e. The result after re!air de!ends on nu erous factorsI in7ury le&el and echanis " associated #one and soft-tissue loss" residual function" !atient co !liance and oti&ation" ti ing of re!air" and su!er&ised reha#ilitation. Muantitati&e !osto!erati&e assess ent of otor and sensory function should #e docu ented. Re!air should #e done 'ith icrosutures 'ith the aid of agnification to !roduce a s!atially correct" tension-free suture line. +er&e grafts are used 'hen direct re!air after seg ental loss or fi#rosis 'ould re$uire tension at the re!air site. Joint !osturing into e)tre e fle)ion or e)tension to decrease tension at the ner&e re!air site should #e a&oided5 ner&e graft is su#stituted for such destructi&e s!linting aneu&ers. Pri ary or delayed !ri ary re!air should #e done 'hene&er a!!ro!riate conditions allo'. The co #ination of grou! fascicular and e!ineurial nonreacti&e icrosutures after identification of the internal to!ogra!hy should !roduce the #est anato ic result. Re!airs are !rotected #y rela)ed 7oint !osturing for a#out ; 'eeks" and the results of re!air are a)i i(ed #y #eginning sensory and otor reeducation after reinner&ation 12igs. 42-?3 and 42-?24. 6ascular Trau a and Re!lantation The a7ority of u!!er e)tre ity re!lantation surgery is #ased on icrosurgical techni$ue. -cular lou!es are useful for lo'er agnification and 'ide-field dissections and are !articularly hel!ful in !re!aring the ends of ner&es and &essels for re!air. Ho'e&er" the o!erating icrosco!e offers a steady field agnification range of 2<N or ore. :iniaturi(ed needle holders and instru ents" #i!olar coagulation" and other odifications are necessary for !ro!er icro&essel handling. The ty!ical re!air in &essels of B.< to ;.B dia eter is !erfor ed 'ith nonreacti&e onofila ent interru!ted sutures to !re&ent lu inal i !inge ent colla!se" although icro&essel grafts and end-to-side connections also are used 12igs. 42-?; and 42-?44. A conta inated soft and #ony tissue in7ury is healed #y !ri ary de#ride ent and

sta#ili(ation of o!en fractures" re!air of e)tensor and fle)or ner&es and &essels 12ig. 42-?<4.

echanis s" and re!air of

Each !atient should #e considered indi&idually on the #asis of the location and e)tent of the in7ury and the !atient%s age and condition. Rele&ant $uestions includeI 134 Can function #e o#tained fro the re!lanted !artO 124 >ill that function e)ceed 'hat can #e achie&ed through a !utation closure and !ossi#le !rosthetic fittingO 1;4 >ill longter function #e i !ro&ed or co !ro ised #y !art re!lantationO 144 /oes the !otential #enefit to the !atient out'eigh the surgical risks" costs" and loss of !roducti&ityO Seg ental" e)tensi&e" or ulti!le-le&el in7uries re$uire re!air and reconstruction o&er an e)tended area. +either co !lete nor near-co !lete !art a !utation akes any !atient an auto atic candidate for re&asculari(ation or reattach ent. Single finger a !utation in the adult" es!ecially at a le&el !ro)i al to the P.P 7oint" including #oth su!erficialis and !rofundus tendons and digital ner&es is not suita#le for re!lantation in the &ast a7ority of cases. Consideration should #e gi&en to re!lantation for thu # a !utations at and !ro)i al to the inter!halangeal 7oint" for single- finger a !utations in children" and for !artial hand and ore !ro)i al 'rist" forear " or ar a !utations. .n adults o&er the age of 4B years" re!air of the ulnar ner&e !ro)i al to the el#o' rarely !roduces a functional result. Crush and a&ulsion in7uries often ake it i !ossi#le to achie&e successful reattach ent and re&asculari(ation. Re!erfusion #efore tissues are non&ia#le is essential. :uscle is the ost o)ygensensiti&e u!!er-e)tre ity tissue and ust #e re&asculari(ed 'ithin ? h of a !utation. Handling of A !utated Parts The a !utated !art should #e cleansed under saline solution" 'ra!!ed in a salineoistened gau(e" and !laced in a !lastic #ag. The !lastic #ag containing the !art should then #e !laced on" not !acked in" a #ed of ice in a suita#le container. The !art should not #e i ersed in non!hysiologic solution such as antise!tics or alcohols. The a !utated !art is ne&er !ut in dry ice" it is not !erfused" and it should not #e allo'ed to free(e. Pre!aring the Patient The !atient is sta#ili(ed" and a co !ression dressing is a!!lied to the stu ! #efore trans!ort to the re!lantation center. .ntra&enous access lines should #e started and #lood sa !les dra'n 'hile a'aiting trans!ortation. .f ti e !er its" )-rays of the stu ! and also of the a !utated !art can #e o#tained. :ost re!lantation centers re$uest that the !atient #e gi&en intra&enous anti#iotics" an as!irin su!!ository 1;2< g4" and 2< to <B , !er hour intra&enous su!!le ent of lo'- olecular-'eight de)tran in de)trose" the latter for antiaggregation !latelet effects. Before the !atient is trans!orted to the re!lantation center" so eone res!onsi#le at the recei&ing institution ust kno'ingly acce!t the !atient as a candidate for !art reattach ent. E&en if the center has an acti&e re!lant tea " its e #ers ay #e occu!ied 'ith another case. Accurate co unication #y tele!hone" !hysician-to- !hysician" is an essential !art of re!lantation triage. E&en if the referring !hysician is unsure of the !atient%s status" !re!arations can still #e ade for !ossi#le trans!ort. >hen the !atient is trans!orted" the !atient should #e told that referral is for e&aluation for !ossi#le re!lantation.

Amputations
1See Cha!. 2B4 The &alue of traditional ethods to anage a !utations is 'orth e !hasis. /igital a !utation affects !recision !inch and !o'er gri!" the latter ore significantly if the hand is !ainful. The treat ent !rinci!les for fingerti! a !utation 'ere discussed earlier. .t is i !ortant that sta#le soft- tissue and skin co&erage o&er an a !utation stu ! at any le&el #e o#tained 12ig. 42-??4. .f a residual stu ! is stiff or !ainful" a !utation or a !utation re&ision through the etacar!al can #e a functional enhance ent. >here a central ray is e)cised" second-ray transfer or thirdPfifth inter etacar!al liga ent closure !reser&es and restores etacar!al align ent and the functional contour of the hand 12igs. 42-?@ and 42-?A4. Co !lications of Trau a Co !art ent Syndro eF6olk ann%s Contracture .n acute co !art ent syndro e" increased fluid !ressure in the tissues contained 'ithin a fascial s!ace or su#co !art ent increases to a le&el that reduces ca!illary #lood flo' #elo' that necessary for continued tissue &ia#ility. >hen untreated" continued !ressure ele&ation !roduces irre&ersi#le uscle and ner&e da age #ecause of ische ia" 'ith secondary necrosis" fi#rosis" contractures" and sensi#ility deficits or chronic !ain. Acute co !art ent syndro e results fro an increase in the &olu e of fluid 'ithin a co !art ent or li itations on the di ensions of an anato ic co !art ent. Posttrau atic ede a or he orrhage" he ato a" s'elling fro infection" or #urns increase co !art ent fluid" as does re&asculari(ation. -ther causes include &enous o#struction and transiently strenuous e)ercise. Constricti&e dressings and casts" e)cessi&ely tight surgical closure" and !rolonged direct li # !ressure during unconsciousness 'ith alcohol and drug stu!or or during e)tended surgical !rocedures add to the li ited di ensions of the anato ic co !art ent. Acute co !art ent syndro e is diagnosed clinically #ut can #e confir ed #y easure ent of intraco !art ental tissue !ressure. Clinical findings include a s'ollen" tense" and tender co !art ent 'ith !ain out of !ro!ortion to that e)!ected fro the originating in7ury" !eri!heral sensi#ility deficits and" finally" otor 'eakness or !aralysis. Pain is accentuated #y !assi&e stretch of the affected uscle. Peri!heral !ulses usually re ain intact #ecause systolic arterial !ressure usually is 'ell in e)cess of the dangerously ele&ated intraco !art ental !ressure. >hile #lood flo' through the a7or arteries is not i !eded" ca!illary !erfusion is co !ro ised #y the ele&ated !ressure 1;B to ?B Hg4 'ithin the co !art ent. Pressure easure ent de&ices are confir atory #ut not infalli#le" and in treat ent decisions clinical concerns should out'eigh s!ecific !ressure easure ents. Threshold !ressure easure ents of ;B Hg or ore are consistent 'ith co !art ent syndro e" and surgical deco !ression should #e !ro !t. Because tissue !erfusion is affected #y syste ic #lood !ressure" a lo'er threshold !ressure for fascioto y should #e used in hy!otensi&e !atients. >hile :R." CT" or ultrasonogra!hy ay delineate areas of uscle ede a or necrosis" these studies do not hel! 'ith the diagnosis of acute co !art ent syndro e. Treat ent should not #e delayed to order and o#tain i aging #eyond !lain radiogra!hs.

Treat ent includes re o&al of all occlusi&e dressings" 'ra!s" layers" and s!lints and s!litting tight casts and cast !adding do'n to the skin. .f sy !to s are not ra!idly relie&ed" fascioto y of the affected areas is re$uired 12igs. 42-?C and 42-@B4. After surgical deco !ression" the 'ounds are left o!en #ut dressed to !re&ent desiccation. Skin closure #y direct eans or 'ith skin grafting is delayed for 4A to C? h at a ini u " #ut ay #e !erfor ed after < to 3B days as s'elling !er its. Hand thera!y is started at 4A h. +euro as +euro as re!resent a nor al !hysiologic res!onse after ner&e in7ury. All #adly in7ured and se&ered ner&es for neuro as" #ut only those neuro as that are e)!osed" su!erficial" and likely to #e i !acted #eco e sy !to atic. -nly sensory fi#ers de&elo! !ainful neuro as 12igs. 42-@3" 42-@2" 42-@;" and 42-@44. :edical and surgical anage ent of sy !to atic neuro as ay #e difficult" #ut !re&ention is ore i !ortant. .nad&ertent in7uries to ner&es can #e a&oided during resection" #ut 'ith a !utation end-ner&e di&isions are at risk for neuro a for ation. /i&ided ner&e stu !s should #e trans!osed to dee! locations" !refera#ly #et'een or 'ithin uscle" or into #one 'hen !added tissue is scant. .n the fingers" 'here there is often li ited soft-tissue !adding" the !ractice of di&iding the ner&e under traction and allo'ing it to retract !ro)i ally is not as certain a ethod as lea&ing the ner&e end long and trans!osing it to a site 'here it is less likely to #e struck #ut ore likely to #e !rotected. A sy !to atic neuro a is a thera!eutic challenge. :ore than a hundred ethods of surgical treat ent ha&e #een descri#ed" #ut no ethod is uni&ersally successful. The sy !to atic neuro a should #e identified" isolated" and dissected intact. The scar #ul# is ke!t in continuity 'ith the ner&e. The sy !to atic ner&e and its continuous neuro a are trans!osed to a dee!er" ore !added" and often ore !ro)i al location" #eneath uscle if !ossi#le" #ut 'ithin #one 'hen needed. The neuro a #ul# is not e)cised fro the ner&e #ecause its e)cision sti ulates ger ination of another neuro a 'hose contents ay not #e contained 'ith this secondary !rocedure. Refle) Sy !athetic /ystro!hy The first clinical descri!tion of a#nor ally e)aggerated and !rolonged !ain after in7ury is attri#uted to the Ci&il >ar surgeon S. >. :itchell" 'ho coined the ter causalgia fro the *reek eaning #urning !ain. Synony s include infla atory #one atro!hy and Sudeck%s atro!hy. Refle) sy !athetic dystro!hy e !hasi(es the i !ortance of the sy !athetic ner&ous syste in !osttrau atic !ain !atho!hysiology. Pro !t diagnosis and early thera!eutic inter&ention are the ost i !ortant factors in o!ti i(ing clinical and functional outco e. Refle) sy !athetic dystro!hy is not a disease. .t is a co !le) interaction of !hysiologic res!onses initiated #y trau a and e)acer#ated #y !osttrau atic e&ents. This !rocess is staged #y ti e and infla atory !hase 'ith characteristic changes 1Ta#le 42-24 and #y descri!ti&e ter inology 1Ta#le 42-;4. The !resu !ti&e diagnosis is #ased on !ain" 'hich is often diffuse" #urning" and hy!er!athic" including allodynia 1!ain to light touch4" hy!eralgesia 1!ainful res!onse to non!ainful sti uli4" dysesthesia 1!ins and needles follo'ing inor sti ulus4" and hy!eresthesia 1increased sensiti&ity or !ain 'ith non!ainful sti uli4. .n addition" the clinical diagnosis of refle) sy !athetic dystro!hy re$uires at least three of the follo'ingI 134 di inished hand function" 124 7oint stiffness" 1;4 atro!hic changes 1ede a" atro!hy" or fi#rosis4" and 144 &aso otor insta#ility or &aso otor distur#ance.

Refle) sy !athetic dystro!hy !resents acutely as a hot" s'ollen" !ainful" or dysesthetic e)tre ity. A s!ecific !reci!itating in7ury" such as a neuro a- incontinuity or an entra!!ed !eri!heral ner&e" ay not #eco e a!!arent until the acute anifestations are treated and resol&e. .n the case of ner&e entra! ent" careful consideration should #e gi&en to surgical deco !ression. Prolonged disco fort or !ain-li ited otion does not auto atically ean that refle) sy !athetic dystro!hy or a refle) sy !athetic dystro!hyPlike syndro e is !resent. Patients ay ha&e secondary soft-tissue and !eriarticular fi#rosis after trau a or surgery and a focally tender scar" #ut 'ith !ain isolated only to that area" not generali(ed. /isuse fro any cause can result in osteo!enia. Patients 'ith refle) sy !athetic dystro!hy often re$uire chronic treat ents" !sychologic su!!ort" including counseling and edication" and an e)tended" intensi&e" and closely onitored thera!y !rogra 1Ta#le 42- 44. Early recognition and treat ent !re&ents secondary stiffness fro 7oint and tendon adhesions.

BUR-S
A!!ro)i ately 2 illion !eo!le sustain #urns that re$uire edical attention annually in the =nited States" resulting in al ost <BB"BBB e ergency de!art ent &isits. .solated hand #urns can result in se&ere functional and aesthetic i !air ent. The direct effect of ther al in7ury to the skin and the conse$uences of this trau a to hand function includeI 134 heat" 124 ede a" 1;4 decreased circulation" and 144 infection. Syste ic !ro#le s include #urn shock" the re$uire ent for fluid resuscitation" secondary i unologic deficits" !roteolysis" and the accu ulation of secondary to)ins. :anage ent of the #urned hand de!ends on the de!th of #urn" its surface area" !atient age and relia#ility" and coe)isting syste ic conditions. Treat ent ust #e indi&iduali(ed. Patients 'ho are relia#le and ha&e an ade$uate su!!ort syste ay #e a!!ro!riately treated outside of the hos!ital. Patients 'ith #urns that !re&ent self-care and indi&iduals 'ho ha&e no !ersonal assistance re$uire a ore controlled setting. Pri ary treat ent should focus on !reser&ing &ia#ility of soft tissues #y !re&enting secondary 'ound dehydration &ia a!!lication of a oist or #iologic dressing. Blisters can #e as!irated to !reser&e o&erlying e!itheliu as a #iologic dressing" #ut if they are leaking and re$uire de#ride ent" the 'ound should #e co&ered 'ith an occlusi&e and nondesiccating co !osite dressing. Circulation aintenance re$uires !re&ention of hy!o&ole ia and a&oidance of echanical o#struction to circulation fro en&elo!ing eschar. Along 'ith clinical e)a ination" the use of /o!!ler ultrasonogra!hy or a 'ick catheter for co !art ent !ressure easure ent is hel!ful in assessing &ascular sufficiency. Escharoto y or fascioto y in a #urned e)tre ity ay #e re$uired to !re&ent secondary ische ic necrosis. :idlateral incisions are used" 'hether in the forear or the fingers. The incision ust #e dee! enough to release all #urn eschar and to identify nor al tissues at the 'ound de!th. .f a single ida)is release does not restore circulation to the !eri!hery" #oth ida)es ust #e incised. The neuro&ascular #undles

the sel&es should #e a&oided to !re&ent iatrogenic in7ury or desiccation after unneeded e)!osure. The ede atous hand ay de&elo! an acute car!al or ulnar tunnel syndro e. .nfection is !re&ented #y !ro!hylactic syste ic anti#iotics in the first 2 days to a&oid selection of resistant organis s" #ut the ainstay of anti icro#ial !ro!hyla)is treat ent is to!ical. The ost fre$uently used anti icro#ial is sil&er sulfadia(ine 1Sil&adene4" 'hich does not !enetrate eschar" is not !ainful" has #road co&erage" !re&ents desiccation" and can #e re o&ed 'ith 'ater" saline solution" or hydrothera!y cleansing. Te !orary re&ersi#le #one arro' su!!ression and neutro!enia ay result fro e)tensi&e" e)tended use of sil&er sulfadia(ine. .n #urn 'ound se!sis" fullthickness 'ound #io!sy cultures allo' diagnosis of se!sis and ad7ust ent of a!!ro!riate anti#iotics. Surgical de#ride ent of infected #urns is necessary" #ut in 'ides!read #urn 'ound se!sis" ortality ay result. 2unctional restoration is the ost i !ortant goal. :ost hand #urns are on the dorsu #ecause of its e)!osed !osition. /ee! #urns to the !al are ore rare e)ce!t 'ith electrical" che ical" and occasional direct contact ther al #urns. Bilateral !al ar #urns or glo&elike #urns in children should #e considered as e&idence of !ossi#le child a#use and carefully in&estigated. +ono!erati&e treat ent allo'ing s!ontaneous healing" and early e)cision 'ith grafting yield the #est functional results in a!!ro!riately selected !atients. Prolonged infla ation di inishes the chances of reco&ering hand otion. .f initial assess ents indicate that the #urned hand re$uires ore than 2 'eeks #efore skin healing" early tangential e)cision and skin grafting should #e undertaken !ro !tly. .f s!ontaneous e!itheliali(ation and 'ound closure are antici!ated 'ithin 2 'eeks" nono!erati&e treat ent 'ith continuous e)ercises and s!linting is a!!ro!riate. S!linting should #e gi&en high !riority in an antidefor ity !osition. S!linting ay #e done in !ositions other than the traditional !osition of function" that is" 'rist e)tension" :P fle)ion" and .P e)tension. .n dorsal hand #urns" the s!lint !osition is 'rist e)tension of ;B degrees or less 'ith a)i u :P fle)ion and full .P e)tension 12ig. 42-@<4. To !reser&e the first 'e#" the thu # should #e 'idely a#ducted !al ar'ard and fle)ed slightly at the car!o etacar!al 7oint to a !osition 'here the radial #order of the hand is flat" i.e." the first etacar!al is !ositioned al ost !al ar to the second etacar!al. The goal of s!linting is to stretch the healing 'ound and !re&ent anato ic distortion #y scar tissue that can !re&ent restoration of hand function. +eglected dorsal #urns de&elo! etacar!o!halangeal hy!ere)tension and inter!halangeal fle)ion defor ities" thu # adduction" and 'rist fle)ion contractures 12ig. 42-@?4. Hand reha#ilitation re$uires a coordinated a!!roach #et'een surgeon and thera!ist to assure a a)i al and ti ely reco&ery. At first" hand thera!y is directed to'ard ini i(ing ede a and !re&enting defor ity. The e)ercise !rogra starts #et'een the first and fifth !osttrau a day to encourage gliding of fle)or and e)tensor tendons and o&e ent of s all 7oints. Thera!y e&entually !rogresses to acti&ities of daily li&ing and reintegration into nor al life. Referral of !atients re$uiring !ost#urn reconstruction is ade to a s!eciali(ed center 'here co&erage and thera!y techni$ues are a&aila#le for hy!ertro!hic scars and contiguous tendon and 7oint in7uries for selected cases.

I-F,CTIOBacterial .nfection Skin infections ost co only deri&e fro direct #acterial inoculation. Secondary s!read fro contiguous sites and he atogenous seeding are less likely. The ost co on infecting organis s are sta!hylococcus and stre!tococcus s!ecies5 gra negati&e" anaero#ic" and i)ed infections are seen" de!ending on the inoculation ethod" e.g." a tooth. Serious" dee! infections re$uire hos!ital ad ission and e)tended use of high-dosage intra&enous anti#iotics. >ound and #lood cultures are o#tained #efore anti#iotic thera!y is started" and ad7ust ents are ade as indicated. Paronychial infections are co on. These in&ol&e the nail and nail #ed" and constitute a#out 3< !ercent of hand infections. -ccurrence is associated 'ith hangnails" nail #iting" finger sucking" and occu!ations re$uiring the hands to #e da ! fre$uently. Acute infection is al'ays #acterial" creating a locali(ed a#scess" #ut chronic infla ation is ost often yeast or fungal" re$uiring different thera!eutic a!!roach 12ig. 42-@@4. Her!etic 'hitlo' is an infection of the soft tissues of the distal !halan) or !aronychial area #y the her!es si !le) &irus. .t is characteri(ed #y intense !ain and cutaneous &esicles or #listers. The &esicle fluid is clear at first #ut ay #eco e cloudy o&er a fe' days. .t is i !ortant to distinguish this fro #acterial infection. Surgical inter&ention ay s!read the her!es &irus syste ically or dis!ose to local secondary #acterial infection. -nly a #acterial a#scess needs surgical drainage. Her!etic 'hitlo' is self-li ited" generally resol&ing 'ithin ; to 4 'eeks. 2elon is an e)!anding a#scess 'ithin the finger !ul!" and re!resents u! to one-$uarter of hand infections. 2elons can also #e e)tre ely !ainful" often re!orted as thro##ing !ul! !ain. The e)!anding a#scess !roduces a locali(ed co !art ent syndro e as a result of the !resence of the fi#rous se!ta that nor ally anchor the !ul! skin and su#cutaneous tissues to the distal !halan). 2elons usually are caused #y !enetrating direct trau a !roducing #acterial inoculation. =ntreated felons" like other co !art ent syndro es" co !ro ise local circulation and !roduce secondary tissue ische ia and necrosis in addition to se!tic destruction. .n surgical drainage additional in7ury to the finger !ul! should #e a&oided" #ut an a#scess ay already !oint to a su!erficial location 12ig. 42-@A4. /ee!-s!ace !al ar infections ay occur ore often in the i unoco !ro ised" drug a#users" elderly" and neglected !o!ulations. These are e)tre ely serious

infections 'ith secondary syste ic sy !to s re$uiring the co #ination of e)tended edical and staged surgical thera!y 12ig. 42-@C4. Tenosyno&itis Acute !yogenic digital tenosyno&itis is ost fre$uently a result of direct !enetrating trau a. Gana&el%s cardinal signs of tenosyno&itis includeI 134 fusifor digital s'elling" 124 se ifle)ed digital !osture" 1;4 significant !ain fro !assi&e e)tension of the finger" and 144 tenderness along the entire fle)or sheath. Pro!er anage ent for this closed-s!ace tenosyno&ial a#scess is surgical drainage and intra&enous anti#iotics. A high inde) of clinical sus!icion is re$uired for diagnosis. As!iration of the sheath 'ill confir the diagnosis. .n early cases" syste ic anti#iotics alone ay #e considered" #ut there ust #e !rofound resolution 'ithin 32 to 24 h5 other'ise" !ro !t o!erati&e drainage is necessary 12ig. 42-AB4. Arthritis and -steo yelitis Se!tic arthritis and osteo yelitis result fro neglected soft-tissue infection and ay occur in the undertreated or unhealthy !o!ulation. These !ro#le s re$uire e)tended surgical and edical thera!ies and often ulti!le" staged sal&age or reconstructi&e !rocedures. High-Pressure .n7ection .n7uries These in7uries occur fro !aint and grease guns" hydraulic lines" and diesel in7ectors that !ro!el aterial under !ressures of u! to @"BBB !ounds !er s$uare inch. Penetration through skin and along e)tended tissue !lanes is the rule rather than the e)ce!tion. These in7uries al ost al'ays in&ol&e the hands. The se&erity of in7ury is related ost directly to the nature of the in7ected aterial. Paint and sol&ents that are cytoto)ic !roduce intense infla ation in addition to the trau a fro the high-force in7ury. This !rolonged infla atory !hase is so eti es istaken for infection. Such in7uries re$uire i ediate echanical and !ulse-la&age de#ride ent in order to !re&ent e)tended tissue loss 12igs. 42-A3 and 42-A24. +on#acterial .nfection +on#acterial infections include tu#erculous" ycotic" and si ilar diseases. *ranulo a" a collection of acro!hages and histiocytes characteristic of the syste ic res!onse to these agents" is diagnostic. A high inde) of sus!icion and a careful history are necessary for accurate diagnosis. Patients !resent 'ith relati&ely !ainless" chronic" indolent soft-tissue !ro#le s. The !atient ay recall a local trau atic e&ent. The correct diagnosis often is a!!reciated only after onths or years. 2or e)a !le" the history of a !enetrating fish hook in7ury 'eeks or onths #efore a nodular or #oggy tenosyno&itis in a fisher an could suggest an aty!ical yco#acterial infection to the sus!icious clinician. Tissue #io!sy and cultures confir the diagnosis of s!ecific granulo atous disease. The distinction #et'een su!erficial and dee! tissue in&ol&e ent is i !ortant in tu#ercular and fungal infections" #ecause su!erficial infections are treated edically and dee! infections re$uire surgical de#ride ent. :yco#acterial infection" including tu#erculosis and the aty!ical yco#acteria originally thought to #e 7ust sa!ro!hytes" occurs !ri arily as soft-tissue infection 'ith secondary #one and 7oint !enetration. The !athologic aty!ical yco#acteria include :yco#acteriu arinu " kansasii" a&iu - intracellulare" fortuitu " and chelonei. -utside of the =nited States" the organis ost fre$uently !roducing defor ity and

destruction of u!!er e)tre ity function is :yco#acteriu le!rae" Hansen%s #acillus. Hansen%s disease should #e considered in !atients fro other nations. CHR-+.C SQ+/R-:ES Tendinitis

De /uer.ain0s Tenos)no.itis
.nfla ation of the tendons in the first dorsal co !art ent and the a#ductor !ollicis longus and e)tensor !ollicis #re&is #eca e associated 'ith de Muer&ain after his 3AC< re!ort of fi&e cases. This tendon infla ation is one of the ost co on causes of !ain along the radial side of the 'rist and the !ro)i al dorsoradial thu #. The !ro#le is ore co on in 'o en" and particularl) in ne1 mothers because o( (re2uent positionin o( the 1rist into (le#ion and thumb in e#tension 1hile carr)in or manipulatin their in(ant3 As #oth tendons !ass across the radial styloid !rocess in their tendon sheath" they are su#7ected to angulation and shear. Patients !resent 'ith tenderness o&er the ida)is of the radial styloid !rocess. Acti&e thu # and 'rist otion" !articularly acti&e thu # e)tension and !assi&e fle)ion 'ith 'rist de&iation" are !ainful. There ay #e cre!itus o&er the tendon sheath" occasional locking" or a secondary ganglionic ass. There also ay #e secondary irritation of the o&erlying su!erficial #ranches of the radial ner&e 'ith !aresthesias along the thu # and first 'e# 12ig. 42-A;4. The tendon infla ation causes restriction of acti&ities and otion. Finkelstein0s test" designed to re!roduce sy !to s #y !assi&e traction on these tendons" the !atient gras!s the fle)ed thu # under the fingers of the sa e hand" and then the e)a iner acti&ely de&iates the 'rist ulnarly. The test is !ositi&e 'hen sy !to s are re!roduced #y this aneu&er. The initial treat ent for de Muer&ain%s tenosyno&itis includes rest and custo s!lint su!!ort of the 'rist and thu #. -ral nonsteroidal anti- infla atory agents ay so eti es #e hel!ful" #ut in7ection 'ith a steroid and local anesthetic co #ination is #est. The in7ection should not #e ade into su#cutaneous tissues" #ecause it can !roduce fat atro!hy or de!ig entation in darker-skinned indi&iduals. -nce acute sy !to s resol&e" s!linting ay #e continued for sy !to -inducing acti&ities" such as 'hen others care for their infants. As 'ith other tendon infla ations" in7ection should relie&e sy !to s ade$uately and for a ini u of 4 to ? onths to erit re!eating. >hen sy !to s !ersist or recur" surgery is carried out through a trans.erse 4+cm incision centered o&er the thickened radial styloid !rocess. All dee!er dissection is done #y gentle longitudinal s!reading. The #ranches of the radial sensory ner&e are retracted gently and the thickened sheath incised longitudinally. :ulti!le tendon sli!s are e&ident 'hen the a#ductor !ollicis longus is e)!osed5 this tendon is co only ultistranded. The e)tensor !ollicis #re&is tendon is in another su#co !art ent that also ust #e released se!arately in u! to CB !ercent of cases. :any surgeons e)cise a !ortion of the sheath5 others close it dee! to the tendons. Posto!erati&ely" the thu # and 'rist are i o#ili(ed for 3 'eek #efore acti&e otion 'ith decreasing s!lint !rotection is started. Resisti&e e)ercises #egin 'hen they can #e tolerated. Other 5rist Tendinitis

2le)or and e)tensor sheath tendinitis ay occur in any of the dorsal and &olar su#grou!s" including the second through si)th e)tensor co !art ents" the fle)or car!i radialis tendon tunnel" and at the fle)or car!i ulnarisP!isifor and !isotri$uetral 7oint. Chronic infla ation of any tendon co !art ent is associated 'ith local and radiating sy !to s. Passi&e stretch and resisted acti&e function of the affected tendons re!roduces sy !to s and confir s the diagnosis in the a#sence of other clinical or )-ray findings. 2le)or tenosyno&itis is not rare after !rolonged gri!!ing acti&ities" such as in stringed-instru ent !layers and ty!ists. E)tensor co !art ent infla ation ay #e found 'ith intense re!etiti&e 'rist and finger otion fro any cause. :ore !ro)i ally" intersection syndro es can occur 'here the e)tensor car!i radialis longus and e)tensor car!i radialis #re&is tendons cross the first co !art ent tendons at their usculotendinous 7unctions. These crosso&er tendon infla ations ay so eti es #e acco !anied #y audi#le and !al!a#le cre!itus. Si ilar !resentations ay occur 'ith the e)tensor !ollicis longus and e)tensor indicis !ro!rius tendons. Tri er Fin er Chronic fle)or tenosyno&itis or teno&aginitis occurs ost co only in the iddle and ring fingers and in the thu #" and ost often in !ost eno!ausal fe ales. Patients ay not recall an in7ury that !redates sy !to s" #ut any can descri#e an e!isode of !rolonged use or forceful trau a 'ith i !act or hy!ere)tension that i ediately !receded the sy !to onset. The sna!!ing !heno enon occurs as the fle)or digitoru su!erficialis and !rofundus tendons" or the fle)or !ollicis longus in the case of the thu #" !ull through a tight A3 fle)or !ulley at the !ro)i al edge of the sheath. There is de#ate as to 'hether tenosyno&ial infla ation or !ulley thickening is the cause. There is a relati&e lack of &olu e in the sheath for the tendon" inducing the cre!itus" catching or locking" and !ain. :any !atients ha&e other associated syste ic diseases" such as dia#etes" connecti&e tissue disease" or additional sites of tenosyno&itis or car!al tunnel syndro e" #ut the !rocess ay #e isolated. Patients !resenting 'ith co !laints of finger !ain" distal !al ar !ain on gras!ing" finger catching and locking should #e e&aluated for syste ic and local !ro#le s. Thickening of the fle)or tendon at the #ase of the finger" in the distal !al " and !al!ation of tendon nodule that glides 'ith acti&e finger otion 'ill ake the diagnosis. .n the locking finger" an audi#le and !al!a#le sna! is noted 12ig. 42-A44. Any condition that causes finger stiffness" di inished fle)ion" or a fle)ion contracture es!ecially at the P.P 7oint" sna!!ing or locking can #e !otentially isdiagnosed as trigger finger. /iagnosis is ade #y careful clinical e)a ination and findings of a locali(ed nodularity and tenderness a#out the fle)or sheath in the distal !al . +onsurgical treat ent should #e offered e)ce!t for !atients 'ith a fi)ed P.P 7oint fle)ion contracture that 'ill not unlock after local anesthetic and steroid in7ection. A!!ro)i ately 3 to 2 , of the i) is in7ected into the fle)or sheath and !ulley. At introduction" the needle !ierces the skin and tendons at the #ase of the !ro)i al !halan)F etacar!al head and is then 'ithdra'n slightly. The sheath is as!irated and in7ection !roceeds 'ith gentle !ressure. 2ir resistance indicates that the needle is in a tendon and needs to #e 'ithdra'n or inserted further. Pal!a#le and &isi#le introduction of fluid into the fle)or sheath is a successful in7ection. :ost !atients

i !ro&e" #ut those 'ith continuing and recurring sy !to s are candidates for surgery. Surgery routinely cures the !ro#le " !ro&iding long-ter relief unless inco !lete A3 !ulley release" digital ner&e in7ury" or di&ision of the ne)t ore distal A2 !ulley occurs. >ith the !atient under local anesthesia and 'ith a forear or el#o' tourni$uet" a longitudinal incision is ade directly o&er the fle)or tendon #et'een the !ro)i al etacar!o!halangeal 7oint fle)ion crease and the distal !al ar crease 12ig. 42-A<4. The thickened !ulley lies directly #eneath this skin incision" 7ust dorsal to the fascia and su#cutaneous fat layers. The neuro&ascular #undles are #oth lateral to the sheath. ,ongitudinal incision in the sheath is ade under direct &ision" carefully releasing the !ro)i al and distal e)tent of the !ulley. To assure restoration of uni !eded tendon gliding &ia acti&e fle)ion and !assi&e traction" a #lunt hook is used. .n the thu #" s!ecial care is taken to a&oid inad&ertent di&ision of the radial !ro!er digital ner&e" 'hich usually crosses o&er and is !al ar to the fle)or tendon !ro)i al to the !ulley. Tendon release under direct &ision !rotects this structure. 2or tendon release in the thu #" an o#li$ue longitudinal or Bruner-style incision is !erfor ed 12ig. 42-A?4. /irect trau a !roducing a !artial tendon laceration distally ay cause a triggering !heno enon in the distal fle)or sheath. Syste ic diseases that !roduce tendon nodularity" such as rheu atoid arthritis and gout" ay cause si ilar" #ut ore distal" locking or catching of the tendon. These less co on causes re$uire ore e)tended fle)or sheath e)!loration" e)cision of tendon nodules" and reha#ilitation. +euro!athies :edian +er&e The edian ner&e ay #e co !ressed any'here along its course fro the cer&ical roots to the fingerti!s" #ut the ost co on site is 'ithin the car!al tunnel" 'here it is dorsal to the trans&erse car!al liga ent. All anato ic sites of co !ression ust #e considered and e&aluated in the differential diagnosis of this increasingly co on !eri!heral neuro!athy. Car!al tunnel syndro e results fro increased !ressure 'ithin the rigid car!al canal" !roducing edian ner&e ische ia and !hysiologic dysfunction. Sy !to s include !aresthesias and nu #ness in the radial ;R fingers" #urning digital dysesthesias" and" later in the course" hand 'eakness or a'k'ardness. 2ocal 'rist and hand !ain are not a !art of the syndro e" 'hile nocturnal !resence of sy !to s is a hall ark of this diagnosis. All treat ents are designed to reduce !ressure 'ithin the canal and relie&e ner&e co !ression. The car!al canal ser&es as a echanical conduit for the digital fle)or tendons. The car!al #ones for the 'alls and floor or dorsal surface of the canal" and the !al ar as!ect is roofed #y the trans&erse car!al liga ent. Tunnel cross-sectional area is dyna ic" 'ith the s allest area !ro#a#ly o#taining at the e)tre es of 'rist fle)ion and e)tension. There is de#ate as to the cause of the increased !ressure. So e ha&e !ostulated tenosyno&itis" 'hile other studies ha&e sho'n collagen" a yloid de!osits" and ede a as causes.

Eighty !ercent of car!al tunnel !atients are o&er the age of 4B years. The fe aleF ale ratio &aries fro 4I3 for idio!athic cases" #ut #e as lo' as 3.<I3 'ith occu!ational !resentation. A direct connection #et'een car!al tunnel syndro e and forceful or re!etiti&e use of the hands has not #een conclusi&ely de onstrated. There are re!orts of lo' and high instances a ong 'orkers in anual industries. Such studies ha&e used clinical criteria alone for the diagnosis and ha&e not eli inated a&ocational or syste ic diseasePinduced causes. The causation is !ro#a#ly ultifactorial in ost !atients. Car!al tunnel syndro e has #een associated 'ith endocrine disorders" including dia#etes" y)ede a" hy!erthyroidis " acro egaly" !regnancy" and the !ost!artu state. Chronic infections and he atologic and autoi une disorders also are associated 'ith car!al tunnel syndro e. S!ace-occu!ying lesions such as li!o as" #one a#nor alities of the radius or car!als" !osttrau atic ede a" and he ato as ay induce increased !ressure 'ithin the canal and co !ro ise edian ner&e function. The diagnosis of car!al tunnel syndro e is clinical. Classic sy !to s include !aresthesias" 'ith a !redo inance of nocturnal or early orning onset" #urning or nu #ness in the edian sensory distri#ution" and a'k'ardness in use of the hand. -n !hysical e)a ination" direct digital !ressure o&er the edian ner&e at the car!al tunnel re!roduces sy !to s 'ithin ;B seconds. .n Phalen%s aneu&er" gra&ityinduced 'rist fle)ion re!roduces sy !to s 'ithin a inute. >hen direct !ercussion of the ner&e elicits and re!roduces !aresthesias in the edian distri#ution" it is a !ositi&e Tinel%s sign. The a!!lication of a !neu atic tourni$uet to the u!!er li # to re!roduce digital sy !to s is of no &alue in aking this diagnosis. E)a ination should include o#7ecti&e docu entation of sensory and otor loss" the for er #y threshold testing" including &i#ration and Se s- >einstein onofila ents rather than inner&ation density or t'o-!oint discri ination. E)a ination of otor function includes o#ser&ation for thenar loss and assessing a#ductor uscle resistance against force 12ig. 42-A@4. Electro!hysiologic studies !ro&ide i !ortant confir atory and differential diagnostic infor ation. Electro!hysiologic studies alone do not for the #asis for this diagnosis" #ut surgery should not #e done 'ithout electro!hysiologic e&aluation. Electro!hysiologic tests are useful 'hen the diagnosis is difficult or 'hen surgical release is conte !lated. =nderlying !eri!heral neuro!athies and ultifocal co !ressions that are other'ise unsus!ected ay #e unco&ered. Electrical studies !ro&ide a #aseline for later co !arison if the res!onse to surgery is disa!!ointing. E&aluation should include studies of the edian ner&e as 'ell as of a second ner&e in the ore sy !to atic e)tre ity. Co !arison of edian and ulnar or of edian and radial sensory sti ulation &alues at the 'rist is useful in confir ing the diagnosis. Studies are not necessarily of !rognostic &alue for the res!onse to surgery. Routine radiogra!hs including the car!al tunnel &ie' are reco ended #y the A erican Acade y of -rtho!aedic Surgery for e&aluation and treat ent of car!al tunnel syndro e. Radiogra!hs are e&aluated for car!al fractures" arthritis" Gien#Hck%s disease" or other !ro#le s that could alter treat ent. CT and :R. scans are seldo needed" #ut #asic la#oratory studies to screen for endocrine and he atologic disorders are hel!ful. Predis!osing edical diseases" such as thyroid dysfunction or rheu atoid arthritis" should #e treated and ay fre$uently i !ro&e or resol&e the neuro!athy 'ithout surgery. .n !regnancy" car!al tunnel syndro e is treated #y salt restriction"

'rist s!linting" analgesics" and" occasionally" diuretics. ,ocal in7ection ay #e needed in the third tri ester. :ost !atients reco&er 'ithin a#out ? onths of deli&ery. 2or acute !osttrau atic car!al tunnel syndro e associated 'ith s'elling or he orrhage" loosening of constricti&e #andages and o&ing the 'rist fro a !osition at the e)tre e of fle)ion or e)tension ay suffice to re&erse or significantly i !ro&e sy !to s. Pressure studies and early surgery ay #e a!!ro!riate for those 'ho do not res!ond. S!lints and nonsteroidal anti-infla atory edications are 'idely used. S!lints should fit co forta#ly and !osition the 'rist in neutral to ini al e)tension. S!lints are 'orn at night if nocturnal sy !to s are a a7or co !laint. +ight s!linting ay #e all that is re$uired. >ith acti&ity-induced sy !to s" dayti e s!lint use during !ro&oking tasks ay #e needed. -ral nonsteroidal anti-infla atory agents are hel!ful" 'ith onitoring for !ossi#le gastrointestinal and syste ic side effects. Although su#clinical &ita in B? deficiency is a !ossi#le cause of car!al tunnel syndro e" no !ros!ecti&e study has de onstrated the efficacy of !yrido)ine" #ut it is nonto)ic. ,ocal steroid in7ection results in i !ro&e ent in AB to CB !ercent of !atients" #ut there is gradual deterioration o&er the ne)t 32 to 24 onths. As 'ith other sites" in7ections should not #e re!eated ore than 2 or ; ti es annually. .nad&ertent in7ection directly into the edian ner&e 'ill 'orsen sy !to s 12ig. 42AA4. Surgical treat ent re$uires co !lete di&ision of the trans&erse car!al liga ent for the entire length of the car!al tunnel under direct &ision. Surgical failure is ost often associated 'ith incorrect diagnosis or inco !lete liga ent di&ision. .nternal neurolysis" fle)or tenosyno&ecto y" conco itant ulnar ner&e deco !ression in *uyon%s canal" or car!al liga ent reconstruction are not indicated 'ith !ri ary release and ay #e har ful. -!en and endosco!ic release can effecti&ely di&ide the trans&erse car!al liga ent and increase canal &olu e 12igs. 42-AC" 42-CB" and 42-C34. -!en release is !erfor ed 'ith the !atient su!ine and under tourni$uet control. After li # e)sanguination and tourni$uet inflation" the field is infiltrated 'ith local anesthetic. .ntra&enous sedation ay #e used as a su!!le ent. .ncision for o!en release !arallels the thenar crease fro the distal end of the trans&erse car!al liga ent to al ost the distal 'rist crease and is ade in line 'ith the third 'e#. The skin should #e arked #efore incision. S all t'igs of !al ar cutaneous ner&e #ranches are identified during su#cutaneous dissection and !reser&ed 'here found crossing the incision. The !al ar fascia is s!lit longitudinally" using a s all cur&ed he ostat" fro the !ro)i al end of the car!al canal o&ing distally in the ost !al ar and ulnar $uadrant of the canal. The ner&e and fle)or tendons #eneath and radial to the cla ! are continuously identified and !rotected. The otor ner&e to the thenar uscles is identified and !rotected. The liga ent incision roughly !arallels the ulnar #order of the edian ner&e and lea&es a s all tissue fla! attached to the hook of the ha ate" ore ulnarly. The 'ound is ins!ected to assure co !lete di&ision of the liga ent" release of the contents" and the a#sence of soft-tissue and #one ano alies. The edian ner&e is found in the !al oradial !ortion of the canal" generally adherent to the underside of the liga ent. The ner&e ay ha&e a central-narro'ing" hourglass constriction at the site of a)i u co !ression. The surgeon should a&oid ani!ulating the ner&e #ecause this induces ore intraneural scarring and interferes #oth 'ith !osto!erati&e ner&e gliding and ulti ate reco&ery. After tourni$uet release

and he ostasis" !al ar fascia ay #e closed" #ut ost surgeons close only the skin" using a fine onofila ent nona#sor#a#le suture. The 'rist is s!linted in slight e)tension for a#out 2 'eeks #efore thera!y is started. Endosco!ic release 'as introduced to a&oid the or#idity of a !al ar scar. Studies suggest a ore ra!id reco&ery 'ith e$ui&alent increase in canal &olu e #y this a!!roach. The single-!ortal endosco!ic deco !ression is associated 'ith less !erio!erati&e disco fort and shorter i o#ili(ation and reco&ery. After endosco!ic release" a can&as 'rist s!lint is offered #ut not re$uired. Thera!y usually can #e started 'ithin the first !osto!erati&e 'eek. The incidence of inad&ertent tissue trau a fro o!en and endosco!ic ethods has not #een deter ined. The #est ethod for a&oiding co !lications is to o!erate carefully" in a #loodless field" cutting only 'hat can #e seen clearly and identified !recisely #efore it is incised. .f the !atient continues to ha&e sy !to s after surgery" a!!ro!riate clinical and ad7uncti&e diagnostic in&estigation should #e undertaken. .nco !lete liga ent di&ision or inaccurate !reo!erati&e diagnosis are the ost fre$uent !ro#le s" #ut !atients 'ith hidden agendas of a nonanato ic nature ay e)!erience !rolonged 'ound disco fort and li ited reco&ery. .n such situations" the real &alue of !reo!erati&e electrodiagnostics #eco es e&ident. =lnar +er&e =lnar ner&e co !ression at the el#o'" the cu#ital tunnel syndro e" has #een kno'n for ore than a century. .t has #een called !osttrau atic ulnar neuritis and tardy ulnar ner&e !alsy to e !hasi(e the trau atic causation. /istal co !ression in the canal of *uyon 1the ulnar tunnel4 at the 'rist is a less co on !ro#le and ore often caused #y a s!ace- occu!ying lesion or direct trau a. The !ossi#le sites of ulnar ner&e co !ression in the fi#ro uscular groo&e !osterior to the edial e!icondyle are su ari(ed in 2ig. 42-C2. All sites of ner&e co !ression ust #e considered. The differential diagnosis ust include edial e!icondylitis and its coe)istence 'ith ulnar ner&e irritation. So e !atients ha&e the echanical !ro#le of a hy!er o#ile or su#lu)ating ulnar ner&e. =lnar traction neuritis 'ith el#o' fle)ion and anterior ner&e su#lu)ation re!roduce radiating !aresthesias in the ulnar t'o fingers. Patients 'ho ha&e actual otor 'eakness" and es!ecially the su#grou! 'ith intrinsic uscle atro!hy and electro!hysiologic changes" ha&e a guarded !rognosis after delayed deco !ression. Patients !resenting 'ith edial e!icondylitis should #e treated for that !ro#le " #ut the !resence of secondary coe)istent ner&e irritation ust #e addressed. Those 'ho do not res!ond to conser&ati&e easures as outlined for the car!al tunnel should #e treated surgically. At o!eration" after ner&e deco !ression" the resultant !ro#le of iatrogenic su#lu)ation ust #e dealt 'ith. So e !refer si ultaneous su#!eriosteal edial e!icondylecto y" e)cising enough of the #ony !ro inence to flatten the skeletal contour of the edial side of the el#o' so that fle)ionFe)tension does not !roduce sna!!ing of the ner&e o&er a tissue !ro inence. Alternati&ely" su# uscular trans!osition can #e !erfor ed. There is no clear ad&antage of one techni$ue o&er the other in ost !atients 12ig. 42- C;4. =lnar tunnel deco !ression at the 'rist ust include the anage ent of s!aceoccu!ying lesions 'hich co !licate this diagnosis. =lnar tunnel syndro e is far less

fre$uent than co !ro ise of the edian ner&e in the car!al tunnel syndro e 12ig. 42C44. Pathologic conditions !redis!osing to ulnar ner&e and artery co !ression in the ulnar tunnel should #e attended to si ultaneously" including e)cision of a ha ulus nonunion" ulnar artery re&asculari(ation" or re o&al of ganglia. Radial +er&e Radial ner&e entra! ent ay cause sensory sy !to s of !aresthesias and dysesthesias in the ner&e%s afferent uscular and cutaneous distri#utions in the dorsal forear " 'rist" and hand. Sy !to s de!end on the !ri ary site of ner&e irritation or co !ression" 'hich is ost fre$uently in the !ro)i al forear . The ter radial tunnel syndro e descri#es a co !ression neuro!athy in&ol&ing the !osterior interosseous ner&e #ranch of the radial ner&e. The co on !resentation is aching disco fort in the dorsal and dorsal-lateral forear . Patients 'ith this !ro#le ay ha&e !receding or coe)istent lateral e!icondylitis" and the distinction #et'een e!icondylitis and !osterior interosseous ner&e co !ression ust #e included in the differential 'orku! of all cases of resistant tennis el#o'. =nlike e!icondylitis" the site of focal tenderness is distal to the e!icondyle" o&er the e)tensor uscles" at the site 'here the !osterior interosseous ner&e !asses into the fi#ro uscular tunnel #ounded #y the fi#rous !ro)i al edge of the su!erficial heads of the su!inator" a!!ro)i ately at the neck of the radius 12ig. 42-C<4. +onsurgical treat ent includes rest" acti&ity odification" s!lint !rotection" and nonsteroidal anti-infla atory agents. .n7ecta#le steroids do not ha&e a useful role. Electrodiagnostic studies are not hel!ful #ecause of the dee! and &aria#le location of the ner&e. -nly !atients 'ith dener&ation of the forear uscles 'ill de!enda#ly ha&e electrical changes0and this grou! should #e easy to diagnose clinically #efore o!erati&e deco !ression. The radial and !osterior interosseous ner&es can #e deco !ressed in the !ro)i al forear and anterolateral el#o' region in !atients 'ith resistant sy !to s. The #rachioradialis s!litting incision is ost efficient 12ig. 42- C?4. Radial sensory entra! ent distally" >arten#erg%s disease or cheiralgia !aresthetica" ay occur" #ut usually only after direct trau a to the radial 'rist" e.g." after a!!lication of handcuffs. -!eration is rarely re$uired for this ty!ically transient !ro#le . Radial sensory sy !to s of local !aresthesias ore often coe)ist 'ith or are secondary to the ore co on !ro#le of de Muer&ain%s tenosyno&itis in the first dorsal co !art ent. This tendinitis should #e e)cluded in the differential diagnosis and is a ore !ro#a#le reason for ner&e irritation than !ri ary entra! ent 12ig. 42C@4. ACM=.RE/ /QS2=+CT.-+ /u!uytren%s Contracture Although this disorder is associated 'ith the nineteenth-century 2rench surgeon Baron *uillau e /u!uytren" he 'as not the first to descri#e it. John Hunter" in 3@@@" and Sir Astley Coo!er" in 3A22" descri#ed the disease" and Coo!er reco ended su#cutaneous fascioto y. The !athologic !roliferation is !ri arily of the longitudinal !ortion of the !al ar fascia and its digital e)!ansions !al ar and dorsal to the neuro&ascular #undles 12ig. 42-CA4. The diagnosis in ad&anced cases is not difficult" #ut in early stages the disorder ay #e confusing. Gnuckle !ads consisting of

fasciotendinous !roliferations o&er the dorsu of the P.P 7oints" of !al ar fascial nodules" or di !ling or !itting of the !al ar skin are characteristic findings. >hile !al ar fascial nodules are #elie&ed !athogno onic" other asses including" retinacular cysts" tendon nodules" foreign #odies" and trigger finger" occasionally cause confusion. The /u!uytren%s fascial nodule does not o&e 'ith acti&e fle)or tendon e)cursion and is located 7ust dee! to the skin and su#cutaneous fat. 2ascial skin tethering ay result in fat #ulging on either side of the diseased !retendinous #and and cause the skin !its that are characteristic of this !athologic !rocess. Proliferating nodules !recede cords" #ut !atients ay not !resent until cords and contractures are !resent. Joint defor ity and contracture is the e&entual result of coalescence of nodules 'ith the de&elo! ent of a shortened" !athologic fascial ass. There is no !ro&en relationshi! to trau a" occu!ation" handedness" or re!etiti&e use in 'ork or s!orts. /u!uytren%s contracture is ost co only seen in Caucasian ales of +orthern Euro!ean descent 'ho are in their si)th decade or older 12igs. 42-CC" 42-3BB" and 423B34. Hand do inance or trau a are not causes5 the ale-to-fe ale ratio &aries fro 2I3 to 3BI3. /u!uytren%s contracture is fa ilial and is inherited as an autoso al do inant #ut 'ith &aria#le !enetrance. There are significant associations 'ith a nu #er of diseases and conditions" the ost !ro inent of 'hich are dia#etes and alcoholis . H.6 ay #e a risk factor. There is no effecti&e nonsurgical treat ent for /u!uytren%s contracture. -!eration should #e reser&ed for those 'hose disease is co !licated #y contracture. Tender !al ar nodules are a transient !heno enon" caused #y the coe)istence of acti&e cellular !roliferation and re!etiti&e daily contact" i !act" or load. .n !atients 'ith such co !laints" often truck dri&ers and others 'ho ust gri! or lift continuously" !added glo&es such as those 'orn #y #icyclists and 'eight lifters ay hel!. Sy !to s resol&e 'ithin a fe' 'eeks or onths. S!linting does not !re&ent later contracture. >hen the !atient can no longer !lace the hand flat on the ta#le" the Huston ta#leto! test" o!eration is indicated. Contracture correction at the :P 7oint is easier than at the P.P 7oint" 'here surgery should !roceed 'hen the fi)ed P.P contracture a!!roaches 4< degrees. -!erating on a !atient 'ith /u!uytren%s contracture re$uires a detailed kno'ledge of nor al hand anato y" !al ar fascial structure" and location of the !athology as it a!!lies to the defor ity" including !athologic dis!lace ent of the neuro&ascular #undles" 'hich !uts the at risk of in7ury during e&en the ost careful of surgical release !rocedures 12ig. 42- 3B24. :ost !atients ha&e the ulnar !al affected first and ost significantly. .n decreasing order" the fourth" fifth" third" second" and first rays are ost fre$uently in&ol&ed. The ost effecti&e techni$ue is digital fasciecto y as o!!osed to fascioto y. The results deteriorate 'ith ti e" ho'e&er5 surgery does not cure the disease #ut treats 7oint defor ities" contracture" and dysfunction. 2asciecto y is !erfor ed under lou!e agnification and e)sanguinated !neu atic tourni$uet control. Skin fla!s are dissected at the le&el of !al ar fascia" !reser&ing the a)i u thickness of contiguous skin and su#cutaneous tissues to a&oid de&asculari(ed" o&er-thinned fla!s 12ig. 42-3B;4. Closed fascioto y is not !erfor ed #ecause of the risk of neuro&ascular in7ury in this #lind release techni$ue.

Posto!erati&e anage ent &aries only to a inor degree 'hether Bruner- style" L!lasty" or the :cCash o!en-!al incision techni$ue is used. >ith the o!en techni$ue" trans&erse areas at the skin creases ini ally affect the reco&ery !rotocol. A drain is not necessary. The lessened risk of he ato a and di inished short-ter !ain afforded #y lea&ing so e incisions o!en and connecting the trans&erse crease incision &ia o#li$ue longitudinal incisions a&oids the need to dissect under an a'ning of !al ar skin 1see 2ig. 42-3B; /4. A &olu inous and oderately co !ressi&e dressing is a!!lied" su!!le ented #y a !al ar" or !al ar and dorsal" !laster s!lint1s4 that aintains the 'rist in ;< degrees or ore of e)tension and the :P and .P 7oints in full corrected e)tension. Thera!y is started under close su!er&ision #y the end of the first !osto!erati&e 'eek. Reha#ilitation includes acti&e and !assi&e otion and custo e)tension s!linting of released 7oints at night. Sutures are re o&ed after 2 'eeks" de!ending on 'ound healing. Soaking and 'ashing" es!ecially 'hen the :cCash techni$ue is used" is ore an indi&idual choice than re$uired. .n addition to 'ound infection and skin slough" secondary s'elling is a serious #ut unco on co !lication. Prolonged !ain leading to refle) sy !athetic dystro!hy is a difficult !ro#le for !atient" thera!ist" and !hysician. /igital ner&es can #e in7ured during o!eration no atter ho' e)!ertly the !rocedure is !erfor ed" #ut such in7ury ust #e recogni(ed and re!aired. Arthritis .nfla atory Arthro!athies The hand is a irror of any infla atory arthro!athies" not 7ust gout or rheu atoid arthritis 12igs. 42-3B4" 42-3B<" and 42-3B? and Ta#le 42-<4. Adult and Ju&enile Rheu atoid Arthritis Pri ary consideration should #e gi&en to arthritis #ecause of 'orld'ide !re&alence and the se&ere disa#ility if untreated or" occasionally" 'hen treated aggressi&ely. Rheu atoid arthritis is a chronic syste ic disorder of unkno'n cause 'hose a7or anifestation is infla atory syno&itis 'ith secondary #one and tendon in&asion and destruction. There ay #e late tendon dysfunction through nodularity and locking or scarring" 7oint su#lu)ation" and !ain. .n ost cases" syno&itis defor ities are sy etrical. Rheu atoid arthritis affects the el#o's" 'rists" and etacar!o!halangeal 7oints. Pro)i al inter!halangeal in&ol&e ent is less co on #ut ay #e significant in a gi&en !atient. -n radiogra!hs" the hands and feet sho' so e of the earliest signs of !eriarticular osteo!enia" de inerali(ation. The earliest erosions occur along the radial-!al ar as!ects of the etacar!al heads" at the !ro)i al !halanges" and in the !restyloid recess of the ulna. -!erati&e inter&ention is #est li ited to !atients 'ho" des!ite edical anage ent" ha&e !ersistent dysfunction #ecause of !ain" stiffness" or insta#ility" or those 'ho ha&e !rogressi&ely 'orsened function and increased defor ities. Scleroder a or Syste ic Sclerosis This is a generali(ed &asculitis affecting the skin" gastrointestinal tract" kidneys" and hands" resulting in thickened" dense" and inelastic skin and connecti&e tissues. Pathologic 7oint in&ol&e ent occurs in u! to AB !ercent of the !atients. 6asculitis and secondary s all-7oint defor ity ay co #ine to !roduce unsta#le skin" chronic ulcerations that cannot heal" and secondary infections and !ainful loss of use 12ig. 423B@4.

Psoriasis This should al'ays #e a consideration in the !atient 'ith infla atory arthritis of the hands" !articularly 'ith nail defor ities and oligoarticular arthritis. Psoriatic arthritis usually affects the distal inter!halangeal 7oints. Crystal Arthro!athies Crystal arthro!athies include gout and !seudogout" 'hich are diagnosed definiti&ely after e)a ination of 7oint as!iration fluid or #io!sy s!eci en. The seru uric acid le&els ay #e nor al e&en in an acute attack. :ost !atients 'ith hy!erurice ia ne&er ha&e acute gouty arthro!athy. Calciu !yro!hos!hate crystalline infla ation" or !seudogout" often affects the 'rist" 'ith chondrocalcinosis classically seen on the !osteroanterior 'rist radiogra!h at the !restyloid recess 12ig. 42-3BA4. +oninfla atory Arthro!athies +oninfla atory arthro!athies include osteoarthritis" herita#le a#nor alities of cartilage !roduction" !ri ary and secondary osteonecrosis or osteo alacia" endocrine-associated articular changes fro thyroid" !arathyroid" !ituitary glands and !ancreas" he atologic diseases such as he o!hilia and he oglo#ino!athies" the collagen storage diseases" and iscellaneous #one" ner&e" and other connecti&e tissue !athologies" including a yloid. Sarcoidosis is infla atory. -steoarthritis -steoarthritis is the ost co on u!!er e)tre ity arthro!athy. Although classically defined as noninfla atory" osteoarthritis is a cartilage disease 'ith at least inter ittent lo'-to- oderate le&els of infla ation. .ts incidence increases 'ith age. There is a significant hereditary co !onent" es!ecially for 'o en. Patients ay de onstrate !rogressi&e loss of articular cartilage" seen on radiogra!hs first as di inished 7oint s!ace" 'ith secondary su#chondral sclerosis and arginal #one s!urs or li!!ing. Joint enlarge ent as a result of li!!ing usually occurs. The !re&alence of distal inter!halangeal 7oint nodularity" He#erden%s nodes 12ig. 42-3BC4" is u! to ten ti es greater in 'o en" es!ecially for those 'ith a fa ily history. Secondary" !osttrau atic" echanical osteoarthritis is ore co on in indi&iduals 'hose occu!ations e)!ose the to in7uries or re!etiti&e load" otion" and i !act. The infla atory &ariant often affects the hands" !articularly the inter!halangeal 7oints" and can #e clinically and radiogra!hically aggressi&e. The inter!halangeal 7oints 1!articularly the ter inal inter!halangeal 7oints of inde) and thu #4" the tra!e(io etacar!al" thu # #asilar 7oint" the !antra!e(ial and radiosca!hoid articulations are ost fre$uently affected. >ith infla atory !ro#le s due to chronic or !rogressi&e syno&itis" tendon in&ol&e ent" secondary 7oint locking and tendon ru!ture ay contri#ute to sy !to s. E)tensor or fle)or tenosyno&ecto ies in the lo'er forear " 'rist" !al " or digits ay #e necessary and should #e co #ined 'ith a su!er&ised !osto!erati&e thera!y !rogra to reco&er otion 12ig. 42-33B4. >hen tendon ru!tures occur" the attritional defect in tendon su#stance and seg ental tendon loss !re&ents direct re!air and re$uires tendon graft or transfer 12ig. 42-3334. Tendon su#lu)ation ay occur as a result of tendon disease or secondarily fro 7oint in&ol&e ent dee! to that tendon.

2ocal s all-7oint defor ities are #est treated 'ith arthro!lasty" es!ecially in :P 7oints and for the less acti&e" older !atient" or 'ith arthrodesis at selected li ited intercar!al and inter!halangeal 7oints 12igs. 42-332" 42- 33;" and 42-3344. 2or successful arthrodesis" selection of o!erati&e ethod is not as i !ortant as eticulous" !recise techni$ue. Sta#ili(ed continuous #one contact o&er the entire surface to #e fused" in the !resence of good #one stock 'ith dura#le soft-tissue co&erage" !roduces a !ositi&e outco e. ,i&ing #one !ro&ides the ost dura#le arthrodesis. >ith re o&al of all the unsightly" !ainful" !ro inent osteo!hytes a#out the dorsal" !al ar" radial" and ulnar 7oint argins" the results are e)cellent. Thu # stiffness" !ain" and alalign ent !roduce arked hand i !air ent5 the !ro#le s are far out of !ro!ortion to the lesion #ecause of the critical i !ortance of co forta#le thu # o#ility and sta#ility in !recision and !o'er hand use 12igs. 4233< and 42-33?4. Thu # #asilar arthro!lasty yields functional" aesthetic results. C-+*E+.TA, /E2-R:.T.ES 2ailures of de&elo! ent" se!aration" and seg entation and intrauterine in7ury such as a niotic #ands or congenital constriction ring syndro e affect o#ility" facility" and self-i age. A#nor alities of the shoulder and hu erus" el#o'" forear " 'rist" and hand !roduce i !ortant #ut different i !air ents" and all di inish hand facility to different degrees 12ig. 42- 33@4. A ong the ost co on congenital afflictions in the hand are syndactyly and !olydactyly 12ig. 42-33A4. Consideration of re!air should #egin 'hen the !atient is ; to ? onths of age. Congenital trigger thu # ay !resent to the !ri ary !ediatric caregi&er as a sna!!ing that ay or ay not #e !ainful" #ut it often !resents as a fi)ed fle)ion of the ter inal thu # 7oint. Trigger thu #s are rarely locked in e)tension. Pathologic findings are locali(ed to the fle)or !ollicis longus tendon and the !ro)i al annular !ulley of the thu #. .t is not clear 'hether the tendon enlarge ent" kno'n as +otta%s node" or thickening of the !ulley 'ith relati&e lessening of the internal dia eter of the sheath is the !ri ary !athology. -nly 3B to 2B !ercent are #ilateral" at ti es se$uential rather than si ultaneous. -ther trigger fingers ay occur in the infant or young child" #ut only rarely. Surgery is conser&ati&e anage ent. There is no 7ustification for steroid in7ection in treating congenital trigger thu #. Children 'ho are diagnosed at 32 onths of age ay #e o#ser&ed for ? to 32 onths for !ossi#le s!ontaneous correction" #ecause 'aiting does not co !ro ise outco e. At any age" 'hen fi)ed fle)ion defor ity of the thu # inter!halangeal 7oint !roduces secondary etacar!o!halangeal 7oint hy!ere)tension" or 'hen a child o&er the age of 2 years initially !resents 'ith sy !to atic locking" surgery to release the !ro)i al fle)or !ulley is in order. The thickened tendon nodule is not de#ulked or de#rided. +one of these children has !er anent loss of inter!halangeal e)tension. .f an inter!halangeal 7oint cannot #e fully e)tended at surgery" it eans that the !ulley has not #een released co !letely until !ro&en other'ise. T=:-RS Princi!les ,ocali(ed asses are co on in the hand and u!!er li #" #ut ost are #enign. :ost ha&e characteristics that assist in aking the diagnosis. The relati&e rarity of

alignant tu ors of the usculoskeletal syste isdiagnosis and under anage ent.

distal to the el#o' can lead to

E&ery ass" !articularly those that are aty!ical in a!!earance or location" should #e diagnosed 'ith staging and i aging !rocedures leading to careful incisional #io!sy. Hand asses tend to !resent earlier" 'hen s aller" #ecause of their su!erficial location. Enlarging" sy !to atic asses are e&aluated 'ith history" la#oratory studies" i aging #y !lain fil s" ultrasonogra!hy" scintigra!hy" CT scans" or :R.. Bio!sy is the last ste! in diagnosis" and only &ery s all lesions or lesions that are ty!ical should #e e)cised initially. Benign +eo!las s Benign tu ors can #e su#di&ided into three categoriesI 134 ,atent Benign. Tu ors arising during childhood ay heal s!ontaneously. :ost are 'ell enca!sulated" 'ith a clearly defined !lane #et'een the tu or ca!sule and nor al surrounding tissue. .n #one" the gro'th !rocess is slo'" allo'ing a argin of ature cortical #one to de&elo! and contain the lesion. 124 Acti&e Benign. ,esions continue to gro'" al#eit slo'ly" and are not self-li ited in si(e or #y !atient age. The tu or is 'ell enca!sulated" #ut the reacti&e (one is thicker and less ature than in the !receding category. >ithin #one" the tu or has an irregular sha!e that alters the internal or e)ternal #one architecture. Surgical anage ent is dictated #y deter ining the grade of the lesion and ade$uacy of local resection. -!erati&e ethod is deter ined #y the anato ical setting and the i !lications for altered usculoskeletal !art function. 1;4 Aggressi&e Benign. ,esions do not etastasi(e #ut are ore difficult to control locally. These lesions do not ha&e clear (ones of ca!sular contain ent. +odules or e)tensions of the tu or ay gro' out into near#y nor al tissue" such as in /u!uytren%s contracture. E)cision through the reacti&e (one e)!oses these tu or !ro7ections at the surgical argins" allo'ing icrosco!ic conta ination into unaffected tissue. 2ailure to fully re o&e the tu or ensures local recurrence. :alignant +eo!las s Surgical staging and treat ent for true and 42-@. alignant tu ors is outlined in Ta#les 42-?

S!ecific Tu ors *anglion Joint and tendon ganglions are a ong the ost co on #enign soft- tissue tu or asses in the u!!er e)tre ity" re!resenting u! to <B to @< !ercent of re!orted tu ors. Although !otentially located any'here" the a7ority of ganglions are in s!ecific sitesI the iddorsal 'rist5 the &olar radial 'rist5 the fle)or sheath at the etacar!al fle)ion crease as a seed or !ea ganglion that is e)tre ely s all #ut hard and tender5 and at the dorsu of the distal inter!halangeal 7oint and nail #ase. The latter is associated 'ith secondary nail defor ity" such as in ucous cyst" !articularly in the older !o!ulation 1see 2ig. 42-;4.

Treat ent o!tions include closed ru!ture i !act" hy!oder ic needle as!iration" and o!erati&e e)cision. Ru!ture #y digital !ressure or 'ith a s'ift #lo' is unnecessarily trau atic and has little chance of succeeding. As!iration and steroid instillation ay #e of &alue" !articularly 'hen the e)!anding lesion has not #een diagnosed or is associated 'ith disco fort. At the dorsal 'rist" the ost co on site of origin is fro the sca!holunate interosseous liga ent" and the occult ganglion ay account for a significant a ount of dorsal 'rist !ain" !articularly in the fe ale teenage !o!ulation. 6olar ganglions are ost co only situated #et'een the fle)or car!i radialis tendon and the radial artery" at or 7ust !ro)i al to the 'rist at the radiosca!hoid 7oint. :ost arise fro a radiocar!al or intercar!al ca!sule. As!iration is hel!ful and ay #e entirely curati&e for the fle)or sheath ganglion that a!!ears as a ;to 3Bhard ass at or 7ust distal to the etacar!o!halangeal 7oint fle)ion crease. As!iration and in7ection of the ucous cyst distal inter!halangeal 7oint ganglion is less likely to #e curati&e. Re!eated drainage increases the risk of 7oint conta ination. Surgical e)cision ust include the ca!sular #ase origin" so eti es referred to as the stalk or root. /eflating the ganglion during o!eration #y incising it #efore dissecting is uch easier than trying to !rotect near#y cutaneous ner&es or &essels 'hile still a&oiding an e)cessi&ely large skin incision around an inflated cyst. *iant Cell Tu or of Tendon Sheath Also kno'n as nodular tenosyno&itis" fi#ro)antho a" giant cell tu or of syno&iu " and !ig ented &illonodular syno&itis" it is the ost co on solid soft-tissue tu or in the hand. .t is ore fre$uent in fe ales" and !atients are generally #et'een the ages of ;B and ?B years. .t !resents as a fir " lo#ular" nontender" slo'ly enlarging ass in the !al " finger" or thu #. .t is ore fre$uently seen on the !al ar surface" gi&en that syno&iu is !resent in the fingers only a#out the fle)or tendons and in the 7oints. Secondary tendon" 7oint" and skeletal in&asion is 'ell kno'n 12ig. 42- 33C4. Effecti&e treat ent re$uires eticulously co !lete e)cision" 'ith care #eing taken not to in7ure the neuro&ascular #undles or the critical fle)or sheath !ulleys. Recurrences occur in u! to 3B !ercent of !atients 'ithin 2 years and ay occur u! to 3B years later" though late recurrences ay #e ne' lesions entirely. ,i!o a ,i!o as are #enign tu ors that contain ature fat cells. They are rare in !eo!le under the age of 2B years. So e are ultifocal. Tu ors usually are asy !to atic #ut gradually enlarging soft to oderately fir asses. >hen they arise near a ner&e or in a ner&e tunnel" they ay cause secondary sy !to s. ,i!o as can #e su!erficial" su#cutaneous" or intra uscular" and in the hand they also ay #e large and dee!. Surgical treat ent is for diagnosis of the unkno'n enlarging ass or for i !ro&ing functional i !air ent. Recurrences are rare 12ig. 42-32B4. Enchondro a Enchondro as" the ost co on cartilage lesion of #one" are ost fre$uently found at the s all tu#ular #ones in the hand. They can !resent at any age" #ut ost are found in young adults. 6irtually all enchondro as !resent as !athologic fractures" although a s all nu #er ay #e found as an asy !to atic enlarge ent of a #one. Radiogra!hs usually are diagnostic 12ig. 42-3234. Surgical treat ent ay #e for diagnosis or thera!y. Pathologic fractures ay heal" #ut the tu or is unlikely to regress s!ontaneously 'ith fracture union. .t is #est to treat the fracture and the tu or

together" #ut so e !atients !refer to allo' the fracture to heal 'hile 'aiting for the tu or to resol&e s!ontaneously. Treating the lesion and the fracture si ultaneously li its the disa#ility to 7ust one inter&al. Thorough lesional curettage is re$uired" and autogenous #one grafting is a!!ro!riate5 so e #ones heal 'ithout added graft. .ncidental disco&ery of s all asy !to atic enchondro as does not andate treat ent. Aggressi&e and alignant tu ors distal to the el#o' are unco on #ut are ore likely to #e of soft-tissue origin. S=R*.CA, PR.+C.P,ES Skin Pre!aration /etergents and solutions assist in echanically de#riding skin and also echanically decrease the icroflora !o!ulation5 ho'e&er" all can irritate skin" and each has li itations. Alcohols 'ork !ri arily through the denaturation of !roteins and !roduce the ost ra!id reduction in icro#ial counts. They 'ork against ost gra -!ositi&e and gra negati&e organis s. Alcohols are not s!oricidal #ut are acti&e against any fungi and tu#erculosis5 they also act against so e &iruses" including H.6 and cyto egalo&irus. Alcohols do not ha&e !ersistent effects. He)achloro!hene is #actericidal through cell 'all destruction and is es!ecially acti&e against gra -!ositi&e cocci. .t is ini ally effecti&e against gra -negati&e" &iral" and fungal organis s. This agent is !otentially to)ic syste ically 'hen a#sor#ed and is not reco ended for o!en 'ounds. .odo!hors" iodine co !le)es that irritate the skin less than the iodineFalcohol tincture solutions" are effecti&e against a #road s!ectru of gra -!ositi&e and gra -negati&e #acteria" fungi" &iruses" and yco#acteria #y cell 'all !enetration and o)idation. .odo!hors ha&e al ost i ediate onset of action" and residual acti&ity declines $uickly. Because the iodo!hors can cause skin irritation" tissue da age" and allergic reactions in so e !atients" these solutions are not reco ended for chronic use on o!en 'ounds" #ecause the additional tissue irritation ay ake the 'ound ore susce!ti#le to late infection. Chlorhe)idine gluconate is a #road-s!ectru anti#acterial that is effecti&e against any &iruses" 'ith li ited acti&ity against fungi and the tu#ercle #acillus. The ti e of onset of action is inter ediate" and residual #actericidal action continues for se&eral hours. Chlorhe)idine gluconate alcohol-#ased solution ay !ro&ide the added #enefit of ra!id onset and residual acti&ity 'ith ini al to)icity. Chloro)ylenol or !arachloro eta)ylenol 1PC:E4 is acti&e through destruction of icro#ial cell 'alls. .t has inter ediate onset and good acti&ity against gra -!ositi&e organis s #ut only fair acti&ity against gra - negati&es" fungi" yco#acterial s!ecies" and &iruses. .t is not to)ic and rarely causes skin irritation. .t ay #e a good choice in any situations. Hair Re o&al >hile the con&entional 'isdo is that routine hair re o&al eli inates a !otential 'ound conta inant" ost studies re&eal that hair re o&al is not a #enign !rocedure and that close skin sha&ing increases the risk of !osto!erati&e 'ound infection" 'ith

risk rising as the ti e #et'een the sha&e and the surgical !rocedure increases. .n a case in 'hich the !resence of hair 'ould interfere 'ith 'ound closure or tissue and skin ani!ulations" the use of electric cli!!ers or de!ilatories is !refera#le" and hair re o&al should #e done at the start of the !rocedure rather than the day #efore. Anesthesia Regional anesthesia for u!!er li # surgery offers effecti&e !ain control and the a&oidance of ental confusion or other side effects fro sedati&es and general anesthesia 12ig. 42-3224. Regional anesthesia is not risk-free or al'ays fully satisfactory5 syste ic and local reactions ay #e serious. A!!ro!riate onitoring is andatory. 2orear or a)illary tourni$uet is used for ost hand surgery" #ut !atients often are not a#le to tolerate continuous !neu atic tourni$uet a!!lications for ore than ;B in. .solated !eri!heral #locks ha&e ore li ited usefulness. /istal !eri!heral #locks in the u!!er e)tre ity should al'ays #e done 'ithout e!ine!hrine added to the anesthetic solution. The in7ection techni$ue is #ased on infiltration of anesthetic around the ner&e and not directly into ner&e su#stance. Although inad&ertent needle entry into ner&es is co on" 'ithout e!ine!hrine in the in7ection solution and 'ith the use of a fine gauge needle it should !resent no !ro#le . Should a !atient co !lain of !aresthesias" the needle is 'ithdra'n and redirected. .ntraneural in7ection 'ith e!ine!hrine-containing solutions ay result in e)tended intraneural ische ia and secondary fi#rosis as 'ell as !eri!heral &ascular co !ro ise" !articularly in the digital end-arterial circulation. =lnar +er&e Block Pro)i al #lock is a ong the ore useful !eri!heral techni$ues 12ig. 42- 32;4. The ulnar ner&e is !al!ated 7ust !osterior to the edial e!icondyle and in7ected 'ith < to A , 3D e!i&acaine hydrochloride 'ithout e!ine!hrine &ia a 2;- to 2?-gauge needle. The ner&e should not #e !inned to the e!icondyle 'ith the needle5 intense !aresthesias elicited fro neural !erforation 'arrant i ediate 'ithdra'al and redirection. The ulnar ner&e at the 'rist is in the &olar fle)or co !art ent located dorsal to the fle)or car!i ulnaris tendon" and 7ust ulnar to the ulnar artery5 #oth ner&e and artery are dorsal to the tendon. The dorsal cutaneous #ranch of the ulnar ner&e has already #ranched 4 to A c !ro)i al to the ulnar styloid !rocess. .nitially dee! to the fle)or car!i ulnaris tendon" it courses dorsally to e)it on its dorsal edge distal to the ulnar styloid !rocess" 'here it can #e #locked se!arately 12ig. 42-3244. A fine-gauge needle is inserted into the skin 7ust dorsal and ulnar to the fle)or car!i ulnaris tendon5 the needle is ai ed !al ar'ard and distally" to'ard the ring finger into *uyon%s canal. The skin conca&ity for needle entry is dorsal to the fle)or car!i ulnaris tendon" and easily !al!ated and &isuali(ed during acti&e 'rist fle)ion and ulnar de&iation. After needle entry" !aresthesias ay #e elicited" and < , of anesthetic is in7ected. As!iration #efore in7ection a&oids intraarterial in7ection. The dorsal #ranch of the ulnar ner&e is #locked 'ith an additional su#cutaneous infiltration of 2 to ; , after first !ulling the needle !ro)i ally and then redirecting it dorsal and distal to the ulnar styloid. Radial +er&e Block The radial ner&e is located #et'een the lateral edge of the #ice!s and the anterior #order of the trice!s uscles5 otor and sensory co !onents can #e anestheti(ed 'ith

in7ection a!!ro)i ately 4 c !ro)i al to the lateral e!icondyle" 'here the ner&e lies on the hu erus in this inter uscular s!ace 12ig. 42-32<4. The needle is ai ed distally and inserted5 !aresthesias confir needle and ner&e location. The needle is then 'ithdra'n slightly and @ to 3B , of anesthetic is in7ected" 'ith another 2 to ; , of anesthetic infiltrated in the su#cutaneous !lane" 'hich also #locks the lateral ante#rachial cutaneous ner&e. The !urely sensory su!erficial radial ner&e e erges at the dorsal edge of #rachioradialis tendon 4 to ? c !ro)i al to the radial styloid !rocess. As it courses distally" the ner&e di&ides into ulti!le ter inal #ranches. Su#cutaneous anesthetic infiltration at the styloid !rocess of the radius 'ith a total of ? to A , of anesthetic effecti&ely #locks the su!erficial radial ner&e in this region 12ig. 42-32?4. :edian +er&e Block Blocking the edian ner&e is ore difficult in the region of the el#o' than in the region of the 'rist. At the el#o' the edian ner&e is !osterior and ulnar to the #rachial artery. A fine hy!oder ic needle is introduced fro a location edial to the !al!ated #rachial artery" ai ing distally. After as!iration" A to 3B , of anesthetic is in7ected. .f intense !aresthesias are elicited" the needle is 'ithdra'n slightly #efore in7ection 12ig. 42-32@4. The edian ner&e #eco es !rogressi&ely ore su!erficial as it a!!roaches the 'rist" 'here it lies in the ost !al ar and radial $uadrant of the car!al canal. Pro)i al to the canal" the ner&e is located dorsal and slightly radial to the !al aris longus tendon" and ulnar to the fle)or car!i radialis tendon0i.e." #et'een the t'o tendons. Pro!er techni$ue a&oids the canal contents and the ner&e. The ost consistent and co forta#le skin !ortal is a#out ; c !ro)i al to the 'rist crease. The needle is ai ed ;B to 4< degrees dorsal and distal" to'ard the third 'e# s!ace 12ig. 42-32A4. .n7ecting ? to A , of anesthetic consistently #locks the edian ner&e. The !al ar cutaneous #ranch of the edian and lateral ante#rachial cutaneous ner&es can #e #locked 'ith another 2 to ; , of anesthetic in7ected su#cutaneously" ai ing ore su!erficially and 4< degrees radially fro the sa e entry !oint. /igital +er&e Block The fingers recei&e their sensory su!!ly fro the co on digital ner&e #ranches of the edian and ulnar ner&es. /igital anesthesia can #e achie&ed #y in7ecting the anesthetic into the looser 'e# tissues a#out the co on digital ner&es" 'hich is !refera#le to a ring #lock in the #ase of the finger. The so-called ring #lock techni$ue risks &ascular co !ro ise fro &olu e co !ression 'hen a solution is in7ected circu ferentially a#out the #ase of the finger. /igital anesthetic solution should not include e!ine!hrine" #ecause any resulting digital &essel s!as ay co !ro ise finger circulation. Anesthetic is in7ected retrograde fro the 'e#" ad&ancing a#out 3 c !ro)i ally into the !al " 'here 2 , of anesthetic is in7ected after as!iration. The needle can #e 'ithdra'n and turned into the dorsal su#cutaneous tissues of the 'e# to ensure anesthesia of the dorsal #ranch of the digital ner&e 'ith another 3 to 2 , of anesthesia. The techni$ue is re!eated on the o!!osite side of the finger or se$uentially in se&eral digits as needed. +o ore than < to @ , total of anesthetic solution should #e in7ected for any one finger 'ith this techni$ue 12ig. 42- 32C4.

2le)or Sheath Block Single-digit anesthesia can also #e achie&ed 'ith in7ection of 2 , of anesthetic directly into the fle)or sheath. A fine hy!oder ic needle is introduced into the fle)or tendon fro the !al ar side at the le&el of the distal !al or :P fle)ion crease. Ra!id onset of anesthesia can #e achie&ed. This ethod has the ad&antage of a single in7ection #ut the disad&antage of so eti es failing to co !letely anestheti(e the dorsal di&isions of the !ro!er digital ner&es. Tourni$uet The use of tourni$uets dates to Ro an ti es" #ut the de&ice ac$uired its na e fro surgical a!!lication in eighteenth-century 2rance" fro tourner" eaning to turn. Hand surgery is !erfor ed using an a)illary or forear !neu atic tourni$uet. 2ingerti! !rocedures can #e done using a digital tourni$uet ade fro a S-inch ru##er drain hose or 'ith the finger slee&e cut fro a sterile surgical glo&e5 the ti! of the finger slee&e is !ierced" and the slee&e is !laced o&er the !atient%s finger and rolled !ro)i ally" si ultaneously e)sanguinating and achie&ing a tourni$uet effect. .n the a#sence of !ro)i al anesthetic #lockade" the a)i u tourni$uet ti e a !atient 'ill tolerate is ;B to ?B in. E)ce!tion in the !resence of infections and sus!ected aggressi&e and alignant tu ors" the ar should #e e)sanguinated #efore tourni$uet inflation5 li # ele&ation ay #e used for !artial e)sanguination. Co&ering the ar 'ith a fa#ric stockinette #efore elastic #andage e)sanguination reduces skin shear5 this is i !ortant in !atients 'ith delicate skin" those 'ith connecti&e tissue diseases" and those 'ho are on steroids. A)illary and forear tourni$uet cuffs are #est a!!lied o&er cast !adding. +onsterile !neu atic tourni$uets should #e dra!ed a'ay fro the o!erati&e field 'ith an occlusi&e !lastic ta!e or dra!e distal to the cuff to !re&ent 'icking of antise!tic solution during e)tre ity !re!aration and risking che ical #urn 12ig. 42-3;B4. Pneu atic tourni$uet !ressures of 22< to 2<B Hg for adults and 2BB Hg in children are ade$uate. Patients 'ith &ery large or o#ese ar s re$uire higher !ressures and larger cuffs" as do hy!ertensi&e !atients" in 'ho tourni$uet !ressure should #e at least 3BB Hg o&er systolic #lood !ressure. Tourni$uet ti e is li ited #y the ost o)ygen-sensiti&e tissue0 uscle0and the ost o)ygen-sensiti&e organelle0 itochondria. Continuous tourni$uet a!!lication should not e)ceed ; h. .n cases in 'hich longer tourni$uet ti es are re$uired" the tourni$uet should #e deflated after the 'ound has #een dressed te !orarily and left deflated for at least 3B in !er hour of !rior inflation. Tourni$uet co !lications in&ol&e not only ische ia in la#ile distal tissues #ut also ische ia and direct in7ury to skin" ner&es" and uscles located i ediately #eneath the tourni$uet. Assu ing o!erati&e tourni$uet ti e of ;B in or ore" at tourni$uet deflation tissues sho' relati&e" reacti&e hy!ere ia dri&en #y the tourni$uet-induced hy!o)ia and directly !ro!ortional to the ti e of tourni$uet use. This hy!ere ia ay co !licate he ostasis. The tourni$uet is deflated #efore 'ound closure5 deflation should #e i ediately follo'ed #y @ to 3B in of direct" oderate 'ound !ressure #efore electrocautery is used. To a&oid he ato as" the 'ound is closed 'hen an acce!ta#ly dry field has #een achie&ed. .f oo(ing !ersists" a suction drain is used to kee! dead s!aces e !ty.

.ncisions and E)!osures Skin incisions can #e linear" cur&ed" or angled. They ay #e oriented in longitudinal or trans&erse directions relati&e to the li #. .deally" electi&e 'ounds are !laced to lie in and a#out the soft-tissue skin creases. Hand incisions are not ade !er!endicular to 7oint creases" so that iatrogenic contracture and unsightly scars are !re&ented 12ig. 423;34. A sterile skin- arking !en is used to dra' out the incisions. Cross- hatching the incision at regular inter&als assists in realigning the skin edges for closure 12ig. 423;24. Angles" !edicles" and turns in incisions should not #e so narro' as to risk &ascular co !ro ise #y creating a narro' skin !eninsula. /ressings and S!lints The hand dressing is an intrinsic !art of the surgical !rocedure. The dressing and s!lint are as i !ortant to the outco e as the o!eration. A!!lication of dressings and s!lints cannot #e delegated 'ithout su!er&ision #y the res!onsi#le surgeon. A !oorly a!!lied dressing ay destroy or disru!t the intended effect of the o!eration. The #otto layer of the dressing should #e confor ing" nonocclusi&e" and !refera#ly nonadherent" such as Eerofor or Ada!tic. A!!lied dressing s!onges ay #e dry or oistened for contour. >hen interdigital dressings are a!!ro!riate" a single gau(e !ad is folded" not t'isted" #et'een fingers. The in&ol&ed fingers or the entire hand is then o&er'ra!!ed loosely 'ith a Gerli) ty!e of #ulky rolled gau(e. Padded dorsal or &olar s!lints are a!!lied to aintain the desired !osition of the o!erated !art. The generic !osition for hand i o#ili(ation includes s!linting the 'rist at a#out 30 degrees of extension, the etacar!o!halangeal 7oints at 70 degrees of flexion" and the inter!halangeal 7oints at 0 to 5 degrees of flexion. The s!lint is e)tended to the fingerti!s" and care is taken to a&oid co !ressing the dressing and s!lint too tightly and risking circulatory co !ro ise. 2ingerti!s should #e e)!osed for circulation checks in hos!ital and at ho e. Hand and ar ele&ation is encouraged for co fort and for ini i(ing ede a during the first se&eral !ostin7ury and !osto!erati&e days. >ith or 'ithout a sling" 'hen the !atient is su!ine" sitting" or 'alking" the hand is ke!t at or a#o&e the le&el of the heart. Posto!erati&e Hand Thera!y Hand thera!y is #egun early and de!ends on the s!ecific diagnosis" !rocedure" and !atient. -!erati&e goals include ini i(ing the ti e of i o#ili(ation" enhancing internal sta#ili(ation" !refera#ly 'ith ini al in&asion" and allo'ing early o#ili(ation of skin" 7oints" and tendons. E)ercises a!!ro!riate for the condition and surgery !erfor ed are !rescri#ed" and a thera!ist instructs the !atient in these e)ercises. E)ercises should #e gentle" not !ainful" and should take the !atient to the li it of !otential otion at that ti e. The thera!y !rogra should e !hasi(e soft-tissue o#ili(ation and a decrease of ede a. >hen doing thera!y for the hand" o#ility in the forear " el#o'" and shoulder should #e included" es!ecially in older !atients. The use of 'hirl!ools is li ited to !atients 'ith s!ecial needs" such as those 'ith #urns and those 'hose 'ounds re$uire !eriodic de#ride ent. Heating the tissues is rarely" if e&er" done acutely5 ice is often ore a!!ro!riate for !osttrau atic conditions. =se of 'ar -'ater or !araffin #aths is

reser&ed for chronic conditions of syste ic infla ation and !eriarticular stiffness. After in7ury" tissue s'elling often increases !ro!ortionally to heat" 'orsening the !ros!ects of reha#ilitation in those s'ollen !arts. 1Bi#liogra!hy o itted in Pal &ersion4