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Surgery_Schwartz. versus computer-navigated acetabular component insertion. J Arthroplasty. 2007;22(2):151-159.Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br. 1982;64(1):17-19.Hootman JM, Helmick CG. Projections of U.S. prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54(1):266-229.Hürlimann M, Schiapparelli FF, Rotigliano N, Testa E, Amsler F, Hirschmann MT. Influence of surgical approach on hetero-topic ossification after total hip arthroplasty—is minimal inva-sive better? A case control study. BMC Musculoskelet Disord. 2017;18(1):27.Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Rel Res. 2010;469(2):503-507.Johnston RC, Brand RA, Crowninshield RD. Reconstruction of the hip. A mathematical approach to determine optimum geometric relationships. J Bone Joint Surg Am. 1979;61:639-652.Jones CW, Jerabek SA. Current role of computer navigation in total knee arthroplasty. J


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Surgery_Schwartz. A mathematical approach to determine optimum geometric relationships. J Bone Joint Surg Am. 1979;61:639-652.Jones CW, Jerabek SA. Current role of computer navigation in total knee arthroplasty. J Arthroplasty. 2018;33(7):1989-1993.Kim YH, Park JW, Kim JS. Computer-navigated versus conven-tional total knee arthroplasty: a prospective randomized trial. J Bone Joint Surg Am. 2012;94(22):2017-2024.Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res. 2006;447:34-38.Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016;31(9):127-130.Meneghini, R. Michael, et al. Direct


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Surgery_Schwartz. BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016;31(9):127-130.Meneghini, R. Michael, et al. Direct anterior approach: risk factor for early femoral failure of cementless total hip arthroplasty: a multicenter study. J Bone Joint Surg Am. 2017;99(2):99-105.Miller, Larry E., et al. Does surgical approach affect outcomes in total hip arthroplasty through 90 days of follow-up? A systematic review with meta-analysis. J Arthroplasty. 2018;33(4):1296-1302.Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59(9):1207-1213.Pai VS. A modified direct lateral approach in total hip arthroplasty. J Orthop Surg. 2002;10(1):35-39.Penninx BW, Messier SP, Rejeski WJ, et al. Physical exercise and the prevention of disability in activities of daily liv-ing in older persons with osteoarthritis. Arch Intern Med. 2001;161(19):2309-2316.Pivec R, Johnson


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Surgery_Schwartz. SP, Rejeski WJ, et al. Physical exercise and the prevention of disability in activities of daily liv-ing in older persons with osteoarthritis. Arch Intern Med. 2001;161(19):2309-2316.Pivec R, Johnson AJ, Mears SC, et al. Hip arthroplasty. Lancet. 2012;380(9855):1768-1777.Pospischill M, Kranzl A, Attwenger B, Knahr K. Minimally inva-sive compared with traditional transgluteal approach for total hip arthroplasty: a comparative gait analysis. J Bone Joint Surg Am. 2010;92(2):328-337.Brunicardi_Ch43_p1879-p1924.indd 192222/02/19 10:42 AM 1923ORTHOPEDIC SURGERYCHAPTER 43Sassoon A, Nam D, Nunley R, et al. Systematic review of patient-specific instrumentation in total knee arthroplasty: new but not improved. Clin Orthop Relat Res. 2015;473(1):151-158.Shih M, Hootman JM, Kruger J, Helmick CG. Physical activity in men and women with arthritis National Health Interview Survey, 2002. Am J Prev Med. 2006;30(5):385-393.Soong M, Rubash HE, Macaulay W. Dislocation after total hip arthroplasty.


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Surgery_Schwartz. Physical activity in men and women with arthritis National Health Interview Survey, 2002. Am J Prev Med. 2006;30(5):385-393.Soong M, Rubash HE, Macaulay W. Dislocation after total hip arthroplasty. Am Acad Orthop Surg. 2004;12:314-321.Taunton MJ, Trousdale RT, Sierra RJ, Kaufman K, Pagnano MW. John Charnley award: Randomized Clinical Trial of Direct Anterior and Miniposterior Approach THA: Which Provides Better Functional Recovery? Clin Orthop Rel Res. 2018;476(2):216-229.Tronzo RG. Surgical approaches to the hip. Surgery of the Hip Joint. New York: Springer; 1984:75-113.Vail T, Callaghan J. Minimal incision total hip arthroplasty. J Am Acad Orthop Surg. 2007;15:707-715.Whatling GM, Dabke HV, Holt CA, Jones L, Madete J, Alderman PM, Roberts P. Objective functional assessment of total hip arthroplasty following two common surgical approaches: the posterior and direct lateral approaches. Proc Inst Mech Eng H. 2008;222(6):897-905.Whiteside LA. Soft tissue balancing: the knee. J


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Surgery_Schwartz. hip arthroplasty following two common surgical approaches: the posterior and direct lateral approaches. Proc Inst Mech Eng H. 2008;222(6):897-905.Whiteside LA. Soft tissue balancing: the knee. J Arthroplasty. 2002;17(4):23-27.Orthopedic OncologyAndresen KJ, Sundaram M, Unni KK, Sim FH. Imaging features of low-grade central osteosarcoma of the long bones and pelvis. Skeletal Radiol. 2004;33(7):373-379.Becker N. Epidemiology of multiple myeloma. In: Moehler T, Goldschmidt H, eds. Multiple Myeloma. Berlin: Springer; 2011:25-35.Chakarun CJ, Forrester DM, Gottsegen CJ, Patel DB, White EA, Matcuk Jr GR. Giant cell tumor of bone: review, mim-ics, and new developments in treatment. Radiographics. 2013;33(1):197-211.Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20): 6243s-6249s.Dai X, Ma W, He X, Jha RK. Review of therapeutic strategies for osteosarcoma, chondrosarcoma, and Ewing’s sarcoma. Med Sci Monit.


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Surgery_Schwartz. risk of skeletal morbidity. Clin Cancer Res. 2006;12(20): 6243s-6249s.Dai X, Ma W, He X, Jha RK. Review of therapeutic strategies for osteosarcoma, chondrosarcoma, and Ewing’s sarcoma. Med Sci Monit. 2011;17(8):RA177-190.Gaspar N, Hawkins DS, Dirksen U, et al. Ewing sarcoma: current management and future approaches through collaboration. J Clin Oncol. 2015;33(27):3036-3046.Giuffrida AY, Burgueno JE, Koniaris LG, Gutierrez JC, Duncan R, Scully SP. Chondrosarcoma in the United States (1973 to 2003): an analysis of 2890 cases from the SEER database. J Bone Joint Surg Am. 2009;91(5):1063-1072.Inwards CY, Wenger D. Parosteal osteosarcoma. In: Tumors and Tumor-Like Lesions of Bone. London: Springer; 2015: 217-226.Jawad MU, Cheung MC, Min ES, Schneiderbauer MM, Koniaris LG, Scully SP. Ewing’s sarcoma demonstrates racial disparities in incidence-related and sex-related differences in outcome: an analysis of 1631 cases from the SEER database, 1973-2005. Cancer. 2009;115(15):3526-3536.Klenke


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Surgery_Schwartz. sarcoma demonstrates racial disparities in incidence-related and sex-related differences in outcome: an analysis of 1631 cases from the SEER database, 1973-2005. Cancer. 2009;115(15):3526-3536.Klenke FM, Wenger DE, Inwards CY, Rose PS, Sim FH. Giant cell tumor of bone: risk factors for recurrence. Clin Orthopaed Relat Res. 2011;469(2):591-599.Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk strati-fication and response assessment of multiple myeloma. Leukemia. 2009;23(1):3-9.Luetke A, Meyers PA, Lewis I, Juergens H. Osteosarcoma treat-ment–where do we stand? A state of the art review. Cancer Treat Rev. 2014;40(4):523-532.Mankin HJ, Hornicek FJ. Paget’s sarcoma: a historical and outcome review. Clin Orthopaed Relat Res. 2005;438:97-102.Mirabello L, Troisi RJ, Savage SA. Osteosarcoma incidence and survival rates from 1973 to 2004: data from the sur-veillance, epidemiology, and end results program. Cancer. 2009;115(7):1531-1543.Most MJ, Sim FH, Inwards CY. Osteofibrous


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Surgery_Schwartz. incidence and survival rates from 1973 to 2004: data from the sur-veillance, epidemiology, and end results program. Cancer. 2009;115(7):1531-1543.Most MJ, Sim FH, Inwards CY. Osteofibrous dysplasia and ada-mantinoma. J Am Acad Orthop Surg. 2010;18(6):358-366.Rougraff BT. Evaluation of the patient with carcinoma of unknown origin metastatic to bone. Clin Orthop Relat Res. 2003;415(suppl):S105-S109.Spychalski JN, Thomas BJ. Treatment and rehabilitation of patho-logic fractures. State of the Art Reviews: Physical Medicine and Rehabilitation. 1995;9(1):77-92.Visuri T, Pukkala E, Paavolainen P, Pulkkinen P, Riska EB. Cancer risk after metal on metal and polyethylene on metal total hip arthroplasty. Clin Orthop Relat Res. 1996; (329 suppl):S280-S289.Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ. Chordoma: current concepts, management, and future directions. Lancet Oncol. 2012;13(2):e69-e76.Pediatric OrthopedicsBoardman MJ, Herman MJ, Buck B, Pizzutillo PD. Hip


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Surgery_Schwartz. JV, Kahle KT, Ferreira MJ. Chordoma: current concepts, management, and future directions. Lancet Oncol. 2012;13(2):e69-e76.Pediatric OrthopedicsBoardman MJ, Herman MJ, Buck B, Pizzutillo PD. Hip fractures in children. J Am Acad Orthop Surg. 2009;17(3):162-173.Brown JH, DeLuca SA. Growth plate injuries: Salter-Harris clas-sification. Am Fam Phys. 1992;46(4):1180-1184.Crawford AH, Mehlman CT, Slovek RW. The fate of untreated developmental dislocation of the hip: Longterm follow-up of eleven patients. J Pediatr Orthop. 1999;19(5):641-644; 369(9572):1541-1552.Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal bra-chial plexus palsy in the United States. J Bone Joint Surg Am. 2008;90:1258-1264.Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12(5):347-359.Gilbert A, Khouri N, and Carloiz H. Birth palsy of the brachial plexus—surgical exploration and attempted repair in twenty one cases (in French). Rev Chir Orthop Reparatrice Appar


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Surgery_Schwartz. 2004;12(5):347-359.Gilbert A, Khouri N, and Carloiz H. Birth palsy of the brachial plexus—surgical exploration and attempted repair in twenty one cases (in French). Rev Chir Orthop Reparatrice Appar Mot. 1980;66:33-42.Herring JA, Tachdjian MO. Tachdjian’s Pediatric Orthopedics. 5th ed. Philadelphia: Saunders/Elsevier; 2014.Jessel RH, Zurakowski D, Zilkens C, Burstein D, Gray ML, Kim YJ. Radiographic and patient factors associated with pre-radiographic osteoarthritis in hip dysplasia. J Bone Joint Surg Am. 2009;91(5):1120-1129.Jowett CR, Morcuende JA, Ramachandran M. Management of con-genital talipes equinovarus using the Ponseti method: a system-atic review. J Bone Joint Surg Br. 2011;93(9):1160-1164.Kim HK. Legg-Calve-Perthes disease. J Am Acad Orthop Surg. 2010;18(11):676-686.Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediat-ric supracondylar humerus fractures: biomechanical analy-sis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22(4):440-443.Lincoln TL, Suen


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Surgery_Schwartz. Mahar AT, Miesen D, Newton PO. Displaced pediat-ric supracondylar humerus fractures: biomechanical analy-sis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22(4):440-443.Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg. 2003;11(5):312-320.Loder RT, Aronsson DD, Weinstein SL, Breur GJ, Ganz R, Leunig M. Slipped capital femoral epiphysis. Instr Course Lect. 2008;57:473-498.Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91(7):1705-1719.Murray AW, Wilson NI. Changing incidence of slipped capital fem-oral epiphysis: a relationship with obesity? J Bone Joint Surg Br. 2008;90(1):92-94.O’Donnell S. Pediatric ankle fractures. In: The Orthopedic Consult Survival Guide. New York: Springer; 2017:265-269.Palocaren T, Holmes L, Rogers K, Kumar SJ. Outcome of in situ pinning in patients with unstable slipped capital femoral


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Surgery_Schwartz. In: The Orthopedic Consult Survival Guide. New York: Springer; 2017:265-269.Palocaren T, Holmes L, Rogers K, Kumar SJ. Outcome of in situ pinning in patients with unstable slipped capital femoral Brunicardi_Ch43_p1879-p1924.indd 192322/02/19 10:42 AM 1924SPECIFIC CONSIDERATIONSPART IITokmakova KP, Stanton RP, Mason DE. Factors influenc-ing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am. 2003;85(5):798-801.Trousdale RT. Acetabular osteotomy: indications and results. Clin Orthop Relat Res. 2004;429:182-187.Wainwright AM, Auld T, Benson MK, Theologis TN. The clas-sification of congenital talipes equinovarus. Bone Joint J. 2002;84(7):1020-1024.Weiler R, Ingram M, Wolman R. Osgood-Schlatter disease. Br Med J (Online). 2011;1:343.epiphysis: assessment of risk factors associated with avascular necrosis. J Pediatr Orthop. 2010;30(1):31-36.Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for


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Surgery_Schwartz. assessment of risk factors associated with avascular necrosis. J Pediatr Orthop. 2010;30(1):31-36.Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop. 2009;29(1):1-8.Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109(suppl 109):8-14.Sjöberg I, Erichs K, Bjerre I. Cause and effect of obstetric (neonatal) brachial plexus palsy. Acta Paediatrica. 1988;77(3): 357-364.Stevenson DA, Mineau G, Kerber RA, Viskochil DH, Schaefer C, Roach JW. Familial predisposition to developmental dysplasia of the hip. J Pediatr Orthop. 2009;29(5):463-466.Brunicardi_Ch43_p1879-p1924.indd 192422/02/19 10:42 AM


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Surgery_Schwartz. Surgery of the Hand and WristScott D. Lifchez and Brian H. Cho 44chapterINTRODUCTIONThe highly mobile, functional, and strong hand is a major dis-tinguishing point between humans and the nonhuman primates. The hand is an essential participant for activities of daily living, vocation, and recreational activities. The hand is even adaptable enough to read for the blind and speak for the mute. The under-lying goal of all aspects of hand surgery is to maximize mobil-ity, sensibility, stability, and strength while minimizing pain. These goals are then maximized to the extent possible given the patient’s particular pathology. Hand surgery is a regional specialty.Hand surgeons integrate components of neurologic, ortho-pedic, plastic, and vascular surgery in the care of patients with disorders of the upper extremities.1ANATOMY OF THE HAND AND WRISTIn order to understand any disorder of the hand, one must under-stand the anatomy of the underlying structures. Examina-tion of the hand is based


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Surgery_Schwartz. the upper extremities.1ANATOMY OF THE HAND AND WRISTIn order to understand any disorder of the hand, one must under-stand the anatomy of the underlying structures. Examina-tion of the hand is based on demonstrating the function or lack thereof of each of these structures.BonesThe hand is highly mobile in space to allow maximum flex-ibility in function. As such, a number of directions particular to the hand are necessary in order to properly describe posi-tion, motion, and so on.1 Palmar (or volar) refers to the anterior surface of the hand in the anatomic position; dorsal refers to the posterior surface in the anatomic position. The hand can rotate at the wrist level; rotation to bring the palm down is called 2Introduction 1925Anatomy of the Hand and Wrist 1925Bones / 1925Muscles Affecting the Hand and Wrist / 1926Tendons and Pulleys / 1929Vascular / 1929Nerve / 1930Hand Examination 1931Emergency Department/Inpatient Consultation / 1931Hand Imaging 1932Plain X-Rays / 1932Computed


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Surgery_Schwartz. the Hand and Wrist / 1926Tendons and Pulleys / 1929Vascular / 1929Nerve / 1930Hand Examination 1931Emergency Department/Inpatient Consultation / 1931Hand Imaging 1932Plain X-Rays / 1932Computed Tomography / 1932Ultrasonography / 1932Magnetic Resonance Imaging / 1933Angiography / 1933Trauma 1933Fractures and Dislocations / 1934Tendons / 1935Nerve Injuries / 1936Vascular Injuries / 1936Anesthesia 1936Local Anesthesia / 1936Hand Surgery Under Local Anesthesia / 1938Postoperative Pain Management / 1938Special Considerations 1938Amputations and Replantation / 1938Fingertip Injuries / 1938High-Pressure Injection Injuries / 1939Compartment Syndrome / 1939Complications 1943Nonunion / 1943Stiffness / 1943Neuroma / 1943Regional Pain Syndromes / 1943Nerve Compression 1943Carpal Tunnel Syndrome / 1944Cubital Tunnel Syndrome / 1944Other Sites of Nerve Compression / 1945Degenerative Joint Disease 1945Small Joints (Metacarpophalangeal and Interphalangeal) 1945Wrist / 1945Rheumatoid Arthritis /


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Surgery_Schwartz. / 1944Cubital Tunnel Syndrome / 1944Other Sites of Nerve Compression / 1945Degenerative Joint Disease 1945Small Joints (Metacarpophalangeal and Interphalangeal) 1945Wrist / 1945Rheumatoid Arthritis / 1946Dupuytren’s Contracture 1947Infections 1947Cellulitis / 1947Abscess / 1948Collar-Button Abscess / 1948Osteomyelitis / 1949Pyogenic Arthritis / 1949Necrotizing Infections / 1949Infectious Flexor Tenosynovitis / 1950Felon / 1951Paronychia / 1951Tumors 1952Benign Soft Tissue Tumors / 1953Malignant Soft Tissue Tumors— Cutaneous / 1955Malignant Soft Tissue Tumors—Noncutaneous / 1956Benign Bone Tumors / 1956Malignant Bone Tumors / 1957Secondary Metastatic Tumors / 1958Burns 1958Acute Management / 1958Surgical Management / 1959Reconstruction / 1959Special Considerations / 1960Vascular Disease 1960Progressive Thrombotic Disease / 1960Systemic Vasculopathy / 1960Vasospastic Disorders / 1961Congenital Differences 1961Failure of Formation / 1961Failure of Differentiation / 1961Duplication /


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Surgery_Schwartz. Thrombotic Disease / 1960Systemic Vasculopathy / 1960Vasospastic Disorders / 1961Congenital Differences 1961Failure of Formation / 1961Failure of Differentiation / 1961Duplication / 1961Overgrowth / 1961Constriction Band Syndrome / 1961Generalized Skeletal Anomalies and Syndromes / 1961Reconstructive Transplantation of the Upper Extremity 1962Brunicardi_Ch44_p1925-p1966.indd 192520/02/19 2:48 PM 1926pronation, and rotation to bring the palm up is called supina-tion. Because the hand can rotate in space, the terms medial and lateral are avoided. Radial and ulnar are used instead as these terms do not vary with respect to the rotational position of the hand. Abduction and adduction, when used on the hand, refer to movement of the digits away from and toward the middle finger, respectively (Fig. 44-1).The hand is comprised of 19 bones arranged in five rays.2 A ray is defined as a digit (finger or thumb) from the metacarpal base to the tip of the digit (Fig. 44-2A). The rays are


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Surgery_Schwartz. (Fig. 44-1).The hand is comprised of 19 bones arranged in five rays.2 A ray is defined as a digit (finger or thumb) from the metacarpal base to the tip of the digit (Fig. 44-2A). The rays are numbered 1 to 5, beginning with the thumb. By convention, however, they are referred to by name: thumb, index, middle, ring, and small. There are five metacarpals, comprising the visible palm of the hand. Each digit has a proximal and a distal phalanx, but only the fingers have a middle phalanx as well. The metacarpopha-langeal (MP) joint typically allows 90° of flexion with a small amount of hyperextension. In addition, the fingers can actively abduct (move away from the middle finger) and adduct (move toward the middle finger). The thumb, in contrast, moves prin-cipally in the flexion-extension arc at the MP joint. Although there can be laxity in the radial and ulnar direction, the thumb cannot actively move in these directions at the MP level. The proximal interphalangeal joint (PIP) is the


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Surgery_Schwartz. at the MP joint. Although there can be laxity in the radial and ulnar direction, the thumb cannot actively move in these directions at the MP level. The proximal interphalangeal joint (PIP) is the critical joint for finger mobility. Normal motion is 0° to 95° (full extension to flexion). The distal interphalangeal joint (DIP) also moves only in a flexion-extension plane from 0° to 90° on average. The thumb interphalangeal joint (IP) also moves only in a flexion-extension plane. Its normal motion is highly variable between individuals, but averages 0° to 80°.Each of the MP and IP joints has a radial and ulnar col-lateral ligament to support it. The IP joint collateral ligaments are on tension with the joint fully extended. For the fingers, the MP joint collateral ligaments are on tension with the joint bent 90°. Collateral ligaments have a tendency to contract when not placed on tension; this becomes relevant when splinting the hand (see later “Trauma” section on splinting).The wrist


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Surgery_Schwartz. with the joint bent 90°. Collateral ligaments have a tendency to contract when not placed on tension; this becomes relevant when splinting the hand (see later “Trauma” section on splinting).The wrist consists of eight carpal bones divided into two rows (see Fig. 44-2B).2 The proximal row consists of the scaph-oid, lunate, and triquetrum. The lunate is the principle axis of motion of the hand onto the forearm. It bears approximately 35% of the load of the wrist onto the forearm. The scaphoid is shaped like the keel of a boat and bears 55% of the load of the hand onto the forearm, but it also serves as the principle link between the proximal and distal rows, allowing for motion while maintaining stability. Both the scaphoid and the lunate articulate with the radius. The triquetrum resides ulnar to the lunate. It does not interact with the ulna proximally; rather, it interacts with a cartilage suspended between the ulnar styloid and the distal radius called with triangular fibrocartilage


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Surgery_Schwartz. to the lunate. It does not interact with the ulna proximally; rather, it interacts with a cartilage suspended between the ulnar styloid and the distal radius called with triangular fibrocartilage com-plex (TFCC) (see Fig. 44-2B). The remaining 10% of load of the hand onto the forearm is transmitted through the TFCC.3The distal row consists of four bones. The trapezium resides between the scaphoid and the thumb metacarpal. Dis-tally, it has a saddle-shaped surface, which interacts with a reciprocally saddle-shaped base of the thumb metacarpal to allow for high mobility of the thumb carpometacarpal (CMC) joint in radial-ulnar and palmar-dorsal directions and opposition (Fig. 44-1B). The trapezoid rests between the scaphoid and the index finger metacarpal. The capitate, the largest carpal bone and first to ossify in a child, lies between the lunate and the middle finger metacarpal, but it also interacts with the scaph-oid on its proximal radial surface. The index and middle finger CMC


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Surgery_Schwartz. bone and first to ossify in a child, lies between the lunate and the middle finger metacarpal, but it also interacts with the scaph-oid on its proximal radial surface. The index and middle finger CMC joints are highly stable and have minimal mobility. The hamate is the ulnar-most bone in the distal row, sitting between the triquetrum proximally and the ring and small finger metacar-pals distally. The ring and small finger CMC joints are mobile, principally in the flexion-extension direction.The pisiform is a carpal bone only by geography. It is a sesamoid bone within the FCU tendon (see following section). It does not bear load and can be excised, when necessary, without consequence.Muscles Affecting the Hand and WristThe wrist is moved by multiple tendons that originate from the forearm and elbow. The digits of the hand are moved by both intrinsic (originating within the hand) and extrinsic (originating in the forearm) muscles. All of these muscles are innervated by the median,


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Surgery_Schwartz. and elbow. The digits of the hand are moved by both intrinsic (originating within the hand) and extrinsic (originating in the forearm) muscles. All of these muscles are innervated by the median, radial, or ulnar nerves (or their branches) (Fig. 44-3).Three muscles flex the wrist, all of which originate from the medial epicondyle of the humerus. The flexor carpi radialis (FCR, median nerve) inserts on the volar base of the index fin-ger metacarpal. The flexor carpi ulnaris (FCU, ulnar nerve) also originates from the proximal ulna and inserts on the volar base of the small finger metacarpal. The palmaris longus (PL) tendon does not insert on a bone; it inserts on the palmar fascia, located deep to the skin in the central proximal palm, and is absent in up to 15% of patients. The FCR also deviates the wrist radially, whereas the FCU deviates the wrist ulnarly.All three wrist extensors are innervated by the radial nerve or its branches. The extensor carpi radialis longus (ECRL) Key


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Surgery_Schwartz. deviates the wrist radially, whereas the FCU deviates the wrist ulnarly.All three wrist extensors are innervated by the radial nerve or its branches. The extensor carpi radialis longus (ECRL) Key Points1 Surgery of the hand is a regional specialty, integrating com-ponents of neurologic, orthopedic, plastic, and vascular surgery.2 Understanding hand anatomy is the key to proper diagnosis of injury, infection, and degenerative disease of the hand.3 After evaluation and/or treatment, patients should be splinted to protect the injured digits and keep the collateral ligaments of the injured joints on tension (metacarpophalangeal joints flexed, interphalangeal joints extended).4 Healing of an injured or diseased structure in the hand is not the endpoint of treatment; the goal of any intervention must be to obtain structure healing, relief of pain, and maximiza-tion of function.5 If a patient managed conservatively for cellulitis does not improve within 24 to 48 hours of appropriate


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Surgery_Schwartz. must be to obtain structure healing, relief of pain, and maximiza-tion of function.5 If a patient managed conservatively for cellulitis does not improve within 24 to 48 hours of appropriate intravenous antibiotics, abscess must be suspected.6 Clinical examination, particularly noting the area of greatest tenderness and/or inflammation, is the most useful diagnos-tic tool for hand infections.Brunicardi_Ch44_p1925-p1966.indd 192620/02/19 2:48 PM 1927SURGERY OF THE HAND AND WRISTCHAPTER 44originates from the distal shaft of the humerus and inserts on the dorsal base of the index finger metacarpal. The extensor carpi radialis brevis (ECRB) originates from the lateral epicondyle of the humerus and inserts on the dorsal base of the middle finger metacarpal. The extensor carpi ulnaris (ECU) also originates from the lateral epicondyle of the humerus and inserts on the dorsal base of the small finger metacarpal. The ECRL deviates the wrist radially, whereas the ECU deviates the wrist


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Surgery_Schwartz. also originates from the lateral epicondyle of the humerus and inserts on the dorsal base of the small finger metacarpal. The ECRL deviates the wrist radially, whereas the ECU deviates the wrist ulnarly.The long flexors of the fingers all originate from the medial epicondyle of the humerus. The flexor digitorum super-ficialis (FDS) inserts on the base of the middle phalanx of each finger and primarily flexes the PIP joint. The flexor digitorum profundus (FDP) inserts on the base of the distal phalanx and primarily flexes the DIP joint. The flexor pollicis longus (FPL) originates more distally, from the ulna, radius, and interosseous membrane between them in the forearm. It inserts on the base of the distal phalanx of the thumb and primarily flexes the IP joint. All of these tendons can also flex the more proximal joint(s) in their respective rays. All of these muscles are innervated by the median nerve (or its branches) except the FDP to the ring and small fingers, which are


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Surgery_Schwartz. can also flex the more proximal joint(s) in their respective rays. All of these muscles are innervated by the median nerve (or its branches) except the FDP to the ring and small fingers, which are innervated by the ulnar nerve.The extrinsic extensors of the fingers and thumb are all innervated by the posterior interosseous nerve (PIN, branch of the radial nerve). The extensor digitorum communis (EDC) originates from the lateral epicondyle of the humerus and extends the MP joints of the fingers. Unlike most tendons that attach directly into a bone, the EDC tendons do not insert on the dorsal base of the proximal phalanx, but rather into a soft tissue sling called the sagittal hood, which surrounds the proximal phalanx base and pulls up on the volar surface in a ABCDFigure 44-1. Directions of finger, hand, and wrist motion. A. Finger abduction (white arrows) and adduction (black arrows). B. Thumb radial (black arrow) and palmar (white arrow) abduction. C. Thumb and small finger


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Surgery_Schwartz. of finger, hand, and wrist motion. A. Finger abduction (white arrows) and adduction (black arrows). B. Thumb radial (black arrow) and palmar (white arrow) abduction. C. Thumb and small finger opposition. D. Hand/wrist pronation (black arrow) and supination (white arrow).Brunicardi_Ch44_p1925-p1966.indd 192720/02/19 2:48 PM 1928SPECIFIC CONSIDERATIONSPART IIhammock-like manner. More distally in the dorsal forearm, the extensor indices proprius (EIP) and extensor digiti quinti (EDQ) originate from the ulna, radius, and posterior interosseous mem-brane and insert on the sagittal hood of the index and small fingers, respectively.The thumb has three separate extrinsic extensors. All of these originate from the dorsal ulna in the mid-forearm and are innervated by the PIN. The abductor pollicis longus (APL) inserts on the radial base of the thumb metacarpal to produce some extension, but mostly abduction. The extensor pollicis ECRL/ECRBEPLEDQECUTCL23455432Radial AANUlnarSCHMedian


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Surgery_Schwartz. pollicis longus (APL) inserts on the radial base of the thumb metacarpal to produce some extension, but mostly abduction. The extensor pollicis ECRL/ECRBEPLEDQECUTCL23455432Radial AANUlnarSCHMedian NAPLEPBFPLPFCREIP/EDCFigure 44-3. Cross-section of the wrist at the midcarpal level. The relative geography of the neurologic and tendinous structures can be seen. The transverse carpal ligament (TCL) is the roof of the carpal tunnel, passing volar to the median nerve and long flexor tendons. The TCL is also the floor of the ulnar tunnel, or Guyon’s canal, passing dorsal to the ulnar artery and nerve. The wrist and digital extensor tendons are also seen, distal to their compartments on the distal radius and ulna. Bones: C = capitate; H = hamate; P = pisiform; S = scaphoid. Tendons (flexor digitorum superficialis is volar to flexor digitorum profundus within the carpal tunnel): 2 = index finger; 3 = middle finger; 4 = ring finger; 5 = small finger. A = artery; APL = abductor pollicis longus;


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Surgery_Schwartz. superficialis is volar to flexor digitorum profundus within the carpal tunnel): 2 = index finger; 3 = middle finger; 4 = ring finger; 5 = small finger. A = artery; APL = abductor pollicis longus; ECRB = extensor carpi radialis brevis; ECRL = extensor carpi radialis longus; ECU = extensor carpi ulnaris; EDC = extensor digitorum communis; EDQ = extensor digiti quinti; EIP = extensor indices proprius; EPB = extensor pollicis brevis; EPL = extensor pollicis longus; FCR = flexor carpi radialis; FPL = flexor pollicis longus; N = nerve.ABFigure 44-2. Bony architecture of the hand and wrist. A. Bones of the hand and digits. All rays have metacarpophalangeal (MP) joints. The fingers have proximal and distal interphalangeal joints (PIP and DIP), but the thumb has a single interphalangeal (IP) joint. B. Bones of the wrist. The proximal row consists of the scaphoid, lunate, and capitate. The distal row bones articulate with the metacarpals: the trapezium with the thumb, the trapezoid with the


Surgery_Schwartz

Surgery_Schwartz. B. Bones of the wrist. The proximal row consists of the scaphoid, lunate, and capitate. The distal row bones articulate with the metacarpals: the trapezium with the thumb, the trapezoid with the index, the capitate with the middle, and the hamate with the ring and small. The pisiform bone is a sesamoid within the flexor carpi ulnaris tendon. It overlaps the triquetrum and hamate but does not contribute to a carpal row. CMC = carpometacarpal; TFCC = triangular fibrocartilage complex.Brunicardi_Ch44_p1925-p1966.indd 192820/02/19 2:48 PM 1929SURGERY OF THE HAND AND WRISTCHAPTER 44brevis (EPB) inserts on the base of the thumb proximal pha-lanx. The extensor pollicis longus (EPL) inserts on the base of the thumb distal phalanx.The intrinsic muscles of the hand are what allow humans fine, subtle movements of the hand. Microsurgery, typing, and even video gaming would be difficult, if not impossible, without them.The thenar muscles originate from the volar radial surface of the scaphoid


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Surgery_Schwartz. movements of the hand. Microsurgery, typing, and even video gaming would be difficult, if not impossible, without them.The thenar muscles originate from the volar radial surface of the scaphoid and trapezium and the flexor retinaculum. The abductor pollicis brevis (APB) inserts on the radial base of the thumb proximal phalanx and abducts the thumb in a radial and volar direction. The opponens pollicis (OP) inserts on the radial distal aspect of the thumb metacarpal and draws the thumb across the palm toward the small finger. The flexor pollicis bre-vis (FPB) inserts on the base of the thumb proximal phalanx and flexes the thumb MP joint. The APB, OP, and superficial head of the FPB are all innervated by the thenar motor branch of the median nerve.The lumbrical muscles are unique in the body in that they originate from a tendon. Each finger’s lumbrical originates from the FDP tendon in the palm. The lumbrical tendon passes along the radial aspect of the digit to flex the MP and extend


Surgery_Schwartz

Surgery_Schwartz. in that they originate from a tendon. Each finger’s lumbrical originates from the FDP tendon in the palm. The lumbrical tendon passes along the radial aspect of the digit to flex the MP and extend the IP joints. The index and middle lumbricals are median nerve inner-vated, and the ring and small finger lumbricals are ulnar nerve innervated.The hypothenar muscles originate from the pisiform, hamate, and flexor retinaculum and insert on the ulnar base of the small finger proximal phalanx. The abductor digiti quinti (ADQ) abducts the small finger. The opponens digiti quinti (ODQ) brings the small finger across the palm in reciprocal motion to the OP. The flexor digiti quinti (FDQ) flexes the small finger metacarpal. All of these muscles are innervated by the ulnar nerve.The interosseous muscles occupy the space between the metacarpal bones. Their tendons insert on the bases of the proxi-mal phalanges. All act to flex the MP joints and extend the IP joints. The three palmar interosseous


Surgery_Schwartz

Surgery_Schwartz. occupy the space between the metacarpal bones. Their tendons insert on the bases of the proxi-mal phalanges. All act to flex the MP joints and extend the IP joints. The three palmar interosseous muscles adduct the fin-gers. The four dorsal interosseous muscles abduct the fingers. The adductor pollicis originates from the middle finger metacar-pal and inserts on the ulnar base of the thumb proximal phalanx. It acts to adduct the thumb. All of these muscles, as well as the deep head of the FPB, are innervated by the ulnar nerve.Tendons and PulleysMultiple pulleys pass over or surround the extrinsic tendons en route to or within the hand. Their purpose is to maintain tendon position near the bone, allowing maximal translation of tendon excursion into joint motion.The most well known of the wrist-level pulleys is the flexor retinaculum, also known as the transverse carpal liga-ment. It attaches to the scaphoid tubercle and trapezium radially and the hook of the hamate bone and pisiform


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Surgery_Schwartz. wrist-level pulleys is the flexor retinaculum, also known as the transverse carpal liga-ment. It attaches to the scaphoid tubercle and trapezium radially and the hook of the hamate bone and pisiform ulnarly. Deep to this ligament, between the scaphoid (radially) and the hamate (ulnarly), pass the FDS, FDP, and FPL tendons as well as the median nerve. This area is also known as the carpal tunnel (see Fig. 44-3).On the dorsum of the wrist, the extensor retinaculum is divided into six compartments. Beginning on the radial aspect of the radius, the first compartment contains the APL and EPB tendons. The second holds the ECRL and ECRB tendons. The EPL passes through the third compartment. The fourth com-partment contains the EIP and EDC tendons, the fifth the EDQ, and the sixth the ECU. The sixth compartment is located on the ulnar aspect of the distal ulna. Although the compartments end at the radiocarpal/ulnocarpal joints, the relative geography of the tendons is preserved over the


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Surgery_Schwartz. sixth compartment is located on the ulnar aspect of the distal ulna. Although the compartments end at the radiocarpal/ulnocarpal joints, the relative geography of the tendons is preserved over the carpal bones (see Fig. 44-3).In the hand, the pulleys maintain the long flexor tendons in close apposition to the fingers and thumb. There are no extensor pulleys within the hand. Each finger has five annular and three cruciate pulleys (Fig. 44-4). The second and fourth (A2 and A4) pulleys are the critical structures to prevent bowstringing of the finger.3 The remaining pulleys can be divided as needed for sur-gical exposure or to relieve a stricture area.VascularTwo major arteries serve the hand. The radial artery travels under the brachioradialis muscle in the forearm. At the junc-tion of the middle and distal thirds of the forearm, the artery becomes superficial and palpable, passing just radial to the FCR tendon. At the wrist level, the artery splits into two branches. The smaller,


Surgery_Schwartz

Surgery_Schwartz. the middle and distal thirds of the forearm, the artery becomes superficial and palpable, passing just radial to the FCR tendon. At the wrist level, the artery splits into two branches. The smaller, superficial branch passes volarly into the palm to contribute to the superficial palmar arch. The larger branch passes dorsally over the scaphoid bone, under the EPL and EPB tendons (known as the anatomic snuffbox) and back volarly between the proximal thumb and index finger metacarpals to form the superficial palmar arch.The ulnar artery travels deep to the FCU muscle in the forearm. When the FCU becomes tendinous, the ulnar artery resides deep and slightly radial to it. At the wrist, the artery travels between the hamate and pisiform bones superficial to the transverse carpal ligament (known as Guyon’s canal) into the palm. The larger, superficial branch forms the superficial A5C3A4C2A3C1A2A1Figure 44-4. Drawing of anteroposterior and lateral view of the pulley


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Surgery_Schwartz. carpal ligament (known as Guyon’s canal) into the palm. The larger, superficial branch forms the superficial A5C3A4C2A3C1A2A1Figure 44-4. Drawing of anteroposterior and lateral view of the pulley system.Brunicardi_Ch44_p1925-p1966.indd 192920/02/19 2:48 PM 1930SPECIFIC CONSIDERATIONSPART IIpalmar arch. The deeper branch contributes to the deep palmar arch (Fig. 44-5A). In 97% of patients, at least one of the deep or superficial palmar arches is intact, allowing for the entire hand to survive on the radial or ulnar artery.5Each digit receives a radial and ulnar digital artery. For the thumb, the radial digital artery may come from the deep palmar arch or the main body of the radial artery. The larger ulnar digi-tal artery comes off the deep arch as either a discrete unit, the princeps pollicis artery, or less frequently as the first common digital artery, which then splits into the radial digital artery to the index finger and the ulnar digital artery to the thumb. The second,


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Surgery_Schwartz. pollicis artery, or less frequently as the first common digital artery, which then splits into the radial digital artery to the index finger and the ulnar digital artery to the thumb. The second, third, and fourth digital arteries typically branch off the superficial palmar arch and pass over the similarly named inter-osseous spaces respectively, ultimately dividing into two proper digital arteries each. The ulnar digital artery of the small finger comes off as a separate branch from the superficial arch. Within the finger, the proper digital arteries travel lateral to the bones and tendons, just palmar to the midaxis of the digit, but dorsal to the proper digital nerves (Fig. 44-5B).NerveThree principal nerves serve the forearm, wrist, and hand: the median, radial, and ulnar nerves. The most critical of these from a sensory standpoint is the median nerve. The median nerve begins as a terminal branch of the medial and lateral cords of the brachial plexus. It receives fibers from


Surgery_Schwartz

Surgery_Schwartz. The most critical of these from a sensory standpoint is the median nerve. The median nerve begins as a terminal branch of the medial and lateral cords of the brachial plexus. It receives fibers from C5–T1. The palmar cuta-neous branch of the median nerve separates from the main body of the nerve 6 cm proximal to the volar wrist crease and serves the proximal, radial-sided palm. The main body of the median nerve splits into several branches after the carpal tunnel: a radial digital branch to the thumb, an ulnar digital nerve to the thumb, and a radial digital nerve to the index finger (sometimes begin-ning as a single first common digital nerve); the second common digital nerve that branches into the ulnar digital nerve to the index finger and the radial digital nerve to the middle finger; and a third common digital nerve that branches into the ulnar digital nerve to the middle finger and a radial digital nerve to the ring finger. The digital nerves provide volar-sided sensation from


Surgery_Schwartz

Surgery_Schwartz. and a third common digital nerve that branches into the ulnar digital nerve to the middle finger and a radial digital nerve to the ring finger. The digital nerves provide volar-sided sensation from the metacarpal head level to the tip of the digit. They also, through their dorsal branches, provide dorsal-sided sensation to the dig-its from the midportion of the middle phalanx distally via dorsal branches. The thenar motor branch of the median nerve most commonly passes through the carpal tunnel and then travels in a recurrent fashion back to the thenar muscles. Less commonly, the nerve passes through or proximal to the transverse carpal ligament en route to its muscles.In the forearm, the median nerve gives motor branches to all of the flexor muscles except the FCU, and the ring and small finger portions of the FDP. Distal median motor fibers (with the exception of those to the thenar muscles) are carried through a large branch called the anterior interosseous nerve.The ulnar nerve is


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Surgery_Schwartz. finger portions of the FDP. Distal median motor fibers (with the exception of those to the thenar muscles) are carried through a large branch called the anterior interosseous nerve.The ulnar nerve is a terminal branch of the medial cord of the brachial plexus. It receives innervation from C8 and T1 roots. The FCU and FDP (ring/small) receive motor fibers from the ulnar nerve. In the distal forearm, 5 cm above the head of the ulna, the nerve gives off a dorsal sensory branch. Once in the hand, the nerve splits into the motor branch and sensory branches. The motor branch curves radially at the hook of the hamate bone to innervate the intrinsic muscles, as described ear-lier. The sensory branches become the ulnar digital nerve to the small finger and the fourth common digital nerve, which splits into the ulnar digital nerve to the ring finger and the radial digi-tal nerve to the small finger. The sensory nerves provide distal dorsal sensation similar to the median nerve branches.The


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Surgery_Schwartz. splits into the ulnar digital nerve to the ring finger and the radial digi-tal nerve to the small finger. The sensory nerves provide distal dorsal sensation similar to the median nerve branches.The radial nerve is the larger of two terminal branches of the posterior cord of the brachial plexus. It receives fibers from C5–T1 nerve roots. It innervates all of the extensor muscles of the forearm and wrist through the PIN branch except for the ECRL, which is innervated by the main body of the radial nerve in the distal upper arm. There is no ulnar nerve contribution to extension of the wrist, thumb, or finger MP joints. As noted ear-lier, the ulnar innervated intrinsic hand muscles are the principle ABFigure 44-5. Arteries of the hand and finger. A. Relative position of the superficial and deep palmar arches to the bony structures and each other; note the radial artery passes dorsal to the thumb metacarpal base, through the first web space, and anterior to the index metacarpal base as it


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Surgery_Schwartz. palmar arches to the bony structures and each other; note the radial artery passes dorsal to the thumb metacarpal base, through the first web space, and anterior to the index metacarpal base as it forms the deep arch. B. The neurovascular bundles lay volar to the midaxis of the digit with the artery dorsal to the nerve; Grayson’s ligament (volar) and Cleland’s ligament (dorsal) connect the bone to the skin surrounding the bundle.Brunicardi_Ch44_p1925-p1966.indd 193020/02/19 2:48 PM 1931SURGERY OF THE HAND AND WRISTCHAPTER 44extensors of the finger IP joints, although the long finger exten-sors (EDC, EIP, EDQ) make a secondary contribution to this function.In the proximal dorsal forearm, the superficial radial nerve (SRN) is the other terminal branch of the radial nerve. It travels deep to the brachioradialis muscle until 6 cm proximal to the radial styloid, where it becomes superficial. The SRN provides sensation to the dorsal hand and the radial three and a half dig-its up to the


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Surgery_Schwartz. to the brachioradialis muscle until 6 cm proximal to the radial styloid, where it becomes superficial. The SRN provides sensation to the dorsal hand and the radial three and a half dig-its up to the level of the mid-middle phalanx (where the dorsal branches of the proper digital nerves take over, as described earlier). The dorsal branch of the ulnar nerve provides sensation to the ulnar one and a half digits and dorsal hand in complement to the SRN.HAND EXAMINATIONEmergency Department/Inpatient ConsultationA common scenario in which the hand surgeon will be intro-duced to the patient is in trauma or other acute situations. The patient is evaluated by inspection, palpation, and provocative testing.On inspection, one should first note the position of the hand. The resting hand has a normal cascade of the fingers, with the small finger flexed most and the index finger least (Fig. 44-6). Disturbance of this suggests a tendon or skeletal problem. Also note any gross deformities or wounds


Surgery_Schwartz

Surgery_Schwartz. cascade of the fingers, with the small finger flexed most and the index finger least (Fig. 44-6). Disturbance of this suggests a tendon or skeletal problem. Also note any gross deformities or wounds and what deeper structures, if any, are visible in such wounds. Observe for abnormal coloration of a portion or all of the hand (this can be confounded by ambient temperature or other injuries), edema, and/or clubbing of the fingertips.Palpation typically begins with the radial and ulnar artery pulses at the wrist level. Pencil Doppler examination can sup-plement this and evaluate distal vessels. A pulsatile signal is normally detectable by pencil Doppler in the pad of the finger at the center of the whorl of creases. Discrepancies between digits should be noted. If all other tests are inconclusive, pricking the involved digit with a 25-gauge needle should produce bright red capillary bleeding. If an attached digit demonstrates inadequate or absent blood flow (warm ischemia), the urgency


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Surgery_Schwartz. pricking the involved digit with a 25-gauge needle should produce bright red capillary bleeding. If an attached digit demonstrates inadequate or absent blood flow (warm ischemia), the urgency of complet-ing the evaluation and initiating treatment markedly increases.Sensation must be evaluated prior to any administration of local anesthetic. At a minimum, light and sharp touch sensation should be documented for the radial and ulnar aspects of the tip of each digit. Beware of writing “sensation intact” at the con-clusion of this evaluation. Rather, one should document what was tested (e.g., “light and sharp touch sensation present and symmetric to the tips of all digits of the injured hand”). For a more detailed evaluation of hand sensation, two-point discrimi-nation may be assessed using a bent paperclip or monofilament. In the setting of a sharp injury, sensory deficit implies a lacer-ated structure until proven otherwise. Once sensation has been evaluated and documented, the injured


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Surgery_Schwartz. bent paperclip or monofilament. In the setting of a sharp injury, sensory deficit implies a lacer-ated structure until proven otherwise. Once sensation has been evaluated and documented, the injured hand can be anesthetized for patient comfort during the remainder of the examination (see below).Ability to flex and extend the wrist and digital joints is typically examined next. At the wrist level, the FCR and FCU tendons should be palpable during flexion. The wrist exten-sors are not as readily palpated due to the extensor retinaculum. Ability to flex the DIP joint (FDP) is tested by blocking the finger at the middle phalanx level. To test the FDS to each finger, hold the remaining three fingers in slight hyperextension and ask the patient to flex the involved digit (Fig. 44-7). This maneuver makes use of the fact that the FDP tendons share a common muscle belly. Placing the remaining fingers in exten-sion prevents the FDP from firing, and allows the FDS, which has a separate muscle


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Surgery_Schwartz. makes use of the fact that the FDP tendons share a common muscle belly. Placing the remaining fingers in exten-sion prevents the FDP from firing, and allows the FDS, which has a separate muscle belly for each tendon, to fire. Strength in grip, finger abduction, and thumb opposition is tested and compared to the uninjured side. Range of motion for the wrist, MP, and IP joints should be noted and compared to the opposite side.If there is suspicion for closed space infection, the hand should be evaluated for erythema, swelling, fluctuance, and localized tenderness. The dorsum of the hand does not have fascial septae; thus, dorsal infections can spread more widely than palmar ones. The epitrochlear and axillary nodes should be palpated for enlargement and tenderness. Findings for spe-cific infectious processes will be discussed in the “Infections” section.ABFigure 44-6. In the normal resting hand, the fingers assume a slightly flexed posture from the index finger (least) to the small


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Surgery_Schwartz. infectious processes will be discussed in the “Infections” section.ABFigure 44-6. In the normal resting hand, the fingers assume a slightly flexed posture from the index finger (least) to the small finger (most). A. Anteroposterior view. B. Lateral view.Brunicardi_Ch44_p1925-p1966.indd 193120/02/19 2:48 PM 1932SPECIFIC CONSIDERATIONSPART IIAdditional exam maneuvers and findings, such as those for office consultations, will be discussed with each disease pro-cess covered later in this chapter.HAND IMAGINGPlain X-RaysAlmost every hand evaluation should include plain X-rays of the injured or affected part. A standard, anteroposterior, lateral, and oblique view of the hand or wrist (as appropriate) is rapid, inexpensive, and usually provides sufficient information about the bony structures to achieve a diagnosis in conjunction with the symptoms and findings.6Lucencies within the bone should be noted. Most com-monly, these represent fractures, but they can on occasion rep-resent


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Surgery_Schwartz. to achieve a diagnosis in conjunction with the symptoms and findings.6Lucencies within the bone should be noted. Most com-monly, these represent fractures, but they can on occasion rep-resent neoplastic or degenerative processes. Great care should be taken to evaluate the entire X-ray, typically beginning away from the area of the patient’s complaint. Additional injuries can be missed, which might affect the treatment plan selected and eventual outcome.Congruency of adjacent joints should also be noted. The MP and IP joints of the fingers should all be in the same plain on any given view. Incongruency of the joint(s) of one finger implies fracture with rotation. At the wrist level, the proxi-mal and distal edge of the proximal row and proximal edge of the distal row should be smooth arcs, known as Gilula’s arcs (Fig. 44-8A). Disruption of these implies ligamentous injury or possibly dislocation (Fig. 44-8B).7Computed TomographyComputed tomography (CT) scanning of the hand and wrist


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Surgery_Schwartz. known as Gilula’s arcs (Fig. 44-8A). Disruption of these implies ligamentous injury or possibly dislocation (Fig. 44-8B).7Computed TomographyComputed tomography (CT) scanning of the hand and wrist can provide additional bony information when plain X-rays are insufficient. Comminuted fractures of the distal radius can be better visualized for number and orientation of fragments. Scaphoid fractures can be evaluated for displacement and com-minution preoperatively as well as for the presence of bony bridging postoperatively (Fig. 44-9). Recent studies have sug-gested that in the setting of suspected scaphoid fractures with negative radiographs, the use of CT scans may decrease the healthcare costs and patient morbidity.8 CT scans are also useful for CMC fractures of the hand where overlap on a plain X-ray lateral view may make diagnosis difficult.Unlike the trunk and more proximal extremities, CT scans with contrast are less useful to demonstrate abscess cavities due to the small area


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Surgery_Schwartz. on a plain X-ray lateral view may make diagnosis difficult.Unlike the trunk and more proximal extremities, CT scans with contrast are less useful to demonstrate abscess cavities due to the small area of these spaces.UltrasonographyUltrasonography has the advantages of being able to demon-strate soft tissue structures and being available on nights and weekends. Unfortunately, it is also highly operator dependent. In the middle of the night when magnetic resonance imaging (MRI) is not available, ultrasound may be able to demonstrate a Figure 44-7. The examiner holds the untested fingers in full exten-sion, preventing contracture of the flexor digitorum profundus. In this position, the patient is asked to flex the finger, and only the flexor digitorum superficialis will be able to fire.ABFigure 44-8. Gilula’s arcs are seen shown in this normal patient (A) and in a patient with a scaphoid fracture and perilunate dislocation (B).Brunicardi_Ch44_p1925-p1966.indd 193220/02/19 2:48 PM


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Surgery_Schwartz. 44-8. Gilula’s arcs are seen shown in this normal patient (A) and in a patient with a scaphoid fracture and perilunate dislocation (B).Brunicardi_Ch44_p1925-p1966.indd 193220/02/19 2:48 PM 1933SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-9. A. Preoperative images demonstrate a nonunion of a scaphoid fracture sustained 4 years earlier. B. Postoperatively, cross-sectional imaging with a computed tomography scan in the coronal plan demonstrates bone crossing the previous fracture line. This can be difficult to discern on plain X-rays due to overlap of bone fragments.ABlarge deep infection in the hand but is rarely more useful than a thorough clinical examination. Additionally, the use of dynamic ultrasound may be used to evaluate tendon motion and aid in the diagnosis of tendon pathology or injury.9Magnetic Resonance ImagingMRI provides the best noninvasive visualization of the soft tis-sue structures. With contrast, MRI can demonstrate an occult abscess. Unfortunately, it is


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Surgery_Schwartz. or injury.9Magnetic Resonance ImagingMRI provides the best noninvasive visualization of the soft tis-sue structures. With contrast, MRI can demonstrate an occult abscess. Unfortunately, it is often not available on an urgent basis for hand issues when this information is often needed. MRI can also demonstrate soft tissue injuries such as cartilage or ligament tears or tendonitis (usually by demonstrating edema in the area in question). It can demonstrate occult fractures that are not sufficiently displaced to be seen on X-ray or CT (again, by demonstrating edema). MRI can also demonstrate vascular disturbance of a bone, as in a patient with avascular necrosis of the scaphoid (Fig. 44-10).AngiographyAngiography of the upper extremity is rarely used. In many cen-ters, MRI and CT angiography provide sufficient resolution of the vascular structures to make traditional angiography unnec-essary. Also, primary vascular disease of the upper extremity is relatively uncommon. In the trauma


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Surgery_Schwartz. provide sufficient resolution of the vascular structures to make traditional angiography unnec-essary. Also, primary vascular disease of the upper extremity is relatively uncommon. In the trauma setting, vascular distur-bance usually mandates exploration and direct visualization of the structures in question, and angiography is thus obviated.For a patient with vascular disease of the upper extrem-ity, angiography of the upper extremity is usually performed through a femoral access much like with the leg. An arterial catheter can be used to deliver thrombolytic drugs to treat a thrombotic process.TRAUMAThe upper extremity–injured patient may have additional inju-ries to other parts of the body. All injured patients should receive an appropriate trauma survey to look for additional injuries.The patient with upper extremity trauma is evaluated as described in the “Hand Examination” section. Sensory exami-nation should be performed early. Once sensory status has been documented,


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Surgery_Schwartz. injuries.The patient with upper extremity trauma is evaluated as described in the “Hand Examination” section. Sensory exami-nation should be performed early. Once sensory status has been documented, administration of local anesthesia can provide comfort to the patient during the remainder of the evaluation Figure 44-10. T1-weighted magnetic resonance imaging shows perfused bone as white. In this patient, there is the absence of white-ness where the scaphoid should be (dashed circle), consistent with avascular necrosis.Brunicardi_Ch44_p1925-p1966.indd 193320/02/19 2:48 PM 1934SPECIFIC CONSIDERATIONSPART IIand subsequent treatment. Patients with nonclean wounds who received fewer than three prior doses of tetanus toxoid (or more than 5 years since last tetanus vaccination) or have an unknown history of prior doses should receive tetanus immunoglobulin as well as tetanus vaccination.10Fractures and DislocationsFor dislocations and displaced fractures, a visible deformity is often


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Surgery_Schwartz. unknown history of prior doses should receive tetanus immunoglobulin as well as tetanus vaccination.10Fractures and DislocationsFor dislocations and displaced fractures, a visible deformity is often present. Nondisplaced fractures may not show a gross deformity but will have edema and tenderness to palpation at the fracture site. A fracture is described by its displacement, rotation, and angulation. A fracture is also described in terms of comminution and the number and complexity of fracture fragments. Displacement is described as a percentage of the diameter of the bone; rotation is described in degrees of supina-tion or pronation with respect to the rest of the hand; angula-tion is described in degrees. To avoid confusion, it is useful to describe which direction the angle of the fracture points. All injuries should be evaluated for nearby wounds (open) that may introduce bacteria into the fracture site or joint space.Once the initial force on the fracture ceases, the tendons


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Surgery_Schwartz. fracture points. All injuries should be evaluated for nearby wounds (open) that may introduce bacteria into the fracture site or joint space.Once the initial force on the fracture ceases, the tendons passing beyond the fracture site provide the principal deforming force. Their force is directed proximally and, to a lesser extent, volarly. Based on this, the stability of a fracture can be deter-mined by the orientation of the fracture with respect to the shaft of the bone. Transverse fractures are typically stable. Oblique fractures typically shorten. Spiral fractures typically rotate as they shorten and thus require surgical treatment.Fractures of the tuft of the distal phalanx are common. Catching of a finger in a closing door is a common causative mechanism. These fractures are often nondisplaced and do not require treatment beyond protection of the distal phalanx from additional trauma while the fracture heals.Displaced transverse fractures of the phalanges can usu-ally be reduced


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Surgery_Schwartz. and do not require treatment beyond protection of the distal phalanx from additional trauma while the fracture heals.Displaced transverse fractures of the phalanges can usu-ally be reduced with distraction. The distal part is pulled away from the main body of the hand and then pushed in the direc-tion of the proximal shaft of the finger, and then distraction is released. Postreduction X-rays should routinely be performed to document satisfactory reduction. Oblique and spiral frac-tures usually are unstable after reduction. The involved digit(s) should be splinted until appropriate surgical intervention can be performed.Articular fractures of the IP and MP joints are worrisome because they may compromise motion. Chip fractures must be evaluated for instability of the collateral ligaments. If the joint is stable, the patient should initially be splinted for comfort. Motion therapy should be instituted early (ideally within the first week) to prevent stiffness. For larger fractures, the


Surgery_Schwartz

Surgery_Schwartz. If the joint is stable, the patient should initially be splinted for comfort. Motion therapy should be instituted early (ideally within the first week) to prevent stiffness. For larger fractures, the patient should be splinted until surgical treatment can be performed. In surgery, the fracture is typically internally fixated to allow for early motion, again with the goal of preventing stiffness.11,12Dislocations of the PIP joints produce traction on the neurovascular structures but usually do not lacerate them. In general, the patient should not be sent home with a joint that remains dislocated. Most commonly, the distal part is dorsal to the proximal shaft and sits in a hyperextended position. For this patient, the examiner gently applies pressure to the base of the distal part until it passes beyond the head of the proximal phalanx. Once there, the relocated PIP joint is gently flexed, confirming the joint is in fact reduced. The joint is splinted in slight flexion to prevent


Surgery_Schwartz

Surgery_Schwartz. it passes beyond the head of the proximal phalanx. Once there, the relocated PIP joint is gently flexed, confirming the joint is in fact reduced. The joint is splinted in slight flexion to prevent redislocation. On occasion, the head of the proximal phalanx may pass between the two slips of the FDS tendon. For these patients, the joint may not be reducible in a closed fashion.Angulated fractures of the small finger metacarpal neck (“boxer’s fracture”) are another common injury seen in the ER. Typical history is that the patient struck another individual or rigid object with a hook punch. These are often stable after reduction using the Jahss maneuver (Fig. 44-11).13Fractures of the thumb metacarpal base are often unstable. The Bennett fracture displaces the volar-ulnar base of the bone. The remainder of the articular surface and the shaft typically dislocate dorsoradially and shorten. The thumb often appears grossly shortened, and the proximal shaft of the metacarpal may reside at the


Surgery_Schwartz

Surgery_Schwartz. remainder of the articular surface and the shaft typically dislocate dorsoradially and shorten. The thumb often appears grossly shortened, and the proximal shaft of the metacarpal may reside at the level of the trapezium or even the scaphoid on X-ray. In a Rolando fracture, a second fracture line occurs between the remaining articular surface and the shaft. These fractures nearly always require open reduction and internal fixation.Most nondisplaced fractures do not require surgical treat-ment. The scaphoid bone of the wrist is a notable exception to this rule. Due to peculiarities in its vascular supply, particularly vulnerable at its proximal end, nondisplaced scaphoid fractures can fail to unite in up to 20% of patients even with appropriate immobilization. Recent developments in hardware and surgi-cal technique have allowed stabilization of the fracture with minimal surgical exposure. One prospective randomized series of scaphoid wrist fractures demonstrated shortening of time to


Surgery_Schwartz

Surgery_Schwartz. and surgi-cal technique have allowed stabilization of the fracture with minimal surgical exposure. One prospective randomized series of scaphoid wrist fractures demonstrated shortening of time to union by up to 6 weeks in the surgically treated group, but no difference in rate of union.14 Surgery may be useful in the younger, more active patient who would benefit from an earlier return to full activity.Ligament injuries of the wrist can be difficult to recognize. Patients often present late and may not be able to localize their pain. In severe cases, the ligaments of the wrist can rupture to the point of dislocation of the capitate off the lunate or even the lunate off the radius. Mayfield and colleagues classified the progression of this injury into four groups.15 In the most severe group, the lunate dislocates off the radius into the carpal tunnel. In some circumstances, the scaphoid bone may break rather than Figure 44-11. The Jahss maneuver. The surgeon fully flexes the patient’s


Surgery_Schwartz

Surgery_Schwartz. the lunate dislocates off the radius into the carpal tunnel. In some circumstances, the scaphoid bone may break rather than Figure 44-11. The Jahss maneuver. The surgeon fully flexes the patient’s small finger into the palm and secures it in his distal hand. The proximal hand controls the wrist and places the thumb on the patient’s fracture apex (the most prominent dorsal point). The examiner distracts the fracture, pushes dorsally with the distal hand (up arrow), and resists dorsal motion with the proximal hand (down arrow).Brunicardi_Ch44_p1925-p1966.indd 193420/02/19 2:48 PM 1935SURGERY OF THE HAND AND WRISTCHAPTER 44the scapholunate ligament rupturing. Attention to the congru-ency or disruption of Gilula’s arcs will help the examiner to recognize this injury. For patients with type 4 (most severe) and some with type 3 injury, the examiner should also evaluate for sensory disturbance in the median nerve distribution because this may indicate acute carpal tunnel syndrome and


Surgery_Schwartz

Surgery_Schwartz. type 4 (most severe) and some with type 3 injury, the examiner should also evaluate for sensory disturbance in the median nerve distribution because this may indicate acute carpal tunnel syndrome and necessitate more urgent intervention. Although the Mayfield pattern of injury is most common, force can also transmit along alternate paths through the carpus.16After reduction of fractures and dislocations (as well as after surgical repair of these and many other injuries), the hand must be splinted in a protected position. For the fingers, MP joints should be splinted 90°, and the IP joints at 0° (called the intrinsic plus position). The wrist is generally splinted at 20° extension because this puts the hand in a more functional posi-tion. This keeps the collateral ligaments on tension and helps prevent secondary contracture. In general, one of three splints should be used for the emergency department (ED) patient (Fig. 44-12). The ulnar gutter splint uses places plaster around the


Surgery_Schwartz

Surgery_Schwartz. and helps prevent secondary contracture. In general, one of three splints should be used for the emergency department (ED) patient (Fig. 44-12). The ulnar gutter splint uses places plaster around the ulnar border of the hand. It is generally appropriate for small finger injuries only. Dorsal plaster splints can be used for injuries of any of the fingers. Plaster is more readily con-toured to the dorsal surface of the hand than the volar surface, particularly in the setting of trauma-associated edema. For thumb injuries, the thumb spica splint is used to keep the thumb radially and palmarly abducted from the hand. Lastly, sugar tong splints include a volar and dorsal slab that includes the elbow in order to prevent supination and pronation. Sugar tong splints are most often used in the setting of acute distal radius or ulna fractures.TendonsInjuries to the flexor and extensor tendons compromise the mobility and strength of the digits. On inspection, injury is nor-mally suspected by


Surgery_Schwartz

Surgery_Schwartz. setting of acute distal radius or ulna fractures.TendonsInjuries to the flexor and extensor tendons compromise the mobility and strength of the digits. On inspection, injury is nor-mally suspected by loss of the normal cascade of the fingers. The patient should be examined as described earlier to evaluate for which tendon motion is deficient. If the patient is unable to cooperate, extension of the wrist will produce passive flexion of the fingers and also demonstrate a deficit. This is referred to at the tenodesis maneuver.Flexor tendon injuries are described based on zones (Fig. 44-13). Up until 40 years ago, zone 2 injuries were always reconstructed and never repaired primarily due to concern that the bulk of repair within the flexor sheath would prevent tendon glide. The work of Dr. Kleinert and colleagues at the University of Lou-isville changed this “axiom” and established the principle of pri-mary repair and early controlled mobilization postoperatively.17 Flexor tendon


Surgery_Schwartz

Surgery_Schwartz. Dr. Kleinert and colleagues at the University of Lou-isville changed this “axiom” and established the principle of pri-mary repair and early controlled mobilization postoperatively.17 Flexor tendon injuries should always be repaired in the operat-ing room. Although they do not need to be repaired on the day 3Figure 44-12. Commons splints used for hand injuries/surgeries. A. Ulnar gutter splint. The ring and small fingers are included and maintain an interphalangeal (IP) joint extension and metacarpopha-langeal (MP) joint flexion to 90°. B. Dorsal four-finger splint. As with the ulnar gutter splint, finger MP joints are flexed to 90° with IP joints kept fully extended. C. Thumb spica splint. One easy method to fabricate is to place one slab of plaster radially over the wrist and thumb with a second square of plaster over the thenar eminence, which joins the first. D. Sugar tong splint. This dorsal and volar slab splints immobilizes the wrist and elbow in neutral and 90° positions,


Surgery_Schwartz

Surgery_Schwartz. with a second square of plaster over the thenar eminence, which joins the first. D. Sugar tong splint. This dorsal and volar slab splints immobilizes the wrist and elbow in neutral and 90° positions, respectively.Figure 44-13. The zones of flexor tendon injury. I. Flexor digito-rum superficialis insertion to the flexor digitorum profundus inser-tion. II. Start of the A1 pulley to the flexor digitorum superficialis insertion. III. End of the carpal tunnel to the start of the A1 pulley. IV. Within the carpal tunnel. V. Proximal to the carpal tunnel.Brunicardi_Ch44_p1925-p1966.indd 193520/02/19 2:48 PM 1936SPECIFIC CONSIDERATIONSPART IIof injury, the closer to the day of injury they are repaired, the easier it will be to retrieve the retracted proximal end in surgery. The laceration should be washed out and closed at the skin level only using permanent sutures. The hand should be splinted as described earlier; one notable difference is that the wrist should be splinted at slight