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Surgery_Schwartz. 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 flexion (about 20°) to help decrease the retracting force on the proximal cut tendon end.Extensor tendons do not pass through a sheath in the fin-gers. As such, bulkiness of repair is less of a concern. With proper supervision/experience and equipment, primary extensor tendon repair can be performed in the ED.Very distal extensor injuries near the insertion on the dor-sal base of the distal phalanx may not have sufficient distal ten-don to hold a suture. Closed injuries, called mallet fingers, can be treated with extension splinting of the DIP joint for 6 contin-uous weeks. For patients with open injuries, a dermatotenodesis suture is performed. A 2-0 or 3-0 suture is passed through the distal skin, tendon remnant, and proximal tendon as a mattress suture. Using a suture of a different


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Surgery_Schwartz. open injuries, a dermatotenodesis suture is performed. A 2-0 or 3-0 suture is passed through the distal skin, tendon remnant, and proximal tendon as a mattress suture. Using a suture of a different color than the skin clos-ing sutures will help prevent removing the dermatotenodesis suture(s) too soon. The DIP joint is splinted in extension.More proximal injuries are typically repaired with a 3-0 braided permanent suture. Horizontal mattress or figure-of-eight sutures should be used, two per tendon if possible. Great care should be used to ensure matching the appropriate proximal and distal tendon ends. The patient is splinted with IP joints in extension and the wrist in extension per usual. MP joints should be splinted in 45° flexion, sometimes less. Although this posi-tion is not ideal for MP collateral ligaments, it is important for taking tension off of the tendon repairs.Nerve InjuriesIn the setting of a sharp injury, a sensory deficit implies a nerve laceration until proven


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Surgery_Schwartz. for MP collateral ligaments, it is important for taking tension off of the tendon repairs.Nerve InjuriesIn the setting of a sharp injury, a sensory deficit implies a nerve laceration until proven otherwise. For blunt injuries, even dis-placed fractures and dislocations, nerves are often contused but not lacerated and are managed expectantly. Nerve repairs require appropriate microsurgical equipment and suture; they should not be performed in the ED. As with tendons, nerve injuries do not require immediate exploration. However, earlier exploration will allow for easier identification of structures and less scar tissue to be present. The nerve must be resected back to healthy nerve fascicle prior to repair. Delay between injury and repair can thus make a difference between the ability to repair a nerve primarily or the need to use a graft. The injured hand should be splinted with MPs at 90° and IPs at 0°, as described earlier.Vascular InjuriesVascular injuries have the potential to be


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Surgery_Schwartz. a nerve primarily or the need to use a graft. The injured hand should be splinted with MPs at 90° and IPs at 0°, as described earlier.Vascular InjuriesVascular injuries have the potential to be limb or digit threaten-ing. A partial laceration of an artery at the wrist level can poten-tially cause exsanguinating hemorrhage. Consultations for these injuries must be evaluated urgently.Initial treatment for an actively bleeding wound should be direct local pressure for no less than 10 continuous minutes. If this is unsuccessful, an upper extremity tourniquet inflated to 100 mmHg above the systolic pressure should be used. One should keep this tourniquet time to less than 2 hours to avoid tissue necrosis. Once bleeding is controlled well enough to evaluate the wound, it may be cautiously explored to evaluate for bleeding points. One must be very cautious if attempting to ligate these to ensure that adjacent structures such as nerves are not included in the ligature.The hand must be


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Surgery_Schwartz. explored to evaluate for bleeding points. One must be very cautious if attempting to ligate these to ensure that adjacent structures such as nerves are not included in the ligature.The hand must be evaluated for adequacy of perfusion to the hand as a whole as well as the individual digits. Capillary refill, turgor, Doppler signal, and bleeding to pinprick all pro-vide useful information regarding vascular status. The finger or hand with vascular compromise requires urgent operative explo-ration. Unlike the complete amputation, in which the amputated part can be cold preserved (see later section, “Amputation and Replantation”), devascularization without amputation produces warm ischemia, which is tolerated only for a matter of hours.For the noncritical vascular injury, two treatment options exist. Simple ligation will control hemorrhage. At least one of the palmar arterial arches is intact in 97% of patients, so this will usually not compromise hand perfusion.5 Each digit also has two


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Surgery_Schwartz. exist. Simple ligation will control hemorrhage. At least one of the palmar arterial arches is intact in 97% of patients, so this will usually not compromise hand perfusion.5 Each digit also has two arterial inflows and can survive on one (see “Amputations and Replantation” section). In the academic hospital setting, however, consideration should be given to repairing all vascular injuries. Instructing a resident in vascular repair in the noncriti-cal setting will produce a more skilled and prepared resident for when a critical vascular injury does arise.ANESTHESIALocal AnesthesiaAnesthetic blockade can be administered at the wrist level, digi-tal level, or with local infiltration as needed. Keep in mind that all local anesthetics are less effective in areas of inflammation.The agents most commonly used are lidocaine and bupiva-caine. Lidocaine has the advantage of rapid onset, whereas bupi-vacaine has the advantage of long duration (average 6–8 hours).18 Although bupivacaine can


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Surgery_Schwartz. most commonly used are lidocaine and bupiva-caine. Lidocaine has the advantage of rapid onset, whereas bupi-vacaine has the advantage of long duration (average 6–8 hours).18 Although bupivacaine can produce irreversible heart block in high doses, this is rarely an issue with the amounts typically used in the hand. For pediatric patients, the tolerated dose is 2.5 mg/kg. This can be easily remembered by noting that when using 0.25% bupivacaine, 1 mL/kg is acceptable dosing.A commonly held axiom is that epinephrine is unaccept-able to be used in the hand. Several recent large series have dispelled this myth.19 Epinephrine should not be used in the fingertip and not in concentrations higher than 1:100,000 (i.e., what is present in commercially available local anesthetic with epinephrine). Beyond that, its use is acceptable and may be use-ful in an ED where tourniquet control may not be available. Also, because most ED procedures are done under pure local anesthesia, many patients will


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Surgery_Schwartz. Beyond that, its use is acceptable and may be use-ful in an ED where tourniquet control may not be available. Also, because most ED procedures are done under pure local anesthesia, many patients will not tolerate the discomfort of the tourniquet beyond 30 minutes.20 Epinephrine will provide hemostasis and also prolong the effect of the local anesthetic.Studies have reported that the addition of sodium bicar-bonate (NaHCO3) in order to buffer local anesthetic solutions and decrease the pain experienced during the administration of local anesthetic.21 This decrease in pain has been attributed to decreasing the acidity of local anesthetic solutions. In the clinical setting, the mixing of 8.4% sodium bicarbonate with 1% lidocaine with 1:100,000 epinephrine in a 1:9 ratio is ade-quate to provide a decrease in pain during the injection of local anesthetic.22Simple lacerations, particularly on the dorsum of the hand, can be anesthetized with local infiltration. This is performed in the


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Surgery_Schwartz. provide a decrease in pain during the injection of local anesthetic.22Simple lacerations, particularly on the dorsum of the hand, can be anesthetized with local infiltration. This is performed in the standard fashion.Blocking of the digital nerves at the metacarpal head level is useful for volar injuries distal to this point and for dorsal injuries beyond the midpoint of the middle phalanx (via dor-sal branches of the proper digital nerves). Fingertip injuries are particularly well anesthetized by this technique. A digit can be anesthetized via a flexor sheath approach or via the dorsal web space (Fig. 44-14A,B).Brunicardi_Ch44_p1925-p1966.indd 193620/02/19 2:48 PM 1937SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-14. Local anesthesia can be administered at the digital or the wrist level. A. A single injection into the flexor tendon sheath at the metacarpal head level provides complete anesthesia for the digit. B. Alternatively, one can inject from a dorsal approach into the


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Surgery_Schwartz. level. A. A single injection into the flexor tendon sheath at the metacarpal head level provides complete anesthesia for the digit. B. Alternatively, one can inject from a dorsal approach into the web space on either side. C. The superficial radial nerve is blocked by infiltrating subcutaneously over the distal radius from the radial artery pulse to the distal radioulnar joint. The dorsal sensory branch of the ulnar nerve is blocked in similar fashion over the distal ulna. D. To block the ulnar nerve, insert the needle parallel to the plane of the palm and deep to the flexor carpi ulnaris tendon; aspirate to confirm the needle is not in the adjacent ulnar artery. E. To block the median nerve, insert the needle just ulnar to the palmaris longus tendon into the carpal tunnel. One should feel two points of resistance: one when piercing the skin, the second when piercing the antebrachial fascia.Brunicardi_Ch44_p1925-p1966.indd 193720/02/19 2:48 PM 1938SPECIFIC


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Surgery_Schwartz. tunnel. One should feel two points of resistance: one when piercing the skin, the second when piercing the antebrachial fascia.Brunicardi_Ch44_p1925-p1966.indd 193720/02/19 2:48 PM 1938SPECIFIC CONSIDERATIONSPART IIBlocking one or more nerves as they cross the wrist can provide several advantages: anesthesia for multiple injured dig-its, avoiding areas of inflammation where the local anesthetic agent may be less effective, and avoiding injection where the volume of fluid injected may make treatment harder (such as fracture reduction). Four major nerves cross the wrist: the median nerve, SRN, ulnar nerve, and dorsal sensory branch of the ulnar nerve (Fig. 44-14C–E). When blocking the median and ulnar nerves, beware of intraneural injection, which can cause irreversible neural scarring. If the patient complains of severe paresthesias with injection or high resistance is encountered, the needle should be repositioned.Hand Surgery Under Local AnesthesiaWide awake hand surgery is


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Surgery_Schwartz. If the patient complains of severe paresthesias with injection or high resistance is encountered, the needle should be repositioned.Hand Surgery Under Local AnesthesiaWide awake hand surgery is surgery that is performed under sur-geon-administered local anesthesia with field sterility but with-out the use of sedation or a tourniquet. A major benefit of this approach is the reduction of healthcare costs due to the elimination of an anesthesia provider and postoperative monitoring because only local anesthesia is used. Further benefits of sedation-free sur-gery include decreased time spent in the hospital for surgery and the ability of patients to follow instructions during surgery. This advantage is evident during flexor tendon repairs, where intra-operative active movement allows direct visualization of the tendon repair under active movement.23 Perceived weaknesses of sedation-free surgery include patient intraoperative anxiety and fear of pain during the administration of local


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Surgery_Schwartz. visualization of the tendon repair under active movement.23 Perceived weaknesses of sedation-free surgery include patient intraoperative anxiety and fear of pain during the administration of local anesthetic. A study by Davison et al, however, found that patients undergoing carpal tunnel release under wide awake local had no difference in anxiety or pain compared to patients undergoing carpal tunnel release with sedation.24Postoperative Pain ManagementSince the recognition of pain as the fifth vital sign in the early 2000s, the number of opioid prescriptions has risen dramati-cally. Accordingly, over the last decade, the United States has seen an increase the number of deaths due to prescription opi-oid overdose. Deaths due to opioid overdose now exceeds the number of deaths caused by heroin and cocaine combined. As healthcare providers, it is essential that we adequately treat post-operative pain with the minimal amount of narcotics necessary. A recent study by Rodgers et al


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Surgery_Schwartz. by heroin and cocaine combined. As healthcare providers, it is essential that we adequately treat post-operative pain with the minimal amount of narcotics necessary. A recent study by Rodgers et al identified that the majority of patients undergoing elective hand surgery used prescription pain medication for only 2 or fewer days after surgery. Many patients achieved adequate pain control with over-the-counter pain med-ication and were often left with unused opioid analgesics.25Accordingly, there has been increased emphasis on educat-ing prescribers on the recognition of opioid abuse and guide-lines for appropriate opioid prescribing. Approaches such as multimodal pain management and opioid prescription protocols have shown to achieve adequate pain control while also reduc-ing excess opioid prescriptions.26SPECIAL CONSIDERATIONSAmputations and ReplantationAfter replantation was first reported, replantation was attempted for nearly all amputations.27 Over the ensuing decades, more


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Surgery_Schwartz. opioid prescriptions.26SPECIAL CONSIDERATIONSAmputations and ReplantationAfter replantation was first reported, replantation was attempted for nearly all amputations.27 Over the ensuing decades, more stringent guidelines have been established regarding what should be replanted. Indications for replantation include ampu-tations of the thumb, multiple digit amputations, and amputa-tions in children. Relative contraindications to replantation include crush injuries, injuries to a single digit distal to the PIP joint, and patients who are unable to tolerate a long surgical procedure. As with all guidelines, one should evaluate the par-ticular needs of the injured patient.In preparation for replantation, the amputated part and proximal stump should be appropriately treated. The ampu-tated part should be wrapped in moistened gauze and placed in a sealed plastic bag. This bag should then be placed in an ice water bath. Do not use dry ice, and do not allow the part to contact ice directly;


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Surgery_Schwartz. should be wrapped in moistened gauze and placed in a sealed plastic bag. This bag should then be placed in an ice water bath. Do not use dry ice, and do not allow the part to contact ice directly; frostbite can occur in the amputated part, which will decrease its chance of survival after replantation. Bleeding should be controlled in the proximal stump by as mini-mal a means necessary, and the stump should be dressed with a nonadherent gauze and bulky dressing.For digital amputations deemed unsalvageable, revision amputation can be performed in the ED if appropriate equip-ment is available. Bony prominences should be smoothed off with a rongeur and/or rasp. Great care must be taken to identify the digital nerves and resect them back as far proximally in the wound as possible; this helps decrease the chance of painful neuroma in the skin closure. Skin may be closed with perma-nent or absorbable sutures; absorbable sutures will spare the patient the discomfort of suture removal several


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Surgery_Schwartz. the chance of painful neuroma in the skin closure. Skin may be closed with perma-nent or absorbable sutures; absorbable sutures will spare the patient the discomfort of suture removal several weeks later. For more proximal unsalvageable amputations, revision should be performed in the operating room to maximize vascular and neural control.Prostheses can be made for amputated parts. The more proximal the amputation, the more important to function the prosthesis is likely to be. Although finger-level prostheses are generally considered cosmetic, patients with multiple finger amputations proximal to the DIP have demonstrable functional benefit from their prosthesis as well.28Fingertip InjuriesFingertip injuries are among the most common pathologies seen in an ED. The usual history is that a door closed on the finger (commonly the middle, due to its increased length) or something heavy fell on the finger.Initial evaluation should include: wound(s) including the nail bed, perfusion,


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Surgery_Schwartz. a door closed on the finger (commonly the middle, due to its increased length) or something heavy fell on the finger.Initial evaluation should include: wound(s) including the nail bed, perfusion, sensation, and presence and severity of fractures. For the common scenario, complex lacerations with minimally displaced fracture(s) and no loss of perfusion, the wound is cleansed, sutured, and splinted in the ED. To properly assess the nail bed, the nail plate (hard part of the nail) should be removed. A Freer periosteal elevator is well suited for this purpose. Lacerations are repaired with 6-0 fast gut suture. Great care must be taken when suturing because excessive traction with the needle can further lacerate the tissue. After repair, the nail folds are splinted with the patient’s own nail plate (if avail-able) or with aluminum foil from the suture pack. This is done to prevent scarring from the nail folds down to the nail bed that would further compromise healing of the nail.In some


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Surgery_Schwartz. plate (if avail-able) or with aluminum foil from the suture pack. This is done to prevent scarring from the nail folds down to the nail bed that would further compromise healing of the nail.In some situations, tissue may have been avulsed in the injury and be unavailable for repair. Choice of treatment options depends on the amount and location of tissue loss (Fig. 44-15). Historically, wounds less than 1 cm2 with no exposed bone can be treated with local wound care and secondary intention. Recently, studies have reported that wounds with an average size of 1.75 cm2 have healed well with excellent functional and aesthetic results.29 For larger wounds or wounds or with bone exposed, one must decide if the finger is worth preserving at the current length or if shortening to allow for primary closure is a Brunicardi_Ch44_p1925-p1966.indd 193820/02/19 2:48 PM 1939SURGERY OF THE HAND AND WRISTCHAPTER 44better solution. A useful guideline is the amount of fingernail still present; if


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Surgery_Schwartz. closure is a Brunicardi_Ch44_p1925-p1966.indd 193820/02/19 2:48 PM 1939SURGERY OF THE HAND AND WRISTCHAPTER 44better solution. A useful guideline is the amount of fingernail still present; if greater than 50% is present, local or regional flap coverage may be a good solution.If sufficient local tissue is present, homodigital flaps can be considered. A wide range of antegrade and retrograde homodig-ital flaps can be mobilized to cover the defect. Some carry sen-sation or can receive nerve coaptation to recover sensation over time.30 For the thumb only, the entire volar skin including both neurovascular bundles can be raised and advanced distally up to 1.5 cm2.31 The thumb receives separate vascularity to its dorsal skin from the radial artery. This flap is not appropriate for the fingers. Patients retain full sensibility in the advanced skin and can be mobilized within days of surgery (Fig. 44-16A–C).For wounds too large to cover with homodigital tissue, regional flaps can be


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Surgery_Schwartz. fingers. Patients retain full sensibility in the advanced skin and can be mobilized within days of surgery (Fig. 44-16A–C).For wounds too large to cover with homodigital tissue, regional flaps can be considered. The skin from the distal radial thenar eminence can be raised as a random pattern flap (Fig. 44-16D–F). The finger is maintained in flexion for 14 to 21 days until division of the flap pedicle and inset of the flap. Some authors have reported prolonged stiffness in patients over 30 years old, but careful flap design helps minimize this complication.32 Alternatively, the skin from the dorsum of the middle phalanx of an adjacent digit can be raised as a flap to cover the volar P3 (Fig. 44-16G–I). The flap is inset at 14 to 21 days. Long-term studies have shown this flap develops sen-sation over time.33Patients with fingertip injures must be assessed for the possibility of salvage of the injured digit(s) taken within the context of the patient’s recovery needs and goals. The


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Surgery_Schwartz. sen-sation over time.33Patients with fingertip injures must be assessed for the possibility of salvage of the injured digit(s) taken within the context of the patient’s recovery needs and goals. The surgeon then matches the available options to the particular patient needs.High-Pressure Injection InjuriesHigh-pressure devices are commonly used for cleaning and applications of liquids such as lubricants and paint. Most commonly, the inexperienced worker accidentally discharges the device into his nondominant hand at the base of the digit. Severity of injury depends on the amount and type of liquid injected; hydrophobic compounds cause greater damage.34These injuries are typically quite innocuous to inspection. They are, however, digit-threatening emergencies. The patient should be informed of the severity of the injury, and explora-tion is ideally performed within 6 hours of injury. Up to 50% of such injuries result in loss of the digit, but early recogni-tion and treatment are


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Surgery_Schwartz. of the severity of the injury, and explora-tion is ideally performed within 6 hours of injury. Up to 50% of such injuries result in loss of the digit, but early recogni-tion and treatment are associated with increased chance of digit survival.35 Early frank discussion with the patient and initiation of appropriate treatment produce the best results and medicole-gal protection.Compartment SyndromeCompartment syndromes can occur in the forearm and/or the hand. As in other locations, these are potentially limb-threat-ening issues. Principle symptoms are pain in the affected com-partments, tense swelling, tenderness to palpation over the compartment, and pain with passive stretch of the muscles of the compartment.36 Pulse changes are a late finding; normal pulses do not rule out compartment syndrome.There are three compartments in the forearm and four groups of compartments in the hand. The volar forearm is one compartment. On the dorsum of the forearm, there is the dorsal compartment as


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Surgery_Schwartz. are three compartments in the forearm and four groups of compartments in the hand. The volar forearm is one compartment. On the dorsum of the forearm, there is the dorsal compartment as well as the mobile wad compartment, begin-ning proximally over the lateral epicondyle. In the hand, the thenar and hypothenar eminences each represent a compart-ment. The seven interosseous muscles each behave as a separate compartment.Compartment syndrome can be caused by intrinsic and extrinsic causes. Intrinsic causes include edema and hematoma due to fracture. Extrinsic causes include splints and dressings that are circumferentially too tight and intravenous infiltrations. Infiltrations with hyperosmolar fluids such as X-ray contrast are particularly dangerous, because additional water will be drawn in to neutralize the hyperosmolarity.Measurement of compartment pressures can be a useful adjunct to assessment of the patient. The Stryker pressure mea-surement device or similar device is kept in many


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Surgery_Schwartz. to neutralize the hyperosmolarity.Measurement of compartment pressures can be a useful adjunct to assessment of the patient. The Stryker pressure mea-surement device or similar device is kept in many operating rooms for this purpose. The needle is inserted into the compart-ment in question, a gentle flush with 0.1 to 0.2 cc of saline clears the measurement chamber, and a reading is obtained. Studies have disagreed about whether the criterion is a measured pres-sure (30–45 mmHg, depending on the series) or within a certain amount of the diastolic blood pressure.37Compartment releases are performed in the operating room under tourniquet control. Release of the volar forearm compartment includes release of the carpal tunnel. As the inci-sion travels distally, it should pass ulnar and then curve back radially just before the carpal tunnel. This avoids a linear inci-sion across a flexion crease and also decreases the chance of injury to the palmar cutaneous branch of the median nerve. One


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Surgery_Schwartz. back radially just before the carpal tunnel. This avoids a linear inci-sion across a flexion crease and also decreases the chance of injury to the palmar cutaneous branch of the median nerve. One dorsal forearm incision can release the dorsal compartment and the mobile wad. In the hand, the thenar and hypothenar com-partments are released each with a single incision. The interos-seous compartments are released with incisions over the index and ring metacarpal shafts. Dissection then continues radial and ulnar to each of these bones and provides release of all the mus-cle compartments. Any dead muscle is debrided. Incisions are left open and covered with a nonadherent dressing. The wounds are reexplored in 2 to 3 days to assess for muscle viability. Often the incisions can be closed primarily, but a skin graft may be needed for the forearm.Fingertip injuryGreater than 50%nailbed remainingHeal by secondaryintentionSufficient same digittissueVolar V-YNoNoNoNoYesYesYesYesCross-finger


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Surgery_Schwartz. but a skin graft may be needed for the forearm.Fingertip injuryGreater than 50%nailbed remainingHeal by secondaryintentionSufficient same digittissueVolar V-YNoNoNoNoYesYesYesYesCross-finger flapBilateral V-YMoberg flap(Thumb only)Shorten bone forprimary stumpclosureTissue lossThenar flapWound <1 cm2 andno exposed bonePrimary repairFigure 44-15. Treatment algorithm for management of fingertip injuries. See text for description of flaps.Brunicardi_Ch44_p1925-p1966.indd 193920/02/19 2:48 PM 1940SPECIFIC CONSIDERATIONSPART IIFigure 44-16. Local flaps for digital tip coverage. A–C. For thumb injuries, Moberg described elevation of the entire volar skin with both neurovascular bundles for distal advancement. Sensation to the advanced skin is maintained. D–F. An 8-year-old girl underwent fingertip replantation that did not survive. A thenar flap was transferred to cover the defect. Some authors advise against its use in patients over 30 years old. G–I. In this 45-year-old man, the


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Surgery_Schwartz. fingertip replantation that did not survive. A thenar flap was transferred to cover the defect. Some authors advise against its use in patients over 30 years old. G–I. In this 45-year-old man, the entire skin of P3 of the long finger was avulsed and unrecoverable. A cross-finger flap was transferred and provides excellent, durable coverage. The border of the flap and surrounding skin is still apparent 4.5 months after surgery.Brunicardi_Ch44_p1925-p1966.indd 194020/02/19 2:49 PM 1941SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-16. (Continued)Brunicardi_Ch44_p1925-p1966.indd 194120/02/19 2:49 PM 1942SPECIFIC CONSIDERATIONSPART IIFigure 44-16. (Continued)Brunicardi_Ch44_p1925-p1966.indd 194220/02/19 2:49 PM 1943SURGERY OF THE HAND AND WRISTCHAPTER 44If the examiner feels the patient does not have a compart-ment syndrome, elevation and serial examination are manda-tory. When in doubt, it is safer to release an early compartment syndrome than wait to release and risk


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Surgery_Schwartz. the patient does not have a compart-ment syndrome, elevation and serial examination are manda-tory. When in doubt, it is safer to release an early compartment syndrome than wait to release and risk muscle necrosis. Pro-gression of compartment syndrome can lead to Volkmann’s ischemic contracture with muscle loss and scarring that may compress nerves and other critical structures. Medicolegally, it is far easier to defend releasing an early compartment syn-drome than delaying treatment until the process has progressed to necrosis and/or deeper scarring.COMPLICATIONSNonunionAny fractured bone has the risk of failing to heal. Fortunately, in the fingers and hand, this is a rare problem. Tuft injuries, where soft tissue interposes between the fracture fragments, have rela-tively higher risk of this problem. The nonunited tuft can be treated with debridement and bone grafting or revision amputa-tion depending on the needs and goals of the patient. Phalan-geal and metacarpal nonunions are


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Surgery_Schwartz. of this problem. The nonunited tuft can be treated with debridement and bone grafting or revision amputa-tion depending on the needs and goals of the patient. Phalan-geal and metacarpal nonunions are also quite rare. They can similarly be treated with debridement of the nonunion, grafting, and rigid fixation.38 More proximally, the scaphoid bone of the wrist has a significant risk of nonunion even if nondisplaced (see Fig. 44-9A). Any patient suspected of a scaphoid injury, namely those with tenderness at the anatomic snuffbox, should be placed in a thumb spica splint and reevaluated within 2 weeks even if initial X-rays show no fracture. Scaphoid nonunions can be quite challenging to repair, and immobilization at the time of injury in a thumb spica splint is essentially always warranted.39StiffnessThe desired outcome of any hand injury is a painless, mobile, functional hand. Multiple factors can contribute to decreased mobility, including complex injuries of soft tissue and bone,


Surgery_Schwartz

Surgery_Schwartz. desired outcome of any hand injury is a painless, mobile, functional hand. Multiple factors can contribute to decreased mobility, including complex injuries of soft tissue and bone, noncompliance of the patient with postoperative therapy, and inappropriate splinting. The surgeon performing the initial eval-uation can greatly impact this last factor. The goal of splinting is to keep the collateral ligaments on tension (MPs at 90°, IP joints straight). For severe cases of stiffness, mobilization sur-geries such as tenolysis and capsulotomies can be performed, but these rarely produce normal range of motion.40 Prevention of joint contractures with appropriate splinting and early, pro-tected mobilization is the best option to maximize mobility at the end of healing. Healing of an injured or diseased structure in the hand is not the endpoint of treatment; the goal of any inter-vention must be to obtain structure healing, relief of pain, and maximization of function.NeuromaAny lacerated


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Surgery_Schwartz. diseased structure in the hand is not the endpoint of treatment; the goal of any inter-vention must be to obtain structure healing, relief of pain, and maximization of function.NeuromaAny lacerated nerve will form a neuroma. A neuroma consists of a ball of scar and axon sprouts at the end of the injured nerve.41 In unfavorable circumstances, this neuroma can become painful. The SRN is particularly notorious for this problem. By provid-ing proximal axon sprouts a target, nerve repair is an excellent preventive technique. In some circumstances, such as injuries requiring amputation, this is not possible. As mentioned earlier, the surgeon should resect the nerve stump as far proximally in the wound as possible to avoid the nerve stump healing in the cutaneous scar to minimize this risk.For the patient who develops a painful neuroma, nonsurgi-cal treatments are initiated first. The neuroma can be identified by the presence of a Tinel’s sign. Therapy techniques of desen-sitization,


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Surgery_Schwartz. the patient who develops a painful neuroma, nonsurgi-cal treatments are initiated first. The neuroma can be identified by the presence of a Tinel’s sign. Therapy techniques of desen-sitization, ultrasound, and electrical stimulation have all proven useful. Corticosteroid injection to the neuroma has also proven useful in some hands.When these techniques fail, surgery is contemplated. The neuroma can be resected, but a new one will form to replace it. The nerve ending can be buried in muscle or even bone to pre-vent the neuroma from residing in a superficial location where it may be impacted frequently.Regional Pain SyndromesInjuries to the upper extremity can occasionally result in the patient experiencing pain beyond the area of initial injury. Reflex sympathetic dystrophy and sympathetic mediated pain are two terms that have been used in the past to describe this phenomenon. Both are inaccurate, as the sympathetic nervous system is not always involved. Current terminology for this


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Surgery_Schwartz. mediated pain are two terms that have been used in the past to describe this phenomenon. Both are inaccurate, as the sympathetic nervous system is not always involved. Current terminology for this condition is complex regional pain syndrome (CRPS). Type I occurs in the absence of a documented nerve injury; type II occurs in the presence of one.42CRPSs manifest as pain beyond the area of initial inju-ries. There is often associated edema and changes in hair and/or sweat distribution. Comparison to the unaffected side is useful to better appreciate these findings. There are currently no imag-ing studies that can be considered diagnostic for CRPS.43For the patient in whom the diagnosis of CRPS is not clear, no definitive diagnostic study exists. Patients suspected of CRPS should be referred for aggressive hand therapy. Brief trials of oral corticosteroids have been successful in some series. Referral to a pain management specialist including a trial of stel-late ganglion blocks is also


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Surgery_Schwartz. for aggressive hand therapy. Brief trials of oral corticosteroids have been successful in some series. Referral to a pain management specialist including a trial of stel-late ganglion blocks is also frequently employed.NERVE COMPRESSIONNerves conduct signals along their axonal membranes toward their end organs. Sensory axons carry signals from distal to proximal; motor axons from proximal to distal. Myelin from Schwann cells allows faster conduction of signals. Signals jump from the start of one Schwann cell to the end of the cell (a loca-tion called a gap junction) and only require the slower mem-brane depolarization in these locations.Nerve compression creates a mechanical disturbance of the nerve.44 In early disease, the conduction signal is slowed across the area of compression. When compression occurs to a sufficient degree for a sufficient time, individual axons may die. On a nerve conduction study, this manifests as a decrease in amplitude. Muscles receiving motor axons may


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Surgery_Schwartz. compression occurs to a sufficient degree for a sufficient time, individual axons may die. On a nerve conduction study, this manifests as a decrease in amplitude. Muscles receiving motor axons may show electri-cal disturbance on electromyogram (EMG) when sufficiently deprived of their axonal input.Compression of sensory nerves typically produces a com-bination of numbness, paresthesias (pins and needles), and pain. Knowledge of the anatomic distribution of the peripheral nerves can aid in diagnosis. Sensory disturbance outside an area of dis-tribution of a particular nerve (e.g., volar and dorsal radial-sided hand numbness for median nerve) makes compression of that nerve less likely. Diseases that cause systemic neuropathy (e.g., diabetes) can make diagnosis more difficult.Nerve compression can theoretically occur anywhere along a peripheral nerve’s course. The most common sites of nerve compression in the upper extremity are the median nerve at the carpal tunnel, ulnar nerve at the


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Surgery_Schwartz. can theoretically occur anywhere along a peripheral nerve’s course. The most common sites of nerve compression in the upper extremity are the median nerve at the carpal tunnel, ulnar nerve at the cubital tunnel, and ulnar nerve at Guyon’s canal. Other, less common locations of nerve 4Brunicardi_Ch44_p1925-p1966.indd 194320/02/19 2:49 PM 1944SPECIFIC CONSIDERATIONSPART IIcompression are described as well. In addition, a nerve can become compressed in scar due to a previous trauma.Carpal Tunnel SyndromeThe most common location of upper extremity nerve compres-sion is the median nerve at the carpal tunnel, called carpal tunnel syndrome (CTS). The carpal tunnel is bordered by the scaphoid bone radially, the lunate and capitate bones dorsally, and the hook of the hamate bone ulnarly (see Fig. 44-3). The transverse carpal ligament, also called the flexor retinaculum, is its super-ficial border. The FPL, four FDS, and four FDP tendons pass through the carpal tunnel along with the median


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Surgery_Schwartz. 44-3). The transverse carpal ligament, also called the flexor retinaculum, is its super-ficial border. The FPL, four FDS, and four FDP tendons pass through the carpal tunnel along with the median nerve. Of these 10 structures, the median nerve is relatively superficial and radial to the other nine.An estimated 53 per 10,000 working adults have evidence of CTS. The National Institute for Occupational Safety and Health website asserts, “There is strong evidence of a positive association between exposure to a combination of risk factors (e.g., force and repetition, force and posture) and CTS.”45 There is disagreement among hand surgeons regarding whether occur-rence of CTS in a patient who does repetitive activities at work represents a work-related injury.Initial evaluation of the patient consists of symptom inven-tory: location and character of the symptoms, sleep disturbance due to symptoms, history of dropping objects, and difficulty manipulating small objects such as buttons, coins,


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Surgery_Schwartz. of symptom inven-tory: location and character of the symptoms, sleep disturbance due to symptoms, history of dropping objects, and difficulty manipulating small objects such as buttons, coins, or jewelry clasps.46Physical examination should begin with inspection. Look for evidence of wasting of the thenar muscles. Tinel’s sign should be tested over the median nerve from the volar wrist flexion crease to the proximal palm, although this test has significant interexam-iner variability.47 Applying pressure over the carpal tunnel while flexing the wrist has been shown in one series to have the high-est sensitivity when compared to Phalen’s and Tinel’s signs.48 Strength of the thumb in opposition should also be tested.Early treatment of CTS consists of conservative man-agement. The patient is given a splint to keep the wrist at 20° extension worn at nighttime. Many patients can have years of symptom relief with this management. As a treatment and diag-nostic modality, corticosteroid


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Surgery_Schwartz. is given a splint to keep the wrist at 20° extension worn at nighttime. Many patients can have years of symptom relief with this management. As a treatment and diag-nostic modality, corticosteroid injection of the carpal tunnel is often employed. Mixing local anesthetic into the solution pro-vides the benefit of early symptom relief (corticosteroids often take 3–7 days to provide noticeable benefit), and report of postin-jection anesthesia in the median nerve distribution confirms the injection went into the correct location. Multiple authors have shown a strong correlation to relief of symptoms with cortico-steroid injection and good response to carpal tunnel release.49When lesser measures fail or are no longer effective, carpal tunnel release is indicated. Open carpal tunnel release is a time-tested procedure with documented long-term relief of symptoms. A direct incision is made over the carpal tun-nel, typically in line with where the ring finger pad touches the proximal palm in


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Surgery_Schwartz. a time-tested procedure with documented long-term relief of symptoms. A direct incision is made over the carpal tun-nel, typically in line with where the ring finger pad touches the proximal palm in flexion. Skin is divided followed by palmar fascia. The carpal tunnel contents are visualized as they exit the carpal tunnel. The transverse carpal ligament is divided with the median nerve visualized and protected at all times. Improve-ment in symptoms is typically noted by the first postoperative visit, although symptom relief may be incomplete for patients with long-standing disease or systemic nerve-affecting diseases such as diabetes.Endoscopic techniques have been devised to address CTS. All involve avoidance of incising the skin directly over the carpal tunnel. In experienced hands, endoscopic carpal tunnel release provides the same relief of CTS with less intense and shorter lasting postoperative pain. After 3 months, however, the results are equivalent to open release.50 In


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Surgery_Schwartz. endoscopic carpal tunnel release provides the same relief of CTS with less intense and shorter lasting postoperative pain. After 3 months, however, the results are equivalent to open release.50 In inexperienced hands, there may be a higher risk of injury to the median nerve with the endoscopic techniques; this procedure is not for the occasional carpal tunnel surgeon.Cubital Tunnel SyndromeThe second most common location of upper extremity nerve compression is the ulnar nerve where it passes behind the elbow at the cubital tunnel. The cubital tunnel retinaculum passes between the medial epicondyle of the humerus and the olec-ranon process of the ulna. It stabilizes the ulnar nerve in this location during elbow motion. Over time, or sometimes after trauma, the ulnar nerve can become less stabilized in this area. Motion of the elbow then produces trauma to the nerve as it impacts the retinaculum and medial epicondyle.Cubital tunnel syndrome may produce sensory and motor symptoms.51 The


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Surgery_Schwartz. in this area. Motion of the elbow then produces trauma to the nerve as it impacts the retinaculum and medial epicondyle.Cubital tunnel syndrome may produce sensory and motor symptoms.51 The small finger and ulnar half of the ring fin-gers may have numbness, paresthesias, and/or pain. The ulnar nerve also innervates the dorsal surface of the small finger and ulnar side of the ring finger, so numbness in these areas can be explained by cubital tunnel syndrome. The patient may also report weakness in grip due to effects on the FDP tendons to the ring and small fingers and the intrinsic hand muscles. Patients with advanced disease may complain of inability to fully extend the ring and small finger IP joints.Physical examination for cubital tunnel syndrome begins with inspection. Look for wasting in the hypothenar eminence and the interdigital web spaces. When the hand rests flat on the table, the small finger may rest in abduction with respect to the other fingers; this is called


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Surgery_Schwartz. for wasting in the hypothenar eminence and the interdigital web spaces. When the hand rests flat on the table, the small finger may rest in abduction with respect to the other fingers; this is called Wartenberg’s sign. Tinel’s sign is often present at the cubital tunnel. Elbow flexion and the shoulder internal rotation tests are affective maneuvers to aid in the diagnosis of cubital tunnel syndrome.52 Grip strength and finger abduction strength should be compared to the unaffected side. Froment’s sign can be tested by placing a sheet of paper between the thumb and index finger and instructing the patient to hold on to the paper while the examiner pulls it away without flexing the finger or thumb (this tests the strength of the adduc-tor pollicis and first dorsal interosseous muscles). If the patient must flex the index finger and/or thumb (FDP-index and FPL, both median nerve supplied) to maintain traction on the paper, this is a positive response.Early treatment of cubital tunnel


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Surgery_Schwartz. If the patient must flex the index finger and/or thumb (FDP-index and FPL, both median nerve supplied) to maintain traction on the paper, this is a positive response.Early treatment of cubital tunnel syndrome begins with avoiding maximal flexion of the elbow. Splints are often used for this purpose. Corticosteroid injection is rarely done for this condition; unlike in the carpal tunnel, there is very little space within the tunnel outside of the nerve. Injection in this area runs a risk of intraneural injection, which can cause permanent scar-ring of the nerve and dysfunction.When conservative management fails, surgery has been contemplated. Treatment options include releasing the cubital tunnel retinaculum with or without transposing the nerve ante-rior to the elbow. While some authors advocate anterior trans-position into the flexor-pronator muscle group with the goal of maximizing nerve recovery, recent studies have demonstrated equivalent results between transposition and in situ


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Surgery_Schwartz. anterior trans-position into the flexor-pronator muscle group with the goal of maximizing nerve recovery, recent studies have demonstrated equivalent results between transposition and in situ release of the nerve even in advanced cases. For this reason, the simpler in situ release, either open or endoscopic, is preferred by many surgeons.53Brunicardi_Ch44_p1925-p1966.indd 194420/02/19 2:49 PM 1945SURGERY OF THE HAND AND WRISTCHAPTER 44Other Sites of Nerve CompressionAll nerves crossing the forearm have areas described where compression can occur.51 The median nerve can be compressed as it passes under the pronator teres. The ulnar nerve can be compressed as it passes through Guyon’s canal. The radial nerve, or its posterior interosseous branch, can be compressed as it passes through the radial tunnel (distal to the elbow where the nerve divides and passes under the arch of the supinator muscle). The SRN can be compressed distally in the forearm as it emerges from under the


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Surgery_Schwartz. the radial tunnel (distal to the elbow where the nerve divides and passes under the arch of the supinator muscle). The SRN can be compressed distally in the forearm as it emerges from under the brachioradialis tendon, called Wartenberg’s syndrome. As mentioned previously, any nerve can become compressed in scar at the site of a previous trauma.DEGENERATIVE JOINT DISEASEAs with other joints in the body, the joints of the hand and wrist can develop degenerative changes. Symptoms typically begin in the fifth decade of life. Symptoms consist of joint pain and stiffness and often are exacerbated with changes in the weather. Any of the joints can become involved. As the articular carti-lage wears out, pain typically increases and range of motion decreases. The patient should always be asked to what degree symptoms are impeding activities.Physical findings are documented in serial fashion from the initial visit and subsequent visits. Pain with axial loading of the joint may be present.


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Surgery_Schwartz. to what degree symptoms are impeding activities.Physical findings are documented in serial fashion from the initial visit and subsequent visits. Pain with axial loading of the joint may be present. Decreased range of motion may be a late finding. Instability of the collateral ligaments of the joint is uncommon in the absence of inflammatory arthritis.Plain X-rays are typically sufficient to demonstrate arthri-tis. Initially, the affected joint has a narrower radiolucent space between the bones. As joint degeneration progresses, the joint space further collapses. Bone spurs, loose bodies, and cystic changes in the bone adjacent to the joint all may become appar-ent. X-ray findings do not always correlate with patient symp-toms. Patients with advanced X-ray findings may have minimal symptoms, and vice versa. Treatment is initiated and progressed based on the patient’s symptoms regardless of imaging findings.Initial management begins with rest of the painful joint. Splints are often


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Surgery_Schwartz. and vice versa. Treatment is initiated and progressed based on the patient’s symptoms regardless of imaging findings.Initial management begins with rest of the painful joint. Splints are often useful, but may significantly impair the patient in activities and thus are frequently used at nighttime only. Oral nonsteroidal anti-inflammatory medications such as ibuprofen and naproxen are also useful. Patients on anticoagulants and antiplatelet medications may not be able to take these, and some patients simply do not tolerate the gastric irritation side effect even if they take the medication with food.For patients with localized disease affecting only one or a few joints, corticosteroid injection may be contemplated. Nee-dle insertion can be difficult since these joint spaces are quite narrow even before degenerative disease sets in. Also, many corticosteroid injections are suspensions, not solutions; injected corticosteroid will remain in the joint space and can be seen as a white paste


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Surgery_Schwartz. even before degenerative disease sets in. Also, many corticosteroid injections are suspensions, not solutions; injected corticosteroid will remain in the joint space and can be seen as a white paste if surgery is performed on a joint that has been previously injected.Small Joints (Metacarpophalangeal and Interphalangeal)When conservative measures fail, two principal surgical options exist: arthrodesis and arthroplasty. The surgeon and patient must decide together as to whether conservative measures have failed. Surgery for arthritis, whether arthrodesis or arthroplasty, is performed for the purpose of relieving pain. Arthrodesis, fusion of a joint can be performed with a tension band or axial compression screw techniques.54 Both methods provides excel-lent relief of pain and is durable over time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant


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Surgery_Schwartz. time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant acts as a spacer between the two bones adja-cent to the joint. This allows for motion without bony contact that would produce pain. Long-term studies have shown that all implants fracture over time, but usually continue to preserve motion and pain relief.56In the past 15 years, resurfacing implant arthroplasties have become available for the small joints of the hand. Multiple different materials have been used to fabricate such implants. These are designed to behave as a true joint resurfacing (as knee and hip arthroplasty implants are) and have shown promising outcomes in shortand intermediate-term studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is


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Surgery_Schwartz. studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is another common location of arthritis pain. Pain in this joint par-ticularly disturbs function because the CMC joint is essential for opposition and cylindrical grasp. Patients will typically com-plain of pain with opening a tight jar or doorknob and strong pinch activities such as knitting. Conservative management is used first, as described earlier. Prefabricated, removable thumb spica splinting can provide excellent relief of symptoms for many patients.Multiple surgical options exist for thumb CMC arthritis. Many resurfacing implants have been used in the past; often they have shown good shortand intermediate-term results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base


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Surgery_Schwartz. results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base is necessary to prevent shortening and instability.57 Some surgeons have demonstrated excellent long-term results from resection of the trapezium without permanent stabilization of the metacarpal base.58 For both of these operations, the thumb base may not be sufficiently stable to withstand heavy labor. For these patients, fusion of the thumb CMC in mild opposition provides excellent pain relief and durability. The patient must be warned preoperatively that he will not be able to lay his hand flat after the surgery. This loss of motion can be problematic when the patient attempts to tuck in clothing or reach into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient


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Surgery_Schwartz. into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient believ-ing it is merely a “sprain”; the patient is first diagnosed with the initial injury when he presents years later with degenerative changes.Degenerative wrist changes associated with the scaph-olunate ligament follow a predictable pattern over many years, called scapholunate advanced collapse or SLAC wrist.60 Because of this slow progression (Fig. 44-17A), patients can usually be treated with a motion-sparing procedure. If there is truly no arthritic change present, the scapholunate ligament can be reconstructed.If arthritis is limited to the radiocarpal joint, two motion-sparing options are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd


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Surgery_Schwartz. are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd 194520/02/19 2:49 PM 1946SPECIFIC CONSIDERATIONSPART IIarticulates with the base of the capitate, whose articular surface is similar in shape to that of the base of the lunate. Studies have shown maintenance of approximately 68% of the wrist flexion-extension arc and 72% of hand strength compared to the con-tralateral side.61 Alternatively, the scaphoid can be excised, and four-bone fusion (lunate, capitate, hamate, and triquetrum) can be performed. This maintains the full length of the wrist and the lunate in the lunate facet of the radius. Some series have shown better strength but less mobility with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient


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Surgery_Schwartz. with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient presents with pancarpal arthritis or motion-sparing measures have failed to alleviate pain, total wrist fusion is the final surgical option. The distal radius is fused, through the proximal and distal carpal rows to the third metacarpal, typi-cally with a dorsal plate and screws. Multiple long-term studies have shown excellent pain relief and durability; this comes at the cost of total loss of wrist motion. This is surprisingly well tolerated in most patients, especially if the other hand/wrist is unaffected. The only activity of daily living that cannot be done with a fused wrist is personal toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and


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Surgery_Schwartz. toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and decreased range of motion. The goals of hand surgery for the RA patient are relief of pain, improvement of function, slowing progression of disease, and improvement in appearance.63 In addition, swelling of the joint due to the inflammation can cause laxity and even failure of the collateral ligaments supporting the joints. Recent advances in the medical care of RA have made the need for surgical care of these patients far less common than in previous decades.MP joints of the fingers are commonly affected. The base of the proximal phalanx progressively subluxates and eventu-ally dislocates volarly with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more


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Surgery_Schwartz. with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more advanced cases, the joint may not be salvageable (Fig. 44-17B). For these patients, implant arthro-plasty is the mainstay of surgical treatment. Silicone implants have been used for over 40 years with good results.64 The sili-cone implant acts as a spacer between proximal and distal bone, rather than as a true resurfacing arthroplasty. The radial col-lateral ligament must be repaired to appropriate length to cor-rect the preoperative ulnar deviation of the MP joint. Extensor tendon centralization is then performed, as needed, at the end of the procedure.For MP joint and PIP joint disease, fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the


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Surgery_Schwartz. fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the finger.Failure of the support ligaments of the distal radioulnar joint (DRUJ) leads to the caput ulnae posture of the wrist with the ulnar head prominent dorsally. As this dorsal prominence becomes more advanced, the ulna head, denuded of its cartilage to act as a buffer, erodes into the overlying extensor tendons. Extensor tenosynovitis, followed ultimately by tendon rupture, begins ulnarly and proceeds radially. Rupture of the ECU ten-don may go unnoticed due to the intact ECRL and ECRB ten-dons to extend the wrist. EDQ rupture may go unnoticed if a sufficiently robust EDC tendon to the small finger exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ


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Surgery_Schwartz. exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ synovitis and instability and ulna head break-down that led to them.65 Excision of the ulna head removes the bony prominence. The DRUJ synovitis must also be resected. Figure 44-17. Arthritis of the hand and wrist. A. This patient injured her scapholunate ligament years prior to presentation. The scapholunate interval is widened (double arrow), and the radioscaphoid joint is degenerated (solid oval), but the radiolunate and lunocapitate joint spaces are well preserved (dashed ovals). B. This patient has had rheumatoid arthritis for decades. The classic volar subluxation of the metacarpophalangeal joints of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively,


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Surgery_Schwartz. of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively, the DRUJ can be fused and the ulna neck resected to create a pseudoarthrosis to allow for rotation. For both pro-cedures, the remaining distal ulna must be stabilized. Multiple techniques have been described using portions of FCU, ECU, wrist capsule, and combinations thereof.The ruptured extensor tendons are typically degenerated over a significant length. Primary repair is almost never pos-sible, and the frequent occurrence of multiple tendon ruptures makes repair with graft less desirable due to the need for mul-tiple graft donors.Strict compliance with postoperative therapy is essential to maximizing the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually


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Surgery_Schwartz. the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually for months, helps prevent recurrence of extensor lag. Finally, the disease may progress over time. Reconstructions that were initially adequate may stretch out or fail over time. Medical management is the key to slowing dis-ease progression and maximizing the durability of any surgical reconstruction.DUPUYTREN’S CONTRACTUREIn 1614, a Swiss surgeon named Felix Plater first described con-tracture of multiple fingers due to palpable, cord-like structures on the volar surface of the hand and fingers. The disease state he described would ultimately come to be known as Dupuytren’s contracture. Dupuytren’s name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in


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Surgery_Schwartz. name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in the palm and fingers. These are primarily longitudinally oriented and reside as a layer between the overlying skin and the underlying tendons and neurovascular structures. There are also connections from this layer to the deep structures below and the skin above. Much is known about the progression of these structures from their normal state (called bands) to their contracted state (called cords), but little is known on how or why this process begins.Increased collagen deposition leads to a palpable nodule in the palm. Over time, there is increased deposition distally into the fingers. This collagen becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of


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Surgery_Schwartz. becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of the molecular and cell biology of Dupuytren’s disease is beyond the scope of this chapter but is available in multiple hand surgery texts.67Most nonoperative management techniques will not delay the progression of disease. Corticosteroid injections may soften nodules and decrease the discomfort associated with them but are ineffective against cords. Splinting has similarly been shown not to retard disease progression.Recently, several minimally invasive treatment approaches have been described for the treatment of Dupuytren’s disease.68 Disruption of the cord with a needle is an effective means of releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with


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Surgery_Schwartz. releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with fasciectomy.69 Injectable clostridial collagenase was approved by the U.S. Food and Drug Administration in 2009, and although it has shown good early results, treatment costs remain high.70For patients with advanced disease including contrac-tures of the digits that limit function, surgery is the mainstay of therapy. Although rate of progression should weigh heavily in the decision of whether or not to perform surgery, general guidelines are MP contractures greater than or equal to 30° and/or PIP contractures greater than or equal to 20°.71Surgery consists of an open approach through the skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize


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Surgery_Schwartz. skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize postoperative skin necrosis. All nerves, tendons, and blood vessels in the operative field should be identified. Once this is done, the involved cord is resected while keeping the critical deeper structures under direct vision. The skin is then closed, with local flap transpositions as needed, to allow for full extension of the fingers that have been released (Fig. 44-18).Alternative cord resection techniques include removal of the skin over the contracture (dermatofasciectomy). This requires a skin graft to the wound and should only be done if skin cannot be separated from the cords and local tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal


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Surgery_Schwartz. tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal nerve laceration, digital artery laceration, buttonholing of the skin, hematoma, swelling, and pain, including some patients with CRPS (see earlier section on CRPS). Digital nerve injury can be quite devastating, producing annoying numbness at best or a painful neuroma in worse situations.Hand therapy is typically instituted within a week of sur-gery to begin mobilization of the fingers and edema control. The therapist can also identify any early wound problems because he or she will see the patient more frequently than the surgeon. Extension hand splinting is maintained for 4 to 6 weeks, with nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common


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Surgery_Schwartz. nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common cause of hand infections. Other predisposing factors include diabetes, neuropathies, and immu-nocompromised patients. Proper treatment consists of incision and drainage of any collections followed by debridement, obtain-ing wound cultures, antibiotic therapy, elevation, and immobi-lization. Staphylococcus and Streptococcus are the offending pathogens in about 90% of hand infections. Infections caused by intravenous drug use or human bites and those associated with diabetes will often be polymicrobial, including gram-positive and gram-negative species. Heavily contaminated injuries require anaerobic coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases


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Surgery_Schwartz. coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases and should be considered when choosing antimicrobial therapy. Ziehl-Neelsen staining and cultures at 28°C to 32°C in Lowenstein-Jensen medium must be performed if there is a suspicion for atypical mycobacteria.73CellulitisCellulitis is characterized by a nonpurulent diffuse spreading of inflammation characterized by erythema, warmth, pain, swell-ing, and induration. Skin breakdown is a frequent cause, but Brunicardi_Ch44_p1925-p1966.indd 194720/02/19 2:49 PM 1948SPECIFIC CONSIDERATIONSPART IIFigure 44-18. Dupuytren’s disease. A. This patient has cords affecting the thumb, middle, ring, and small fingers. B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor


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Surgery_Schwartz. B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor is identified. Group A α-hemolytic Streptococcus is the most common offending pathogen and causes a more diffuse spread of infection. S aureus is the second most common offending pathogen and will cause a more local-ized cellulitis. The diagnosis of cellulitis is clinical. Septic arthritis, osteomyelitis, an abscess, a deep-space infection, and necrotizing fasciitis are severe infectious processes that may initially mimic cellulitis. These must be ruled out appropriately before initiating treatment, and serial exams should be con-ducted to ensure proper diagnosis. Treatment of cellulitis con-sists of elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who


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Surgery_Schwartz. elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who fail to improve on oral antibiotics after 24 to 48 hours. Failure to improve after 24 hours indicates a need to search for an underlying abscess or other infectious cause.735AbscessAn abscess will present much like cellulitis, but they are two clinically separate entities. The defining difference is an area of fluctuance. Skin-puncturing trauma is the most common cause. S aureus is the most common pathogen, followed by Streptococcus. Treatment consists of incision and drainage with appropriate debridement, wound cultures, wound packing, elevation, immo-bilization, and antibiotics. The packing should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed


Surgery_Schwartz

Surgery_Schwartz. should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed primary clo-sure should only be performed after repeat washouts for larger wounds where complete infection control has been achieved.Collar-Button AbscessThis is a subfascial infection of a web space and is usually caused by skin trauma that becomes infected; it often occurs in Brunicardi_Ch44_p1925-p1966.indd 194820/02/19 2:49 PM 1949SURGERY OF THE HAND AND WRISTCHAPTER 44laborers. The adherence of the palmar web space skin to the pal-mar fascia prevents lateral spread, so the infection courses dor-sally, resulting in both palmar web space tenderness and dorsal web space swelling and tenderness. The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same


Surgery_Schwartz

Surgery_Schwartz. The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same treatment as for any abscess or deep-space infection.OsteomyelitisOsteomyelitis in the hand usually occurs due to an open fracture with significant soft tissue injury. The presence of infected hard-ware, peripheral vascular disease, diabetes, and alcohol or drug abuse are also predisposing factors. Presentation includes per-sistent or recurrent swelling with pain, erythema, and possible drainage. It will take 2 to 3 weeks for periosteal reaction and osteopenia to be detected on radiographs. Bone scans and MRI Figure 44-19. Collar-Button abscess A. The fingers surround-ing the involved (second) web space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too


Surgery_Schwartz

Surgery_Schwartz. space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too early.are useful modalities to aid in diagnosis. Erythrocyte sedimenta-tion rate (ESR) and C-reactive protein (CRP) have low specific-ity but are useful for monitoring the progress of treatment, with CRP being more reliable. Treatment consists of antibiotics alone in the early stage as long as there is favorable response. All necrotic bone and soft tissue, if present, must be debrided. Initial intravenous antibiotic therapy should cover S aureus, the most common pathogen, and should then be adjusted according to bone cultures. Antibiotic therapy is continued for 4 to 6 weeks once the patient clinically improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as


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Surgery_Schwartz. improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as it is stable and the fracture has not yet healed. If the hardware is unstable, it must be replaced. An external fixation device may be useful in this setting. If osteo-myelitis occurs in a healed fracture, all hardware and necrotic bone and soft tissue must be removed.74Pyogenic ArthritisInfection of a joint will progress quickly to severe cartilage and bony destruction if not addressed quickly. Direct trauma and local spread of an infection are the most common causes. Hema-togenous spread occurs most commonly in patients who are immunocompromised. S aureus is the most common pathogen, followed by Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint


Surgery_Schwartz

Surgery_Schwartz. Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint movement, severe pain on axial load, swell-ing, erythema, and tenderness. Radiographs may show a foreign body or fracture, with widened joint space early in the process and decreased joint space late in the process due to destruc-tion. Joint aspiration with cell count, Gram stain, and culture is used to secure the diagnosis. Treatment of nongonococcal septic arthritis includes open arthrotomy, irrigation, debridement, and packing the joint or leaving a drain in place. Intravenous antibi-otics are continued until there is clinical improvement, followed by 2 to 4 weeks of additional oral or intravenous antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint


Surgery_Schwartz

Surgery_Schwartz. antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint pressure.75Necrotizing InfectionsNecrotizing soft tissue infections occur when the immune system is unable to contain an infection, leading to extensive spread with death of all involved tissues. This is different from an abscess, which forms when a functioning immune system is able to “wall off” the infectious focus. Necrotizing infections can result in loss of limb or life, even with prompt medical care.Bacteria spread along the fascial layer, resulting in the death of soft tissues, which is in part due to the extensive blood vessel thrombosis that occurs. An inciting event is not always identified. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with


Surgery_Schwartz

Surgery_Schwartz. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with group A β-hemolytic Streptococcus being the most common pathogen, followed by α-hemolytic Streptococcus, S aureus, and anaerobes. Prompt clinical diag-nosis and treatment are the most important factors for salvag-ing limbs and saving life. Patients will present with pain out of proportion with findings. Appearance of skin may range from normal to erythematous or maroon with edema, induration, and blistering. Crepitus may occur if a gas-forming organism Brunicardi_Ch44_p1925-p1966.indd 194920/02/19 2:49 PM 1950SPECIFIC CONSIDERATIONSPART IIis involved. “Dirty dishwater fluid” may be encountered as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated


Surgery_Schwartz

Surgery_Schwartz. as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated intravas-cular coagulation. Radiographs may reveal gas formation, but they must not delay emergent debridement once the diagnosis is suspected. Intravenous antibiotics should be started imme-diately to cover gram-positive, gram-negative, and anaerobic bacteria. Patients will require multiple debridements, and the spread of infection is normally wider than expected based on initial assessment.73Necrotizing myositis, or myonecrosis, is usually caused by Clostridium perfringens due to heavily contaminated wounds. Unlike necrotizing fasciitis, muscle is universally involved and found to be necrotic. Treatment includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is


Surgery_Schwartz

Surgery_Schwartz. includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is usually polymicrobial. Patients will present with a necrotic digit that is purulent and very malodorous, with rapidly evolving pain, swelling, skin discoloration, and systemic collapse. Emergent treatment is the same as for other necrotizing infections, and amputation of the involved digit or extremity must often be performed.Infectious Flexor TenosynovitisFlexor tenosynovitis (FTS) is a severe pathophysiologic state causing disruption of normal flexor tendon function in the hand. A variety of etiologies are responsible for this process. Most acute cases of FTS are due to purulent infection. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and


Surgery_Schwartz

Surgery_Schwartz. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and sarcoidosis.The primary mechanism of infectious FTS usually is penetrating trauma. Most infections are caused by skin flora, including both Staphylococcus and Streptococcus species. Bac-teria involved vary by etiology of the infection: bite wounds (Pasteurella multocida—cat, E corrodens—human); diabetic patients (Bacteroides, Fusobacterium, Haemophilus species, gram-negative organisms); hematogenous spread (Mycobacte-rium tuberculosis, N gonorrhoeae); or water-related punctures (Vibrio vulnificus, Mycobacterium marinum). Infection in any of the fingers may spread proximally into the wrist, carpal tun-nel, and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results


Surgery_Schwartz

Surgery_Schwartz. and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results from bacteria multiplying in the closed space of the flexor tendon sheath and culture-rich synovial fluid medium causing migration of inflammatory cells and subsequent swelling. The inflammatory reaction within the closed tendon sheath quickly erodes the paratenon, leading to adhesions and scarring, as well as increase in pressures within the tendon sheath that may lead to ischemia. The ultimate con-sequences are tendon necrosis, disruption of the tendon sheath, and digital contracture.Patients with infectious FTS present with pain, redness, and fever (Fig. 44-20). Physical examination reveals Kanavel’s “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive


Surgery_Schwartz

Surgery_Schwartz. “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive exten-sion of the digit.77 Kanavel’s signs may be absent in patients who are immunocompromised, have early manifestations of Figure 44-20. Suppurative flexor tenosynovitis of the ring finger. A. The finger demonstrates fusiform swelling and flexed posture. B. Proximal exposure for drainage. C. Distal drainage incision.Brunicardi_Ch44_p1925-p1966.indd 195020/02/19 2:49 PM 1951SURGERY OF THE HAND AND WRISTCHAPTER 44infection, have recently received antibiotics, or have a chronic, indolent infection.If a patient presents with suspected infectious FTS, empiric intravenous antibiotics should be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For


Surgery_Schwartz

Surgery_Schwartz. be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For immunocompromised patients (including diabetics) or infections associated with bite wounds, empiric treatment should include coverage of gram-negative organisms as well.78Adjuncts to antibiotics include splint immobilization (intrinsic plus position preferred) and elevation until infec-tion is under control. Hand rehabilitation (i.e., range-of-motion exercises and edema control) should be initiated once pain and inflammation are under control.If medical treatment alone is attempted, then initial inpa-tient observation is indicated. Surgical intervention is necessary if no obvious improvement has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme


Surgery_Schwartz

Surgery_Schwartz. has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme that can be use-ful in guiding surgical treatment (Table 44-1).79 Figure 44-20 (B and C) demonstrates drainage of a stage II FTS. A Brunner incision allows better initial exposure but may yield difficul-ties with tendon coverage if skin necrosis occurs. A 16-gauge catheter or 5-French pediatric feeding tube then is inserted into the tendon sheath through the proximal incision. The sheath is copiously irrigated with normal saline. Avoid excessive fluid extravasation into the soft tissue because the resulting increase in tissue pressure can lead to necrosis of the digit. The catheter is removed after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the


Surgery_Schwartz

Surgery_Schwartz. after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the distal incision site. Continuous or intermittent irrigation every 2 to 4 hours with sterile saline can then be per-formed through the indwelling catheter.After surgery, an intrinsic plus splint is applied, the hand is elevated, and the appropriate empiric antibiotic coverage is instituted while awaiting culture results. The hand is reexamined the following day. Whirlpool therapy and range of motion are begun. Drains are removed before discharge from the hospital. The wounds are left open to heal by secondary intention. In severe cases, repeat irrigation and operative debridement may be required.Antibiotic therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed.


Surgery_Schwartz

Surgery_Schwartz. therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed. Consultation with an infectious disease specialist should be considered early in order to maximize efficiency and efficacy of therapy.FelonA felon is a subcutaneous abscess of the fingertip and is most commonly caused by penetrating trauma. S aureus is the most common pathogen. The fingertip contains multiple septa con-necting the distal phalanx to the skin. These septa are poorly compliant, and presence of an abscess will increase pressure and lead to severe pain and tissue death. Patients will experience erythema, swelling, and tenderness of the volar digital pad. Oral antibiotics may resolve the infection if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal


Surgery_Schwartz

Surgery_Schwartz. if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal fluctuance (Fig. 44-21). Transverse and lateral incisions should be avoided, and the incision should never extend across the distal phalangeal joint crease. Deep incision should not be performed as this may cause seeding of bacteria into the flexor tendon sheath. The wound is irrigated and packed, with warm soapy water soaks and packing changes initiated within 24 hours and performed two to three times daily until secondarily healed. Antibiotic coverage should cover for Staphylococcus and Streptococcus species.73ParonychiaParonychia is an infection beneath the nail fold. The nail plate can be viewed as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail


Surgery_Schwartz

Surgery_Schwartz. as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail biting. The infection may spread around Table 44-1Michon’s stages of suppurative flexor tenosynovitis and appropriate treatmentSTAGEFINDINGSTREATMENTIIncreased fluid in sheath, mainly a serous exudateCatheter irrigationIIPurulent fluid, granulomatous synoviumMinimal invasive drainage ± indwelling catheter irrigationIIINecrosis of the tendon, pulleys, or tendon sheathExtensive open debridement and possible amputationBAFigure 44-21. Felon. A. Lateral view of the digit showing fluctu-ance between the skin of the pad and the underlying distal phalanx bone. B. The authors prefer to drain felons with a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from


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Surgery_Schwartz. a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from one side to the other, or it may extend into the pulp and result in a felon. An acute paronychia is usually caused by S aureus or Streptococcal species. Patients report pain, ery-thema, swelling, and possibly purulent drainage involving the periungual tissue. Treatment consists of warm water soaks and oral antibiotics if diagnosed early. If purulence or fluctu-ance is present, then a freer elevator or 18-gauge needle can be passed along the involved nail fold to decompress the collection (Fig. 44-22). If the infection involves the eponychial fold, a small proximally based flap of eponychium is created by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by


Surgery_Schwartz

Surgery_Schwartz. by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by warm water soaks and local wound care. Usually, the wound cannot be repacked once the dressing is removed.73A chronic paronychia is most commonly caused by Can-dida species and is most often found in patients who perform jobs involving the submersion of their hands in water or other moist environments. These develop into thickened nails with callus-like formation along the nail folds and may occasion-ally become red and inflamed. They do not respond to antibi-otic treatment, and nail plate removal with marsupialization of the skin proximal to the eponychial fold will allow the wound to heal secondarily. The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal


Surgery_Schwartz

Surgery_Schwartz. The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal management. Clinical examination, particularly noting the area of greatest tenderness and/or inflammation, is the single most useful diagnostic tool to localize any puru-lence requiring drainage. Specific recommendations for differ-entiating among the possible locations of hand infection are included in the diagnostic algorithm shown in Fig. 44-23.TUMORSTumors of the hand and upper extremity can be classified as benign soft tissue tumors; malignant soft tissue tumors (subclas-sified into cutaneous and noncutaneous malignancies); benign bony tumors; malignant bony tumors; and secondary metastatic tumors. Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia


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Surgery_Schwartz. Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia using the bevel of an 18-gauge needle inserted between the nail fold and the nail plate at the location of maximal fluctuance.NondiagnosticFractureForeign bodyCellulitisadmit, IV Abxserial examSite of fluctuanceEntire fingerseYoNPyogenic FTSKanavel’ssigns presentMRI if nofluctuanceSubcutaneousabscessThenarabscessMidpalmabscessHypothenarabscessDistalLoss ofpalmarconcavityRadial toIF MCUlnar toSF MCWeb spaceabscessPalmPain withaxial loadingof jointPyogenic vs.crystallinearthritisConsiderarthrocentesisNo improvementin 48 hoursHand inflammationPlain X-raysPartial fingerDorsalCenteredon jointBetweendigitsLocalized fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious


Surgery_Schwartz

Surgery_Schwartz. fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious diagnoses. Abx = antibiotics; FTS = flexor tenosynovitis; IF MC = index finger metacarpal; MRI = magnetic resonance imaging; SF MC = small finger metacarpal.Brunicardi_Ch44_p1925-p1966.indd 195220/02/19 2:49 PM 1953SURGERY OF THE HAND AND WRISTCHAPTER 44history and physical exam. Hand and/or wrist X-rays should be obtained in every patient presenting with a mass unless clearly not indicated (e.g., a superficial skin lesion with no aggressive/malignant features). The workup proceeds in an orderly fashion until a diagnosis is obtained. Once a benign diagnosis is secured (by strong clinical suspicion in an experienced hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed


Surgery_Schwartz

Surgery_Schwartz. hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed without advanced imaging or tissue biopsy. When necessary, additional workup may include baseline laboratory studies, CT and/or MRI of the involved region, and a bone scan or positron emission tomography (PET) scan. Staging of a malignant tumor may occur before biopsy if a malignancy is strongly suspected, or it may occur after formal biopsy. Staging includes a chest X-ray and CT with intravenous contrast of the chest, abdomen, and pelvis to detect possible metastasis. Biopsy of the mass is always the last step of a workup and should occur only after all other available information has been gathered. Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic


Surgery_Schwartz

Surgery_Schwartz. Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic appearance war-rants workup and biopsy to rule out malignancy.CT scans are useful for detecting bony tumor extension across planes and identifying tumors of small bones, such as the carpal bones. MRI is useful for evaluating soft tissue tumor involvement (e.g., which muscle compartments are involved) as well as intramedullary lesions. Most soft tissue tumors will appear dark on T1-weighted images and bright on T2-weighted images. Hematomas, hemangiomas, lipomas, liposarcomas, and adipose tissue will appear bright on T1-weighted images and dark on T2-weighted images. Scintigraphy uses methylene diphosphonate attached to technetium-99m. This complex will attach to hydroxyapatite. Immediate uptake is seen in areas of increased vascularity, such as infection, trauma, and neoplasia. Increased uptake 2