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Surgery_Schwartz. 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 to 3 hours later is seen in “pooled” areas where new bone formation has occurred. This modality is useful for detecting areas of tumor invasion or metastases not other-wise seen on prior CT, MRI, or radiographs.Biopsy is reserved for masses that cannot be diagnosed as benign based on prior clinical and radiographic exams. Needle biopsy is not reliable for primary diagnosis, but it can be use-ful for recurrent or metastatic disease. Open excisional (if mass is less than 5 cm in size) or incisional (if mass is greater than 5 cm in size) biopsy is the most common biopsy method. Proper surgical oncologic technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous


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Surgery_Schwartz. technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous hemostasis; carrying the incision directly down to the tumor with no development of tissue planes (i.e., making a straight-line path from skin to tumor); incising through the fewest number of muscle compartments; and avoid-ing critical neurovascular structures. The CT or MRI images will help determine the best surgical approach for biopsy or resection in order to avoid uninvolved compartments and criti-cal structures.80Benign Soft Tissue TumorsGanglion Cyst. This is the most common soft tissue tumor of the hand and wrist, comprising 50% to 70% of all soft tis-sue tumors in this region. They can occur at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes


Surgery_Schwartz

Surgery_Schwartz. at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes be associated with mild pain. Compressive neuropathies may be seen if they occur in Guyon’s canal or the carpal tunnel, but they are uncommon. There are no reports of malignant degeneration. History and physical exam are usually sufficient to establish a diagnosis. Occurrence by location is as follows: 60% to 70% occur on the dorsal wrist between the third and fourth exten-sor compartments and are connected by a stalk to the scaph-olunate ligament (Fig. 44-24); 18% to 20% occur on the volar wrist; and 10% to 12% occur in the digits as volar retinacular or flexor tendon sheath cysts. The cyst transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells


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Surgery_Schwartz. transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells present. Clear viscous mucin fills the cyst and is composed of glucosamine, albumin, globulin, and hyaluronic acid. The etiology is unclear. The most accepted theory currently is Angelides’ who proposed that repeated stress of a joint, ligament, or tendon sheath causes an increase of mucin-producing cells and subsequent mucin pro-duction. The increased mucin production dissects superficially and coalesces into a cyst. The successful treatment of dorsal ganglion cysts by excising only the stalk supports this theory.80Treatment consists of observation if asymptomatic. If symptoms exist or the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal


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Surgery_Schwartz. the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal extensor compartments and have a stalk connecting the base of the cyst to the scapholunate ligament.Brunicardi_Ch44_p1925-p1966.indd 195320/02/19 2:49 PM 1954SPECIFIC CONSIDERATIONSPART IIsuccessful cure rate ranging from 15% to 89%. The benefit of injected steroids is inconclusive. Aspiration of a volar wrist ganglion cyst can be dangerous due to the potential of injur-ing neurovascular structures. Open excision and arthroscopic excision of the cyst stalk are surgical options for cysts that are not amendable to aspiration. A recent meta-analysis reported recurrence rates after either needle aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to


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Surgery_Schwartz. aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to seventh decades, and the underlying cause is associated osteoarthritis of the DIP joint. They are slow growing and usually occur on one side of the ter-minal extensor tendon between the DIP joint and the eponych-ium. The earliest clinical sign is often longitudinal grooving of the involved nail plate followed by a small enlarging mass and then attenuation of overlying skin. X-rays will show signs of osteoarthritis within the DIP joint. Heberden nodes (osteophytes within the DIP joint) are often seen on X-ray.Possible treatment includes observation, aspiration, or excision. If the cyst is not draining and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised.


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Surgery_Schwartz. and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised. If the cyst is symp-tomatic, painful, or the patient desires removal for cosmetic pur-poses, excision should be performed. Any osteophytes in the DIP joint must be removed to reduce recurrence. Aspiration is an option for treatment, but this poses the risk of DIP joint infec-tion through seeding of bacteria into the joint or by the devel-opment of a draining sinus tract. It is generally not performed.Giant Cell Tumor of the Tendon Sheath. Also known as a xanthosarcoma, fibrous xanthoma, localized nodular synovitis, sclerosing hemangioma, or pigmented villonodular tenosynovi-tis, giant cell tumor of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of


Surgery_Schwartz

Surgery_Schwartz. of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of malignant transformation. Despite the simi-larity in name, it is not histopathologically related to giant cell tumor of the bone.82Giant cell tumor of the tendon sheath occurs as a firm slow-growing painless mass over months to years and will often feel bumpy or nodular, which is a distinguishing characteristic helpful for diagnosis. It has a predilection for occurring in close proximity to joints along flexor surfaces of the wrist, hands, and digits (especially the PIP joints of the radial digits) and occurs most commonly between the second and fifth decades (Fig. 44-25A). These tumors do not transilluminate. Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color


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Surgery_Schwartz. Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color due to the large amount of hemosiderin content, which is easily detected on histologic staining (Fig. 44-25B). Multinucleated giant cells and hemosiderin-laden macrophages are characteristic.80This tumor is not visible on radiographs. Approximately 20% will show extrinsic cortical erosion on X-ray. This is a risk factor for recurrence, and removal of the cortical shell should be considered. MRI is useful for delineating involvement with tendons, ligaments, and joints.The standard treatment is marginal excision. These tumors will often grow next to or around neurovascular bundles, and an Allen’s test should always be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of


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Surgery_Schwartz. be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of the external finger. B. The excised giant cell tumor has a multilobulated, tan-brown appearance.ABwell as dual blood supply to an involved digit via the ulnar and radial proper digital arteries. It is important to completely excise the stalk because this will greatly reduce tumor recurrence even in the setting of residual tumor. If tumor is suspected to have extended into the joint, the joint must be opened and all tumor removed. Despite this being a benign lesion, local recurrence is varies widely from 4% to 44%. Some variants can mimic more aggressive processes, and malignancy must be considered if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly


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Surgery_Schwartz. if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly (especially thenar or hypothenar muscles); deep spaces; carpal tunnel or Guyon’s canal; and rarely bone or nerve. They typically present as a painless, slow-growing, soft, and mobile mass over a period of months to years. Painful findings sug-gest close approximation to a neurovascular structure or, less commonly, a malignant lesion such as liposarcoma. Lipomas do not transilluminate. They resemble mature fat histologically. X-rays typically reveal no abnormality. MRI is a helpful imag-ing modality to evaluate a lipoma and will show signal charac-teristics that are suggestive of adipose tissue.80Asymptomatic lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended


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Surgery_Schwartz. lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended for deep lipomas to evaluate proxim-ity or involvement of critical structures, followed by marginal excision if MRI findings are consistent with a lipoma. If MRI findings are not consistent with a lipoma, incisional biopsy is warranted. Recurrence after marginal excision is rare.80Brunicardi_Ch44_p1925-p1966.indd 195420/02/19 2:50 PM 1955SURGERY OF THE HAND AND WRISTCHAPTER 44Schwannoma. A schwannoma, also known as a neurilem-moma, is a type of benign peripheral nerve sheath tumor. It is the most common benign peripheral nerve sheath tumor of the upper extremity.83 The majority occur as single solitary masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors


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Surgery_Schwartz. masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors arise from the Schwann cell and occur most often in the middle decades of life. They grow as painless, slow-growing, firm, round, well-encapsulated masses with a predilection toward flexor surfaces of the forearm and palm (given their presence of large nerves). Schwannomas grow from the peripheral nerve sheath and are usually connected by a pedicled stalk. The tumor is well demar-cated and can be readily separated from the nerve fascicles (Fig. 44-26). Unlike neurofibromas, they do not grow within the nerve. Paresthesias or other neurologic findings may occur, but they are usually absent, as is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni


Surgery_Schwartz

Surgery_Schwartz. is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni type A palisades of spindle cells with large oval nuclei with interlacing fascicles. Less cellular regions appear as Antoni type B areas. Mutations of the schwanomin gene on chromosome 22 are found in 50% of sporadic cases and 100% of acoustic schwannomas in patients with NF2.84Surgical treatment is reserved for symptomatic tumors and those that require biopsy to rule out a malignant process. An MRI should be obtained prior to surgery to confirm that the tumor is not located within the nerve (i.e., a neurofibroma) and that it is consistent with a schwannoma. Operative treatment involves excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is


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Surgery_Schwartz. excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is exceedingly rare.83Malignant Soft Tissue Tumors—CutaneousSquamous Cell Carcinoma. Squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, accounting for 75% to 90% of all malignancies of the hand. Eleven percent of all cutaneous SCC occurs in the hand.85 It is the most common malignancy of the nail bed. Risk factors include sun exposure, radiation exposure, chronic ulcers, immu-nosuppression, xeroderma pigmentosa, and actinic keratosis. Marjolin’s ulcers represent malignant degeneration of old burn or traumatic wounds into an SCC and are a more aggressive type. Transplant patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small,


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Surgery_Schwartz. patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small, firm nodules or plaques with indistinct margins and surface irregularities ranging from smooth to ver-ruciform or ulcerated (Fig. 44-27). They are locally invasive, with 2% to 5% lymph node involvement. Metastasis rates of up to 20% have been reported in radiation or burn wounds. Stan-dard treatment is excision with 0.5to 1.0-cm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.85Basal Cell Carcinoma. Basal cell carcinoma (BCC) is the sec-ond most common primary malignancy of the hand, accounting for 3% to 12%; 2% to 3% of all BCCs occur on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small,


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Surgery_Schwartz. on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small, well-defined nodule with a translucent, pearly border and overlying telangi-ectasias (Fig. 44-28). Metastasis is very rare. Standard treatment is excision with 5-mm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.Melanoma. Melanoma accounts for approximately 4% of skin cancers and is responsible of 80% of all deaths from skin cancer. Approximately 2% of all cutaneous melanomas occur in the hand.87 Risk factors include sun exposure (especially blis-tering sunburns as a child), dysplastic nevi, light complexion, family history of melanoma, immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the


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Surgery_Schwartz. immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the nerve fascicles relatively easily because they do not infiltrate between them (unlike neurofibromas).Figure 44-27. Squamous cell carcinoma involving the nail fold and nail bed. Note the wart-like and ulcerated appearance.Brunicardi_Ch44_p1925-p1966.indd 195520/02/19 2:50 PM 1956SPECIFIC CONSIDERATIONSPART IInevi. Pigmented lesions with irregular borders, color changes, increase in growth, or change in shape are suggestive of mela-noma. Breslow thickness is the most important factor in predicting survival for a primary melanoma. Melanoma in situ lesions should be surgically excised with 0.5 cm margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions


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Surgery_Schwartz. margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions over 1 mm in thickness or for any lesion that is over 0.76 mm in thickness and exhibits ulcer-ation or high mitotic rate.89 Any clinically palpable lymph node requires a formal lymph node dissection of the involved basin, as do sentinel lymph nodes positive for melanoma. Lymph node dis-section has not been shown to offer any long-term survival ben-efit, but the information gained from sentinel lymph node biopsy (or lymph node dissection) does offer valuable staging informa-tion that is important for prognosis. For cases of subungual mela-nomas, DIP amputation is the current standard of care. A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude


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Surgery_Schwartz. A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude if one treatment was superior to another.90Malignant Soft Tissue Tumors—NoncutaneousPrimary soft tissue sarcomas of the upper extremity are very rare. Approximately 12,000 new cases of sarcomas are diag-nosed each year and of those, only 15% occur in upper extremity.80 Statistical inference is limited due to the rare occur-rence of these tumors, but mortality rate is very high despite the aggressive treatments. Fewer than 5% of soft tissue sarcomas of the upper extremity will develop lymph node metastasis. Cutaneous malignancies must be considered in the differential diagnosis for any patient with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant


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Surgery_Schwartz. with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant until proven otherwise.91Treatment for soft tissue sarcomas can range from pallia-tive debulking to attempted curative resection. Many muscles of the upper extremity and their compartments cross joints (e.g., forearm flexors). Any malignancy within a compartment mandates complete resection of that compartment, and there-fore, amputations must often be performed at levels much more proximal than the level of the actual tumor. Many soft tissue sarcomas are not responsive to radiation or chemotherapy, and use of these adjuvant treatments must be decided upon after discussion with medical and radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not


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Surgery_Schwartz. radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not ultimately receive treatment. These studies recommend biopsy be performed at the institution at which definitive treatment will be provided.92 Institutions best suited for such treatment should have pathologists familiar with soft tissue sarcomas, medical and radiation oncologists, surgical oncologists, and a multidisciplinary tumor board.An in-depth review of each type of soft tissue sarcoma is beyond the scope of this chapter. Epithelioid sarcoma is the most common primary soft tissue sarcoma of the upper extremity and usually presents as a benign-like slow-growing mass during the third or fourth decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the


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Surgery_Schwartz. decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the most common primary soft tissue sarcoma of the hand and wrist, but the paucity of case reports is inconclusive. It is a high-grade malignancy that is painless and slow-growing and usually occurs adjacent to, but not involving, joints. It is most common in the second to fifth decades of life. Tumor size (greater than 5 cm) is positively correlated with mortality. Other sarcomas include malignant fibrous histiocytoma, liposarcoma, fibrosarcoma, dermatofibrosarcoma protuberans, and malignant peripheral nerve sheath tumors, and more information can be found in further selected reading.93 The majority of metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up


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Surgery_Schwartz. metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up a total of 7% of all primary benign bone tumors in the body. Benign tumors of cartilage origin comprise 79% of all primary benign bone tumors of the hand and wrist.94Enchondroma. This is the most common primary benign bone tumor of the hand and wrist and is of cartilage origin. Up to 90% of all bone tumors in the hand and wrist are enchondromas, with 35% to 54% of all enchondromas occurring in the hand and wrist. They are often found incidentally on X-rays taken for other reasons (e.g., hand trauma). They are usually solitary and favor the diaphysis of small tubular bones and are most com-mon in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the


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Surgery_Schwartz. in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the trapezoid. Presentation is usually asymptomatic, but pain may occur if there is a pathologic fracture or impending fracture. The etiology is believed to be from a fragment of carti-lage from the central physis. Histology shows well-differentiated hyaline cartilage with lamellar bone and calcification.94Figure 44-28. Basal cell carcinoma of the dorsal hand with sur-rounding telangiectasia.Brunicardi_Ch44_p1925-p1966.indd 195620/02/19 2:50 PM 1957SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-29. Enchondroma. A. X-ray of the phalanx demon-strates a well-defined central lucency. Surrounding cortex may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect


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Surgery_Schwartz. may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect to help ensure that there is no tumor (similarly radiolucent to the defect after curettage) left behind prior to bone grafting.BATwo variants of enchondroma include Ollier’s disease (multiple enchondromatosis) and Maffucci’s syndrome (multi-ple enchondromatosis associated with multiple soft tissue hem-angiomas). Malignant transformation is very rare in the solitary form, but there is a 25% incidence by age 40 in Ollier’s patients and a 100% life-time incidence in Maffucci’s patients. When malignant transformation does occur, it is almost uniformly a chondrosarcoma with pain and rapid growth.95Diagnosis is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning


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Surgery_Schwartz. is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning or, sometimes, thickening (Fig. 44-29A). Further imaging is seldom needed, but a CT would be the study of choice.Observation is indicated for asymptomatic enchondromas with no risk of impending fracture, followed by annual X-rays for 2 years. If a pathologic fracture is found, it is treated with immobilization until fracture union and then surgically treated. If there is any uncertainty as to whether it is an enchondroma, incisional biopsy is indicated, and definitive treatment is postponed pending final pathology. Symptomatic lesions and those with impending fracture are treated surgically. Surgical treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor.


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Surgery_Schwartz. treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor. Intraoperative fluoroscopy is used to confirm complete ablation (Fig. 44-29B). The defect is then packed with bone graft or bone substitute. Recurrence ranges from 2% to 15%. X-rays should be obtained serially after surgery.94Periosteal Chondroma. Periosteal chondromas are benign bone tumors of cartilage origin that arise most commonly within or adjacent to periosteum at the metaphyseal-diaphyseal junc-tion in phalanges. They occur usually in the second or third decade as solitary lesions with pain, swelling, deformity, and possible pathologic fracture. X-rays reveal a subperiosteal lytic, unilobular lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from


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Surgery_Schwartz. lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from chondrosarcomas.94Diagnosis involves X-rays with incisional biopsy to con-firm the benign diagnosis and avoid unnecessary amputation. Treatment includes en bloc resection of periosteum and cortico-cancellous bone. Recurrence is less than 4%.Osteoid Osteoma. This is a tumor of bone origin. Approxi-mately 5% to 15% of all osteoid osteomas occur in the hand and wrist and are most often found in the proximal phalanx or car-pus. They usually occur in the second or third decade and pres-ent with a deep, dull ache that is classically worse at night and relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID


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Surgery_Schwartz. (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID therapy only, and resolu-tion occurs at an average of 33 months. If the patient does not wish to undergo prolonged discomfort with conservative ther-apy, curettage or percutaneous ablation of the nucleus may be performed.96Giant Cell Tumor of Bone. Giant cell tumors of bone make up only 4% to 5% of all benign bone tumors in the body, and only 12% of these occur in the hand or wrist. Although its name is similar to that of “giant cell tumor of tendon sheath,” they are two separate tumors and do not share the same clinical or histo-pathologic characteristics. Approximately 2% occur in the hand and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell


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Surgery_Schwartz. and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell tumor of the bone is unique in that it is benign on histology but does have metastatic potential and can cause death. It should be considered a low-grade malignancy.97 Workup includes a CT of the chest and total-body scintigra-phy to evaluate for metastases and multifocal lesions and MRI to evaluate the extent of local tissue involvement. The recom-mended treatment consists of surgical resection of the involved phalanges or metacarpals and wide excision of entire carpal rows. Treatment with curettage and adjuvant treatments only results in a high rate of recurrence. Local and systemic surveil-lance must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the


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Surgery_Schwartz. must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the hand, like soft tissue malignancies, are exceedingly rare. An in-depth Brunicardi_Ch44_p1925-p1966.indd 195720/02/19 2:50 PM 1958SPECIFIC CONSIDERATIONSPART IIreview is beyond the scope of this chapter. The same principles for soft tissue sarcomas of the upper extremity apply here with regard to evaluation, biopsy, and treatment.Chondrosarcoma comprises 41% of all primary malignant bone tumors of the hand and wrist but only 1.5% of all chon-drosarcomas overall. It is most likely to occur from malignant degeneration from a preexisting lesion, with enchondromatosis and osteochondromatosis being the most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion,


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Surgery_Schwartz. most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion, cortical expan-sion, cortical destruction, and calcification. Metastasis has never been reported for chondrosarcomas of the hand. Chondrosarco-mas are not responsive to chemotherapy or radiation.99Osteosarcoma of the hand is exceedingly rare; only 0.18% of osteosarcomas occur in the hand. It usually presents as a painful swelling with pathologic fracture in the fifth to eighth decades of life. Radiation exposure is believed to be a possible risk factor. X-ray findings vary widely, with 90% of tumors occurring at a metaphyseal location. Findings include an osteo-blastic or osteolytic lesion, cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic


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Surgery_Schwartz. cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic factor, with a 5-year survival of 70% in the absence of metastases and a 5-year survival of 10% if present. Preoperative chemotherapy is usually given, but radi-ation therapy plays no role.100Secondary Metastatic TumorsMetastases to the hand or wrist are rare, with only 0.1% of skel-etal metastases occurring in the hand. The majority of metas-tases to the hand are bone lesions, but soft tissue metastases have been reported. The most common primary site is the lung (40%), followed by the kidney (13%) and the breast (11%). Approximately 16% will have no known diagnosis of cancer.101 The most common sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes


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Surgery_Schwartz. sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes felon, gout, osteomyelitis, trauma, RA, or skin cancer. Treatment of a hand or wrist metastatic lesion must not interfere with treatment of the primary cancer. Treatment is usually palliative (simple excision or amputa-tion). The average life expectancy for these patients is less than 6 months.101BURNSThe palm of the hand makes up approximately 1% of the total body surface area. A burn involving the entire hand and digits is unlikely to cause life-threatening injury or shock, but seem-ingly small burns to the hand may cause severe permanent loss of function if not treated appropriately. Burns to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This


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Surgery_Schwartz. to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This manage-ment will include a multidisciplinary team consisting of hand surgeons, burn surgeons, burn-specialized nurses, occupational therapists, case managers, and social workers.Superficial burns involve damage to the epidermis only and present with erythema, no blistering, and full sensation with blanching of skin. These will heal without scarring. Super-ficial partial-thickness burns involve damage to the papillary dermis; all skin appendages are preserved, and therefore, these readily reepithelialize with minimal to no scarring. Superficial partial-thickness burns are sensate and present with pain, ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages,


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Surgery_Schwartz. ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, as well as the dermal plexus blood vessels and nerves. These have decreased sensation and no cap refill and appear pale or white. Blistering may be present. Damage to the skin append-ages and blood supply in the dermal plexus precludes spontane-ous healing without scar. Excision with skin grafting is needed. Third-degree burns involve full-thickness damage through the dermis and are insensate with no blistering. They appear dry, leathery, and even charred.Acute ManagementAdvanced trauma life support guidelines should be followed. After primary survey, circulation to the hand should be assessed. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar


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Surgery_Schwartz. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar digital pad. A sensorimotor exam should be per-formed. Objective evidence of inadequate perfusion (i.e., deteri-orating clinical exam with changes in or loss of pulse or Doppler signal) indicates the need for escharotomy, especially in the set-ting of circumferential burns. Escharotomy may be performed at bedside with scalpel or electrocautery under local anesthesia or intravenous sedation. In the forearm, axially oriented midra-dial and midulnar incisions are made for the entire extent of the burn. Escharotomy should proceed as distally as necessary into the wrist and hand to restore perfusion. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index,


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Surgery_Schwartz. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index, middle, and ring fingers.102 These locations for digital escharotomies avoid pain-ful scars on the heavy-contact surfaces of each respective digit. After primary survey, vascular, and sensorimotor exams are complete, careful documentation should be made of all burns. This is best done with a Lund and Browder chart and includes location, surface area, and initial depth of burn.The burns should be dressed as soon as examination is complete. Gauze moistened with normal saline is a good initial dressing because it is easy, readily available, and will not leave ointment or cream on the wounds, which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity


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Surgery_Schwartz. which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity ischemia if a circum-ferential dressing is in place. It is important to maintain body temperature above 37°C, especially in burn patients who have lost thermoregulatory function of the skin and now have moist dressings in place. The hands should be elevated above heart level to decrease edema formation, which can hinder motion and lead to late scar contracture. The hand should be splinted in the intrinsic plus position with the MPs flexed to 90° (placing MP collateral ligaments under tension), the IPs in straight extension (prevents volar plate adhesion), and the wrist in approximately 15° of extension.103 In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary


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Surgery_Schwartz. In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary joint stabilizer.After the primary and secondary surveys are complete, the wound should be evaluated again. Devitalized tissue should be Brunicardi_Ch44_p1925-p1966.indd 195820/02/19 2:50 PM 1959SURGERY OF THE HAND AND WRISTCHAPTER 44debrided. Wounds should be cleansed twice daily, typically with normal saline. Second-degree superficial burns may be dressed with Xeroform gauze and bacitracin. Silver sulfadiazine cream is another option for any secondor third-degree wound. It cov-ers gram-positive and gram-negative microbes, but it does not penetrate eschar. It should be applied at least one-sixteenth of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn


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Surgery_Schwartz. of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn wound will eventually heal with proper wound care. However, this may involve unacceptable scarring, deformity, contractures, pain, and unstable wounds that are prone to breakdown. The goal is to restore preinjury function as much as possible with a wound that is durable, supple, nonpainful, and allows the patient to return to society as an active member. Local wound care is the ideal treatment for wounds that can heal completely within 14 days while not sacrificing function. For deep partial-thickness or full-thickness burns, early surgical excision and skin grafting is necessary.103Considerable controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational


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Surgery_Schwartz. controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational activities they enjoyed in order to have a better understanding of which issues should be addressed. Tangential excision of the wounds should be performed under tourniquet to minimize blood loss and is carried down to viable tissue. Avoid excising through fascia (epimysium) overlying muscles or exposing tendons, bone, joint capsules, or neurovascular structures. Tissues capable of receiv-ing a skin graft include well-vascularized fat, muscle, perineu-rium, paratenon, perichondrium, and periosteum. Exposure of deep structures without an adequately graftable bed mandates further coverage before skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a


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Surgery_Schwartz. skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a temporary dressing such as Allograft (human cadaver skin) should be placed and the patient reexamined fre-quently for signs of granulation tissue and wound bed viability. It can remain in place for up to 14 days before rejection and can serve as a way of “testing” if a wound is ready to receive a skin graft. Skin grafts to the dorsum of the hand are typi-cally split-thickness sheet grafts (not meshed), as sheet grafts have a superior aesthetic appearance. Skin grafts to the palmar aspects of the hand should be full-thickness in order to provide the dermal durability needed for daily functions. Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with


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Surgery_Schwartz. Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with the wound bed, preventing fluid collections that can lead to graft loss. A bol-ster may consist of a tie-over bolster and a splint or a negativepressure dressing. The hand should be splinted in intrinsic plus for 7 days after skin grafting. Once the graft is adherent, hand therapy should begin, consisting of active and passive range-of-motion exercises and modalities.103ReconstructionReconstruction of burn wounds can begin as early as the acute setting and continue into the subacute and late stages. Burns may initially be superficial but later convert to deep burns (especially with grease, oil, and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle,


Surgery_Schwartz

Surgery_Schwartz. and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle, bone, tendon, cartilage, joints, and neurovascular structures, as well as loss of fascial layers that are required for overlying soft tissue to glide during movement. Simply skin grafting these exposed structures will result in unstable wounds that are prone to chronic breakdown. Soft tissue contractures will develop as the skin grafts adhere to the structures, effectively anchoring them in static position. This is especially true for tendons, where gliding capability is paramount for function. Flap coverage is required in these situ-ations. The reversed radial forearm flap is a local flap and is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh,


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Surgery_Schwartz. is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh, or even free parascapular flaps, may be useful, provided the patient can tolerate a free tissue transfer (see Chapter 45) operation (Fig. 44-30). The digits may also be buried subcutaneously in the lower abdominal skin or groin crease. Vascular ingrowth from the digits into the abdominal or groin skin occurs over 2 to 3 weeks, allowing division of the flap(s) and achieving full-thickness coverage of the wounds.104An acellular dermal regenerative substitute (e.g., Integra) may be used for wounds that have exposed structures and require more durability than is offered by a skin graft such as full-thickness loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor


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Surgery_Schwartz. loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor candidates for an extensive surgery. Integra is com-posed of acellular cross-linked bovine tendon collagen and gly-cosaminoglycan with an overlying silicone sheet. It is applied much like a skin graft. After incorporation in 14 to 21 days, it is capable of accepting a skin graft (after removing the silicone sheet). Conceptually, it works by replacing the lost dermis and adds durability to a wound bed. It may be reapplied multiple times to the same area if thicker neodermis is desired. Although cultured autologous keratinocytes have been used, they are expensive, time-consuming, and do not provide prompt or durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar


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Surgery_Schwartz. durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar Figure 44-30. Free anterolateral thigh flap reconstruction of a large dorsal hand wound. Once wound coverage is stable, this flap will need to be surgically revised to achieve proper contour.Brunicardi_Ch44_p1925-p1966.indd 195920/02/19 2:50 PM 1960SPECIFIC CONSIDERATIONSPART IIaspect of the web is distal to the dorsal aspect. This is reversed in web space contractures and limits digit abduction. Local modified Z-plasty (double-opposing Z-plasty) is the preferred treatment (Fig. 44-31).Special ConsiderationsChemical burns pose a risk to healthcare providers and should be considered hazardous material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid


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Surgery_Schwartz. material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid produces a slow onset of severe pain and continues to penetrate deeper structures. It avidly binds tissue and circulating calcium and can lead to hypocalcemia and cardiac arrest. The wound should be irrigated copiously with water followed by topical or intra-arterial injection of calcium gluconate. Chromic acid burns should be treated with immediate lavage, phosphate buffer soaks and immediate surgical excision. Cement can result in chemical burns and should be treated with immediate irrigation and topical antibacterial ointments. Alka-line and acid burns require copious irrigation with water, with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease


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Surgery_Schwartz. with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease encompasses a broad spectrum of disorders leading to compromised perfusion to the hand and digits and may potentially cause ischemia and necrosis. Chronic vascular disorders tend to develop slowly and are typically seen in older patients. This includes progressive thrombosis, aneurysms, sys-temic vasculopathy, and vasospastic disorders. Disorders unique or common to the hand are discussed in the following sections.Progressive Thrombotic DiseaseHypothenar hammer syndrome involves occlusion of the ulnar artery at the wrist and is the most common occlusive vascular disorder of the upper extremity. The etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that


Surgery_Schwartz

Surgery_Schwartz. etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that cause prolonged vibration and repetitive impact on the ulnar aspect of the palm. This causes periadventitial arterial damage that results in scar-ring and eventual compression, as well as medial and intimal damage.107 The artery then becomes weakened and prone to aneurysm and/or thrombosis. If a thrombus forms, it may embo-lize, producing digital ischemia. Symptoms may be chronic or acute and include pain, numbness and tingling, weakness of grip, discoloration of the fingers, and even gangrene or ulcers of the fingertips.If acute in onset, proximal occlusions may be extracted with a balloon catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and


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Surgery_Schwartz. catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and reperfusion may result in edema and compartment syndrome, requiring fasciotomy. A high index of suspicion must be maintained.For the more common scenario of chronic, progres-sive occlusion, the involved segment of ulnar artery should be resected. There is disagreement in the literature regarding whether simple ligation and excision is sufficient for patients with sufficient distal flow or if all patients should undergo vas-cular reconstruction.108 The authors’ personal preference is to reconstruct all patients.Systemic VasculopathyBuerger’s disease (thromboangiitis obliterans) is an inflamma-tory occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute,


Surgery_Schwartz

Surgery_Schwartz. occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute, intermediate, and chronic, depending on histologic progression of the disease. Migratory phlebitis occurs distal to the elbow, resulting in ischemia, rest pain, and ulceration and necrosis of the digits. It can continue to cause more proximal ischemia and ultimately lead to loss of the hands. Treatment must start with smoking cessation. Failure to stop smoking will make any surgical intervention unsuccessful. Arteriography is useful to determine arterial flow and whether bypass is possible. ABFigure 44-31. Z-plasty release of web space contracture. A. First web space burn contracture. B. Immediate postoperative result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the


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Surgery_Schwartz. result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the venous system by connecting the dorsal venous network to the brachial artery or possible free microvascular omental transfer beneath the dorsal forearm or hand for indirect revascularization.109Vasospastic DisordersRaynaud’s syndrome results from excessive sympathetic ner-vous system stimulation. Perfusion is diminished and fingers often become cyanotic. Although the onset of the symptoms is benign, chronic episodes can result in atrophic changes and painful ulceration or gangrene of the digits. Raynaud’s disease occurs without another associated disease. This disease predom-inately affects young women and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an


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Surgery_Schwartz. and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an underlying connective tissue disorder, such as scleroderma. Arterial stenosis is present due to disease changes in blood vessels as a result of the specific medical disorder.110Scleroderma is an autoimmune connective tissue disorder resulting in fibrosis and abnormal collagen deposition in tissue. Many organs can be affected, with the skin most commonly and noticeably involved. In this disease, blood vessels are injured by intimal fibrosis leading to microvascular disease. The ves-sels become subject to Raynaud’s phenomenon, and patients develop painful, ulcerated, and sometimes necrotic digits.109,110Sympathectomy can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar


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Surgery_Schwartz. can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar artery, superficial palmar arch, and digital arter-ies in various combinations based on the affected digits being treated. The decrease in sympathetic tone allows for vasodila-tion and increased blood flow. If the patient notes significant distal pain relief and/or previously ischemic tissue improves in color after a test administration of local anesthetic, sympathec-tomy may provide the same results in a long-term fashion.111 Recently, several studies have investigated the use of botulinum toxin on improving digital perfusion in patients with Raynaud’s. Reports have shown improved objective measurements of hand function 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The


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Surgery_Schwartz. 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The degree of anomaly can range from minor, such as a digital disproportion, to severe, such as total absence of a forearm bone. In recent years, increasing knowledge of the molecular basis of embryonic limb development has sig-nificantly enhanced the understanding of congenital differences. Congenital hand differences have an incidence of 1:1500 births. The two most common differences encountered are syndactyly and polydactyly.113There are numerous classification systems for hand dif-ferences. The Swanson classification, adopted by the American Society for Surgery of the Hand, delineates seven groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a


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Surgery_Schwartz. groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a result of a transverse or longitudinal arrest of development. Conditions in this group include radial club hand, a deformity that involves some or all of the tissues on the radial side of the forearm and hand, and ulnar club hand, which involves underdevelopment or absence of the ulnar-sided bones.Failure of DifferentiationThe failure of the differentiation of parts comprises conditions where the tissues of the hand fail to separate during embryo-genesis. Syndactyly, in which two or more fingers are fused together, is the most common congenital hand deformity and occurs in 7 out of every 10,000 live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either


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Surgery_Schwartz. live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either simple (soft tissue only) or complex (bone and/or cartilage also involved), and complete (full length of the digits) or incomplete (less than the full length).Surgical release of syndactyly requires the use of local flaps to create a floor for the interdigital web space and to partially surface the adjacent sides of the separated digits (Fig. 44-32). Residual defects along the sides of the separated fingers are covered with full-thickness skin grafts. Surgery usu-ally is performed at 6 to 12 months of age.DuplicationDuplication of digits is also known as polydactyly. Radial polydactyly is usually manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely


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Surgery_Schwartz. manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely both normal in size, alignment, and mobility. In the most common form of thumb duplication, a single broad metacarpal supports two proximal phalanges, each of which supports a distal phalanx. Optimal reconstruction requires merging of elements of both component digits. Usually the ulnar thumb is maintained. If the duplication occurs at the MP joint, the radial collateral ligament is preserved with the metacarpal and attached to the proximal phalanx of the retained ulnar thumb. Surgery is usually performed at 6 to 12 months of age. Ulnar-sided polydactyly may often be treated by simple excision of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare


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Surgery_Schwartz. of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare condition, all parts of a digit are affected; however, in most cases, only one digit is involved, and it is usually the index finger. This condition is more commonly seen in males. Surgical treatment of this condi-tion is complex, and the outcomes may be less than desirable. Sometimes, amputation of the enlarged digit provides the best functional result.Constriction Band SyndromeUnderdeveloped fingers or thumbs are associated with many congenital hand deformities. Surgical treatment is not always required to correct these deformities. Underdeveloped fingers may include the following: small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified


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Surgery_Schwartz. small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified problems.Brunicardi_Ch44_p1925-p1966.indd 196120/02/19 2:50 PM 1962SPECIFIC CONSIDERATIONSPART IIRECONSTRUCTIVE TRANSPLANTATION OF THE UPPER EXTREMITYHand transplantation was first performed in humans in the late 1990s both in Louisville, Kentucky, and Lyon, France.117 The treating surgeons were able to successfully remove an upper extremity from a brain-dead donor, attach it to an upper extrem-ity amputee, and have the tissue survive. In the subsequent 15 years, many additional centers have achieved technical suc-cess with upper extremity transplantation as well.The technical considerations of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in


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Surgery_Schwartz. of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in 1962.118 In a limb replantation, there is a zone of injury, and cold preser-vation of the amputated part does not begin immediately. In a limb transplant, the harvest can be done as proximally as neces-sary to ensure that only healthy tissue is present on both sides of the repair and to obviate the need for limb shortening, and cold preservation of the amputated part can begin immediately after harvest.A major concern regarding the use of limb transplanta-tion is the immunosuppression medications required to prevent rejection of the transplanted limb. Unlike organ transplantation, which provides a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an


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Surgery_Schwartz. a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an immediate threat to a patient’s survival. Multiple studies have documented the nephrotoxic and other side effects of tacrolimus (FK 506), the principle antirejection agent used in transplant immunomodulation protocols.119,120Due to these concerns, much research has been directed at minimizing the amount of antirejection medication as well as promoting tolerance or even chimerism. Donor bone mar-row transplantation to the limb transplant recipient has been shown to be beneficial toward this purpose and is part of the limb transplant protocol in some centers.121,122 Recent research with donor bone marrow infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and


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Surgery_Schwartz. infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and utility of donor bone mar-row transfusions and how they impact transplant recipients in the short and long term.The final challenge in consideration of a patient for limb transplantation is selection of an appropriate candidate. There are multiple patient factors that need to be considered to deter-mine if a patient is an appropriate candidate for hand transplan-tation. These include medical concerns, such as immunologic issues (both antibodies and the presence of occult neoplasms or indolent viruses such as cytomegalovirus), hematologic issues including coagulopathies, and anatomic issues such as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with


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Surgery_Schwartz. as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with postoperative medication and therapy protocols as well as to cope with a continuous visible presence of a limb originating from another person.123The promise of upper limb transplantation as a recon-structive technique remains high. Both civilian and military amputees stand to receive a marked functional benefit from this treatment. With the number of transplants performed worldwide ABCFigure 44-32. Syndactyly. A. Hand of a 1-year-old patient with complex syndactyly between the long and ring fingers. Complex syndactyly refers to fingers joined by bone or cartilaginous union, usually in a side-to-side fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the


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Surgery_Schwartz. fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the floor of the web space, and full-thickness skin grafts. Note the skin grafts on the ulnar and radial sides of the new web space.Brunicardi_Ch44_p1925-p1966.indd 196220/02/19 2:50 PM 1963SURGERY OF THE HAND AND WRISTCHAPTER 44approaching 100 as well as decades of animal research, under-standing of how best to use this technique from functional, patient safety, and cost-effectiveness standpoints continues to grow.REFERENCESEntries highlighted in bright blue are key references. 1. American Society for Surgery of the Hand. The Hand: Examination and Diagnosis. 3rd ed. New York: Churchill Livingstone; 1990:5-13. 2. Moore KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission


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Surgery_Schwartz. KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission through the normal wrist. A theoretical two-dimensional study in the posteroanterior plane. J Biomech. 1995;28(5):587-601. 4. Gordon JA, Stone L, Gordon L. Surface markers for locating the pulleys and flexor tendon anatomy in the palm and fingers with reference to minimally invasive incisions. J Hand Surg Am. 2012;37:913-918. 5. Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg. 1998;102:1993-1998. 6. Green DP. General principles. In: Green DP, Hotchkiss RN, Pedersen WC, Wolfe SW, eds. Green’s Operative Hand Sur-gery. 5th ed. Philadelphia: Churchill Livingstone; 2005:3-24. 7. Gilula LA. Carpal injuries: analytic approach and case exer-cises. AJR Am J Roentgenol.


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Surgery_Schwartz. on Immuni-zation Practices (ACIP) and recommendation of ACIP, sup-ported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006;55(Rr-17):1-37. 11. Hastings H 2nd, Carroll C 4th. Treatment of closed articu-lar fractures of the metacarpophalangeal and interphalangeal joints. Hand Clin. 1988;4:203-227. 12. Liodaki E, Xing SG, Mailaender P, Stang F. Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint. J Hand Surg Eur Vol. 2015;40(1):16-23. 13. Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg. 1938;20(1):178-186. 14. Bond CD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-a(4):483-488. 15. Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec.


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Surgery_Schwartz. 1982;7(3):291-297. 33. Johnson RK, Iverson RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am. 1971;53(5):913-919. 34. Cannon TA. High-pressure injection injuries of the hand. Orthop Clin North Am. 2016;47(3):617-624. 35. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The sur-gical treatment and outcomes of high-pressure injection inju-ries of the hand. J Hand Surg Eur Vol. 2007;32(4):394-399. 36. Kalyani BS et al. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am. 2011;36(3):535-543. 37. Staudt JM, Smeulders MJ, van der Horst CM. Normal com-partment pressures of the lower leg in children. J Bone Joint Surg Br. 2008;90(2):215-219. 38. Al-Qattan MM, Abou Al-Shaar H, Al Mugaren FM. Non-union without avascular necrosis of finger phalangeal neck Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone


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Surgery_Schwartz. Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand. 2004;75(5):618-629. 40. Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954;36-a(6):1219-1232. 41. Brogan DM, Kakar S. Management of neuromas of the upper extremity. Hand Clin. 2013;29(3):409-420. 42. Zimmerman RM, Astifidis RP, Katz RD. Modalities for complex regional pain syndrome. J Hand Surg Am. 2015;40(7):1469-1472. 43. Schurmann M, Zaspel J, Löhr P, et al. Imaging in early post-traumatic complex regional pain syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and


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Surgery_Schwartz. syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and Human Services. Hand/wrist musculoskeletal disorders (carpal tunnel syndrome, hand/wrist tendonitis, and hand-arm vibration syndrome): evidence for work-relatedness. Available at: https://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf. Accessed August 16, 2018. 46. American Academy of Orthopedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf. Accessed August 16, 2018. 47. Lifchez SD, Means KR, Jr, Dunn RE, Williams EH, Dellon AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure


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Surgery_Schwartz. AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg. 1992;29(1):8-11. 49. Marshall S, Tardif G, Ashworth N. Local corticosteroid injec-tion for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007(2):Cd001554. 50. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal tunnel release compared with open release : a prospective, randomized trial. J Bone Joint Surg Am. 2002;84-a(7):1107-1115. Carpal tunnel release is one of the most common procedures performed by hand sur-geons. This study by Trumble highlights that although patients undergoing endoscopic carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB.


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Surgery_Schwartz. carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016:921-958. This chapter does well to explain the mechanism, pathophysiology, and treatment for compression neuropathies in the upper extremity. 52. Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782-787. 53. Goldfarb CA, Sutter MM, Martens EJ, Manske PR. Incidence of re-operation and subjective outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379-383. 54. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis


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Surgery_Schwartz. Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32(1):23-29. 59. Kenniston JA, Bozentka DJ. Treatment of advanced carpo-metacarpal joint disease: arthrodesis. Hand Clin. 2008;24(3): 285-294, vi-vii. 60. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3):358-365. 61. Wall LB, Didonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013;38(8):1498-1504. 62. Goldfarb CA, Stern PJ, Kiefhaber TR. Palmar midcarpal instability: the results of treatment with 4-corner arthrodesis. J Hand Surg Am. 2004;29(2):258-263. 63. Chung KC, Pushman AG. Current concepts in the man-agement of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article


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Surgery_Schwartz. of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article serves as thorough review for hand surgeons on the treatment of rheumatoid hand. 64. Swanson AB. Silicone rubber implants for replacement of arthritis or destroyed joints in the hand. Surg Clin North Am. 1968;48(5):1113-1127. 65. Fujita S, Masada K, Takeuchi E, Yasuda M, Komatsubara Y, Hashimoto H. Modified Sauve-Kapandji procedure for disorders of the distal radioulnar joint in patients with rheu-matoid arthritis. Surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1 Pt 1):24-28. 66. Elliot D, Ragoowansi R. Dupuytren’s disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative


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Surgery_Schwartz. the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 68. Murphy A, Lalonde DH, Eaton C, et al. Minimally inva-sive options in Dupuytren’s contracture: aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014;134(5):822e-829e. 69. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fas-ciectomy. Plast Reconstr Surg. 2012;129:469-477. Although percutaneous needle fasciotomy is less invasive than limited fasciectomy, this study showed that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med.


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Surgery_Schwartz. that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968-979. 71. Saar JD, Grothaus PC. Dupuytren’s disease: an overview. Plast Reconstr Surg. 2000;106:125-134. 72. Crean SM, Gerber RA, Le Graverand MP, Boyd DM, Cappelleri JC. The efficacy and safety of fasciectomy and fas-ciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. J Hand Surg Eur Vol. 2011;36:396-407. 73. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am. 2011;36(8):1403-1412.Brunicardi_Ch44_p1925-p1966.indd 196420/02/19 2:50 PM 1965SURGERY OF THE HAND AND WRISTCHAPTER 44 74. Honda H, McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin.


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Surgery_Schwartz. McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. 1998;14(4):579-587, viii. 76. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin. 1998;14(4):567-578. 77. Kanavel AB. The treatment of acute suppurative tenosynovi-tis—discussion of technique. In: Infections of the Hand; A Guide to the Surgical Treatment of Acute and Chronic Sup-purative Processes in the Fingers, Hand, and Forearm. 5th ed. Philadelphia: Lea and Febiger; 1925:985. 78. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40(7):720-728. 79. Michon J. Phlegmon of the tendon sheaths (in French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier;


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Surgery_Schwartz. French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 81. Head L, Gencarelli JR, Allen M. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015;40(3):546-553.e8. 82. Lanzinger WD, Bindra R. Giant cell tumor of the tendon sheath. J Hand Surg Am. 2013;38(1):154-157; quiz 157. 83. Phalen GS. Neurilemomas of the forearm and hand. Clin Orthop. 1976;114:219-222. 84. Lekanne Deprez RH, Bianchi AB, Groen NA, et al. Fre-quent NF2 gene transcript mutations in sporadic menin-giomas and vestibular schwannomas. Am J Hum Genet. 1994;54:1022-1029. 85. TerKonda SP, Perdikis G. Non-melanotic skin tumors of the upper extremity. Hand Clin. 2004;20:293-301. 86. Webber T, Wolf JM. Squamous cell carcinoma of the hand in solid organ transplant patients. J Hand Surg Am. 2014;39(3):567-570. 87. English C, Hammert WC. Cutaneous


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Surgery_Schwartz. of sarcoma. Surg Oncol Clin N Am. 2000;9(3):503-524, ix. 92. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78(5):656-663. 93. Murray PM. Soft tissue sarcoma of the upper extremity. Hand Clin. 2004;20(3):325-333, vii. The subject of soft tissue sarcomas is very broad and specific. This article by Murray provides a concise and accurate summary of soft tissue sarco-mas of the upper extremity. 94. Unni KK, Dahlin DC. Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases. 5th ed. Philadelphia: Lippincott-Raven; 1996. 95. Henderson M, Neumeister MW, Bueno RA, Jr. Hand tumors: II. Benign and malignant bone tumors of the hand. Plast Reconstr Surg. 2014;133(6):814e-821e. 96. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-443. 97. Maloney WJ, Vaughan LM, Jones HH, Ross J, Nagel DA. Benign metastasizing giant-cell tumor of bone. Report


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Surgery_Schwartz. tumors of the hand. J Hand Surg Am. 1987;12:311-316. 102. Sheridan RL. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands. Ann Surg. 1999;229:558-564. 103. Pan BS, Vu AT, Yakuboff KP. Management of the acutely burned hand. J Hand Surg Am. 2015;40(7):1477-1484; quiz 1485. 104. Herndon D. Total Burn Care. 2nd ed. London: WB Saunders; 2002. 105. Haslik W, Kamolz LP, Nathschläger G, et al. First experi-ences with the collagen-elastin matrix Matriderm as a der-mal substitute in severe burn injuries of the hand. Burns. 2007;33:364-368. 106. Robinson EP, Chhabra AB. Hand chemical burns. J Hand Surg Am. 2015;40(3):605-612; quiz 613. 107. Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery. 1970;68(6):1122-1128. 108. Lifchez SD, Higgins JP. Long-term results of surgical treat-ment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216. 109. Michelotti BM, Rizzo M,


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Surgery_Schwartz. Surg Eur Vol. 2014;39(8):876-880. 113. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from Stockholm, Sweden. J Hand Surg Am. 2010;35(11):1742-1754. 114. Swanson AB. A classification for congenital limb malfor-mations. J Hand Surg Am. 1976;1:8-22. Swanson developed the seven key categories for the organization of congenital limb malformations later adopted by the American Society for Surgery of the Hand. 115. Bates SJ, Hansen SL, Jones NF. Reconstruction of congeni-tal differences of the hand. Plast Reconstr Surg. 2009;124 (1 Suppl):128e-143e. 116. Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res. 1969;64: 175-193. 117. Lee WP, Mathes DW. Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd


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Surgery_Schwartz. Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd 196520/02/19 2:50 PM 1966SPECIFIC CONSIDERATIONSPART II 119. Starzl TE, Fung J, Jordan M, et al. Kidney transplantation under FK 506. JAMA. 1990;264:63-67. 120. Gorantla VS, Brandacher G, Schneeberger S, et al. Favoring the risk-benefit balance for upper extremity transplantation: the Pittsburgh Protocol. Hand Clin. 2011;27:511-520. 121. Schneeberger S, Gorantla VS, Brandacher G, et al. Upperex-tremity transplantation using a cell-based protocol to mini-mize immunosuppression. Ann Surg. 2013;257:345-351. 122. Brandacher G, Lee WP, Schneeberger S. Minimizing immu-nosuppression in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin.


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Surgery_Schwartz. in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin. 2011;27:539-543.Brunicardi_Ch44_p1925-p1966.indd 196620/02/19 2:50 PM


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Surgery_Schwartz. Plastic and Reconstructive SurgeryRajiv Y. Chandawarkar, Michael J. Miller, Brian C. Kellogg, Steven A. Schulz, Ian L. Valerio, and Richard E. Kirschner 45chapterINTRODUCTIONPlastic and reconstructive surgery is a unique subspecialty of surgery that consists of a set of techniques intended to mod-ify the amount, position, quality, or organization of tissues in order to restore function and appearance. The name of the field is derived from the Greek word plastikos, which means “to mold.” An object is considered plastic if its shape can be modi-fied without destruction. In this sense, all human tissues have some degree of plasticity. They can be nondestructively modi-fied if the surgeon adheres to certain principles. Understanding and applying these principles to solve clinical problems is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John


Surgery_Schwartz

Surgery_Schwartz. is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John Staige Davis published the first textbook dedicated to the field in 1919, entitled Plastic Surgery—Its Principles and Practice. He coined the term that we have used to refer to the specialty ever since. Science has always evolved in a nonlinear fashion: seminal discoveries in different parts of the world have all col-lectively fueled progress and addressed an unmet need. The evolution of plastic and reconstructive surgery has followed the same path: the Edwin Smith Papyrus1 (Egypt, 1600 b.c.) (Fig. 45-1) described facial reconstruction; the Shushruta Samhita (India, 1500 b.c.) (Fig. 45-2) described nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring