Surgery of the Hand

Dupuytren’s surgery‌‌	193	Tendon transfers	224
Synovial cyst treatment‌	201	Soft tissue reconstruction	228
Arthrodesis in the hand‌	203	Trigger finger surgery	234
Arthroplasty in the hand	209	Trigger thumb surgery	235
Extensor tendon repair	213	Viva questions	237
Flexor tendon repair preoperative planning	219

 

9

Surgery of the Hand

Norbert Kang, Ben Miranda and Dariush Nikkhah

 

 

Dupuytren’s surgery‌

Preoperative planning

Indications

Dupuytren’s surgery is indicated in patients with a flexion deformity that interferes with their activities of daily living. Using the ‘table-top test’ (i.e. an inability to get the hand flat on the table) or specific degrees of flexion deformity (e.g. 30° at the proximal interphalangeal [PIP] joint) as an indication for surgery is unhelpful as this may over- or underestimate the need for surgery. The best indication is to intervene only if the patient requests it –regardless of the degree of the deformity.

 

Operative planning

It is vital to record the range of movement, vascularity and sensation in the digit(s) preoperatively so that a comparison can be made with the postoperative outcome.

There are three common procedures:

 

• Fasciotomy (open, needle or enzymatic) or segmental fasciotomy

• Fasciectomy

• Dermofasciectomy

  Fasciotomy

  This is a procedure to divide rather than excise the Dupuytren’s cord tissue. It can be performed under direct vision (open fasciotomy), percutaneously (needle fasciotomy),

   

  enzymatically or by excising a short segment of cord tissue – also under direct vision (segmental fasciotomy).

   

  Indications

• Discrete Dupuytren’s cord at any level in the finger or hand.

• Metacarpophalangeal (MCP) joint flexion deformity.

• PIP joint flexion deformity. Although there is a greater risk of neurovascular injury after both needle and enzymatic fasciotomy at this level, no complications should be encountered if appropriate techniques are used.

• Patients unwilling to undergo or unsuitable for a major operative procedure or wishing to avoid general anaesthesia.

• Needle fasciotomy is performed under local anaesthesia or regional block, while it is recommended that enzymatic fasciotomy be performed without anaesthesia to maintain awareness of the digital nerves.

   

  Contraindications

• Diffuse Dupuytren’s disease can be difficult to treat with fasciotomy but this is only a relative contraindication.

• Patients unable or unwilling to comply with indefinite postoperative night-time splintage with the digit(s) in full extension. If they fail to comply with splintage postoperatively, recurrence of the flexion deformity may be rapid (within a few weeks).

   

   

  Consent and risks

  • Injury to the neurovascular bundle. (This risk is reduced with open/segmental fasciotomy.)

  • Skin tears are common after needle and enzymatic fasciotomy. These heal rapidly (within 2–3 weeks) by secondary intention (McCash technique).

  • Tendon ruptures have been infrequently reported after enzymatic fasciotomy.

  • Chronic regional pain syndrome Type 1.

  • Short procedure (takes 5–10 minutes to treat a single digit).

   

   

  Anaesthesia and positioning

  Local anaesthesia, upper limb blockade or general anaesthesia can be used. The arm should be placed supine on an arm table or arm board. It is helpful to use a tourniquet for open and segmental fasciotomy; no tourniquet is required for needle or enzymatic fasciotomy.

   

  Surgical technique

  Landmarks

  The cord(s) to be divided are palpated and marked.

   

  (b)

  (a)

   

   

   

  Figure 9.1 Needle fasciotomy: (a) needling of fascia and (b) postoperative appearance.

   

  Needle fasciotomy

  A white-hubbed (16G) hypodermic needle is held in a tripod grip using the thumb, index and middle fingers of one hand (Figure 9.1). The orientation of the needle tip is important –the bevel should face proximally – allowing the needle tip to be used like the blade of a very fine scalpel. The first 2–3 mm of the tip of the needle are inserted vertically through the skin and into the cord with the digit held in full extension to make the cord easy to palpate and to facilitate division of the cord tissue. Small, sweeping movements are now made at right angles to the cord using the needle tip to divide the cord tissue. Simultaneously, the digit is pushed into extension. If successful, a tearing sound is often heard as the weakened cord tissue is torn in half allowing the finger to extend. If this does not happen, then repeat the process to divide and weaken more of the cord tissue. Now, repeat the process of gentle passive manipulation of the finger to see if it will extend. Be wary when doing this not to overdo the manipulation as this can result in fracture of the phalanges – especially in older, female patients with osteoporosis. If the finger will still not extend, it may be necessary to convert to an open procedure to release the volar plate under direct vision.

  Skin tears are very common, especially when there has been a long-standing and significant flexion deformity (e.g. PIP joint flexion of >60°). However, the surgeon can be assured that even when the tendon or neurovascular bundles are exposed, all wounds on the volar aspect of the hand and digit can be left to heal by secondary intention within 2–3 weeks. While healing is taking place it is critical to keep the digit in full extension at rest to prevent rapid recurrence of the flexion deformity. After releasing the digit(s), the hand is placed in a plaster of Paris splint with all the digits in full extension and the wrist in neutral for 10 days. The plaster splint is then removed and the hand is mobilised as quickly as possible.

   

  Enzymatic fasciotomy

  Collagenase is isolated from the gram-negative bacterium clostridium histolyticum and acts to lyse collagen (peptide bonds) resulting in disruption of Dupuytren’s cords. After carefully following the manufacturer’s reconstitution guidelines, a 26/27G hypodermic needle may be used to infiltrate the diseased cord percutaneously using a three-step approach (initial injection, just distal and just proximal). This is performed in an outpatient setting. Care must be taken not to infiltrate the underlying flexor tendon since this will then be at increased risk of rupture during subsequent passive manipulation. Passive manipulation of the finger is performed 24 hours later (also within an outpatient setting)

   

  by firmly and vigorously pushing the flexed digit into extension. If successful, a ‘carrot snap’ sound is heard as the enzymatically treated diseased cord ‘breaks suddenly’.

   

  Open fasciotomy

  A longitudinal incision is made over the course of the cord tissue. The incision is made sufficiently long to allow direct visualisation of the cord and adjacent structures. The cord tissues are divided with a scalpel while forcibly extending the digit. If successful, the cord tissues are torn in half allowing the finger to extend.

   

  Segmental fasciotomy

  The procedure is the same as for open fasciotomy but, in addition, a short segment (approximately 1 cm) of cord tissue is excised in the belief that this reduces the risk of recurrence.

   

  Closure

  After needle or enzymatic fasciotomy, the puncture wounds and skin tears are allowed to heal by secondary intention. This takes 2–3 weeks with simple dressings. For open and segmental fasciotomy, the skin is closed with absorbable sutures (e.g. using 5–0 Vicryl rapide).

   

  Postoperative care and instructions

  All patients undergoing fasciotomy of any type should be able to mobilise their digits freely after treatment. For patients where there has been a long-standing flexion deformity, a period of static splintage (e.g. 7–14 days) in extension may also be helpful. However, in order to decrease the recurrence of a significant flexion deformity in the long term, patients should be advised about the advantages of using a thermoplastic splint at night –indefinitely. The splint should hold the treated digit(s) in full extension.

   

  Fasciectomy

   

  Consent and risks

  • ‘White finger’ due to vascular injury followed by finger necrosis

  • Paraesthesiae or anaesthesia due to digital nerve injury (10% risk after a redo procedure)

  • Infection

  • Skin flap necrosis

  • Flexion loss

  • Recurrence of Dupuytren’s followed by recurrence of the flexion deformity

  • Chronic regional pain syndrome Type 1

  • Lengthy procedure (typically takes 30–45 minutes for single digit)

   

   

  Indications

  Any degree of Dupuytren’s contracture. This includes recurrent disease and MCP, PIP and distal interphalangeal (DIP) joint flexion deformities.

   

  Contraindications

• Diffuse Dupuytren’s disease with extensive skin involvement (pits and fixed skin over cords) can be difficult to address with a fasciectomy. However, this is only a relative contraindication.

• Multiple previous fasciectomies with subsequent recurrence of flexion deformities. Scarring from previous surgery can make a redo procedure very challenging.

• Patients with a severe Dupuytren’s diathesis (males, onset <50 years, Garrod’s pads,

  ectopic disease, bilateral disease, strong family history, e.g. a sibling or parent).

• Patient unwilling or unable to comply with hand therapy postoperatively.

• Heavy smoker and unwilling to stop smoking preoperatively.

Anaesthesia and positioning

Fasciectomies can be performed under local anaesthesia (maximum of two digits), upper limb block or general anaesthesia. The arm should be held supine on an arm table with a lead hand. All surgery should be carried out under tourniquet with loupe magnification.

 

Surgical Technique

Landmarks

A straight-line incision is marked over the midline on the volar aspect of the affected digit, beginning at the distal finger crease. An alternative is the Bruner zigzag pattern. A straight-line incision allows the surgeon to perform Z-plasties when there is a volar skin shortage, recruiting skin from the sides of the finger. However, Bruner incisions can also recruit extra skin onto the volar side of the finger by converting each flap into ‘Y to V’ plasties, and this approach has the added advantage of avoiding the need to design Z-plasties. All incisions are extended proximally to the mid-palmar crease. A further transverse incision is marked across the palm following the line of the mid-palmar crease. The length and position of the transverse incision are determined by the position and number of digits which are to be treated (Figure 9.2).

Incision

For fingers with significant flexion deformities, it is often helpful to carry out a fasciotomy to gain access to the volar side of the finger and palm before starting the dissection. Having an extended finger at the start of the procedure makes marking and surgical access much simpler.

The transverse incision is created before proceeding into the digits. All incisions should be full thickness.

 

(a)

(b)

(c)

 

 

 

Figure 9.2 Fasciectomy. (a) Skoog’s straight-line incision. (b,c) Z-plasty marked out and performed.

 

Dissection

 

Structures at risk

• Neurovascular bundles

• Skin flap tip necrosis

• Flexor sheath (loss of pulleys)

 

Thin skin flaps should be developed above the cords. Particular care must be taken to avoid buttonholing the skin when there is significant pitting or skin involvement. Ensure that the skin flaps are thick enough to be viable (ideally just thicker than subdermal) but thin enough so that minimal amounts (ideally none) of the diseased cord tissue is left in the hand – in the hope that this will avoid a recurrence.

Any longitudinal cord tissue should be excised, leaving the transverse fibres of the palmar aponeurosis in place wherever possible. The neurovascular bundles should be visualised in the palm on either side of the flexor tendon. The rest of the dissection is directed at freeing the neurovascular bundles from the cord tissue on both sides of the finger by a combination of blunt and sharp dissection. Once both bundles have been skeletonised as far as the DIP joint, any soft tissues remaining between the skin and the tendon sheath can be excised and discarded.

Any remaining flexion deformity must now be assessed (e.g. due to a Boutonniere deformity, volar plate contracture, shortening of the flexor sheath or volar skin shortage). In many cases, it is due to a combination of all of these factors. Boutonniere deformities sometimes respond to static splintage in full extension for 1 week – but only if the flexion deformity has not been long-standing (i.e. <6 months). Volar plate contractures require either passive manipulation of the PIP joint or sharp release of the volar plate/check-rein ligaments.

Any ‘white fingers’ must be noted. The tourniquet must be released before skin closure to check the perfusion of the digit and to carry out haemostasis. If the finger fails to perfuse, then both

 

vessels need to be visualised to ensure that they are in continuity. You only need one intact artery to perfuse the digit. If the vessels are intact but the digit is still white, the digit is allowed to flex to its former position for 5–10 minutes. If this fails, the surgeon can try bathing the vessels in a few drops of verapamil (2.5 mg/mL) or glyceryl trinitrate (5 mg/mL). It is important to tell the anaesthetist before doing this. If the vessels have been divided, they will require someone experienced in microvascular techniques to restore circulation to the finger.

 

Closure

Treatment of any skin shortage in the digit may require closure of the skin with a Z-plasty. The ideal Z-plasty for closure in the digit has a 30° angle and is as large as possible. It is not necessary to locate the transverse limb of the Z-plasty at a flexor crease. This simply makes planning difficult. Often, only one Z-plasty is required to allow sufficient lengthening of the volar incision to allow closure with minimal skin tension. The skin of the finger is closed with interrupted or continuous absorbable sutures (e.g. 5/0 Vicryl rapide).

Any transverse palmar incisions should be left open. As long as the maximum width of the incision does not exceed 1.5 cm it will heal by secondary intention within 2 weeks, without contracting. Leaving the palm open also simplifies closure and reduces the risk of a haematoma by allowing free drainage from the dissected areas.

Postoperative care and instructions

All patients undergoing fasciectomy should be allowed to mobilise their digits freely after treatment unless they have a significant Boutonniere deformity and/or needed significant manipulation/release of the PIP joint intraoperatively. This later group of patients should be splinted continuously in full extension for 1–2 weeks. Thereafter, all patients must use a splint at night for at least 3 months to keep the treated digit(s) in full extension.

 

Dermofasciectomy

This is a fasciectomy combined with excision of the skin of the proximal digit (Figure 9.3). All the soft tissues on the volar side of the proximal part of the digit are excised, down to the mid-lateral line, with the exception of the tendon/tendon sheath and the neurovascular bundles. The resulting defect is then resurfaced with a full-thickness skin graft. The aim is to remove any tissue that may result in subsequent recurrence of a longitudinal cord volar to the axis of flexion of the digit.

 

Consent and risks

• Full-thickness graft loss

• Loss of flexion

• Scarring from harvest of graft

• Injury to neurovascular bundles

• ‘Hairy’ digit – from failure to remove hair follicles in the graft

• Chronic regional pain syndrome – Type 1

 

 

(b)

(a)

 

 

 

Figure 9.3 (a) Dermofasciectomy of little and ring fingers and (b) 3 months postoperatively with healed graft.

 

Correction of the flexion deformity is now checked – as for a fasciectomy (p. 196). Haemostasis and digital perfusion are also checked – as for a fasciectomy (p. 196). Then a full-thickness graft of appropriate size is harvested from the forearm or groin and secured to the finger with 4/0 or 5/0 Vicryl rapide. The authors’ preferred approach is to anchor the four corners of the graft and to then secure all the edges of the graft with a continuous (over and over) suture of 5/0 Vicryl rapide. The middle of the graft is then secured to the tendon sheath with two or three quilting sutures of 5/0 Vicryl rapide to reduce the tendency for the graft to slide, thereby improving graft take.

Postoperative care and instructions

The hand should be splinted continuously with the digits in full extension for 1 week to help the graft take. The splint and dressings are then removed, and the graft is checked. Regardless of whether the graft has taken, the patient should mobilise the digit with the assistance of a hand therapist. Patients will still need to splint the digit in full extension at night for 3 months.

Recommended references

Hall PN, Fitzgerald A, Sterne GD et al. Skin replacement in Dupuytren’s disease. J Hand Surg Br.

1997;22:193–197.

Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytren’s diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am. 2006;31:1626–1634.

Hueston JT. Recurrent Dupuytren’s contracture. Plast Reconstr Surg. 1963;31:66–69.

Hurst LC, Badalamente MA, Hentz VR et al.; CORD I Study Group. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968–979.

McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture. Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54:31–44.

Nikkhah D, Kang N. Percutaneous needle fasciotomy – Further insights. JPRAS. 2017;70(1):144–146.

Peimer CA, Blazar P, Coleman S et al. Dupuytren’s contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS study): 3-year data. J Hand Surg Am. 2013;38(1):12–22. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg Br.

2006;31:498–501.

 

Synovial cyst treatment‌

Preoperative planning

Ganglia are the result of mucoid degeneration of fibrous connective tissue and are most frequently encountered arising dorsally associated with the scapholunate joint (in 70% of cases) or at the DIP joint. Volar wrist ganglia are rarer and constitute 10% of cases. Long-term follow-up of ganglia has demonstrated that the majority should be treated non-surgically in the first instance because 50% will resolve spontaneously within a few years and the morbidity of surgical excision is significant. This does not mean that ganglia should never be treated but patients should be advised appropriately and over-enthusiastic reliance on surgical excision should be avoided. In specific cases, simultaneous treatment of the underlying pathology (e.g. arthrodesis of a DIP joint for osteoarthritis) will remove the ganglion and the underlying cause – permanently.

 

Indications

• Pain (may be caused by underlying pathology – e.g. arthritic joint)

• Impaired function (if a ganglion is large enough, it may catch on clothing)

• Cosmesis: This is probably the most common reason for patients to seek help

  Contraindications

  There are no absolute contraindications for treating a ganglion.

   

  Consent and risks

  • Bleeding

  • Infection

  • Recurrence

  • Joint instability

  • Stiffness

  • Troublesome scars

  • Accidental nerve injury

   

  Anaesthesia and positioning

  This depends on the location of the ganglion and the preference of the patient. Anaesthesia is unnecessary for simple aspiration of a ganglion. For excision of a ganglion in the digit, most cases can be treated under local anaesthesia. However, excision of a ganglion at the wrist should be treated under regional block or general anaesthesia as deep dissection is often necessary. A tourniquet should be used in the majority of volar wrist ganglions where the radial artery is in close proximity.

   

  Surgical technique

  Aspiration of ganglia

  The largest gauge needle compatible with comfort for the patient is attached to a 2 mL syringe – typically, a blue hubbed (23G) needle. The needle is inserted into the ganglion

   

  with one swift movement and aspiration begins immediately. If the contents do not enter the syringe, the needle is extracted, and the contents manually expressed through the small puncture hole. Injecting a small amount of Adcortyl (5 mg) into the ganglion/ adjacent tissues reduces post-treatment inflammation and discomfort. Ultrasound may also be used for diagnostic and therapeutic purposes.

   

  Flexor sheath ganglia

  Landmarks and incision

  Typically, these ganglia arise from the A2 pulley at the level of the proximal finger crease and can easily be ruptured with a needle. For excision, a transverse incision, directly over the ganglion, is used.

   

  Dissection and procedure

   

  Structures at risk

  • Neurovascular bundles

  • Flexor tendon

   

  The ganglion is excised en bloc with (if necessary) a small cuff of the flexor sheath.

   

  Closure

  The skin is approximated with interrupted 5/0 Vicryl rapide sutures. A light dressing is applied, which will not impede movement and allows immediate mobilisation.

   

  Mucous cysts

  As it enlarges, it emerges on either the ulnar or radial side of the joint at the interval between the terminal extensor tendon and the collateral ligament of the joint (Figure 9.4). The

   

  (a)

  (b)

   

  Mucous cyst

  Terminal tendon

   

   

   

  Figure 9.4 A mucous cyst.

   

  skin over the mucous cyst is often very thin. Therefore, attempts to separate the skin from the ganglion wall are fruitless. The surgeon can decide to either excise the skin with the ganglion or simply make a longitudinal incision over the ganglion knowing that it will burst.

   

  Dissection and procedure

   

  Structures at risk

  • Terminal extensor tendon – injury may cause mallet deformity

  • Germinal matrix of nail complex – injury may result in notching of the nail plate

   

  Whether or not an ellipse of skin was excised with the ganglion, excision of the rest of the ganglion wall is often an academic exercise because the remnant is usually so flimsy. Excise whatever remains of the ganglion wall (piecemeal if necessary) down to the DIP joint. Any obvious osteophytes should also be removed with a bone nibbler as this improves cosmesis.

   

  Closure

  The skin is closed with interrupted 5/0 Vicryl rapide sutures. If an excessively large area of skin has been excised, it will be difficult to close the wound directly. The options then are to use a small split-thickness skin graft or a local rotation flap – converting an operation of dubious value (excising a mucous cyst) into an operation with a multitude of potential complications. If the defect is very small and no important structures are exposed, then allowing the wound to heal by secondary intention is more acceptable. The finger is dressed lightly, which allows immediate mobilisation.

   

  Postoperative care and instructions

  The hand is elevated to reduce pain and swelling. Any bulky dressings are removed after 48–72 hours. The hand/finger is mobilised with the help of a hand therapist, as quickly as possible.

   

  Recommended references

  Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcomes 6 years after intervention. J Hand Surg Eur. 2007;32:502–508.

  Green DP, Hotchkiss RN, Pederson WC eds. Green’s Operative Hand Surgery. 5th ed. Edinburgh, Scotland: Elsevier, 2005.

  Arthrodesis in the hand‌

  Preoperative planning

  Indications

  An arthrodesis is a very reasonable salvage operation for certain joints and for certain situations. It can restore its pain-free form and function in one operative step. Indications include:

• Pain

• Instability

   

• Deformity

• Failed arthroplasty

• Joints where arthroplasty is not desirable/possible

   

  Certain joints respond particularly well to arthrodesis because of the functional requirements of the hand. Others do less well (see ‘Operative planning’ later).

   

  Contraindications

• Poor skin cover over the joint.

• Active infection in the upper limb – inserting metalwork should be avoided.

• Non-compliant patient – the joint needs to be immobilised for 8 weeks after surgery to allow bony union.

• Smoking is a contraindication due to poor wound healing.

   

  Consent and risks

  • Damage to any of the adjacent structures (e.g. tendons, neurovascular bundles, damage to the nail bed in DIP joint fusion)

  • Infection

  • Malunion

  • Non-union (up to 10% – especially the DIP joint) – more frequent in smokers

  • Stiffness of adjacent joints and fingers

  • Flexor and/or extensor adhesions

   

   

  Operative planning

  Distal interphalangeal joint

  Patients do very well after arthrodesis of this joint because the loss of range of movement at the DIP joint has relatively little effect on overall hand function. DIP joint arthrodesis is particularly useful in cases of delayed presentation after flexor digitorum profundus (FDP) tendon rupture, chronic mallet deformity or painful arthritis of the DIP joint (with or without deformity) and chronic mucous cysts.

   

  Proximal interphalangeal joint

  Arthrodesis of the PIP joint results in significant impairment of hand function because the PIP joint accounts for up to 40% of total active flexion of the finger. However, it is still a reasonable option to deal with chronic pain and instability, especially for the little and ring fingers. This is because PIP joint replacements do particularly badly in the little and ring fingers.

   

  Interphalangeal joint of the thumb

  The IP joint of the thumb responds very well to arthrodesis. The thumb, in contrast to the fingers, is used as a pillar for opposition, and (therefore) loss of active range of motion at the IP joint and MCP joint do not affect function as much.

   

  Metacarpophalangeal joint

  The MCP joints of the fingers should not be arthrodesed as this results in significant impairment of function. In contrast, arthrodesis of the MCP joint of the thumb is an excellent procedure that significantly enhances hand function.

   

  Carpometacarpal joint

  The first carpometacarpal (CMC) joint should not be fused, as this will result in significant impairment of hand function. The second and third CMC joints normally behave as if they are fused; therefore, arthrodesis of these joints is seldom necessary. In contrast, the fourth and fifth CMC joints are surprisingly mobile, even in normal hands. Nevertheless, arthrodesis of these joints remains a reasonable solution in cases of chronic pain and instability (typically after trauma).

   

  Anaesthesia and positioning

  Local anaesthetic digital block is suitable for IP joint, DIP joint or PIP joint arthrodesis. Regional block (wrist or axillary) or general anaesthesia with arm tourniquet may be more suitable for arthrodesis of the thumb MCP joint or CMC joints. Use of local anaesthetic with adrenaline should also be considered in order to minimise or avoid the need to use a tourniquet.

   

  Surgical technique

  Several different techniques are available for arthrodesis of a joint (e.g. K-wires, interosseous wires, screws, plates and staples). Different methods of fixation are more or less suitable for particular joints and in particular situations. Regardless of the technique, the usefulness of the arthrodesis is determined by the final position of the bones after fusion (Table 9.1). Also, the arthrodesed digit will be shorter by the amount of bone that needs to be removed to allow the arthrodesis to be performed.

   

  Table 9.1 Arthrodesis positions in the hand

   

  	Thumb	Index	Middle	Ring	Little
  DIP joint	N/A	0°–10°	0°–10°	0°–10°	0°-10°
  IP joint	0°–20°	N/A	N/A	N/A	N/A
  PIP joint	N/A	30°	30°–40°	40°–50°	50°
  MCP joint	0°–20°	Do not fuse	Do not fuse	Do not fuse	Do not fuse
  CMC joint	Do not fuse	N/A	N/A	0°	0°

  Abbreviations: CMC, carpometacarpal; DIP, distal interphalangeal; IP, interphalangeal; MCP, metacarpophalangeal; N/A, not applicable; PIP, proximal interphalangeal.

   

  Fusion techniques

  This depends on the joint. Image intensifier guidance (preferably using a mini-C-arm) is essential in ensuring that any metalwork is correctly positioned.

   

  Landmarks and incisions

• DIP and thumb IP joint: An ‘H’- or ‘Y’-shaped incision over the dorsum of the joint or a mid-lateral incision for plating (Figure 9.5).

• PIP joint: Longitudinal incision over the dorsum of the joint.

• Thumb MCP joint: Longitudinal incision over the dorsum of the joint.

• CMC or intercarpal arthrodesis: Longitudinal incisions over the dorsum of the relevant joint.

 

 

 

Figure 9.5 Incisions for access to DIP joint.

 

Distal interphalangeal joint

The terminal extensor tendon is detached from the base of the distal phalanx, exposing the joint. The collateral ligaments are excised, and the volar plate detached from the base of the distal phalanx. This allows the joint to be disarticulated completely. The joint surfaces are removed with a saw or bone nibbler to expose the cancellous bone with the intention of creating two flat surfaces with the correct angulation (i.e. 0°–10°). For fixation, 90°–90° wiring is probably the easiest technique to understand and perform. Tension band wiring is also acceptable but technically more challenging (Figure 9.6). Other acceptable alternatives include the use of a Lister loop (although the K-wire then needs to be removed at 8 weeks), Herbert or cannulated screw fixation and plating.

 

Proximal interphalangeal joint

A longitudinal split in the extensor tendon or a Chamay approach (distally based ‘V’-shaped incision in the central slip; Figure 9.7) can be used for PIP joint exposure. The joint is

 

(a)

(b)

(c)

(d)

 

 

 

Figure 9.6 Methods of distal interphalangeal (DIP) joint fusion. (a) ‘90–90’ wiring. Two interosseous wires of 0.35 to 0.45 gauge dental wire passed at 90° to each other. (b) Tension band wiring using two

1.1 mm K-wires and a 0.35–0.45 gauge dental wire. (c) Lister loop with a single 1.1 mm K-wire and a 0.35–0.45 gauge dental wire. The K-wire must be removed at 4 weeks. (d) Plating of the DIP joint with

a mini-plate (the most difficult technique).

 

 

(a) (b)

 

 

 

Figure 9.7 (a) Chamay approach. (b) Longitudinal split.

disarticulated by excising the collateral ligaments and detaching the volar plate. The joint surfaces are removed with a saw or a bone nibbler to create two flat surfaces with the correct angulation (Table 9.1). As for the DIP joint, there is no preferred method of fixation. Any techniques which are appropriate for DIP joint fusion are also suitable for PIP joint

 

fusion. The senior author’s preference is to use a tension band technique – because the metalwork is easy to insert and remove.

 

Metacarpophalangeal joint of the thumb

The joint is exposed through a longitudinal split in the extensor tendon and disarticulated by dividing the collateral ligaments and detaching the volar plate. The joint surfaces are excised. The senior author’s preference for arthrodesis of the thumb MCP joint is a tension band wire technique.

 

Carpometacarpal joint

The extensor tendons are retracted from over the CMC joints and soft tissue excised to expose the specific joint. Use of an image intensifier confirms that the correct joint has been identified. The joint surfaces are excised, and bone graft is inserted. The graft is harvested from the distal radius. Bone substitute (e.g. hydroxyapatite) can also be used. The joint is secured with an oblique K-wire passed through the base of the respective metacarpal and the corresponding trapezoid, capitates or hamate. The wire is buried and removed after 8 weeks.

 

Closure

Any extensor tendons that have been split to approach the joints should be repaired with 4/0 or 5/0 PDS interrupted or continuous sutures. The tourniquet is then released and haemostasis achieved with bipolar diathermy. All wounds should be washed out with saline to remove any loose particles of bone. Incisions are closed with interrupted, absorbable 4/0 or 5/0 Monocryl sutures for the dermis followed by a subcuticular 5/0 Monocryl or 4/0/5/0 Vicryl rapide suture. Surgeons should avoid using interrupted, non-absorbable sutures on the dorsum of the hand and fingers as they leave very unsightly suture marks which may require scar revision at a later stage.

 

Postoperative care and instructions

A light dressing is applied and removed after 48–72 hours to allow active joint mobilisation on either side of the treated joint. A splint must be used to immobilise the joint for 8 weeks. Scars are massaged from 2 weeks onwards. Coban elastic bandage should also be applied to reduce soft tissue swelling from 2 weeks after surgery. A removable thermoplastic splint should be supplied to support the relevant joint for 6–8 weeks while the bone heals.

 

Recommended references

Allende BT, Engelem JC. Tension band arthrodesis in the finger joints. J Hand Surg Am. 1980;5:269–271. Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 5th ed. Edinburgh, Scotland:

Elsevier, 2005.

Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg Am. 1978;3:427–435.

Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. Stuttgart, Germany: Thieme, 2000. Sennwald G, Segmuller G. The metacarpophalangeal arthrodesis of the thumb according to the tension-

band principle: Indications and technique. Ann Chir Main. 1983;2:38–45.

 

Arthroplasty in the hand‌

Preoperative planning

The decision to operate must not be made purely on the basis of the X-ray appearances. However, function is not always the only consideration. Although it is generally not a good idea to perform an arthroplasty in patients who have good function, many patients still ask for surgery to ‘improve’ the appearance of their hands.

 

Indications

• Painful or stiff joints unresponsive to medical treatment

• Deformity and/or loss of range of movement affecting activities of daily living

• Failure of conservative measures; however, before this can be said, patients must have had an adequate trial of

  • Regular non-steroidal anti-inflammatory drugs (NSAIDs) and splintage

  • Steroid injections (administer at least one or two of these)

  • Using home or work aids

  • Appropriate alterations to their home or work circumstances

• To ‘improve’ the appearance of the hand

• MCP joint in preference to PIP joints

• Index or middle finger PIP joints

  Contraindications

• Absent or poor flexor or extensor tendon function

• Absent or poor nerve function (e.g. peripheral neuropathy)

• Patients with significant vascular compromise (e.g. scleroderma, Raynaud’s phenomenon)

• Patients with poor skin cover over the joint

• Patients unwilling or unable to comply with postoperative hand therapy

• Heavy smoker and unwilling to stop preoperatively

• DIP joint – an arthrodesis is recommended instead

• PIP joint of ring and little fingers – joint instability is often worse after arthroplasty in these digits

Artificial joints fare better in older/lower-demand patients. A resurfacing/interposition arthroplasty is less destructive and tries to restore the normal shape of the joint using either autologous or artificial materials and is more suitable for young or active patients.

In general, replacement arthroplasty works best for the MCP but not for the PIP or DIP joints. If PIP joint arthroplasty is contemplated, then this is best performed in the index and middle fingers only. Although DIP joint arthroplasty (e.g. with a Swanson’s replacement) has been reported to be successful in post-traumatic osteoarthritic joints, arthrodesis is a more reliable option in patients who are not concerned about preserving movement.

A variety of artificial materials has been described for replacement arthroplasty. However, silicone is the only material that has withstood the test of time (e.g. Swanson’s implant; Figure 9.8). The technique for insertion is described here.

 

Consent and risks

• Flexor tendon/neurovascular injury

• Instability (only for PIP joint arthroplasty)

• Recurrent deformity (affects one-third of arthroplasties)

• Dislocation, loosening or fracture of the implant (implant failure affects one-third of implants)

• Infection necessitating implant removal

• Range-of-motion loss

• Ongoing pain

• Dislocation, fracture or implant extrusion (7%–15%)

• Silicone synovitis

 

 

 

 

 

Operative planning

Figure 9.8 Swanson’s implant in place.

The choice is between a replacement arthroplasty or a resurfacing/interposition arthroplasty. A replacement arthroplasty excises the joint completely and replaces it with an artificial or autologous joint (usually taken from the foot).

 

Anaesthesia and positioning

Local, regional or general anaesthesia can be used. The position is supine with the hand on an arm table.

Surgical technique Metacarpophalangeal joint Landmarks and incision

A longitudinal incision (straight or curvilinear) is made over the dorsum of the joint. Any

curvature in the incision is usually towards the radial side. This makes it easier to access and reef the radial sagittal bands of the extensor hood. Reefing of the extensor hood allows ulnar subluxation of the extensors to be corrected in cases with rheumatoid arthritis.

Dissection

The skin and subcutaneous fat are widely degloved over the joint to expose the extensor tendons and the sagittal bands. The sagittal bands are divided longitudinally on the radial side, leaving a minimum 2–3 mm fringe along the extensor tendon edge: this allows the bands to be reefed at a later stage. The extensor mechanism is now freed from the underlying capsule and retracted ulnarly. The joint capsule is often flimsy in these patients, and it is often easier to

 

simply excise it together with any synovial proliferations. After excising the capsule and any associated synovial tissue, any remnants of the collateral ligaments can also be excised.

Procedure

The volar plate must be freed from the neck of the metacarpal to allow the base of the proximal phalanx to align correctly with the metacarpal. The metacarpal head is excised with an oscillating saw. In the rheumatoid patient, the metacarpal head is often excised with a slight radial tilt to help correct any ulnar drift. The amount of bone that should be excised is determined by the requirement to accommodate any pre-existing intrinsic muscle tightness: the tighter the intrinsics, the more bone that needs to be excised (up to a limit). However, excessive bone shortening should be avoided, and intrinsic release considered instead. (This simply means dividing the intrinsic tendons until the IP joints are able to flex easily with the MCP joint in hyperextension.) The base of the proximal phalanx is not excised unless there is a severe deformity. However, any osteophytes must be removed with bone nibblers since these may interfere with flexion. The base of the proximal phalanx is now pierced with an awl. This opening is enlarged, and the medullary cavities of the proximal phalanx and metacarpal are now reamed by hand using progressively larger reamers. Sizers are used to determine the correct size of Swanson’s implant which should be used. In general, the largest implant which fits should be selected. The implant fits when the long stem fits snugly in the metacarpal and the short stem fits snugly in the proximal phalanx. There should be no compression of the midsection with the fingers in extension. Generally, size 3 or 4 implants are used for the MCP joints. The sizer is removed, and the wound is washed with saline to remove any bone particles. The appropriate permanent implant is now inserted using a ‘no-touch’ technique. The implants are usually supplied with stainless steel ‘grommets’. These should not be used.

 

Closure

It is not necessary to formally repair the collateral ligaments – scar tissue forms rapidly around the implant and confers stability to the joint – especially if the patient mobilises quickly after surgery. The sagittal bands are repaired with 4/0 or 5/0 PDS and are reefed as necessary if there is significant subluxation of the extensor tendons into the ulnar gutters. The skin is then closed with absorbable sutures. The senior author recommends using interrupted 5/0 Monocryl for the dermis (to approximate the wound edges) and then a running subcuticular 5/0 Monocryl or 5/0 Vicryl rapide suture for final closure.

 

Proximal interphalangeal joint

Landmarks and incision

A longitudinal incision (straight or curvilinear) is made over the dorsum of the joint.

 

Dissection

After the incision is made, the skin and subcutaneous fat are widely degloved over the joint to expose the extensor tendon and lateral bands. To reach the joint, the central slip of the extensor tendon can be split longitudinally or a Chamay approach can be used (see Figure 9.7). It is important to preserve the central slip insertion whichever method is used.

As for the MCP joint, the capsule of the PIP joint is usually very flimsy and should be excised together with any associated synovial proliferations. If possible, the collateral

 

ligaments and volar plate are preserved to maintain joint stability. However, sometimes these structures are grossly damaged and it is necessary to excise/detach them to restore the correct alignment of the proximal and middle phalanges.

Procedure

 

Structures at risk

• Flexor tendon

• Neurovascular bundles

 

The head of the proximal phalanx is now excised at neutral, using an oscillating saw. Care is taken not to damage the flexor tendon on the volar side of the joint. The base of the middle phalanx is not usually resected except in cases of severe deformity. However, osteophytes must be nibbled away as these may interfere with flexion. Sizing and reaming of the middle and proximal phalanges are performed in the same way as for the MCP joint. For the PIP joint a size 1 or 2 implant is usually used.

Closure

The longitudinal split in the extensor tendon or the Chamay flap is repaired with a continuous 4/0 or 5/0 PDS suture. In all other respects, closure is the same as described for MCP joint arthroplasty.

 

Distal interphalangeal joint

Landmarks and incision

The procedure is performed under ring block anaesthesia. An ‘H’- or ‘Y’-shaped incision is used to access the DIP joint.

Dissection

Dissection involves division of the collateral ligaments and removal of all tissue lateral to the extensor tendon. The extensor tendon can be divided and later repaired once the Swanson implant is fitted. Another approach is to preserve the extensor tendon by removing the damaged joint and osteophytes with a Ronguer. Once the extensor has been divided, an oscillating saw is used to remove bone.

Procedure

After excision of bone, the joint is irrigated with sterile saline and a size 1 or size 0 implant is inserted with a no-touch technique. The extensor apparatus is now repaired with 5/0 PDS sutures and the skin closed with interrupted 5-0 Vicryl rapide.

 

Structures at risk

• Extensor tendon

• Flexor tendon

• Nail complex

 

 

Postoperative care and instructions

• MCP joint: Patients are placed in a resting splint (volar plaster of paris [POP] or thermoplastic) or bulky bandage for 3–5 days. This is then replaced with alternate-day flexion (MCP joints at 70°–90°) and then extension (MCP joint at neutral) splints for 24-hour periods. After 4 weeks these splints are worn at night only and the patient mobilises the hand during the day with protective splinting only.

• PIP joint: The digit is placed in a T-bar (thermoplastic) splint. This maintains the PIP joint in full extension with the MCP joint flexed at 60° for 6 weeks at night and at rest. During the day, the patient is encouraged to begin immediate, regular, active mobilisation of the PIP joint out of the splint.

• DIP joint: Immediately after surgery, a Zimmer splint is applied to immobilise the DIP joint. Active mobilisation begins as soon as possible. For rehabilitation, patients are taught to carry out active flexion and extension exercises of the DIP joint(s) of the

  involved finger(s) themselves five times per day. A thermoplastic splint is used at night for 8 weeks to protect the DIP joint.

  The emphasis in therapy for MCP, PIP and DIP joint arthroplasty is early supervised, active and passive movement.

   

  Recommended references

  Sierakowski A, Zweifel C, Sirotakova M, Sauerland S, Elliot D. Joint replacement in 131 painful osteoarthritic and post-traumatic distal interphalangeal joints. J Hand Surg Eur. 2012;37(4):304–309.

  Swanson AB. Silicone rubber implants for replacement of arthritic or destroyed joints in the hand. Surg Clin North Am. 1968;48:1113–1127.

  Swanson AB. Flexible implant arthroplasty for arthritic finger joints: Rationale, technique and results of treatment. J Bone Joint Surg Am. 1972;54:435–437.

  Takigawa S, Meletiou S, Sauerbier M et al. Long-term assessment of Swanson’s implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg Am. 2004;29:785–795.

  Extensor tendon repair‌

  Injuries to the hand extensor apparatus are common. Non-surgical intervention is the best treatment for some of the more common injuries – especially in the finger, e.g. mallet deformity. The key to a successful outcome is recognition of the specific injury and implementation of appropriate surgical repair, splintage and/or early mobilisation to deal with the particular problem (Figure 9.9; Table 9.2). This will be influenced by whether the patient presents early (within a few days) or late (weeks or months later). In all cases, appropriate hand therapy and splintage are more important than any surgery to restore full function.

   

  Indications and operative planning

• Zone 1: A mallet deformity. If it is open, the wound should be washed out as the DIP joint is often opened as well. The skin is then closed (converting an open mallet injury into a closed mallet injury) but the extensor tendon should not be repaired. Surgical repair is usually fruitless and leaves sutures close to the skin where they often extrude. If 12 weeks of dedicated and consistent splintage fails, then the patient should either accept the

   

  Zone 1

   

  Zone 2

   

  Zone 3

  Zone 4

  Zone 5

   

   

   

  Figure 9.9 The zones of the extensor tendon.

   

  Table 9.2 Anatomy of the extensor tendon

   

  Zone	Description of tendon anatomy
  1	The terminal tendon formed from the convergence of the two lateral bands
  2	Lateral bands held together by the triangular ligament
  3	Insertion of the central slip into the proximal phalanx
  4	Central slip and intrinsic tendons
  5	Extensor hood
  6	Over the metacarpals
  7	Over the wrist
  8	In the forearm

   

  position or consider arthrodesis of the DIP joint. An avulsion fracture of the insertion of the terminal extensor tendon also results in a mallet deformity. This fracture does not need surgical fixation regardless of the size of the fragment and the appearances on an X-ray. Very, very rarely, percutaneous fragment reduction under image intensifier guidance may be necessary to improve the position of the avulsion fragment.

• Zone 2: Injuries to the extensor apparatus in zone 2 result in a mallet deformity and are treated as for injuries in zone 1.

• Zone 3: Injury to the central slip results in a Boutonniere deformity, and this is often a late presentation. If it is an open injury and the damage to the central slip is recognised acutely, then it may be worth considering surgical re-insertion or repair of the central slip. The lack of soft tissue for reattachment means a mini-Mitek bone anchor or a ‘washing-line’ will often be needed to suture the tendon to the bone (see later for details of the surgical technique). Even if the central slip is reinserted surgically, the

   

  patient will need the same splintage and hand therapy postoperatively as for a closed injury. So, there is a strong argument for not doing anything other than closing the skin as for injuries in zones 1 and 2. If the presentation is delayed or chronic, the PIP joint

  is statically splinted in full extension for 3 weeks followed by application of a Capener (dynamic) splint for another 3 weeks. Only if this fails, should surgery be considered to reinsert/reef the central slip and/or to mobilise the lateral bands which will have slipped volar to the axis of movement of the PIP joint.

• Zone 4: Injuries in zone 4 behave like zone 3 injuries. However, there is now sufficient tendon material to consider surgical repair using interrupted horizontal mattress sutures of 4/0 PDS.

• Zone 5: Injuries in zone 5 result in an extensor lag which can be debilitating. However, patients usually do very well after surgical repair of tendons in this zone followed by early active mobilisation (see later for mobilisation regimen).

• Zones 6–8: In these zones, the extensor tendons are more rounded, making a surgical repair much easier.

   

  Contraindications

• Active infection: The repair may rupture and the tendon may become adherent.

• Skeletal instability: Unstable fractures must be fixed at the same time as any tendon repair.

• Fixed joints: There is no point in repairing a tendon injury.

• Delayed presentation (more than 6–8 weeks) of extensor ruptures in zones 6, 7 and 8 can rarely be repaired primarily as the tendon ends will have retracted and shortened.

• Attrition ruptures: Tendon grafts or transfers are required and may or may not be possible.

• Smokers: Because the tendon repairs are more likely to fail and the soft tissues may not heal.

• Poor social or psychological circumstances.

• Patients who do not understand their injury and cannot or do not comply with the hand therapy that is required after a tendon injury seldom regain full function of the affected part. This often includes very young children.

• If there is 20% (or less) division or loss of the extensor apparatus at any level then the skin should be closed and the tendon injury ignored.

   

  Consent and risks

  • Scars: It is often necessary to extend the wounds to gain access to the tendon ends.

  • Splintage and physiotherapy: The patient will not have full use of the affected hand for 8–10 weeks. This may have significant economic consequences. The importance of compliance with the postoperative physiotherapy must be stressed.

  • Infection.

  • Rupture: 5%.

  • Adhesions: A particular problem if there is an underlying fracture.

  • Bow stringing: In zone 7 injuries.

   

   

  Anaesthesia and positioning

  For finger injuries up to zone 5, a ring block is sufficient. For more proximal injuries, in zones 6–8, a general anaesthesia or regional block is used. Positioning is supine with an arm table and a tourniquet appropriate to the part affected.

   

  Surgical technique

  Landmarks and incisions

  If there is a skin laceration over the injured extensor tendon then it can be incorporated into any incision after suitable debridement of the wound edges. Incisions are extended proximally and distally as needed to gain access to the tendon ends. This is particularly necessary in zones 6, 7 and 8 where the proximal ends may have retracted a considerable distance. ‘Zigzag’ or ‘lazy-S’ incisions are preferred since these heal better when making long incisions over the dorsum of the hand and wrist.

   

  Dissection

   

  Structures at risk

  • Necrosis of skin flaps – especially in smokers

  • Injury to dorsal veins and nerves

   

  Skin and subcutaneous fat are incised and then skin flaps are elevated. These can be retracted with skin hooks or held in place with ‘stay’ sutures. The dorsal veins and nerves should always be preserved wherever possible. The extensor tendons are identified and care is taken to preserve the paratenon.

   

  Procedure

• Zones 1 and 2: The tendon injury is usually treated non-operatively.

• Zone 3: Where appropriate, the central slip can be reinserted using a mini-Mitek bone anchor or a ‘washing-line’ (Figure 9.10). Two mini-Miteks are inserted into the base of the middle phalanx. The PIP joint is fully extended, and the central slip is secured

   

  Mini-Mitek

  ‘Washing-line’ (0.35–0.45 gauge dental wire)

   

   

   

  Figure 9.10 Reinserting the central slip with mini-Mitek anchors or a ‘washing-line’.

   

  with the two strands of suture. Alternatively, a 0.35–0.45 gauge dental wire is inserted across the base of the middle phalanx. The wire is formed into a loop close to the bone, leaving enough of a gap to allow the passage of multiple sutures (PDS preferred) under the wire. The whole wire acts as a suture anchor allowing multiple sutures to be passed into the central slip and under the ‘washing-line’.

• Zones 4 and 5: The extensor tendons are flat, so horizontal mattress sutures using 5/0 or 4/0 PDS are best for any repair. The repair is augmented with a continuous, over-and-over suture of 5/0 PDS to keep the tendon ends tidy (Figure 9.11). In zone 5, any lacerations to the sagittal bands must be repaired with 5/0 PDS to prevent the extensor tendon subluxing into the radial or ulnar gutters.

• Zones 6–8: The ends of the tendon are minimally trimmed and repaired with a modified Kessler core suture, using a 3/0 or 4/0 PDS. If necessary, the core suture can be further augmented with a single horizontal mattress suture of 4/0 PDS. A continuous epitendinous suture is then placed around the circumference of the repair using 5/0 or 6/0 PDS (Figure 9.12). This also augments the repair and helps to keep the tendon ends

  tidy. A round bodied needle is preferred for both core and epitendinous sutures to reduce the chance of cutting the core suture accidentally. If a primary repair of the extensor tendon cannot be performed (e.g. delayed presentation or loss of tendon substance) an interposition tendon graft or tendon transfer must be used, e.g. with palmaris longus tendon. A Pulvertaft weave (Figure 9.13) must be used to secure the tendon graft to the ends of the tendon as this is strong enough to allow early mobilisation.

• Zone 7: Free excursion of the repaired extensor tendon must be confirmed under the retinaculum. If necessary, the retinaculum is divided to allow free movement of the tendon but preserving as much of it as possible intact prevents later bow-stringing. The repair is now tested by passively flexing and extending the finger. There must be no gapping of the repair and it must glide freely through the full excursion of the tendon.

   

   

   

   

  Figure 9.11 Repair of an extensor tendon in zones 4 and 5.

   

  (a)

  (b)

  (c)

   

   

   

  Figure 9.12 Zones 6–8 extensor tendon repair. (a) Kessler stitch, (b) epitendinous suture and

  (c) augmentation with a horizontal mattress suture.

   

   

   

   

   

  Closure

  Figure 9.13 A Pulvertaft weave.

  The tourniquet is released and haemostasis achieved. The wound is washed out with saline and closed with interrupted absorbable 4/0 or 5/0 Monocryl sutures and a subcuticular 5/0 Monocryl suture. Interrupted, non-absorbable sutures are avoided on the dorsum of the hand and fingers as this leaves very unsightly suture marks. Mepitel or non-adherent silicone dressings are applied to the wound together with dressing gauze and Velband padding before placing the hand and forearm in a volar plaster of Paris splint with the fingers in full extension and the wrist at neutral. The plaster should be allowed to set before the patient comes off the operating table.

   

  Postoperative care and instructions

  The senior author recommends the Norwich regimen for injuries in zones 5–7. The plaster of Paris is replaced with a thermoplastic splint the day after surgery. Passive and active

   

  extension are commenced straight away, protected in the splint for 4 weeks. For a further 4 weeks, the patient removes the splint for active extension and active flexion of the IP/ MCP joints but wears it at all other times. For central slip injuries (zones 3 to 4) the finger is placed in a cylinder splint (PIP joint static in extension, DIP joint free) for 3 weeks and then 3 further weeks in a Capener splint.

   

  Recommended references

  Abouna JM, Brown H. The treatment of mallet finger. The results in a series of 148 consecutive cases and a review of the literature. Br J Surg. 1968;55:653.

  Lange RH, Engber WD. Hyper-extension mallet finger. Orthopaedics. 1983;6:1426.

  Newport ML, Williams CD. Biomechanical characteristics of extensor tendon suture techniques. J Hand Surg Am. 1992;17:111.

  Newport ML, Pollack GR, Williams CD. Biomechanical characteristics of suture techniques in extensor zone IV. J Hand Surg Am. 1995;20:650–656.

  Stuart D. Duration of splinting after repair of extensor tendons in the hand. A clinical study. J Bone Joint Surg Br. 1965;47:72.

  Sylaidis P, Youatt M, Logan A. Early active mobilisation for extensor tendon injuries. The Norwich regime.

  J Hand Surg Br. 1997;22:594.

  Wehbé MA, Schneider L. Mallet fractures. J Bone Joint Surg Am. 1984;66:658.

  Flexor tendon repair preoperative planning‌

  Indications and operative planning

• Zone 1: The technique for flexor repair in zone 1 depends on how close to the insertion the FDP has been divided. If the tendon is divided close to the bone (e.g. FDP avulsion) then it may be necessary to use a suture anchor (such as a mini-Mitek) to secure the tendon end.

• Zone 2: Proximal zone 1 and zone 2 repairs of the FDP tendon are treated in a similar way. The aim is to repair the tendon but to avoid any bulkiness at the repair site to allow the tendon to glide within the flexor sheath. If the repair is done badly it will be too bulky and may trigger, rupture or jam in position unless the flexor sheath is opened. Special care must be taken with repairs of FDS in this zone (see later).

• Zone 3: Zone 3 repairs are easier to perform because there is no tight flexor sheath to contend with and the tendon ends are larger. Distal zone 3 repairs may catch on the A1 pulley, which may need to be divided.

• Zones 4–5: Repairs in these zones are the same as repairs of the extensor tendons in zones 6–8.

• Complete division: Primary repair of a flexor tendon should be performed as soon as possible. Unlike extensor tendons, surgical intervention in some form is always necessary when the flexor tendons have been divided.

• Timing of repair: There is good evidence that the outcome of primary repair is superior when carried out as quickly as possible (within 72 hours). There is a particular urgency in carrying out a repair of the flexor tendons (as compared to the extensor tendons) because the flexor pulleys will eventually collapse/fill with scar tissue after 3–4 weeks. Any tendon repair will then need to reconstruct the pulleys and make surgery more complicated than necessary.

• Particular tendons: The flexor muscle bellies (especially flexor pollicis longus, FPL) have a tendency to shorten quickly. This may make primary repair of a tendon

   

  impossible. The ring and middle fingers are particularly prone to avulsion injuries of the FDP tendon. Repair of combined injuries of flexor digitorum superficialis (FDS)/ FDP tendons in the little and ring fingers are particularly prone to form adhesions to the surrounding tissues. Therefore, consideration should be given to repairing just the FDP tendon in these digits.

• Zone of injury: As for extensor tendons, the surgical technique for repair of flexor tendons varies depending on the zone of injury (Figure 9.14).

• Partial division of flexor tendons: There is good evidence that inserting sutures into a tendon results in necrosis of the tendon substance. Therefore, the use of sutures should be avoided for any partial tendon injury involving less than 50% of the diameter of

  the tendon. Instead, we recommend trimming the edges of the tendon laceration to prevent triggering (if any is present) followed by supervised mobilisation in a splint for a complete flexor tendon division for the next 8 weeks.

   

   

  Zone 1 (distal to

  FDS insertion)

   

  Zone 2 (A1 to FDS

  insertion)

   

  Zone 3 (palm)

   

  Zone 4

  (carpal tunnel)

   

  Zone 3 (forearm)

   

   

   

  Figure 9.14 The zones of flexor tendon injury. FDS, flexor digitorum superficialis.

   

  Contraindications

• Active infection

• Skeletal instability

• Fixed joints

• Delayed presentation (more than 3–4 weeks) can rarely be repaired primarily as the tendon ends will have retracted and shortened and the flexor pulleys will have collapsed

• Attrition ruptures

• Smokers

• Poor social or psychological circumstances

• Partial tendon rupture of less than 50% should not be repaired

• Delayed presentation

 

Consent and risks

• Scars: It is often necessary to extend the wounds to gain access to the tendon ends.

• Splintage and physiotherapy: Patients will not have full use of the affected hand for 12 weeks. The importance of compliance with the postoperative physiotherapy must be stressed.

• Infection.

• Adhesions: A particular problem when there is an underlying fracture. Overall, there is a 5% tenolysis rate.

• Rupture: Zone 2 finger flexors – 5%, FPL repair – 12%.

• Bow stringing: May not be evident for some years after the original event. It may occur if it proves necessary to divide the flexor sheath completely in order to repair the tendons. A subsequent pulley reconstruction will then be required.

• Neuroma formation.

 

 

Anaesthesia and positioning

For isolated FDP injuries, it is usually possible to perform a repair under digital nerve block with a finger tourniquet. For FPL, FDS and more proximal flexor injuries, general anaesthesia or a regional block may be necessary because of the need for an arm tourniquet. To avoid the need for a tourniquet, surgeons should consider using local anaesthetic with adrenaline. This ‘wide-awake’ approach has many additional advantages. The arm is positioned in the supine position with an arm table.

 

Surgical technique

Landmarks and incisions

The Bruner (zigzag) incision (Figure 9.15) is preferred. If there is a laceration, then it can be incorporated into the incision after suitable debridement of the wound edges.

 

Dissection

 

Structures at risk

• Edges of the skin flaps

• Neurovascular bundles

 

The flaps can be retracted with skin hooks or held in place with ‘stay’ sutures. A ‘window’ is opened in the flexor sheath by creating zigzag flaps or by lateral ‘venting’ of the pulley on one side. Ideally, the window should be as small as possible and should be positioned only between the annular pulleys to allow maximum preservation of the pulley system. If the flexor sheath is opened with zigzag flaps, it is usually possible to repair the sheath with a slightly larger diameter by approximating the tips of the flaps. This will allow any

 

 

 

 

Figure 9.15 Suggested Bruner incisions to approach the flexors.

 

reconstructed pulley system to accommodate a bulkier, less than perfect, tendon repair. However, it is also worth noting that there is good evidence that division of the A4 pulley does not cause significant bow stringing of the flexor tendon if the distal part of the A2 pulley remains intact. Therefore, consider leaving the A4 pulley completely open to avoid any concerns about snagging of the repair in the sheath once the patient starts to mobilise.

 

Tendon retrieval

If a tendon has been fully divided, flexion of the finger or thumb normally delivers the distal end into the wound. If the proximal end of the tendon has retracted it can sometimes be retrieved by passing a small curved artery clip or skin hook into the flexor sheath. If this method is not successful, then the palm of the hand must be opened, and the tendon(s) pushed up into the finger with forceps. In exceptional cases, it may be necessary to use a paediatric feeding tube or dental wire to retrieve the FDP or FPL tendon. If the laceration is in the wrist or palm, it may be necessary to extend the incisions more proximally to find the tendon ends. Once retrieved, a 20G (blue-hub) needle can be passed through the tendon ends to prevent them from retracting again until the repair is complete.

 

Tendon suture technique

Zone 1. If there is a very short stump of tendon (<1 cm), then it is possible to repair the tendon by inserting 4/0 or 5/0 PDS sutures as a half-Kessler proximally and as a horizontal mattress distally. Multiple sutures can be inserted to increase the strength of the repair since there is no concern about the bulk of the repair getting caught in the flexor sheath. When the tendon is avulsed and/or there is a fracture of the distal phalanx, then alternative methods of fixation must be considered, e.g. suturing the tendon to the

 

remnants of the periosteum or using a suture anchor (such as a mini-Mitek). If there is a fracture, then a mini-plate can be used to fix the fracture, and the plate can also be used as a suture anchor.

 

Flexor digitorum superficialis distal to the metacarpophalangeal joint

If the FDS is injured where it is beginning to flatten out or after it has split into its two terminal slips, then horizontal mattress sutures must be used to repair the tendon because there will not be enough tendon substance for a modified Kessler core suture. Each terminal slip must be repaired separately. If there is room for it, an epitendinous suture using 5/0 or 6/0PDS can be used to tidy the ends of the repair. Note that in combined FDS/ FDP injuries of the little and ring fingers there is an argument for not repairing the FDS tendon to avoid creating two bulky tendon repairs, both of which will be unable to glide in the flexor sheath.

 

Flexor digitorum superficialis, flexor pollicis longus and flexor digitorum superficialis proximal to metacarpophalangeal joint

The tendon ends are approximated and held in position by transfixing them with a 20G needle. The ends of the tendon are trimmed, and the back wall of the repair is started with a continuous 5/0 or 6/0 PDS ‘over-and-over’ or Silfverskiold-pattern epitendinous suture. A four-strand, core suture (e.g. 2 × modified Kessler, 1 × modified Kessler with 1 × horizontal mattress or 1 × cruciate) is now inserted using 4/0 or 3/0 PDS, taking particular care to bury the knot(s) in the middle of the repair. The anterior part of the epitendinous suture is then completed (Figure 9.16). The core suture should always be over-tightened to prevent gapping when early active mobilisation is started postoperatively. Only round-bodied needles should be used - to reduce the risk of cutting the core suture accidentally. There must be no gapping of the repair and it must glide freely through the full excursion of the tendon when the repair is complete. Active testing of the repair is easy to achieve using the ‘wide-awake’ approach. Any pulleys restricting gliding of the tendon should be divided in a zigzag fashion or excised altogether.

 

(a)

(b)

(c)

(d)

(e)

 

 

 

Figure 9.16 (a–e) Steps in the repair of flexor tendons.

 

Closure

All wounds are washed out with saline and closed with interrupted, absorbable 4/0 or 5/0 Vicryl rapide sutures. Unlike the dorsum of the hand, suture marks are not so much of a problem on the volar side because of the thicker epidermis. Therefore, subcuticular sutures do not have to be used. Mepitel or other non-adherent, dressings, gauze and Velband bandage are applied and the hand and forearm are placed in a dorsal plaster of Paris with the fingers flexed at 90° at the MCP joint and the wrist in neutral. The plaster should be set before the patient comes off the operating table.

 

Postoperative care and instructions

Early active mobilisation begins on day 1 following the Belfast regimen. The plaster of Paris is replaced with a thermoplastic splint the following day. Full passive flexion is commenced in all digits. The repaired tendon is allowed to commence immediate, controlled, active flexion and extension. All exercises are performed in the splint for the first 4 weeks. After 4 weeks, the patient can remove the splint, but only to do exercises. At all other times, the splint must remain in place. No passive extension is permitted for 8 weeks.

 

Recommended references

Kessler I, Nissim F. Primary repair without immobilisation of flexor tendon division within the digital sheet. Acta Orthop Scand. 1969;40:587–601.

Kleinert HE, Kutz JE, Ashbell TS et al. Primary repair of lacerated flexor tendons in ‘No Man’s Land’.

Proceedings, American Society for Surgery of the Hand. J Bone Joint Surg Am. 1967;49:577.

Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011;38(4):761–769.

Silfverskiold KL, Anderson CH. Two new methods of tendon repair: An in vitro evaluation of tensile strength and gap formation. J Hand Surg Am. 1993;18:58–65.

Sirotakova M, Elliott D. Early active mobilisation of primary repairs of the flexor pollicis longus tendon with two Kessler two-strand core sutures and a strengthened circumferential suture. J Hand Surg Br. 2004;29:531–535.

Small JO, Brennan MD, Colville J. Early active mobilisation following flexor tendon repair in Zone 2. J Hand Surg Br. 1989;14:383–391.

Sourmelis SG, McGrouther DA. Retrieval of the retracted flexor tendon. J Hand Surg Br. 1987;12:109–111. Tang JB. Release of the A4 pulley to facilitate zone II flexor tendon repair. J Hand Surg Am.

2014;39(11):2300–2307.

Wong J, McGrouther DA. Minimizing trauma over ‘no man’s land’ for flexor tendon retrieval. J Hand Surg Eur. 2014;39:1004–1006.

Tendon transfers‌

Preoperative planning

Tendon transfers are useful to restore hand function in patients where primary tendon repair is difficult or impossible. The essence of a good transfer is to keep it simple and to plan carefully. The senior author recommends listing all the functions (absent and present) to allow formulation of a plan. An example is given in Table 9.3.

 

Indications

• Nerve palsies: Tendon transfers are particularly useful for isolated nerve palsies. For a transfer to be possible, the hand or upper limb must have sufficient numbers of functioning tendons which can be used for the transfer without adversely affecting

   

  Table 9.3 Example: Planning for an anterior interosseous nerve injury

   

  Tendons present	Tendons absent	Suggested options
  All extensors + brachioradialis (BR)	Flexor pollicis longus (FPL)	FDS from ring to FPL BR to FPL Arthrodesis interphalangeal joint
  Pronator teres	FDP to index	Suture FDP middle to FDP index
  Flexor carpi ulnaris (FCU)	Pronator quadratus	Do not replace
  Flexor digitorum profundus (FDP) to little, ring and middle		Do not replace
  Flexor digitorum superficialis (FDS)		Do not replace
  Flexor carpi radialis (FCR)		Do not replace

   

  overall hand function. Therefore, patients with a global loss of nerve function (e.g. cerebral palsy) will always do less well.

• Delayed presentation of a tendon rupture: Tendon transfers may be necessary to restore function even in cases of delayed presentation because of shortening of the muscle bellies after rupture.

  Contraindications

• The joint which the tendon is intended to move is not fully supple.

• The part of the hand/upper limb which is to be moved by the tendon is not fully sensate.

• The soft tissue bed through which the transfer will pass is poorly vascularized and/or heavily scarred (e.g. under a skin graft).

• The transfer results in loss of an essential function.

• The power of the transferred muscle is less than 5 (Medical Research Council [MRC] grade). This is because any transferred muscle loses at least one MRC grade after the transfer.

• If the amplitude of the transferred muscle is not similar to that of the muscle which it is replacing. For example, finger flexors have an excursion of about 70 mm. Wrist extensors/flexors have an excursion of only 30–40 mm. This is not a good match.

• Before 9–12 months have elapsed after any motor nerve repair. If motor recovery has not occurred by this time, then it is very unlikely to occur, and a tendon transfer is then justified.

• Where other procedures would be more beneficial, e.g. for delayed presentation of an FDP laceration or avulsion, a tendon graft or an arthrodesis of the DIP joint may be the preferred options. Similarly, a flexor rupture in zone 1 and 2 for patients with rheumatoid arthritis is usually better treated with a tendon graft.

   

  Consent and risks

  • Donor site morbidity: Patients may experience weakness or some loss of function after harvest of a tendon. For example, after harvest of the extensor indicis proprius (EIP), patients may experience an extensor lag at the index finger MCP joint.

   

   

  • Additional scarring: After harvest of the tendons/grafts.

  • Rupture: To reduce this risk, the senior author recommends using a Pulvertaft weave or a side-to-side repair with multiple horizontal mattress sutures. It is a particular risk after interposition tendon grafting with two repairs.

  • Patients must be warned of the prolonged rehabilitation which must be followed after

    any tendon transfer (8–12 weeks) during which they will be unable to use their hand normally.

  • Infection.

  • Neuromas: The superficial branch of the radial nerve is a particular problem because of its propensity for neuroma formation after even minor trauma.

  • Recurvatum deformity (essentially a swan-neck posture of the donor finger) due to

    hyperextension of the PIP joint after harvest of the FDS in patients with hyperextensible joints.

  • Damage to adjacent tendons or pulleys.

  • Imbalance of the transfer (i.e. too tight or too loose).

  • Tendon imbalance due to spontaneous recovery of normal functions if the tendon transfers were performed too early (i.e. before 9–12 months after repair of a motor nerve).

   

   

  Anaesthesia and positioning

  Most transfers are performed under general or regional anaesthesia. However, there is an increasing trend to perform tendon transfers using the ‘wide-awake’ approach which allows the tension in any transfer to be assessed more accurately with the cooperation of the patient. Patients should be supine, and the arm should be placed on a hand table. Use of an arm tourniquet is essential.

  Surgical techniques

  Over many years, hand surgeons have developed standard combinations of transfers to deal with specific nerve palsies. In all cases, the assumption is made that only one nerve is injured, and the rest of the hand forearm is ‘normal’.

• For a high radial/posterior interosseous nerve palsy

  • Palmaris longus (PL) to extensor pollicis longus (EPL) to restore thumb extension.

  • Flexor carpi radialis (FCR) or flexor carpi ulnaris (FCU) to extensor digitorum communis (EDC) to restore finger extension. For posterior interosseous palsy, FDS from ring or middle finger to EDC is preferred instead.

  • Pronator teres (PT) to extensor carpi radialis longus or brevis (ECRL/ECRB) to restore wrist extension.

• For a low median nerve palsy

  • FDS from ring finger or EIP or abductor digiti minimi (ADM) (Huber) to abductor pollicis brevis (APB). Palmaris longus can also be used to improve abduction (Camitz transfer).

  • Loss of the lumbricals may result in clawing of the index and middle fingers. The best solution is a dynamic transfer using FDS from the ring finger split into two slips inserted into the A2 pulleys of index and middle fingers (i.e. a Zancolli ‘lasso’).

     

• For a high median palsy

  • FDS from ring finger or EIP or ADM to APB for an opponensplasty as in a low median palsy.

  • The FDP from ring or little fingers can be sutured side-to-side to the FDP of the index and middle fingers to restore finger flexion.

  • BR or FDS from ring or little finger to FPL to restore thumb flexion.

  • If clawing is present, then a Zancolli lasso as for a low median palsy. Alternatively, a PL free tendon graft from the transverse carpal ligament to the radial lateral bands of the index and middle fingers for a static extension block.

• For a low ulnar palsy

  • The best solution for clawing (which is passively correctible) is a Zancolli lasso.

  • FDS from the middle or index finger to adductor pollicis for weak adduction.

  • EIP to extensor digitorum minimi (EDM) corrects Wartenberg’s deformity.

• For high ulnar palsy

  • Suture of FDP middle and index side to side to FDP for the little and ring fingers.

  • FDS from middle or index to adductor pollicis if adduction is weak.

     

    Other technical aspects of tendon transfers

    When measuring the length of donor tendon required for transfer, remember that 2–3 cm of tendon are required to perform a Pulvertaft weave. A Pulvertaft weave is one of the keys to a good transfer because the repair is sufficiently strong to allow early mobilisation. Getting the correct tension in the transferred tendon is another key point. The joint should be positioned where the transfer will be at its maximum length and the tendon is then sutured under maximum tension. Unfortunately, this is not always possible if the donor tendon is too short. Therefore, it is important to carry out a tenodesis test to ensure that an overly tight transfer has been avoided. Having said that, all repairs should be ‘over-tensioned’ on the table to allow for a small amount of subsequent ‘stretching’ of the tendon.

     

    Closure

    All wounds are closed in layers with absorbable sutures using interrupted 4/0 or 5/0 Monocryl to dermis and 4/0 or 5/0 Vicryl rapide as a subcuticular stitch. Mepitel, dressing, gauze and Velband bandage are applied as needed and the hand and forearm are placed in a resting volar plaster. The plaster should be set before the patient comes off the operating table.

     

    Postoperative care and instructions

    After 24–48 hours, the plaster of Paris splint is removed, and the patient can be placed in an appropriate thermoplastic resting splint which can be removed by the patient and therapist to allow early mobilisation to begin. The precise rehabilitation regimen depends on the tendons which have been transferred. However, in all cases, one of the keys to a successful outcome is the ability to begin early active mobilisation. In order for this to happen, any tenorrhaphy must be sufficiently strong to allow this mobilisation to occur.

     

    Nerve transfers

    A nerve transfer is a surgical technique that involves the transfer of redundant or expendable nerves to restore muscle function and/or sensation after nerve injury. With appropriate planning, a nerve transfer can be as good as a tendon transfer in patients with isolated nerve palsies and has additional advantages over traditional tendon transfers. Nerve transfers use nerves (or branches of nerves) that perform redundant or less important roles and then uses them to restore function to muscles which are normally innervated by the injured nerve. Surgeons aim to carry out the nerve repair as close to the target muscle as possible to shorten the re-innervation time (i.e. before the motor end plates degenerate after the muscle is denervated). Interestingly, nerves whose original function was entirely outside the limb (e.g. intercostal nerves) can be used to restore function in the limb (e.g. to re-innervate biceps). Initially, the patient may have to breathe in to make the muscle contract, but brain plasticity eventually allows the patient to move the limb just by thinking about it. Another example of a nerve transfer is in proximal ulnar nerve injuries. The anterior interosseous nerve (AIN) is the nerve transfer of choice for recovering ulnar nerve motor function after a proximal ulnar nerve transection where repair of the ulnar nerve is difficult or impossible. The AIN is transferred end to side to the ulnar nerve in the forearm. This has the effect of transferring the motor functions of one of the terminal branches of the median nerve to the (normally) ulnar innervated muscles.

     

    Recommended references

    Davidge KM, Yee A, Moore AM, Mackinnon SE. The supercharged end-to-side anterior interosseous-to-ulnar motor nerve transfer for restoring intrinsic function: Clinical experience. Plast Reconstr Surg. 2015;136(3):344e–352e.

    Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 5th ed. Edinburgh, Scotland: Elsevier, 2005.

    Lalonde DH. Wide-awake extensor indicis proprius to extensor pollicis longus tendon transfer. J Hand Surg Am. 2014;39(11):2297–2299.

    Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin Orthop Surg.

    2015;7(3):275–781.

    Soft tissue reconstruction‌

    Preoperative planning

    For the purposes of this handbook, the focus is on three areas:

• The operative correction of aberrant scarring

• The use of split-thickness skin grafts

• The use of full-thickness skin grafts

   

  Indications

• Primary wound closure cannot be achieved.

• Primary wound closure can be achieved but may result in functional impairment.

• Allowing a wound to heal by secondary intention will result in functional impairment. For example, leaving tendons exposed which would result in their desiccation and necrosis.

• There is aberrant scarring. Examples include webbed volar scars from poorly placed incisions, burns or other traumatic scarring (Figure 9.17).

   

  (c)

  (b)

  (a)

   

   

   

  Figure 9.17 Soft tissue reconstruction needed for (a) skin loss after sepsis, (b) burns or (c) a poor volar scar.

   

  Contraindications

• Active infection: Beta-haemolytic streptococci in particular will dissolve any graft. Other bacteria will reduce the likelihood of the graft taking and can result in patchy graft take.

• Smoking: Expect a 40% increase in wound healing complications in any patient who smokes.

• Long-term steroid use: Particularly in rheumatoid arthritis (relative contraindication).

• Peripheral vascular disease or similar, e.g. Buerger’s disease, scleroderma or severe Raynaud’s.

• Previous radiotherapy to the hand.

• Recipient site unsuitable: Grafts will not take on bare bone or tendon unless these areas are very small (<5 mm diameter) in which case the grafts may survive by ‘bridging’.

• Donor site problems.

   

  Consent and risks

  • Scarring: Particularly with split skin grafting which leaves large, unsightly scars.

  • Infection.

  • Flap necrosis: This is nearly always the result of technical error (e.g. flaps too narrow, closure too tight) but may also be a consequence of infection.

  • Graft loss.

  • Prolonged healing: A split skin graft (SSG) donor site may take months (or even years) to heal if the patient and donor site are poorly selected.

   

  Operative planning

  There are three main techniques to master:

• Z-plasty: An operation that involves the transposition of two triangular skin flaps of equal dimension to lengthen a scar or change its direction. There is a risk of necrosis of the flaps if they are poorly designed.

   

• Split-thickness skin grafts: If an SSG is used, it is often used as a temporary biological dressing rather than for definitive skin cover.

• Full-thickness skin grafts (FTGs): These can be used for definitive skin cover anywhere on the hand except the pulps of the fingers and thumb.

   

  Anaesthesia and positioning

  The form of anaesthesia depends on the size of graft that needs to be harvested and the area where it is needed. Local anaesthesia is suitable for harvesting small grafts and for surgery to the digits. However, patients may be more grateful for a general anaesthetic when harvesting large grafts and operating on multiple areas (e.g. harvest a FTG from the groin for use in the hand) and on the palm of the hand. The hand is placed in the supine position on an arm table. A tourniquet is extremely useful during surgery involving the use of flaps or grafts in the hand.

   

  Surgical technique

  Z-plasties are used when there is a need to change the direction and/or length of a scar. The best example of their use is to correct a webbed volar scar. Z-plasties can also be used to lengthen a scar after Dupuytren’s fasciectomy (see Figure 9.2, p. 198).

   

  Landmarks and incisions

  In most cases, a 30° or 60° angle is used for the Z-plasty design. A 60° angle achieves more lengthening of the scar, but a 30° angle is often easier to transpose. The width of the base of each flap in relation to its length is important in determining flap survival. The longer and narrower the flap, the less likely it is to survive. The flaps are marked out as shown in Figure 9.2 (p. 198).

  It is a myth that the limbs of the Z-plasty must be aligned to fall in skin crease. Skin creases exist because the fingers flex. When a finger ceases to flex (e.g. after an arthrodesis) the creases eventually disappear. The Z-plasty should be placed where it is needed.

   

  Superficial dissection

  The flaps are raised with a small amount of subcutaneous fat to ensure the subdermal plexus is uninjured. When raising the flaps, the underlying anatomy must be considered. For example, it is very easy to divide the neurovascular bundle when raising the Z-plasty flaps after a Dupuytren’s fasciectomy.

   

  Procedure

• The first stage is to raise one flap and transpose it across the scar. This ensures that the design is right for the second flap before you commit yourself to raising it.

• If the design is correct, then the two flaps should automatically transpose themselves across the scar when the finger straightens.

• The flaps are now tacked into the correct corners and any dog-ears ignored. (These will flatten in a few weeks anyway.)

 

Closure

Interrupted or continuous, absorbable, 4/0 or 5/0 Vicryl rapide sutures are used for closure. Do not use non-absorbable sutures in the hand. There is no difference in wound healing and scar quality comparing absorbable and non-absorbable sutures in the hand, and patients find it very painful to have them removed.

 

Split-thickness skin grafis

A small SSG (<3 cm × 3 cm) can be harvested with a handheld knife (e.g. Watson). The description of the technique given below assumes a hand-powered knife is being used. However, ideally, a powered dermatome (air or electric) should be used to harvest all SSGs (Figure 9.18). The technique for harvesting a graft with a powered dermatome is similar to that using a handheld knife.

 

 

(a)

(b)

 

 

 

Figure 9.18 A Watson hand knife (a) and an air-powered dermatome (b) for harvesting split skin grafts.

 

Landmarks and incisions

The first decision is to determine the amount of SSG needed. This is best worked out in terms of the length and width of the defect which needs to be covered. A marginally larger area than you think you will need should always be taken (approximately 1 cm beyond is ‘about right’). It is easy to trim the SSG down to size, but harvesting more graft is always a problem. Ensure the correct settings are selected on the hand knife or dermatome. Typically, the SSG should be between 0.2 and 0.4 mm thick. The thicker the SSG, the less it will contract, but the longer it will take for the donor site to heal and the more obvious the donor site scar.

 

Harvesting

Liquid paraffin (or Hibiscrub cleaning solution) is applied to the skin and the knife. This acts as a lubricant and prevents the blade from catching on the skin. If the blade catches rather than cuts, it will tear the SSG or result in holes where you do not want them. It is also critically important to ensure that the skin at the donor site is under tension while the skin is being harvested. The best way to do this is to have an assistant who can squeeze the thigh or arm while you concentrate on harvesting the skin. A rapid sawing motion is used

 

to harvest the skin with a hand knife, keeping the blade flat with respect to the skin and not pressing too hard or the graft thickness will increase. If a powered dermatome is used, the machine does the sawing for you. Regardless, the aim is to harvest the graft in one smooth action.

Meshing the skin increases the area which can be covered with a given size of SSG. It also increases the take rate by allowing free drainage of haematoma and seroma. It is possible to mesh skin by hand but using a skin mesher is quicker and neater. However, once it has taken, meshed skin contracts even more than a sheet graft. An alternative is to perforate it with multiple stabs using a number 15 blade. The perforations allow haematoma and seroma to ooze through.

The donor site is dressed with Mefix adhesive dressing applied directly to the wound. Gauze, Velband and crepe bandages are applied over this to absorb any exudate.

 

Grafiing

The SSG is applied shiny side down onto a prepared wound bed and secured with absorbable 4/0 or 5/0 Vicryl rapide either as interrupted or continuous sutures. The same sutures are used to ‘quilt’ the SSG onto the wound bed to reduce shearing movements, improve contact with the wound bed and improve haemostasis under the graft. The SSG is dressed with Jelonet and a layer of gauze. A bulky bandage (Velband and crepe) is applied and the hand immobilised in a plaster of Paris. The graft should be reviewed in 2–3 days.

 

Full-thickness grafi

The best donor sites for a FTG are the groin and postauricular sulcus because these areas are well hidden. However, skin taken from these sites is usually a poor colour match for the skin of the hand. Therefore, a FTG applied to the hand will always be obvious as a darker area with a different texture. In males, a FTG from the groin is also likely to be hairy resulting in obvious problems when it is applied to any part of the hand unless a concerted effort is made to remove the hair follicles before the FTG is used.

 

Landmarks and incisions

An assessment of the area of FTG needed is made, using a piece of paper as a template. The template is transferred to the donor site to mark out a similar area of skin. If harvesting a FTG for a case of Dupuytren’s dermofasciectomy, multiple small pieces of FTG may be needed (Figure 9.19).

 

(c)

(b)

(a)

 

 

 

Figure 9.19 (a) Templating, (b) marking and (c) planning incision for multiple full-thickness grafts for Dupuytren’s dermofasciectomy.

 

Harvesting

The outlines of the pieces of skin that you intend to take are scored with a number 15 scalpel blade. This ensures that you do not lose the outline of the individual pieces of skin. Lift up one corner of the ellipse that you intend to raise and grip this with an artery clip. This saves your hand from getting tired and allows the graft to be held firmly over your index finger while harvesting the graft. Fat should be removed from the graft as it is harvested. This avoids the need to de-fat the graft after it has been detached from the donor site.

The donor site can now be closed with a couple of interrupted 4/0 Monocryl sutures in the dermis. Final closure is completed with a continuous suture of 4/0 Monocryl into the dermis which is locked at both ends with a buried knot. Once the dermal suture is complete, final closure continues with a 4/0 Monocryl subcuticular suture.

 

Grafiing

Any remaining fat on the graft is removed using a pair of tenotomy scissors. This is a very tedious but very important step. The more fat there is on your FTG, the less likely it is to take. The FTG is secured to the recipient site with a couple of interrupted 4/0 or 5/0 Vicryl rapide sutures. Securing the graft is now completed with a continuous over-and-over suture at the edge, using 4/0 or 5/0 rapide. It is important to add quilting sutures to the center of the graft to prevent haematoma formation and reduce shearing movements. Copious quantities of Vaseline ointment are now spread onto the graft and a Jelonet and gauze dressing is applied. The graft should be reviewed in 5–7 days.

 

Postoperative care and instructions

• Z-plasty: The patient can mobilise their hand immediately unless a graft was also used. Even if the last 2–3 mm of the tips of the flaps do not survive, the wound will go on to heal by secondary intention without compromising the final outcome. Therefore, mobilise the hand since mobility is more important than any concern about the wounds.

• SSG: The graft is left undisturbed for 48–72 hours. If it is pink after that, then it has taken and gentle mobilisation can begin. The donor site on the thigh or arm is left undisturbed until 10–14 days have passed, and the patient says it is no longer painful. If the dressing is taken off too early, newly formed epithelium will be ripped off with the dressing. Once a continuous layer of epithelium is present at both recipient and donor sites, the patient applies a thick layer of Vaseline to both areas. The SSG has no sweat or sebaceous glands and will quickly dry out, crust, flake and crack if it is not protected in this way.

• FTG: The hand is immobilised for 1 week in a plaster of Paris splint to further minimise shearing forces that would interfere with graft take. At 5–7 days, all the dressings are removed, and the graft can be inspected. If graft take is complete, then copious quantities of Vaseline ointment must be applied daily for the next

  3 months after which the glands in the graft will have started to function and it can self-moisturize.

   

  Recommended references

  McGregor AD, McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications.

  10th ed. Edinburgh, Scotland: Churchill Livingstone, 2000.

  Thorne CH, Bartlett SP, Beasley RW et al. (eds). Grabb and Smith’s Plastic Surgery. 5th ed. New York, NY: Lippincott-Raven, 1997.

  Trigger finger surgery‌

  Preoperative planning

  The diagnosis of triggering is normally easy to make but overt triggering is sometimes absent, and the patient only gives a history of pain on flexion of the digit which may be confused with or concurrent with arthritis. Trigger finger is common in patients over the age of 50 years, patients with diabetes and patients with rheumatoid arthritis. Where overt triggering is absent, but pain is present, the use of steroid injections is particularly efficacious.

   

  Indications

• Persistent triggering (not relieved by steroid injections)

• Acutely locked finger

  Contraindications

• Presence of infection.

• Triggering in a patient with rheumatoid arthritis (RA). A rheumatoid patient with triggering needs steroid injections or a synovectomy. Release of the A1 pulley in RA patients may make ulnar drift worse by creating further changes in the alignment of the tendons.

   

  Consent and risks

  • Infection

  • Injury to the tendon and neurovascular bundles

  • Recurrence

  • Stiffness/loss of flexion

   

   

  Anaesthesia and positioning

  Local anaesthesia is used with the patient supine and with the arm on an arm table. Use of a tourniquet is optional.

   

  Surgical technique

  Landmarks and incision

  The proximal border of the A1 pulley lies at the neck of the corresponding metacarpal (Figure 9.20), roughly at the level of the mid-palmar crease. A 1.5 cm long, transverse, incision is made in the crease over the corresponding metacarpal.

   

  A1 pulley

  Steroid injection around A1 pulley reduces inflammation allowing the nodule to pass under the pulley

   

  Recurrence

  Nodule on tendon

  Trauma to tendon

  Nodule on tendon

  Surgical release of A1 pulley

   

   

   

   

  Surgical dissection

  Figure 9.20 Trigger finger.

  Blunt dissection is performed through the subcutaneous fat and palmar fascia, using tenotomy scissors, to expose the flexor sheath. It is rarely necessary to visualise the neurovascular bundles running parallel to the flexor tendons: in any case, these should be protected by retractors.

  The proximal edge of the A1 pulley is identified, and the pulley is then divided longitudinally with a scalpel taking particular care to stay over the midline of the tendon to avoid the risk of damage to the neurovascular bundles. The patient is then asked to flex and extend the digit several times to test for any residual triggering. The arm tourniquet is released, the wound washed out with saline and haemostasis achieved.

   

  Closure

  Skin closure is with interrupted absorbable sutures. A bulky dressing is applied to the hand for 24–48 hours. This can then be de-bulked by the patient to allow the fingers to flex freely.

   

  Postoperative care and instructions

  Active mobilisation of the hand is commenced immediately. The bulky dressing should be taken down after 24–48 hours to facilitate this.

   

  Recommended references

  Doyle JR, Blythe WF. The finger flexor tendon sheath and pulleys: Anatomy and reconstruction. In: AAOS Symposium on Tendon Surgery in the Hand. St. Louis, MO: Mosby, 1975:81–87.

  Idler RS. Anatomy and biomechanics of the digital flexor tendons. Hand Clin. 1985;1:3–11.

  Trigger thumb surgery‌

  Preoperative planning

  Indications

• Persistent triggering not relieved by steroid injections. Administer at least one, sometimes two injections before going ahead with surgery and wait 3 months after each injection to assess outcome.

   

• Locked thumb in an adult.

• Locked thumb in a child (usually noticed at <2 years) unresolved for 12 months. Thirty percent of trigger thumbs in infants will resolve within the first year after it is noticed. Flexion contractures do occur, but these will correct themselves

  spontaneously if the triggering resolves or if surgical release is performed before the age of 3 years.

  Contraindications

• Presence of infection

 

Consent and risks

• Infection

• Injury to the tendon and neurovascular bundles

• Recurrence

• Stiffness/loss of range of movement

• Bow stringing of the FPL due to accidental division of A1 pulley and oblique pulley (more likely if the A1 pulley is divided through its ulnar attachment)

 

 

Incision and dissection

In the thumb, the proximal border of the A1 pulley is at the level of the proximal digital skin crease over the MCP joint. A 1–1.5 cm transverse incision is created in the crease. Tenotomy scissors are used for blunt dissection through the subcutaneous fat and palmar fascia to expose the FPL tendon sheath and A1 pulley. The digital nerves and vessels running parallel to the FPL tendon are identified and protected with right-angle retractors. The A1 pulley is identified, and the radial attachment of the pulley is divided completely with a scalpel from proximal to distal. The thumb is then flexed and extended several times to test for any residual triggering. Any tourniquet is released and haemostasis is achieved. The wound is washed out with saline before closure.

 

Closure

The skin is closed with 5/0 Vicryl rapide interrupted or subcuticular sutures. A light bandage should be applied which does not interfere with movements of the thumb.

 

Postoperative care and instructions

Active mobilisation of the hand and thumb is begun immediately after surgery. Heavy use of the hand is avoided for 1–2 weeks.

 

Recommended reference

Ger E, Kupcha P, Ger D. The management of trigger thumb in children. J Hand Surg Am. 1991;16:944–947.

 

Viva questions‌

1. What are the theoretical advantages of dermofasciectomy compared to fasciectomy for Dupuytren’s disease?

2. What is the mechanism of action of collagenase used for Dupuytren’s contracture and how is it obtained?

3. How do you deal with any residual flexion deformity of a digit after excision of all diseased Dupuytren’s cord tissue?

4. What are the possible complications of a fasciectomy?

5. Describe the solutions for a painful distal interphalangeal joint with mucous cyst in a 50-year-old manual worker.

6. An elderly woman with rheumatoid arthritis comes to you with a painful and unstable thumb metacarpophalangeal joint. Describe your management.

7. A man of 30 years with a history of psoriatic arthropathy attends your clinic with painful and deformed distal interphalangeal joints affecting all the fingers of both hands. How would you treat this?

8. A woman of 40 years attends your clinic with a history of an untreated pilon fracture of the PIP joint of her right little finger dominant hand 10 years ago. The finger is painful, angulated and has restricted (20°–40°) active flexion. What surgical options would you give her?

9. A 50-year-old builder attends your clinic with a painful right index finger carpometacarpal joint. He punched a fellow builder 5 years ago and heard a loud ‘click’ at the time. Since then, he has experienced increasing movement at the joint associated with pain on lifting heavy objects. What options would you offer him?

10. Describe the management and treatment options for a young manual worker with a painful, stiff, PIP joint after previous trauma with evidence of marked joint deformity on X-ray.

11. A young woman presents with a painless but stiff index finger MCP joint after an infection. What surgical options would you present to her?

12. Describe the surgical management of a manual worker with a laceration in zone 6 and loss of extension of the thumb and index finger of his dominant hand?

13. What is the management of a closed mallet injury in a 16-year-old rugby player?

14. A 60-year-old woman presents with a passively correctible boutonniere deformity of her index and middle fingers of her dominant hand 1 year after a fall in the street. How would you treat this?

15. A 50-year-old lawyer with rheumatoid arthritis has suddenly lost extension of his little and ring fingers of his non-dominant hand. What options can you offer him?

16. How do you manage an isolated division of the flexor digitorum profundus tendon in the little finger of a dominant hand?

 

 

1. Describe the operative steps involved in the repair of a combined FDS/FDP tendon injury in zone 2 of the ring finger of a 30-year-old painter and decorator?

2. A patient presents with a tight volar web scar after Dupuytren’s fasciectomy. How would you correct this?

3. You have decided to carry out a correction of a congenital camptodactyly of the little finger. The finger is now straight, but it is obvious that there is a shortage of skin on the volar side of the finger which contributed to the flexion deformity in the first place. How would you correct this?

4. Describe the risks and pitfalls in the management of trigger finger.

5. Describe your management of an acutely locked trigger thumb.