Hand and Wrist Surgery - part 2 doc

Kanavel's Four Signs of Flexor Tendon Sheath Infection Diffusely swollen finger Interphalangeal joints rest in flexion Increased pain with passive digital extension Pain to palpation ov

• Early diagnosis followed by

early antibiotic and surgical

intervention

• Adequate drainage of

infec-tion

• Appropriate antibiotic

man-agement based on cultures

Supporative Flexor Tenosynovitis

John C P Floyd and Waldo E Floyd III

History and Clinical Presentation

A 52-year-old insulin-dependent diabetic man presented to his primary carephysician 4 days after sustaining a palmar stab wound while sharpening a knife.Due to swelling and erythema about the wound overlying the palmar aspect ofthe fourth metacarpophalangeal joint, the patient was admitted to the hospitaland placed on parenteral cefazolin Significant medical history included insulin-dependent diabetes mellitus, peripheral vascular disease, and coronary arterydisease Bilateral above the knee amputations, multiple coronary artery bypassgrafts complicated by wound healing problems, and drug allergies to vancomy-cin, sulfa, doxycycline, clindamycin, and ceftazidime characterized his medicalhistory

The patient had undergone a limited incision and drainage procedure by an thopedic surgeon in the palmar wound just proximal to the A-1 pulley The flexortendons were reported to have been intact Purulent fluid had been expressed from

or-a rent in the flexor tendon sheor-ath The sheor-ath wor-as further incised or-and irrigor-atedthrough a pediatric feeding tube Purulent material was obtained for cultures andsensitivities Despite oral amoxicillin management, purulent drainage and erythemapersisted, prompting hand surgery referral

Physical Examination

On presentation to the hand surgeon, the palmar wound was draining serous fluidand there was no flexor tendon function (Fig 8–1) Flexor tendons were visiblewithin the wound, with a significant amount of surrounding nonviable tissue Fur-ther surgical intervention was deemed appropriate

OsteomyelitisForeign body

The diagnosis was flexor tendon rupture secondary to suppurative flexor

tenosyn-ovitis Kanavel outlined the four classic, cardinal signs of digital flexor tenosynovitis:

(1) fusiform digital swelling, (2) semiflexed digital posture, (3) significant pain sociated with passive extension of the digit, and (4) exquisite tenderness along the

Kanavel's Four Signs of Flexor Tendon Sheath Infection

Diffusely swollen finger

Interphalangeal joints rest in flexion

Increased pain with passive digital extension

Pain to palpation over flexor tendon sheath

Figure 8–2 Kanavel’s dinal signs of suppurative digital flexor tenosynovitis are (1) fusiform digital swelling, (2) semiflexed digi- tal posture, (3) pain with passive digital extension, and (4) pain along the flexor ten- don sheath Pain with passive digital extension is the earli- est and most sensitive sign.

car-entire flexor tendon sheath (Fig 8–2) All four signs are present in an advanced caseand a combination of one or more signs is found in less severe cases However, inthis case, the semiflexed posture was not present as the flexor tendons had rupturedsecondary to the advanced process

High-dose parenteral antibiotic management should be instituted at the time ofdiagnosis and continued postoperatively Cultures and sensitivities guide the choice

of antibiotic management An infectious disease specialist best manages complexantibiotic therapy The risk of infections in high-risk individuals should play an im-portant part in the diagnosis Diabetes and peripheral vascular disease are associatedwith hand infections refractory to medical intervention To prevent the serious se-quelae of suppurative flexor tenosynovitis, the treating physician must maintain ahigh index of suspicion for this diagnosis Adequate drainage of the flexor tendonsheath and removal of necrotic tissue were necessary

Surgical Management

The transverse, open, draining, palmar wound was extended proximally ulnarwardand distally radially, and full-thickness flaps were elevated The flexor tendons wereconfirmed to be ruptured, and the edges of the tendons were quite friable There was

no frank pus present With pressure over the palmar aspect of the digit, serous fluidcould be expressed from the tendon sheath The necrotic flexor tendons had become

a protected focus of infection, necessitating their excision With ring finger flexion,the distal tendons could be delivered into the palmar wound An ulnar midaxial inci-sion was begun distally at the level of the digital whorl and carried back to the ulnarmidaxial line at the distal interphalangeal joint level and back to the ulnar midaxialline at the proximal interphalangeal joint level Subcutaneous tissue was divided and

a full-thickness volar flap was elevated containing the neurovascular bundles.The flexor tendon sheath was opened proximally distal to the A-4 pulley Theprofundus was divided distal to the A-4 pulley and was completely excised Theflexor superficialis was divided at its insertion and was completely excised Aerobicand anaerobic cultures were obtained The digital and palmar incisions were looselyapproximated, leaving the transverse wound open The wounds were dressed and avolar splint was applied, immobilizing the wrist in slight dorsiflexion

Postoperative Management

The patient’s postoperative care consisted of daily dressing changes and whirlpooltherapy Due to the patient’s multiple drug allergies, no parenteral antibiotics were

administered Cultures were positive for Staphylococcus aureus susceptible to

van-comycin, gentamicin, rifampin, Bactrim, and tetracycline Infectious disease sultation was obtained Two weeks postoperative, wounds were healing well with noevidence of active infection As the protected focus of nonviable flexor tendon tissuehad been removed, the decision was made in this complex case not to proceed with

con-a vcon-ancomycin desensitizcon-ation progrcon-am The surgiccon-al con-approcon-ach, independent of ther antibiotic administration, resulted in healing and resolution of the infectiousprocess

fur-Once the infection began to abate, a lighter dressing to enable early motion replacedthe splint Following wound healing, resolution of infection, recovery of passive mo-tion, and the development of tissue equilibrium, delayed flexor tendon reconstructionmay be considered in such cases

Alternative Methods of Management

Selected early cases of flexor tenosynovitis may be managed with parenteral travenous antibiotics, splinting of the hand in the functional position, and eleva-tion In early cases, Kanavel’s signs are limited to pain with passive digital extension.More advanced cases are characterized by the additional findings of a semiflexeddigital posture and pain along the entire flexor digital sheath Significant improve-ment must occur within 24 hours with complete resolution of presenting signs by

in-48 hours Patients initially presenting with all four of Kanavel’s signs demand moreurgent surgical intervention

Closed tendon sheath irrigation is an excellent surgical management technique,

which should be instituted early in severe cases and in those less severe cases that

do not quickly respond to intensive antibiotic management This technique quires a zigzag incision in the palm proximal to the A-1 pulley of the involveddigit At the proximal margin of the A-1 pulley, the flexor tendon sheath is ex-cised, and cultures are obtained A second incision is made in the midaxial lineover the distal portion of the middle digital segment sheath distal to the A-4 pul-ley A long 16- or 18-gauge flexible catheter is directed from the A-1 pulley intothe flexor sheath for a distance of up to 1.5 to 2 cm A small rubber drain isdirected from the distal wound to beneath the A-4 pulley proximally Followingproximal wound closure around the catheter, the system is tested for patency byflushing the catheter with sterile saline and observing the effluent from the dis-tal wound/drain The hand is then immobilized with a splint secured by a softdressing with the catheter and drain exposed Postoperatively the sheath is con-tinuously or intermittently flushed with saline After 24 hours, if the signs ofinfection have resolved, then the catheter and drain are removed and mobiliza-tion begun

re-Complications

The most important method for prevention of further complications is adequatedrainage If inadequate drainage occurs, adhesions, tendon rupture, and osteomyelitiscan result The use of antibiotic treatment in combination with inadequate drainagecan result in the development of resistant organisms

Suggested Readings

Burkhalter WE Deep space infections Hand Clin 1989;5:553–559.

Floyd WE III, Troum S, Frankle MA Acute and chronic sepsis In: Peimer CA, ed

Surgery of the Hand and Upper Extremity 1st ed New York: McGraw-Hill; 1996:1741.

Glass KD Factors related to the resolution of treated hand Infections J Hand Surg

1982;7A:388–394

Kanavel AB Infections of the Hand: A Guide to the Surgical Treatment of Acute and

Chronic Suppurative Processes in the Fingers, Hand, and Forearm Philadelphia: Lea &

Neviaser RJ Closed tendon sheath irrigation for pyogenic flexor tenosynovitis

J Hand Surg 1978;3A:462–466.

Neviaser RJ Tenosynovitis Hand Clin 1989;5:525–531.

Neviaser RJ Infections In: Green DP, ed Green’s Operative Hand Surgery 3rd ed.

New York: Churchill Livingstone; 1993:1021–1038

Stern PJ, Staneck JL, McDonough JJ, et al Established hand infections: a

con-trolled prospective study J Hand Surg 1983;8A:553–559.

Figure 9–1 Grouped vesicular lesions of the index finger.

9

Herpetic Whitlow

Kevin D Plancher

History and Clinical Presentation

A 23-year-old nursing student, working in the intensive care unit for the firsttime, treated a patient without gloves The patient reported symptoms of pain andburning or tingling of the infected digit Erythema and edema followed with the de-velopment of vesicles on an erythematous base over the next 7 to 10 days Thesevesicles are filled with clear or cloudy fluid

Physical Examination

On examination, the patient’s finger is tender and edematous Unlike a felon, thepulp space is not swollen Examination revealed grouped vesicular lesions, whichprogressed to ulcers at 2 weeks (Fig 9–1), and extension of the infection into sub-ungual space and lymphangitic streaking was found In the following 7 to 10 daysthe vesicles dried and began to heal (Fig 9–2, different patient)

Diagnostic Studies

Diagnosis of herpetic whitlow is usually based on clinical presentation The nosis can be confirmed with a Tzanck smear, which reveals characteristic multi-nucleated giant cells Other smears, stains, and serologic tests can be used fordiagnosis of primary infections Herpes antibody titers can also be used to confirmthe diagnosis

diag-Figure 9–2 In the following 7 to 10 days the vesicles dry and begin

to heal.

Differential Diagnosis

CellulitisFelonParonychiaPyogenic infections

Diagnosis

Herpetic Whitlow of the Index Finger

Diagnosis of herpetic whitlow is usually based on presentation of the affected digitwith the characteristic lesions and the patient’s history In health care workers (den-tists, dental hygienists, nurses, physicians), infection is usually due to exposure to in-fected oropharyngeal secretions of patients (herpes simplex virus type 1) This caneasily be prevented by use of gloves and by scrupulous observation of universal fluidprecautions In the general adult population, herpetic whitlow is most often due toautoinoculation from genital herpes; therefore, it is most frequently secondary toinfection with herpes simplex virus type 2 (HSV-2) Infection involving the fin-ger usually is due to autoinoculation from primary oropharyngeal lesions as a result

of finger-sucking or thumb-sucking behavior in patients with herpes labialis or petic gingivostomatitis Care should be taken as viral shedding may occur for another

her-12 days and the lesions may be infective The paronychial region should be examinedfor abscesses indicating a concomitant pyogenic infection The oral cavity should beexamined for preexisting herpetic lesions Herpetic whitlow may be accompanied byaxillary and epitrochlear adenopathy with lymphangitis of the forearm

Nonsurgical Management

The infection resolves spontaneously in 2 to 3 weeks and treatment is directed ward the patient’s symptoms relief In primary infections, topical acyclovir 5% hasbeen demonstrated to shorten the duration of symptoms and viral shedding Oralacyclovir may prevent recurrence Use antibiotic treatment only in cases compli-cated by pyogenic infections or bacterial superinfections

to-Surgical Technique

In most cases, surgical treatment is not recommended and if undertaken, it can lead

to bacterial superinfection, viremia, and encephalitis In rare instances, with an scess and concomitant pyogenic infections, surgical incision and drainage may bewarranted

• Distinguishing between a felon

and herpetic whitlow is

impor-tant, because incision and

drainage is contraindicated

for herpetic whitlow

• Splint and elevate

• Level of suspicion is high in

dental personnel

PITFALLS

• Surgical treatment can lead

to bacterial superinfection,

viremia, and encephalitis.

• Do not undertake irrigation

and debridement unless

bacterial infection warrants

treatment

Hurst LC, Gluck R, Sampson SP, Dowd A Herpetic whitlow with bacterial abscess.

J Hand Surg 1991;16A:311–314.

Klotz RW Herpetic whitlow: an occupational hazard AANA J 1990;58:8–13 McNicholl B Recurrent herpetic whitlow Arch Emerg Med 1990;7:124–125.

Smith E, Hallman JR, Pardasani A, McMichael A Multiple herpetic whitlow lesions

in a patient with chronic lymphocytic leukemia Am J Hematol 2002;69:285–288 Walker LG, Simmons BP, Lovallo JL Pediatric herpetic hand infection J Hand Surg

1990;15A:176–180

Weisman E, Troncale JA Herpetic whitlow: a case report J Fam Pract 1991;33:

516,520

• Open lavage with adequate

debridement to avoid

compli-cations

• Early intervention to avoid

collar button abscess

• Appropriate immediate

anti-biotic coverage

• Must evaluate the wound in

the same position as the injury

occurred to appreciate the

depth

PITFALLS

• Undertreatment with closure of

wound seen after 8 hours from

injury

• Underestimation of full depth

of penetration to wound and

joint

Figure 10–1 (A) Tooth from bite severing skin and entering metacarpophalangeal (MP) joint of the hand (B) Although the wound looks small and innocuous, when the digit is

in extension the penetration

is much deeper Adequate bridement and opening of the wound are essential.

de-10

Bites to the Hand

Kevin D Plancher

History and Clinical Presentation

A 17-year-old college student presented to the emergency room with an open wound

to the dorsum and a piece of human tooth in the wound The patient reported hehad been in a bar brawl last evening Closed fist injuries are encountered almost ex-clusively in young males, usually occurring during adolescence through the fourthdecade of life Although toddlers are notorious for biting each other, these injuriestend to be superficial and low risk

Physical Examination

If the bite results in a puncture wound that is swollen, red, and painful, thewound is likely to be infected Patients with infection may have an elevated tem-perature, swollen glands, or a history of fever Any loss of motion or sensation inthe fingers suggests that a tendon or nerve has been severed If a flexor tendonhas been severed, the patient will be unable to extend or flex some portion of thefinger When a nerve has been lacerated, there is a loss of sensation over the tip ofthe finger

Closed fist injuries often result in injury to the extensor tendon and its sheath When

a closed fist injury occurs to someone with a clenched fist, the bacterial load is oftencarried back into the hand as the tendon slides back to its relaxed state (Fig 10–1) Thismeans that the problem of contamination cannot be easily resolved using normalmethods of irrigating and cleaning a wound

Patients who present with dog or cat bites have a wounded area that is painful,red, and swollen Abscess formation may develop

aureus, Streptococcus viridans, Bacteroides spp., and P multocida may be cultured All

patients with lacerations over the metacarpophalangeal joint should be x-rayed forretained teeth fragments, regardless of patient-reported history

Radiographs are used to exclude fractures or foreign bodies (e.g., teeth) ographs can be used to determine if osteomyelitis is present, which has been fre-quently reported in cat bites

Radi-Differential Diagnosis

Puncture wound

Insect bite

Other animal bite

Marine animal bite

Diagnosis

Human Bite to the Hand

There are two major mechanisms of human bites to the hand An example of

pene-trating trauma is a closed fist injury, in which one person strikes another in the

mouth, causing a fight bite to the hand If the hand is clenched in a fist, laceration

of the skin over the knuckle may damage a tendon sheath or tendon, as well as rounding tissue or underlying bones of the joint Wounds over the fingers or other

sur-surfaces of the hand are the result of a direct and deliberate (“chomping”) human

bite (Fig 10–2) The most common site of injury is the third and fourth digits atthe metacarpophalangeal joint Osteochondral fractures are common.

Bite wounds to the hand may cause cellulitis and abscess Human bite wounds areparticularly virulent because of the gram-positive and anaerobic bacteria present inthe mouth

Nonsurgical Management

Patients who present less than 1 day following injury may not have signs of sepsis, andwound exploration and swabbing for aerobic and anaerobic cultures to determine an-tibiotic treatment may be sufficient Treatment includes antibiotics and close observa-tions If their injury is treated within 8 hours, then the wound may be closed, whereasany wound after that time should be left open Close observation in all cases must beperformed Antibiotics recommended may include penicillin G, ampicillin, carbeni-

cillin, or tetracycline for E corrodens, and a cephalosporin for Staphylococcus organisms.

For dog bites, most suspected organisms are sensitive to penicillin Tetanus prophylaxisshould also be included with the use of antibiotics in dog bite injuries The organism in

cat bites, P multocida, is usually sensitive to penicillin.

Surgical Management

In patients where treatment is delayed, signs of sepsis may be present For thesebite wounds, open joint drainage and irrigation may be necessary A wide-openincision should be used for the irrigation and debridement Several liters should

be used in the irrigation This is followed by close observation in the hospital and

knuckle must be treated aggressively with exploration, irrigation, antibiotics, and

drainage (Fig 10–3) Human saliva contains more than 10 9 bacteria per milliliter, and the risk of infection is great Human bite wounds to the hand thus should rarely, if ever be closed.

Animal bite wounds can be closed loosely after debriding the wound edges andthoroughly irrigating in select cases where time is crucial Oral antibiotics are ad-ministered; however, in advanced cases, IV antibiotics should be used

Postoperative Care

Bite wounds are wrapped in a bulky dressing Motion exercises can be started at

24 hours after drainage Follow-up visits should be mandatory at 48 and 72 hoursfollowing treatment The patient should cleanse the wound daily (Fig 10–4)

Complications from bite injuries include osteomyelitis, which is frequently reported

in cat bites, fractures, joint stiffness, and arthritis Less common complications clude digital amputation, systemic sepsis, and death

Dire DJ, Hogan DE, Riggs MW A prospective evaluation of risk factors for

infec-tions from dog-bite wounds Acad Emerg Med 1994;1:258–266.

Grant I, Belcher HJ Injuries to the hand from dog bites J Hand Surg 2000;25B:

Kelly IP, Cunney RJ, Smyth EG, Colville J The management of human bite

in-juries of the hand Injury 1996;27:481–484.

Lewis KT, Stiles M Management of cat and dog bites Am Fam Physician 1995;

52:479–490

Mennen U, Howells CJ Human fight-bite injuries of the hand A study of 100 cases

within 18 months J Hand Surg 1991;16B:431–435.

Moran GJ, Talan DA Hand infections Emerg Med Clin North Am 1993;11:601–

Wiggins ME, Akelman E, Weiss AP The management of dog bites and dog bite

in-fections to the hand Orthopedics 1994;17:617–623.

A B

Figure 11–1 (A) Progressive hand and wrist swelling (B) Eighteen months following a penetrating volar wrist injury by a saltwater fish (With permission from Floyd WE III, Foulkes GD Tuberculous, mycotic, and granulomatous disease In: Peimer CA, ed Surgery of the Hand and Upper Extremity, 1st ed New York: McGraw-Hill; 1996.)

cat-11

Mycobacterial Tenosynovitis

John C P Floyd and Waldo E Floyd III

History and Clinical Presentation

A 66-year-old man employed as a machinist was referred for further evaluation oflimited range of motion and swelling in his left hand and distal forearm, which hadbeen progressive over the past 8 months The patient had been impaled over thevolar aspect of the volar forearm by a saltwater catfish fin 18 months previously Thepatient’s surgical and medical history was otherwise negative

Physical Examination

The patient had limited range of motion in the thumb and small finger and a 4 ⫻ 5

cm cystic mass over the volar aspect of the wrist and distal forearm (Fig 11–1).Over the volar aspect of the thumb, there was marked swelling about the flexor ten-don sheath To a lesser degree, the small finger was also swollen over the flexorsheath and rested in slight flexion at the interphalangeal joints There was limitation

of composite digital flexion, but all flexor tendons were intact Neurovascular ination of the hand was normal No evidence of axillary or epitrochlear node in-volvement was present

exam-Diagnostic Studies

Anteroposterior and lateral radiographs of the left hand were positive for soft tissueswelling No evidence of osseous involvement was present A magnetic resonanceimaging scan demonstrated a 4 ⫻ 5 ⫻ 3 cm mass volar to the pronator quadratus

Figure 11–2 Magnetic resonance imaging scan demonstrating a solid soft tissue mass volar to the pronator quadratus (With permission from Floyd

WE III, Foulkes GD Tuberculous, mycotic, and granulomatous disease In: Peimer CA, ed Surgery

of the Hand and Upper

Extremity, 1st ed New York: McGraw-Hill; 1996.)

without evidence of bone involvement (Fig 11–2) The mass was homogeneousand had a signal intensity consistent with soft tissue

Differential Diagnosis

NeoplasmFungal infectionMycobacterial infectionBacterial infection

Diagnosis

Microbacterial Infection

The diagnosis was a horseshoe abscess of noncaseating granulomatous disease ondary to mycobacteria other than tuberculosis (MOTT) Cultures were positive

sec-for Mycobacterium avium-intracellulare complex.

A major cause of granulomatous infections is mycobacteria Two of the earliest

identified mycobacteria were Mycobacterium tuberculosis and Mycobacterium leprae.

Tuberculosis remains the most common pathologic organism of this genus Hansen’s

disease or M leprae has long been recognized as a separate species, but leprosy is far

less common in most parts of the United States than some of the more newly nized species “Atypical mycobacteria” has traditionally meant a mycobacterium that

recog-is neither tuberculosrecog-is nor leprosy An increased understanding of all nontuberculosrecog-is

infections has led to the introduction of the term mycobacteria other than tuberculosis

(MOTT)

Timpe and Runyon first showed MOTT to be pathogenic in humans in 1954.The Runyon classification system has been used to delineate species on the basis ofpigment production or growth rate in culture Runyon groups I, III, and IV havebeen identified as pathogenic in humans

Mycobacteria may be identified immediately with acid-fast stain, but most often,

as in this case, MOTT is not seen Current microbiologic methods may take 8 to 10

PEARLS

• High index of suspicion

• Obtain a thorough history of

• Treatment should be modified

to the specific species

weeks to identify the slow-growing MOTT In vitro sensitivities may not be able for at least another week.

avail-MOTT infections have become more frequently recognized, especially in compromised patients Contemporary culture and diagnostic techniques have led tothe recognition of several new species of nonpulmonary infections within the immuno-competent population Fifteen percent of all mycobacterial infections and an evenlarger percentage of extrapulmonary mycobacterial infections are of the “atypical” vari-ety They are most commonly encountered in tropical and subtropical areas At our in-stitution, we saw 28 extrapulmonary MOTT infections over the last 4 years compared

immuno-with nine M tuberculosis extrapulmonary infections over the same period.

Because the hand is the major manipulator of the environment, the hand ismore likely to be inoculated with saprophytic bacteria Infection occurs by eithercutaneous or deep (noncutaneous) pathways Cutaneous infections are far morecommon Abrasions on the extremities involving an aquatic environment (swim-ming pools, aquaria, fishing) are the prototypical cases These infections canspread proximally with multiple abscesses resembling sporotrichosis Deep infec-tions in the adult patient present as a spectrum of disease progressing fromtenosynovitis to septic arthritis All species of MOTT can be acquired from prior

trauma except Mycobacterium kansasii, which usually shows no clear mode of oculation Mycobacterium marinum is the most common cause of MOTT infec- tions of the upper extremity followed in frequency by M kansasii Symptoms

in-appear slowly and are only occasionally characterized by typical inflammatorycriteria A thorough remote and recent history is essential in raising suspicion of

a MOTT infection, because MOTT infections are indolent and may presentlong after inoculation

Surgical Management

A zigzag incision was made over the volar aspect of the wrist The median nerve wasidentified and carefully protected A large mass was present about the flexor ten-dons The mass was opened and contained multiple rice bodies (Fig 11–3) Afrozen section biopsy demonstrated the presence of granulomatous disease

Figure 11–3 Significant rice body formation was encountered upon excision

of the flexor compartment Histopathology demonstrated noncaseating granulomatous inflammation, and cultures identified Mycobacterium avium-intracellulare com- plex (With permission from Floyd WE III, Foulkes GD Tuberculous, mycotic, and granulomatous disease In: Peimer CA, ed Surgery of

the Hand and Upper

Ex-tremity, 1st ed New York: McGraw-Hill; 1996.)

Figure 11–4 The thumb and little finger flexor sheaths, respec- tively, represent the distal extent of the radial and ulnar bursae The potential spaces may communicate

at the distal forearm level through Parona’s space volar to the pronator quadratus muscle Inoculation at any site within this space may pro- duce a horseshoe abscess involving the thumb and little finger flexor tendons sheaths as well as a deep compartment infection of the level

of the distal forearm.

This evidence of granulomatous tenosynovitis indicated the need for flexor ovectomy Complete tenosynovectomy was performed with removal of diseased tissuefrom about all flexor tendons Thumb and little finger distal flexor tenosynovectomieswere performed Findings demonstrated a horseshoe abscess pattern of involvement of

tenosyn-the radial and ulnar bursae through Parona’s space (Fig 11–4) The “eight pack” recently

emphasized by Patel provides a simple pattern that should be followed when collecting

a specimen for further diagnosis The “eight pack” consist of smears (Gram stain, acid-fast stain, and fungal KOH stain) and cultures (aerobic, anaerobic, acid fast at 37°C, acid fast

at 30°C, and fungal).

Postoperative Management

An infectious disease specialist consultation was obtained The patient was placed

on a planned 30-day course of rifampin and ethambutol He developed a rashthought to be secondary to the ethambutol, and this medication was discontinuedafter 2 weeks His wounds continued to improve without further evidence of infec-tion, and hand function improved with a formal rehabilitation program

Alternative Methods of Management

Multidrug therapy is acceptable for initial treatment of less severe cases of lomatous disease The efficacy of antibiotic management in MOTT infections has

granu-not been clearly established Most MOTT infections are sensitive, at least in vitro, to

antimycobacterials, but this may not translate into an in vivo response We believethorough surgical debridement should be the primary therapy for all known deep

granulomatous infections M tuberculosis often responds to chemotherapy alone, but

once a diagnosis of a MOTT infection is confirmed, treatment should be modified

to the specific species In the case of most MOTT infections, surgical debridement

is the primary means of effecting a cure, but adjunctive treatment with antibiotics isconsidered appropriate These drugs have multiple side effects and are best managed

by an infectious disease specialist familiar with their use

Complications

Failure to make the correct diagnosis and inadequate surgical debridement aresignificant problems in MOTT infections The immunocompetence of the patientshould be established, and infectious disease consultation should be obtained

Suggested Readings

Dawson DJ, Blacklock ZM, Ashdown LR, Bottger EC Mycobacterium asiaticum

as the probable causative agent in a case of olecranon bursitis J Clin Microbiol

1995;33:1042–1043

Floyd WE III, Foulkes GD Tuberculous, mycotic, and granulomatous disease In:

Peimer CA, ed Surgery of the Hand and Upper Extremity 1st ed New York:

McGraw-Hill; 1996:1766

Foulkes GD, Floyd JCP, Stephens JL Flexor tenosynovitis due to Mycobacterium

asiaticum J Hand Surg [Am] 1998;23A:756.

Gunther SF, Elliott RC, Brand RL, Adams JP Experience with atypical

mycobacter-ial infection in the deep structures of the hand J Hand Surg [Am] 1977;2:90–96 Gunther SF, Levy CS Mycobacterial infections Hand Clin 1989;5:591–598 Hurst LC, Amadio PC, Badalamente MA, et al Mycobacterium marinum infections

of the hand J Hand Surg [Am] 1987;12A:428–435.

Kelly PJ, Karlson AG, Weed LA, Lipscomb PR Infections of synovial tissues by

Mycobacteria other than tuberculosis J Bone Joint Surg Am 1967;49A:1521–1530 Leung PC Tuberculosis of the hand Hand 1978;10:285–291.

Patel MR Chronic infections In: Green DP, ed Green’s Operative Hand Surgery,

4th ed Philadelphia: Churchill Livingstone; 1999:1048–1050

Runyon EH Anonymous mycobacteria in pulmonary disease Med Clin North Am

1959;43:273–290

Timpe A, Runyon EH The relationship of “atypical” acid-fast bacteria to human

disease A preliminary report J Lab Clin Med 1954;44:202–209.

Visuthikkosol V, Aung PS, Navykarn T, Nitiyanant P Tuberculosis infections of the

hand and wrist J Med Assoc Thai 1992;75:45.

Wolinsky E Mycobacteria In: Davis BD, Dulbecco R, Eisen HH, Ginsberg HS, eds

Microbiology 3rd ed Philadelphia: Harper & Row; 1980:724–742.

Wyngaarden JB, Smith LH, Bennett JC Cecil Textbook of Medicine 19th ed.

Philadelphia: WB Saunders; 1992

Section III

Compression Neuropathy

Carpal Tunnel Syndrome

Kevin D Plancher

Pronator Syndrome

Kevin D Plancher

Anterior Interossus Nerve Syndrome

Michael F Bothwell and Kevin D Plancher

B Ulnar Nerve Cubital Tunnel Syndrome

Eric Freeman, Dennis Rodin, and Kevin D Plancher

Ulnar Tunnel Syndrome

Robert M Szabo

C Radial Nerve Posterior Interosseus Syndrome

William B Geissler

D Cervical Nerve Cervical Root Compression

Bradley M Thomas, John M Olsewski, and Jerry G Kaplan

Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy)

Carole W Agin

• Avoid the limited open

tech-nique in patients with distorted

anatomy, fracture of the distal

radius, or fracture dislocation

of carpus.

• Avoid this technique in patients

with marked thenar wasting,

or complete or near loss of

sensory perception

• Always extend the excision

proximally to allow adequate

visualization if limited

tech-nique does not provide direct

visualization

PITFALLS

• Do not use this technique in

recurrent carpal tunnel

syn-drome for a repeat procedure

when an open procedure was

done previously

• Never exert force in passing

instruments across the

liga-ment without good

visualiza-tion to avoid cutting the

median nerve.

12

Carpal Tunnel Syndrome

Kevin D Plancher

History and Clinical Presentation

A 46-year-old right hand dominant woman presents with symptoms of numbness

5 cm proximal to the right wrist crease as well as loss of sensation in her palm overthe thumb area She noticed her hands go to sleep while driving her car Her symp-toms have been present for 4 to 6 weeks, and have been progressively getting worse.The patient denies cramping in her hand and has no palmar hypersensitivity Sheneeds to shake her hands out at night and experiences numbness or tingling to thefingertips The patient spends ~6 hours a day working on a computer

Physical Examination

A positive Tinel’s sign is present directly over the palmar cutaneous branch of themedian nerve, which the patient says simulates her numbness and tingling to thethenar eminence In addition to this, she has an area of numbness of 3 ⫻ 2 cm di-rectly over the area of innervation at the palmar cutaneous branch of the mediannerve in her palm Her Phalen’s test is positive and her Tinel’s test to the wrist

is negative Her median nerve compression test is positive and her Weber statictwo-point discrimination is greater than 1 cm to all her median innervated digits.The patient’s grip strength is 110 on the left and 110 on the right on the Jamardynometer Pinch is 18 pounds on the left and 18 pounds on the right All mea-surements are an average of three trials

Diagnostic Studies

Radiographs are negative for bony or soft tissue abnormalities Electromyograms(EMGs) show nerve conduction velocities significantly slowing at the median nervedistribution more on the sensory fibers, even to the index with proximal conductionand ulnar conduction normal

Differential Diagnosis

Carpal tunnel syndromeNeuroma

ArthritisThyroid diseaseDiabetes mellitusTenosynovitisGout

Figure 12–1 Dumbbell appearance of median nerve after chronic constriction.

Diagnosis

Moderate Carpal Tunnel Syndrome with Compression

of the Palmar Cutaneous Branch of the Median Nerve

Carpal tunnel syndrome is one of the most common conditions of the hand.Swelling of the median nerve or compression of the median nerve by surroundingstructures causes sensory and motor disturbances (Fig 12–1) Chronic repetitivestress on the carpal tunnel and the median nerve within it is the most commoncause of idiopathic carpal tunnel syndrome Occupations that require stress on thewrist, such as typing and carpentry, often lead to a high incidence of carpal tunnelsyndrome Sporting activities that involve repetitive or continuous flexion and ex-tension of the wrist, such as cycling, throwing sports, racquet sports, archery, andgymnastics, also predispose individuals to carpal tunnel syndrome

Carpal tunnel syndrome can be diagnosed by obtaining a careful patient history.Common complaints include nocturnal paresthesia, a heavy feeling, or hands going

to sleep Pain may radiate up the arm to the shoulder and neck Patients also plain of weakness that hinders their ability to grasp objects Numbness when grip-ping objects may prevent the patient from being able to lift objects

com-Nonoperative treatments include activity modification, splinting (Fig 12–2),magnetic support wraps, and injections (Fig 12–3) In younger patients with earlystages of carpal tunnel syndrome, these modalities may relieve symptoms Followingfailed conservative treatment, patients may require surgical intervention to regainlost function Open carpal tunnel release has been shown to relieve symptoms ofmedian nerve compression for many years (Fig 12–4) Endoscopic carpal tunnel re-

Figure 12–2 Custom carpal tunnel splint with wrist in neutral alignment.

Figure 12–4 Classic open carpal tunnel incision.

Figure 12–3 Injection with a high rate of success when done as demonstrated (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.)

Figure 12–5 Local sia administered to the prox- imal palm.

anesthe-lease was shown to reduce tissue trauma and speed postoperative recovery However,the endoscopic technique requires extensive equipment and has a steep learningcurve In our patients, we perform a limited open incision carpal tunnel release.This technique combines the advantages of the open procedure with the advantage

of reduced tissue trauma and postoperative morbidity of endoscopic release

Surgical Treatment

The patient is brought into the operating room and a localized injection of sia is injected at the wrist and into the carpal canal (Fig 12–5) A 2- to 2.5-cm inci-sion (Fig 12–6) is made parallel to the radial side of the ring finger and one-thirddistal to and two-thirds proximal to a proximal line extending slightly off of the dis-tal border of the thenar muscle

anesthe-A Miltex retractor is positioned in the wrist The superficial palmar fascia is cised in line with its fibers and the retractor is placed deeper into the wound (Fig.12–7) A Ragnell retractor is placed in the distal aspect of the incision The soft tis-sue is spread to identify the fat, which pouches up at the distal aspect of the trans-verse carpal ligament Distal and proximal tissues are retracted until at least onethird of the distal transverse carpal ligament can be visualized The ligament is thenincised for a distance of 1 cm The distal end of the ligament is cut until the fatoverlying the superficial palmar arch is exposed The contents of the carpal tunnel,including the median nerve, can now be identified and protected throughout theremainder of the operation (Fig 12–8)

in-A smooth blunt pilot instrument is then placed proximally between the underside

of the transverse carpal ligament and the carpal tunnel contents (Fig 12–9) The strument is withdrawn and a palmar stripper is then placed under the ligament andinto the wound under direct visualization This sharp instrument is designed to pre-pare a channel through the thick connecting tissues directly palmar to the ligament.The stripper is inserted into the groove that was formed by the distal division of theligament and pushed proximally until resistance is felt The design of the instru-ment prevents it from penetrating the ligament The stripper is removed and a dou-ble pilot instrument is introduced This instrument, with long, dull lower and upperskids, allows for full visualization of the passageway beneath the ligament It pro-vides an area for the cutting “tome” to enter and allows for safe passage above andbelow the transverse carpal ligament The pilot is removed and the “tome” guide is

in-deepened through the palmar fascia the wound.

Figure 12–8 (A) The surgeon, although not seeing this anatomy, must understand all the relationships within the wrist (B) Anatomic relationships (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.)

Figure 12–9 The blunt pilot is placed

in the depths of the wound between the underneath surface of the transverse carpal ligament and the contents of the carpal canal.

inserted between the undersurface of the transverse carpal ligament and the carpaltunnel contents To allow for complete division of the transverse carpal ligament,the “tome” guide is placed proximally.

The patient’s wrist is fully hyperextended and positioned in a neutral alignment The

cutting “tome” is inserted into the prepared ligament and passed proximally (Fig.12–10) The cutting “tome” should not be reintroduced after the primary ligamenttransection The cutting “tome” is removed and the contents of the carpal tunnelcan be inspected (Fig 12–11)

The skin is closed and a soft dressing is applied to the palm and wrist (Fig 12–12).Digital range-of-motion and tendon gliding exercises are taught to the patient in theoperating room The patient returns in 2 weeks for suture removal

Figure 12–10 The carpal tunnel tome-cutting blade.

Figure 12–12 A soft tissue, bulky dressing placed after successful division

of the transverse carpal ligament.

Complications

Complications that may occur include stiffness, nerve injury, vascular injury, tions, and incomplete release Although complications are rare, inaccurate diagnosismay predispose the patient to complications Patients with recurrent carpal tunnelsyndrome or with distorted anatomy due to fractures or dislocations should never un-dergo limited open incision carpal tunnel release Open carpal tunnel release shouldalso be performed in patients who have neurologic deficits in the thenar muscle areaand near complete loss of sensory perception

infec-Suggested Readings

Agee JM, McCarroll HR Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA scopic release of the carpal tunnel: a randomized prospective multicenter study

Endo-J Hand Surg 1992;17A:987–995.

Braun RM, Rechnic M, Fowler E Complications related to carpal tunnel release

Hand Clin 2002;18:347–357.

Brown RA, Gelberman RH, Seiler JG III, et al Carpal tunnel release: a prospective,

randomized assessment of open and endoscopic methods J Bone Joint Surg 1993;

75A:1265–1275

Lee WP, Plancher KD, Strickland JW Carpal tunnel release with a small palmar

in-cision Hand Clin 1996;12:271–284.

Plancher KD, Idler RS, Lourie GM, Strickland JW Recalcitrant carpal tunnel The

hypothenar fat pad flap Hand Clin 1996;12:337–349.

Plancher KD, Parekh SR Limited open incision carpal tunnel release Tech Hand

Upper Extrem Surg 1998;2:64–71.

Vasen AP, Kuntx KM, Simmons BP, Katz JN Open versus endoscopic carpal tunnel

release: A decision analysis J Hand Surg 1999;24A:1109–1117.

• EMG slowing in the forearm,

not in the carpal tunnel

• Tinel’s sign in the proximal

forearm

• Pain on long finger flexor

digi-torum superficialis (FDS) flexion

• Negative Phalen’s test

• No nocturnal symptoms

• Numbness of the palmar

cuta-neous branch of the median

nerve

• Pain on resistance to pronation

PITFALLS

• Numbness of the radial 31⁄2digits

• Full knowledge of the anatomy

to avoid a complication on

ex-ploration is essential

13

Pronator Syndrome

Kevin D Plancher

History and Clinical Presentation

A 35-year-old woman presents to our office with symptoms of forearm discomfortconsisting of fatigue-like pain and numbness in her hand She works long hours on

a computer and reports that this repetitive activity is what reproduces the symptoms

in her right arm; however, she denies any symptoms at night The condition hasbeen gradually getting worse

Physical Examination

The patient presents with symptoms of general forearm pain in addition to thesias and hypersthesia in the thumb, index finger, long finger, and radial half ofthe ring finger There is pain on flexion of the long finger at the proximal interpha-langeal (PIP) joint Sensory symptoms are also present over the thenar eminence inthe distribution of the palmar cutaneous nerve

pares-Patient experiences pain on palpation of the median nerve in the proximal forearm

In addition, the pronator teres muscle can be tender, firm, or enlarged Tinel’s sign ispresent on the nerve site just distal to the elbow and paresthesias increase with mildcompression of the proximal muscle mass of the pronator teres Phalen’s test is negative

Diagnostic Studies

Electrodiagnostic tests are suggestive, but not always diagnostic Although slowingwill often show in the forearm, it does not always show in the carpal canal Thethreshold testing with Semmes-Weinstein monofilaments may reveal decreased sen-sibility over the distribution of the median nerve

Needle electromyography (EMG) may be useful if fibrillations, positive sharpwaves, and reduced interference patterns are noted in the pronator quadratus andflexor pollicis longus (FPL) It is important to note that the EMG does not differen-tiate median nerve lesions at the pronator teres from those more proximal

Differential Diagnosis

Carpal tunnel syndromeCompartment syndromePronator syndrome

Diagnosis

Pronator Syndrome of the Right Arm

Pronator syndrome is defined by functional problems of the median nerve due

to some mechanical abnormality at the level of the forearm This disturbance in