Ebook Key notes on plastic surgery (2/E): Part 2

Part 2 book “Key notes on plastic surgery” has contents: The upper limb, the lower limb, the trunk and urogenital, burns, aesthetic surgery, ethics, the law and statistics.Invite to reference.

The Upper Limb

Traumatic brachial plexus injury, 371

Obstetric brachial plexus palsy, 382

• Upper limb bud appears in the flank of the embryo on day 26

• Consists of a core of lateral plate mesoderm covered by ectoderm

∘ This mesoderm will differentiate into bone, cartilage and tendon

• Ectoderm thickens at the tip of the bud in the anteroposterior (AP) axis to form the apicalectodermal ridge (AER)

∘ In the embryo, the AP axis is analogous to the radio-ulnar axis

• The limb bud is initially supplied by a capillary network

• This coalesces into a main stem artery that drains into a marginal vein

∘ Artery becomes the subclavian-axillary-brachial axis

∘ Vein becomes the basilic-axillary-subclavian axis

• The brachial artery branches into interosseous and median arteries

∘ The median artery provides the main blood supply to the hand

∘ It is usually replaced by ulnar and radial arteries around day 44

∘ Regresses to provide the blood supply of the median nerve

• By day 33 a paddle-shaped hand is present

Key Notes on Plastic Surgery, Second Edition Adrian Richards and Hywel Dafydd.

© 2015 John Wiley & Sons, Ltd Published 2015 by John Wiley & Sons, Ltd.

309

• Prechondrogenic condensations of mesenchyme appear where skeletal elements willform.

• Around day 36, nerve trunks enter the arm

• Somitic mesoderm invades the limb and aggregates into dorsal and ventral masses

∘ These differentiate into myoblasts that become muscle

• By day 42, digital rays are present and the hand assumes a webbed appearance

• During the 7th week, upper limbs rotate 90∘ laterally to bring the palm anteriorly

• At the same time, the elbow begins to flex

• During this period, ossification begins and digital separation occurs

∘ This occurs by the apoptosis of tissue between finger rays

• By the 8th week, the upper extremity resembles a miniature adult upper limb

Mechanisms of development

• Our understanding comes largely from transplanting tissue within chick embryos

• Discrete cell signalling pathways establish the three axes of limb development:

Proximodistal axis

• Controls how the limb differentiates into a shoulder proximally but fingers distally

• The critical area is the AER

∘ Resection of the AER results in a truncated limb

∘ Earlier resection results in more proximal limb truncation

∘ Grafting of the AER elongates limbs of chick embryos

• AER produces fibroblast growth factors (FGFs), most importantly FGF 2, 4 and 8

Anteroposterior axis

• Controls how an ulna and little finger develop on one side but a radius and thumb on theother

• The critical area is the zone of polarising activity (ZPA)

∘ ZPA is a cluster of mesenchymal cells in the posterior limb bud margin

∘ Grafting of ZPA cells to the anterior limb margin induces mirror image duplication

• The ZPA produces Sonic hedgehog (Shh)

∘ Higher concentrations of Shh result in more posterior (ulnar) digits being formed

• Cells of the AER and ZPA are interdependent:

∘ FGFs from the AER are required for Shh expression

∘ Shh signal is required to maintain AER integrity

• This may explain why loss of elements often occurs in both AP and proximodistal axes

Dorsoventral axis

• Controls how the limb differentiates into a dorsal and palmar surface

• The critical area is non-AER ectoderm

∘ Removing and replacing ectoderm from a chick limb bud, having reversed its tral polarity, will produce a reversal in the polarity of the underlying mesoderm

dorsoven-• Wnt-7a is a protein encoded by the WNT7A gene

∘ WNT7A is expressed specifically by dorsal limb ectoderm and determines dorsal limbidentity, e.g fingernails

∘ Wnt-7a activates expression of LIM homeodomain factor Lmx1

• In contrast, ventral ectoderm expresses engrailed-1 (en-1), which inhibits Wnt-7a andrestricts its actions to the dorsal ectoderm.

• Failure of these systems produces duplicated palms or circumferential fingernails

Congenital deformities

Classification

• Swanson’s classification is widely accepted

• The following account does not include the full hierarchy of the classification:

I Failure of formation of parts (arrest of development)

• Central ray (cleft hand)

• Intersegmental (intercalated) type of longitudinal arrest

II Failure of differentiation (separation) of parts

A Soft tissue involvement

• Elbow, forearm and carpal synostosis

C Congenital tumorous conditions

VI Congenital constriction band syndrome

• Constriction band either with or without lymphoedema

• Acrosyndactyly

• Intrauterine amputation

VII Generalised skeletal abnormalities

• Chromosomal abnormalities

• Other generalised abnormalities

• This classification is based on work published in the 1960s and 1970s

• As understanding of the pathogenesis has progressed, the shortcomings of the tion have become evident

classifica-• Differentiating between transverse arrest, brachysyndactyly and symbrachydactyly(previously termed atypical cleft hand) can be difficult:

∘ Some consider brachysyndactyly and symbrachydactyly to be the same entity, on a tinuum with transverse arrest, rather than classified as undergrowth

con-∘ Buck-Gramcko wrote in 1999: ‘The Congenital Committee of the IFSSH has recognizedthe problem of symbrachydactyly classification since 1995 but has not come to anyconclusions and recommendations’

∘ Swanson himself noted: ‘Brachysyndactyly could be placed in either Category I or IIbecause of some of its features … Its most obvious failure clinically, however, is hypopla-sia or undergrowth, and for that reason it is placed in Category V’

Failure of formation

Transverse arrest

• Can occur at any level

• Most common at the junction of proximal and middle thirds of the forearm

• Treatment is usually non-surgical with a prosthesis from 6 months

∘ Children with unilateral deformities tend to discard the prosthesis

• When there are metacarpal remnants, these may be amenable to:

∘ Distraction lengthening

∘ Free phalangeal or toe transfer

Longitudinal arrest

Radial deficiency

• A spectrum of abnormalities affecting the radial side of the forearm

• Radius, radial carpus, thumb, tendons, ligaments, muscles, nerves and blood vessels canall be involved

• Most common type of longitudinal failure of formation, affecting one in 55,000 live births

• Usually manifests as hypoplastic or absent radius with radial deviation of the hand –formerly known as ‘radial club hand’.

Associated abnormalities

• Up to 40% of unilateral and 77% of bilateral cases are syndromal

• All require assessment by a paediatrician and geneticist

• Associated conditions include:

∘ Holt–Oram syndrome

– Cardiac septal defects and various upper limb malformations

– Autosomal dominant inheritance

∘ VACTERL association

– Vertebral anomalies, Anal atresia, Cardiac defects, Tracheal anomalies (including tracheo-oesophageal fistula), Esophageal atresia, Renal and radial abnormalities, other Limb abnormalities.

∘ TAR syndrome

– Thrombocytopaenia-Absent Radius; autosomal recessive inheritance.

– The thumb is usually present in TAR

∘ Fanconi’s anaemia

– Rare autosomal recessive cause of bone marrow failure

– Radial deficiency affects 40%; aplastic anaemia develops around 6 years

– Fatal without bone marrow transplantation

Clinical features

• Short forearm, bowed on the radial side

• Complete or partial absence of the radius, which may be replaced by a fibrous anlage

∘ [In German, Anlage (pronounced ann-lager), means ‘foundation’ or ‘plan’]

• Radially deviated hand with reduced passive wrist motion

• Radial skin deficiency with relative excess on the ulnar side

• Hypoplastic or absent thumb

• Flexion contracture and stiffness of the radial digits

• Elbow stiffness, which may be due to bony fusion (synostosis)

• Proximal muscles of the arm and shoulder can also be affected

• Bilateral and unilateral involvement are equally common

∘ Involvement of the contralateral limb may be subtle and asymmetric

Classification

• Classified into four types by Bayne and Klug:

∘ Type I: Short distal radius

∘ Type II: Hypoplastic radius

∘ Type III: Partial absence of the radius

∘ Type IV: Total absence of the radius

Treatment

• Based on age, severity and degree of functional deficit

• Physiotherapy to elbow and wrist prevents progressive stiffness and maintains range ofmotion

∘ Parents should do this at least twice a day

• Mildest deformities can be treated with physiotherapy alone

• Splintage is difficult to apply and adds little benefit

• External fixators are widely used to distract radial soft tissues prior to surgery

Surgery

• Performed around 12 months, but this varies

• The following abnormalities may be found:

∘ Variable deficiencies of the radial forearm structures

∘ Aberrant radial wrist extensors and extrinsic thumb muscles

∘ Absence of the radial artery

∘ Absence of the radial nerve below the elbow

∘ Median nerve is always present – often the most radial structure of the wrist

• Centralisation

∘ Carpus is repositioned over the ulna and stabilised with a pin through the thirdmetacarpal and carpus into the ulna

– Usually requires extensive soft tissue release

∘ Radial wrist extensors are transposed onto extensor carpi ulnaris (ECU) to counter theradial deforming force

∘ Some recommend transposing redundant skin from the ulnar wrist to release the radialcontracture

• Radialisation

∘ Scaphoid is placed over the ulna and secured with a pin through the second carpal

meta-∘ Transfer of flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) to the ulnar carpus

or fifth metacarpal decreases the radial deforming force

• Microvascular joint transfer

∘ Centralisation and radialisation are associated with high recurrence rates

∘ They also have the potential to injure the distal ulnar physis, causing growth arrest

∘ Vilkki described vascularised transfer of the second MTPJ to avoid these problems

∘ It is technically demanding and not widely practised

• Pollicisation of the index finger

∘ Indicated for cases with a severe hypoplastic thumb

∘ Aims to reproduce thumb function by shortening and rotating the index finger

1 A radial palmar incision is made, creating skin flaps at the base of the index finger.

• Allows subsequent creation of a first webspace

2 Ulnar digital nerve is mobilised by interfascicular dissection of the common digital

nerve to the index-middle finger web

3 Radial digital artery to the middle finger is ligated and divided.

4 Interossei are elevated from the index finger metacarpal.

5 Index metacarpal is removed, except for its head, which forms the new trapezium.

• The epiphysis is resected to prevent subsequent growth

6 Metacarpal head is rotated 160∘ – this will subsequently relax to 120∘, ideal for

opposition

• Secured with K wires in 40∘ of palmar abduction with metacarpophalangeal joint(MCPJ) hyperextended

7 The length of metacarpal removed is measured and a similar length of flexor and

extensor tendon is excised

• Some do not remove tendon because they are said to shorten over time

8 Rebalancing the intrinsics is essential:

• First dorsal interosseous is sutured to the radial lateral band to become abductorpollicis brevis (APB)

• First palmar interosseous is sutured to the ulnar lateral band to become adductorpollicis

• Extensor indicis proprius (EIP) acts as extensor pollicis longus (EPL)

• Extensor digitorum communis (EDC) to the index finger acts as the abductor licis longus (APL)

pol-• Many children require opponensplasty between 5 and 8 years

Ulnar deficiency

• One-tenth as common as radial deficiency

• Spectrum of abnormalities, from hypoplasia of ulnar digits to absence of ulna

• Hand and carpus are always affected: missing digits, syndactyly, thumb abnormalities

• It differs from radial deficiency:

∘ The wrist is stable but elbow unstable

∘ Associated more with musculoskeletal abnormalities than cardiovascular

∘ Total absence is most common for the radius; partial absence is most common for theulna

∘ Less likely to occur as part of a syndrome

Classification

• Classified by Bayne into four types:

∘ Type I: hypoplasia of the ulna (both proximal and distal epiphyses present)

∘ Type II: partial aplasia of the ulna (absence of the distal or middle third)

∘ Type III: total aplasia of the ulna

∘ Type IV: radiohumeral synostosis

Treatment

• Depends on the nature and severity of the deformity; there is no consensus view

• Release of the fibrous anlage with realignment of the carpus and forearm

∘ The anlage, present in types II and IV, is claimed to increase ulnar deviation of the handand ulnar bowing of the radius as the child grows

• Hand function is improved as required by:

∘ Separating any syndactyly

∘ Deepening the first webspace

∘ Thumb reconstruction: opponensplasty, rotation osteotomy or pollicisation

• Rotation osteotomy of the humerus improves hand position for some cases of humeral synostosis

radio-Central deficiency

• Also known as cleft hand

• Historically, cleft hand was divided into typical and atypical types

Typical cleft hand

• V-shaped cleft in the centre of the hand; one or more digits may be absent

• Often bilateral; frequently involves both the hands and feet

• Family history is common – inheritance is autosomal dominant

• May form part of a syndrome, e.g split-hand/split-foot, EEC (ectrodactyly, ectodermaldysplasia, facial clefts)

• First webspace often narrowed

• ‘Transverse metacarpals’ can further widen the cleft over time

• Phalanges may have longitudinally bracketed epiphyses or duplications

Classification of typical cleft hand

• The Manske and Halikis classification focuses on the first webspace:

∘ Type I: normal web

∘ Type IIA: mildly narrowed web

∘ Type IIB: severely narrowed web

∘ Type III: syndactylised web (first webspace is obliterated)

∘ Type IV: merged web (index ray suppressed; first webspace merged with the cleft)

∘ Type V: absent web (thumb elements suppressed; first webspace not present)

Treatment of typical cleft hand

• Patients usually have good hand function

• Labelled ‘a functional triumph, but a social disaster’

• Early surgery may be required to prevent progressive deformity:

1 To separate syndactyly between unequal digits, especially thumb-index.

2 To remove transverse bones that would worsen the cleft with growth.

• Other surgery can be postponed until between 1 and 2 years:

1 Release or reconstruction of the first webspace.

2 Closure of the cleft.

– Snow-Littler technique: palmar-based flap from the cleft is transposed to the firstweb

– Miura and Komada method: simpler – palmar and dorsal flaps are redraped.– 2nd metacarpal is transferred to the 3rd metacarpal base and secured with K wires

• Transposing the 2nd metacarpal at the level of its neck may preserve the adductorpollicis origin from the 3rd metacarpal

– Deep transverse metacarpal ligament is reconstructed using adjacent A1 pulleys,unfolded towards one another

3 Creation of a thumb for cases where it is absent.

– Pollicisation or, if no radial ray available, free toe transfer

4 Addressing the foot deformity

– Only indicated when there are difficulties fitting footwear

– The fibular ray is the most important for weight bearing and gait.

– The tibial toe can usually be transferred to the hand if required

Atypical cleft hand

• Now known as symbrachydactyly

• Characterised by short vestigial digits, like small nubbins

∘ Often have vestigial nails

• May occur with Poland’s syndrome

• Symbrachydactyly, in contrast to central ray deficiency:

∘ Is usually unilateral

∘ Seldom involves the feet

∘ Is not usually associated with a family history

• Its place within Swanson’s classification is controversial

∘ Probably not a longitudinal central ray deficiency

Classification of symbrachydactyly

• Blauth and Gekeler classify symbrachydactyly into four types:

∘ Short finger type – a thumb and four short stiff digits

∘ Oligodactylic type – central aplasia – the classic ‘atypical cleft hand’

∘ Monodactylic type – a thumb and four nubbins

∘ Peromelic type – complete absence of fingers and thumb

Treatment of symbrachydactyly

• Short finger type usually have excellent function

∘ Some may require syndactyly release or free phalangeal bone transfer

• Oligodactylic type achieve pincer grip with thumb and little finger

∘ Metacarpal rotation osteotomy can improve the position of these digits

• Some oligodactylic and monodactylic types may be suitable for toe-to-hand transfers ifmetacarpals and extrinsic tendons are present

• Peromelic type is difficult to reconstruct due to lack of proximal structures

Intersegmental deficiency

• ‘Phocomelia’ is the historical term for intercalated deficiency of the upper limb

∘ Phocomelia derives from the Greek, meaning ‘seal limb’, i.e a flipper

• The hand is always present

• Prevalent in the 1960s due to the use of thalidomide for hyperemesis gravidarum

∘ Worldwide, thalidomide is still used as an anti-angiogenic drug to treat leprosy andmyeloma

• Frantz and O’Rahilly classify phocomelia into three types:

∘ Type I: complete – the hand is directly attached to the trunk

∘ Type II: proximal – the forearm and hand are attached to the trunk

∘ Type III: distal – the hand is attached to the humerus at the elbow

• A prosthesis may be required if the hand cannot reach the mouth

• Surgery, usually to stabilise the limb, is rarely indicated

Failure of differentiation

Soft tissue failures of differentiation

Syndactyly

• Derived from the Greek, ‘syn’ – ‘together’ and ‘dactylos’ – ‘digit’.

• May result from failure of apoptosis in interdigital tissue

• Occurs once every 2000 live births

• One of the two most common upper limb malformations, the other being polydactyly

• 20% have a family history (autosomal dominant); 50% are bilateral

• Twice as common in males

• Most common in Caucasian races

• May be associated with other deformities such as Apert’s and Poland’s

Classification

• Complete – digits fused to the level of the tips

• Incomplete – fusion does not extend to the tips

• Simple – only soft tissue connections between the digits

• Complex – soft tissue and bony connections between the digits

• Complex complicated – associated accessory digits or phalanges within the syndactyly

• Acrosyndactyly – characterised by fused distal parts of the fingers

∘ Small spaces (fenestrations) are always present between the digits proximally

∘ Pathogenesis of acrosyndactyly is different from other forms of syndactyly:

– Distal parts of the digits are thought to re-fuse due to constriction ring syndrome

Clinical features

• Middle-ring finger web is most commonly affected – 58% of cases

∘ 27% ring-little finger web

∘ 14% middle-index web

∘ 1% thumb-index web

• Nail fusion (synonychia) with loss of the paronychial fold suggests synostosis of the distalphalanges

• Associated limb, chest wall and foot abnormalities

• Radiographs may show synostosis, synpolydactyly or other anomalies

• More complex syndactyly is associated with tendon, nerve and vessel anomalies

• Variable vascular anatomy and distal bifurcation of common digital vessels can lead tovascular compromise following separation

Indications for surgical correction

• Not usually performed before 1 year of age

• Aim to have separation completed by school age

• Indications for earlier surgery, as soon as the child is deemed fit, include:

∘ Syndactyly of thumb-index or little-ring fingers

– Released early because length discrepancy can cause deformity with growth

Principles of surgical correction

• Aim to separate the digits, provide a lined commissure, create minimal scarring

• The normal webspace slopes 45∘ dorsal to palmar and runs from the metacarpal heads tothe midpoint of the proximal phalanx

• Most techniques share the following principles:

∘ Release only one side of a digit at a time to avoid jeopardising finger vascularity

∘ If multiple digits are involved, surgery is staged:

– First stage: release thumb-index and middle-ring fingers

– Three months later: release index-middle and ring-little fingers

∘ The bifurcation of the digital NVB may be distal to the position of the new webspace.– Web release is therefore limited to the level of the bifurcation, unless:

• The other side of the finger is not operated on, allowing the bifurcation to bedivided

• There is definitely a second digital artery to supply the finger

– Alternatively, vein grafts can be used to lengthen the artery

∘ The nerve can be separated by interfascicular dissection

∘ Linear incisions are avoided due to the risk of scar contracture

∘ The web is reconstructed with proximally based dorsal or volar flaps

– Skin grafts in the web spaces can result in web creep

∘ Dorsal and volar interdigitating flaps close defects along the borders of the digits.– Full thickness skin grafts may be required to resurface residual raw areas

∘ Mild first web syndactyly can be released with local flaps, e.g four-flap Z-plasty

∘ Severe syndromal syndactyly may require transposition flaps, tissue expansion ordistant/free flaps

∘ Hyponychial interdigitating flaps, described by Buck-Gramcko, can reconstruct thelateral nail fold

• Complications include: vascular compromise, infection, dehiscence, graft loss

∘ The commissure may be pulled distally by scar contraction (web creep)

∘ Scars may cause joint contracture

∘ Joint instability, due to insufficient collateral ligaments

Camptodactyly

• From the Greek, meaning ‘bent finger’

• Characterised by progressive flexion deformity of the proximal interphalangeal joint(PIPJ)

• Often bilateral; most commonly involves the little finger

• Affects<1%.

• Virtually anything crossing the volar aspect of the finger may cause camptodactyly

∘ Most commonly an abnormal lumbrical insertion or short flexor digitorum superficialis(FDS)

• Examining PIPJ extension with the MCPJ alternately flexed and extended can ate between intrinsic and extrinsic causes

differenti-• Function is rarely affected; treatment is usually sought for the appearance.

• Bone and joint abnormalities on x-ray are usually secondary changes rather than theprimary cause

Classification

• Type I: presents during infancy; most common type Most do not require treatment

• Type II: presents during preadolescence (age 7–11); affects girls more than boys

∘ Often progresses to a severe deformity

• Type III: severe type associated with various syndromes

Treatment

• The majority of cases with contractures<40∘ are treated conservatively.

∘ Involves stretching exercises, splinting and serial casting

• Difficult to correct surgically

• Radiological signs that indicate the deformity may be difficult to correct:

∘ Narrowing of the joint space

∘ Indentation of the neck of the proximal phalanx

∘ Flattening of the head of the proximal phalanx

• Surgical options:

∘ Exploration and release of any tethering structures

∘ FDS tendon transfer to the extensor surface

∘ Angulation osteotomy

∘ Arthrodesis

Trigger thumb

• ‘Congenital’ trigger thumb is a misnomer because it is not found in newborns

∘ Also, the thumb does not usually ‘trigger’ – it is typically fixed in flexion

• Prevalence at 1 year is 3 per 1000; bilateral in up to 30%

• Trigger thumb likely develops with postnatal growth

• Notta’s nodule is always present

∘ May be palpable within flexor pollicis longus (FPL) just proximal to the A1 pulley

• Trigger finger is less common than trigger thumb

∘ The pathology may lie at the A1 pulley and/or at the decussation of FDS

Treatment

• Observation is reasonable under 1 year of age

∘ 30% resolve spontaneously within the first year

• Joint contractures do not occur if release is delayed until age 3

• When to operate is agreed between surgeon and parents, considering the risks andbenefits

• Surgical treatment involves release of the A1 pulley

• Diagnosis often delayed because infants hold thumbs in their palms for the first

3 months

• Extension lag of the MCPJ differentiates it from trigger thumb

Treatment

• Goal of treatment is to restore the thumb’s ability to grasp

• Initial treatment is splintage in extension for up to 6 months

∘ Effective when commenced<1 year.

• Surgery indicated if splintage fails, or the child is older than 2 years

• Adduction contracture requires release of the first web

• Tendon transfers or grafts to the extensor mechanism for severe deformities that remainpassively correctable

• Joint fusions for malpositioned fixed deformities

Arthrogryposis

• From the Greek, meaning ‘curved joint’

∘ Also known as arthrogryposis multiplex congenita

• A syndrome of non-progressive joint contractures present at birth

• Spectrum of severity and many different types, including clasped thumb and windblownhand

• Most common types occur sporadically; can be part of Freeman–Sheldon syndrome

• Proposed aetiology is lack of motion during fetal development, leading to joint tures

contrac-∘ Can be caused by neuromuscular abnormalities, restricted intrauterine space, vascularinsufficiency or maternal illness

∘ There may be reduced numbers of spinal anterior horn cells

Clinical findings

• Congenital contractures, usually symmetrical and bilateral

• Adduction and internal rotation of the shoulders

• Elbows fixed in extension with pronated forearms

• Wrists flexed with the hand in ulnar deviation

• Flexed and stiff digits

• Lack of subcutaneous tissue and muscle wasting

• Thin, waxy skin with no joint creases

• Lower limb involvement is an important consideration

Treatment

• Goals of treatment:

1 Independent function for feeding and perineal care.

2 Maintaining or increasing passive and active motion.

3 Preserving bimanual function.

• A team approach is required, with the help of adaptive equipment

• Treatment begins early:

∘ Dynamic and static splintage

∘ Passive stretching and range of motion exercises

• Surgical intervention is controversial; indicated for specific functional problems:

1 Recalcitrant elbow contracture release.

2 Restoration of elbow flexion with muscle transfers.

– Examples include partial triceps, pectoralis major or free gracilis

3 Distraction lengthening of wrist soft tissues.

– Dorsal wedge osteotomy of the radius and tendon transfer may allow use of a board

key-4 Reconstruction of a clasped thumb.

Skeletal failures of differentiation

Clinodactyly

• From the Greek, meaning ‘inclined finger’

• Characterised by curvature of a digit in the radio-ulnar plane

• Associated with many syndromes, including 25% of Down’s syndrome

• Most commonly affects the little finger

• Usually turns the fingertip towards the middle finger

• The cause is usually deformity of the middle phalanx – often a triangular shaped deltaphalanx

∘ Formed by a J- or C-shaped epiphysis, which extends onto the lateral side of thephalanx

∘ Also known as a longitudinal bracketed epiphysis

• Growth from the longitudinal arm of the epiphysis results in abnormal lateral growth ofthe bone

• Kirner’s deformity should not be confused with clinodactyly:

∘ Progressive palmar-radial curvature of the distal phalanx, usually the little finger

∘ Develops in adolescence; can be inherited or occur sporadically

∘ Almost never affects function

Treatment

• The majority of cases are mild and should be discouraged from surgery

• Surgery considered if function is limited

∘ This should be delayed until skeletal maturity

• Wedge osteotomy corrects the angulation

∘ Usually an opening wedge because the finger is often short

∘ Exchange wedge osteotomy inserts the wedge excised from the longer side of the lanx into an opening wedge osteotomy on the shorter side

pha-• Soft tissue shortage may require Z-plasty or local flaps

• Resection of the epiphyseal bracket with interposition fat graft was described by Vickers

Symphalangism

• Congenital fusion of one phalanx to another within the same digit

• Associated with a number of other conditions, including:

∘ Syndactyly

∘ Apert’s syndrome

∘ Poland’s syndrome

∘ Radial longitudinal deficiency

• Flexion and extension creases over the affected joints are absent

• Radiological changes:

∘ Short middle phalanges

∘ Poorly developed joints and epiphyses

Treatment

• Managed conservatively with physiotherapy and splintage

• Osteotomy or arthrodesis is considered once skeletally mature

Synostosis

• Abnormal fusion of two bones

• Can occur at any site where two bones are adjacent to one another

• Synostosis between phalanges occurs in complex syndactyly

• Carpometacarpal, intercarpal and radiocarpal synostosis seldom require surgery

• Radio-ulnar synostosis poses functional problems if both forearms are affected

• Rotational osteotomy through the synostosis is performed around 5 years of age

∘ Aims to fix the dominant limb in 10∘ –20∘ pronation and the other midprone

∘ Allows eating, writing, bimanual manipulation and perineal care

Duplication

• Can involve the whole limb or any part of the limb

• Polydactyly is when more than five digits are present in a hand

∘ One of the most common upper limb malformations

∘ Extra digits may be located on the ulnar border, centre or radial border

Ulnar polydactyly

• Also known as postaxial polydactyly

• Usually an autosomal dominant trait with variable penetrance

• Often associated with syndromes in Caucasians

∘ Other systemic abnormalities should be sought

• Often bilateral; commoner in boys

• Incidence is 1:2000 among Caucasians; 1:150 among African Americans

• Stelling classification of polydactyly:

∘ Type I: soft tissue mass without skeletal structure

∘ Type II: digit contains all normal components and articulates with a normal or bifidmetacarpal or phalanx

∘ Type III: complete digit with metacarpal

Treatment

• Type I: excised under local anaesthetic in the first few weeks of life

∘ Avoids a residual nubbin resulting from simple ligation

• Types II and III: surgical excision and reconstruction of soft tissue elements:

∘ Attachments of the ulnar collateral ligament (UCL) and abductor digiti minimi (ADM)are transferred to the adjacent finger

Central polydactyly

• Rarest form of duplication; affects the ring finger in most cases

• Stelling type II variants usually occur with syndactyly

Treatment

• Types I and III: excision with soft tissue reconstruction

• Type II synpolydactyly may share tendons, nerves and vessels with adjacent fingers

∘ The most suitable skeletal and tendinous elements are selected to create the best digit

Radial polydactyly

• Refers to duplication of the thumb – preaxial polydactyly

• Isolated thumb polydactyly is usually unilateral and sporadic

• Syndromal association is documented but rare

∘ Children should be screened for Fanconi’s anaemia

• Unlike ulnar polydactyly, it affects Caucasians more than African Americans

• Typically, there is a degree of hypoplasia of both duplicates

• Neurovascular anatomy is variable; most have only one vessel to each duplicate

Classification

• Wassell’s classification, with prevalence of each type:

∘ Type I: bifid distal phalanx (2%)

∘ Type II: duplicated distal phalanx (15%)

∘ Type III: bifid proximal phalanx with duplicated distal phalanx (6%)

∘ Type IV: duplicated proximal and distal phalanx (43%)

∘ Type V: bifid metacarpal with duplicated proximal and distal phalanx (10%)

∘ Type VI: duplicated metacarpal, proximal and distal phalanx (4%)

∘ Type VII: triphalangeal thumb accompanied by a normal thumb (20%)

Surgical correction

• The goal is to create the best thumb possible using parts of each duplicate:

∘ A well-aligned thumb with stable joints, balanced motor functions and a cosmeticnailplate

• Surgery is usually done at 1 year, prior to development of thumb-index pinch

• In deciding which duplicate to retain, consider:

∘ Size – occasionally one is rudimentary

∘ Deviation – at the point of duplication or at distal joints

∘ Function – can differ between duplicates; functions may be shared

– Flexion in one but extension in the other

∘ Passive mobility – both normal and abnormal

∘ Radiological appearances – may reveal a triphalangeal thumb

• Surgical options:

1 Removing one duplicate and reconstructing the other.

– For types III and IV, or types I and II with significant asymmetry

– The radial duplicate is usually proximal and smaller than the ulnar

– Radial collateral ligaments should be reconstructed

• Usually by taking a periosteal sleeve from the digit to be amputated

– Intrinsic muscles are reattached in a similar fashion

– Additional articular facets of the proximal joint surface are excised

• Improves angular deformity

– The reconstruction is protected with a transarticular K wire for 4 weeks

– Principles of treatment are similar for types V and VI

• More complex reconstruction of the intrinsics is required

• In addition, first webspace narrowing may need to be addressed

2 Removing parts of both duplicates and combining the remaining tissue.

– Symmetric types I and II are treated this way

– The Bilhaut-Cloquet procedure shares equal parts of each:

• Remove adjacent inner halves of each duplicate

• The remaining outer segments are brought together and secured with sutures or

K wire

– Problems include nail deformity, epiphysiodesis and joint stiffness

– Proposed modifications involve unequal sharing of parts:

• The entire nail bed is taken from one of the duplicates

• Bone resection preserves the entire physis and joint surface from one of theduplicates

Triphalangeal thumb polydactyly

• The duplicate has three rather than two phalanges

• Relatively common; usually an autosomal dominant trait

• The extra ‘middle’ phalanx may be:

1 Triangular (a delta phalanx)

2 Rectangular but short

3 Rectangular and normal length.

• Treatment follows the principles above

• If the triphalangeal duplicate is retained, the extra interphalangeal joint (IPJ) must beaddressed:

∘ Any delta phalanx is excised and soft tissues reconstructed

∘ If the extra phalanx is rectangular – chondrodesis of the least mobile joint

Mirror hand

• Rare condition – symmetrical duplication of the limb in the midline

∘ Quoted incidence of 60 cases per 300 years

• A central digit with three fingers either side representing middle, ring and little

• Results in a hand with at least seven fingers but no thumb

• The forearm has two ulnae (no radius) that support a duplicated ulnar carpus.

• The elbow is usually stiff and forearm rotation reduced

• The surgical anatomy is variable and complex

Treatment

• Passive stretching and mobilisation of the elbow

• Fabrication of a first webspace

• Pollicisation and reducing the number of fingers

• It is a rarely performed operation, even for congenital hand specialists

Overgrowth

Macrodactyly

• Enlargement of a digit noted at birth, or within the first years of life

• True macrodactyly is enlargement of both the soft tissue and skeleton of a finger

• Aetiology is unknown

• It is distinct from conditions such as haemangiomas, vascular malformations and Ollier’sdisease (multiple enchondromatosis) where overgrowth is due to a specific lesion

• Macrodactyly is usually unilateral; the index finger is most commonly affected

• Multiple digits can be involved; can also affect toes

• Enlargement often corresponds to the cutaneous distribution of specific nerves

∘ ‘Nerve territory-oriented macrodactyly’ describes this relationship

Classification

1 Static macrodactyly: the enlarged finger grows in proportion to the rest of the hand.

2 Progressive macrodactyly: the enlarged finger grows out of proportion to the rest of the

hand

• Flatt classifies macrodactyly according to the pathology:

∘ Type I: Lipofibromatosis

– Epineural and perineural fibrosis with fatty infiltration of the nerve

∘ Type II: Neurofibromatosis

– Occurs in conjunction with plexiform neurofibromatosis

∘ Type III: Digital hyperostosis

Osteochondral periarticular nodules but no nerve enlargement

∘ Type IV: Hemihypertrophy

– Commonly known as Proteus syndrome

Surgical correction

• Complicated by delayed healing due to relative vascular insufficiency (vessels are rarelyenlarged)

• Surgical options are usually inadequate:

∘ Soft tissue reduction, including digital nerve stripping

∘ Osteotomy

∘ Epiphysiodesis

∘ Amputation

Thumb hypoplasia

• Most common site of clinically significant undergrowth

• Part of radial longitudinal deficiency – associated with the same syndromes

∘ Children should be screened for Fanconi’s anaemia

– Hypoplastic thenar muscles

– Adduction contracture of the first web

– Insufficiency of the UCL at the MCPJ

∘ Type III

– Features of type II plus abnormal extrinsic tendons

– Skeletal abnormalities further subclassify type III (Manske et al.):

• A: stable carpometacarpal joint (CMCJ)

• B: unstable CMCJ

∘ Type IV

– Small thumb attached to the hand by a soft tissue bridge

– Known as a floating thumb or ‘pouce flottant’.

∘ Type V

– Total absence of the thumb

Surgical correction

• Usually done at 1–2 years when thumb function is developing

• Type I: good function; do not require surgery

• Type IIIB, IV and V: ablation of any thumb elements and pollicisation

∘ Pollicisation is described under ‘Radial deficiency’

• Type II and IIIA are reconstructed as follows:

1 First webspace release with, e.g four-flap Z-plasty.

– May require release of the first dorsal interosseous from the second metacarpal

2 UCL reconstruction.

– UCL deficiency may be primary or secondary to a pollex abductus

• This is an abnormal connection between FPL and EPL

– Any pollex abductus is released and the MCPJ stabilised:

• Chondrodesis (joint fusion), or

• Tendon graft to augment the vestigial UCL, or

• UCL reconstruction incorporated into an FDS opponensplasty

3 Opponensplasty to augment hypoplastic thenar muscle function.

– Using the ring finger FDS is favoured by many due to its length, power and ability toreconstruct the UCL

– Others prefer the Huber transfer (ADM to APB)

4 Extrinsic tendon reconstruction.

– EIP can be transferred to EPL

– Reconstructing FPL may need pulley reconstruction in addition to tendon transfer

• Surgery is seldom required – function is relatively well preserved

∘ Surgery frequently produces stiff fingers

• Brachymetacarpia may be corrected by distraction osteogenesis to restore normal cascade

Madelung’s deformity

• Excessive radial and palmar angulation of the distal radius caused by growth disturbance

of the palmar and ulnar portion of the distal radial physis

• An abnormal palmar ligament may tether the lunate to the radius (Vickers’ ligament)

• Deformity becomes apparent in early adolescence; usually bilateral

• The distal ulna is prominent dorsally; ulnar deviation of the wrist is limited

• The forearm is usually short but function is minimally impaired

• More severe cases may be limited by pain

• Madelung’s may form part of Leri–Weill dyschondrosteosis, a genetic condition resulting

in short stature

∘ For this reason it is sometimes classified as a ‘generalised skeletal abnormality’

Treatment

• No treatment is required for painless deformities

• Surgery may involve:

1 Resection of Vickers’ ligament and dome osteotomy to correct the radius.

2 Closing wedge osteotomy of the radius with ulnar shortening.

3 Opening wedge osteotomy of the radius.

4 Osteotomy of the radius and distal ulnar resection.

5 Osteotomy of the radius and a Sauvé–Kapandji procedure.

– This fuses the distal radio-ulnar joint (DRUJ) and resects a segment of ulna to allowforearm rotation

Constriction ring syndrome

• Constriction rings, or amniotic bands, form partial or complete circumferential tions around limbs or digits

constric-• This can lead to:

1 Acrosyndactyly

2 Terminal absence or amputation

3 Localised swelling with oedema distal to the constrictions.

• Occurs sporadically; affects one in 15,000 live births

• 50% of cases are associated with talipes equinovarus, cleft lip and palate, haemangioma,and cranial or cardiac defects.

• Aetiology may be disruption of the amniotic membrane with release of amniotic bands

that encircle limbs in utero.

Classification

• Patterson’s classification:

1 Simple constriction rings

2 Rings accompanied by distal deformity, with or without lymphoedema

3 Rings accompanied by distal fusion: acrosyndactyly

4 Intrauterine amputations.

Surgical correction

• Digital ischaemia at birth is rare

∘ Requires surgical release, although the distal limb rarely survives

• Centres of expertise have released bands fetoscopically

• Nerve palsies can be difficult to treat because there may not be a distal nerve trunk

• Treatment of the ring itself is done for cosmesis and function

• Excision of the constriction band and soft tissue release with Z or W plasties is done formost cases

• Traditionally, no more than half the circumference was released at one sitting due to risk

of distal ischaemia

∘ However, complete circumferential release can be performed safely

• Principles of acrosyndactyly management are similar to syndactyly

• Intrauterine amputations, in contrast to other congenital causes of absent digits, haveintact proximal bone, tendon and neurovascular structures

∘ This makes toe transfer an attractive option for restoration of function

• Hand dominance, occupation, hand-critical hobbies

• Mechanism of injury and forces involved

• Time of injury, particularly ischaemia time

• If machinery is involved:

∘ Configuration of the moving parts

∘ How much force it delivers

∘ What material is normally cut or deformed by the machine

∘ Are parts of the machine heated and to what temperature?

• If an electrical saw is involved: thickness of the saw blade

• The direction a knife or shard of glass entered the skin.

• Position of the hand at the time of injury

Examination

1 Is the injured hand or finger viable?

2 Vascular injury or compartment syndrome?

3 Tendon, nerve or bony injury?

4 True skin loss, or impending skin loss?

• Plain X-rays assist with pre-operative assessment

• Fractures and dislocations present with swelling, deformity and loss of function

∘ On palpation, there is tenderness, crepitus and abnormal motion

– Abnormal motion is also seen with periarticular ligament injury

• Tendons are initially assessed by inspecting the posture of the hand

• Passive flexion and extension of the wrist can demonstrate tendon integrity by the odesis effect

ten-∘ However, partial tendon division or isolated FDS division will appear normal

∘ Intrinsic muscles can extend IPJs even when extrinsic extensors are divided

• Active motion of each tendon is then tested independently

• Composite motion produces the following grip types:

1 Power grip

2 Pinch grip

– Pure (tip) pinch

– Tripod pinch

– Key (lateral) pinch

• Nerve injuries present with sensory loss, motor loss or both

• Sensation is grossly assessed by stroking within a nerve territory and simultaneously paring with the uninjured hand

com-• Sweating is lost in the distribution of a divided peripheral nerve

∘ Skin feels smooth and dry

∘ The tactile adherence test assesses sweating by lightly dragging the smooth surface of aplastic pen along the skin

• Sensation is assessed more objectively by static and dynamic two-point discrimination(2PD):

∘ If a specific tool is unavailable, a paper clip can be folded into two points

∘ The pressure applied should not result in blanching

∘ Guideline values for normal 2PD are:

– Distal phalanx pulp – 4 mm

– Middle phalanx pulp – 5 mm

– Proximal phalanx pulp – 6 mm

• Paralysis of APB most reliably indicates median nerve injury.

• Paralysis of FDM most reliably indicates ulnar nerve injury

∘ Other intrinsic muscles may be cross-innervated

Position of safe immobilisation (POSI)

• Immobilising the hand has the following advantages:

∘ Pain relief

∘ Reduction of post-traumatic inflammation and oedema

∘ Protection of soft tissue repairs

– Places the collateral ligaments at their maximum length

3 IPJs in full extension

– Prevents volar plate shortening

4 Thumb abducted and pronated

– Prevents first webspace contracture

• Splintage is combined with elevation to reduce oedema

Tourniquets in hand surgery

• Modern tourniquet units are pneumatic and microprocessor-controlled

Guidelines for safe use

• There is little evidence in support of any guidelines

• Use the widest cuff possible – wider cuffs occlude at lower pressure

• Wrinkle-free padding under the cuff minimises risk of skin pinching

• Avoid aggressive exsanguination for infection or malignancy

• Suggested maximum inflation pressure for the upper limb is 250 mmHg, or 100 mmHgabove systolic blood pressure

• Suggested maximum inflation time is 2 hours; the evidence ranges from 45 minutes to

4 hours

• Breaks of 20 minutes allow the venous pH of the limb to normalise between inflations

Complications of tourniquet use

Local

• Muscle injury

∘ Mechanical compression by the cuff

∘ Ischaemia beneath and distal to the cuff

∘ Reperfusion injury following tourniquet deflation

• Nerve injury

∘ Most occurs directly under the cuff

∘ Disturbance of myelin and nodes of Ranvier due to mechanical pressure

∘ Tourniquet-related nerve injury has a reported incidence of 0.1–8%.

∘ Most lesions recover spontaneously within 6 months

• Vascular injury

∘ Rare – thought to occur when atheromatous plaques rupture

• Skin injury

∘ Chemical burns – seepage of alcoholic skin preparations beneath the tourniquet

∘ Pressure necrosis – inadequate padding or poor application of the tourniquet

• Tourniquet pain

∘ Dull aching pain that develops after 10–20 minutes

∘ Can occur despite regional anaesthesia, possibly because C fibres are more resistant tolocal anaesthetic

Systemic

• Cardiovascular effects

∘ Poorly tolerated in patients with little cardiac reserve

∘ Limb exsanguination can increase circulating volume by 15%

– May precipitate cardiac failure

∘ Tourniquet release decreases CVP and mean arterial pressure due to:

– Shift of blood back into the limb

– Release of ischaemic metabolites causing myocardial depression

• Pulmonary effects

∘ Increased end-tidal CO2following tourniquet release

∘ Acute lung injury has been described after limb reperfusion

• Neurological effects

∘ Increased PaCO2following deflation increases cerebral blood flow

∘ Causes reflex decrease in systolic blood pressure, which can critically decrease cerebralperfusion pressure in a brain-injured patient

Replantation and revascularisation

• Replantation is the reattachment of totally amputated parts

• Revascularisation is the repair of incomplete amputations

1 Macroreplantation

∘ The amputated part contains muscle bulk and is therefore less resistant to ischaemia

∘ Muscle necroses after 6 hours of warm ischaemia or 12 hours of cold ischaemia

2 Microreplantation

∘ The amputated parts are usually digits that are more resistant to ischaemia

∘ Digits tolerate at least 12 hours of warm ischaemia or 24 hours of cold ischaemia

• The expectations of the patient must be addressed:

∘ Many choose terminalisation rather than replantation for a shorter recovery time

Relative indications

• Thumb

• Multiple digits

• Amputation through the palm

• Almost any part in a child

• Wrist, forearm, elbow and above elbow

• Single digit distal to the FDS insertion

• Patients who ‘must’ have a 10-digit hand, e.g musicians

Relative contraindications

• Severely crushed or mangled parts

• Avulsion injuries with structures dangling from the part associated with:

∘ The ‘red streak sign’ – bruising over the neurovascular pedicle

∘ The ‘ribbon sign’ – a corkscrew appearance to the vessels

• Amputations at multiple levels

• Extreme contamination

• Previous injury of the amputated part

• Other serious injuries or diseases

• Classified by Urbaniaket al.

∘ Class I: Circulation adequate

∘ Class II: Circulation inadequate Microvascular reconstruction will restore circulationand function

∘ Class III: Complete degloving or complete amputation

• Class III amputations, particularly proximal to the FDS insertion, have poor prognosis andare best terminalised

• Others have subdivided class II injuries:

∘ IIA: Only digital arteries require repair

∘ IIB: Arteries, bone, tendon or nerves are involved

∘ IIC: Only veins are involved

• Replantation may be attempted distal to the FDS insertion if the PIPJ and proximal lanx are intact

pha-Transportation of the amputated parts

• Aim to keep the part cool, prevent freezing and avoid maceration

• This can be achieved by:

∘ Wrapping the part in moist gauze and placing it in a sealed container or bag

∘ This is then placed in another container or bag containing ice and water

Surgical treatment

• Two surgical teams greatly shorten the operative time

Team 1

• Osteosynthesis is planned based on X-rays of the hand and amputated part

• The part is debrided and neurovascular structures tagged in theatre

∘ Longitudinal midaxial incisions give good exposure

• Bone shortening may allow primary repair of neurovascular structures

• The distal half of the bony fixation can be inserted into the amputated part in advance.

• Common methods of fixation:

∘ K wires

∘ Interosseous wires

∘ Miniplates and screws

Team 2

• Debride the stump and tag neurovascular structures

• Shorten and fix the bone

• Repair the extensor and flexor tendons

• Anastomose the arteries, coapt the nerves, then anastomose the veins

• Skin cover

• Interposition vein grafts or vessel transposition from an adjacent finger may be required

∘ Grafts from the volar wrist match the calibre of digital arteries

∘ Grafts can be placed extra-anatomically to the radial artery at the wrist

• If suitable veins are not available, venous drainage may be achieved by:

1 Repairing any volar veins.

2 Anastomosing a digital artery (which has backflow) to a vein, creating an arteriovenous

Special considerations in macroreplantation

• The priority is establishing arterial inflow to minimise muscle necrosis

∘ Achieved by a temporary vascular shunt, such as a Sundt, Pruitt-Inahara or Javid shunt

• Considerable bone shortening is required if amputated through muscle bellies

∘ Shortening also makes primary vessel and nerve repair easier

• Fixation of bone is then done, prior to definitive arterial repair

• Venous blood is drained from the amputated part for some time to flush accumulated toxicmetabolites

∘ Blood transfusion is usually required

• Fasciotomies are always indicated

• Assess for further muscle necrosis within 48–72 hours under general anaesthesia

Fingertip injuries

Nail bed injury

• Usually caused by doors in children and DIY tools in adults

• All require X-ray because 50% have an underlying fracture

Classification

• Subungual haematoma

• Simple lacerations

• Stellate lacerations

• Severe crush

• Avulsion

Treatment

• Haematoma with intact nail edges is treated by trephination of the nail

• Disrupted nailplates are removed to allow assessment of the nail bed

• Lacerations are approximated with fine dissolving sutures or skin glue

• Nail bed avulsions can be replaced as grafts

• Central defects can be repaired directly after paronychial releasing incisions

• Split thickness nail bed graft from an adjacent finger or toe can be used for defects>30%

• Optimal management is controversial

• Reasonable attempts should be made to preserve the length of the thumb

Classification

• Many systems are available, notably proposed by Tamai, Ishikawa and Allen

• Allen’s classification:

∘ Type I: pulp only

∘ Type II: pulp and nail bed

∘ Type III: distal phalanx fracture with associated pulp and nail loss

∘ Type IV: lunula, distal phalanx, pulp and nail loss

Treatment

• The amputated part can be replaced as a composite graft

∘ Most successful in children<3 years old when replaced within 5 hours.

• If replantation or composite grafting is not possible or not indicated:

Healing by secondary intention

• Considered by many to be the best option when bone is not exposed

∘ Exposed bone can be shortened to allow healing to occur

Skin grafting

• Studies show superior results are obtained by allowing the wound to heal

Local and regional flaps

• Prior to flap surgery, the surgeon should be satisfied that the outcome will be superior tobone shortening and healing by secondary intention

• Rates of cold intolerance and altered sensation are similar with both treatments

• Options include:

∘ Atasoy-Kleinert volar V-Y

∘ Kutler lateral V-Y

∘ Segmüller lateral V-Y

• Tension on the nail bed is avoided during inset to avoid a hook nail

• Many advocate resecting the nail bed if<25% remains

∘ Nail spikes and cysts can result if the nail bed is not completely excised

• Loss of the distal phalanx may not lead to functional problems

• Amputation proximal to the shaft of the proximal phalanx is inadequate for pinch andpower grip

Classification

• Lister has rationalised thumb defects:

1 Acceptable length with poor soft tissue cover.

2 Subtotal amputation with questionable remaining length.

3 Total amputation with preserved CMCJ.

4 Total amputation with loss of the CMCJ.

Treatment

• Treatment is dictated by Lister’s classification:

Acceptable length with poor soft tissue cover

• Healing by secondary intention

• Revision amputation

• V-Y advancement flaps, as described for fingertip injuries

• Moberg volar advancement flap

• Innervated cross-finger flap

• First dorsal metacarpal artery (FDMA) flap (Foucher, 1979)

• Littler heterodigital island flap

Subtotal amputation with questionable remaining length

• Deepening the first webspace to relatively lengthen the stump

Total amputation with preserved CMCJ

• Free toe transfer is ideal

• Alternatively:

∘ Metacarpal distraction lengthening

∘ Osteoplastic reconstruction (bone graft covered with soft tissue flap)

∘ Pollicisation of an injured or partially amputated digit

Total amputation with loss of CMCJ

• Toe digital arteries arise from two systems:

1 Dorsal arterial system, from dorsalis pedis.

2 Plantar arterial system, from plantar metatarsal arteries.

• Determining which system is dominant is key when harvesting a toe

∘ First dorsal metatarsal artery is dominant in 70%

∘ First plantar metatarsal artery is dominant in 20%

∘ In 10%, both systems are of equal calibre

• Most are harvested with the superficial dorsal venous system

• Plantar sensation is supplied by plantar digital nerves

Variants of toe transfer

Great toe transfer

• Used to reconstruct a thumb

• The donor site may be unacceptable to some patients

Wraparound technique

• Uses the great toenail, skin envelope and bone graft

• Gives a smaller thumb than conventional great toe transfer

• Does not restore joint mobility

• Not used in children due to the lack of capacity for growth

Trimmed great toe transfer

• Combines the advantages of toe transfer and wraparound technique

• Harvested like a conventional great toe transfer

• Longitudinal osteotomy removes a strip of bone from the side of the phalanges

• Soft tissue is excised from the medial side to match the intact thumb

Second toe transfer

• Used following finger amputations

• Can reconstruct a thumb for those who prefer the donor site to that of the great toe

• Disadvantages: tendency to claw, bulky pulp

Second toe wraparound transfer

• For distal soft tissue loss of the fingers

• The distal phalanx is included to prevent pulp instability and nail deformity

Third toe transfer

• Rarely used; indicated if a second toe is not available

Combined toe transfer

• Useful if two adjacent digits are required

• Combinations of second-third or third-fourth toes can be transferred

• Provides a webspace, and both toes are supplied by a shared pedicle

Vascularised joint transfer

• Indicated for a destroyed PIPJ or MCPJ

• Limited range of motion, but is stable, durable and shows capacity for growth

• Usually harvested from the second toe, based on articular branches from the medial digitalartery

Neurosensory free flaps

• Useful for large pulp defects that cannot be reconstructed with local flaps

• Free pulp flaps from the great toe provide potentially sensate glabrous skin from a donorsite that is closed primarily

• First webspace flaps are thin, potentially sensate islands of glabrous skin

Donor site

• Sequelae of toe harvest should be discussed in detail with patients

• Photographs of feet following toe harvest should be shown

• The donor site should be closed primarily with minimal tension

• Most patients do not have problems walking

∘ Some experience fatigue when playing ball sports

Fractures and dislocations

Collected words of wisdom

• There is a wide range of acceptable treatment

• Little evidence supports superiority of one method over another

• Treat fractures using methods that work for you

∘ Some eminent hand surgeons treat almost all fractures non-operatively

∘ Others treat almost all fractures operatively, with similar results

• Surgery causes bleeding, swelling, scarring, and implants can become infected

∘ Operative treatment can therefore result in worse outcomes than no treatment

• More aggressive surgery generally attracts more spectacular complications.

• First do no harm – do not operate unless you can provide a superior outcome to operative management

non-• Oedema causes stiffness – elevate the fractured limb above heart level

Principles of fracture management

Assessment

• Identify and treat immediately life-threatening injuries prior to considering the handfracture

• Assessment should answer these specific fracture-related questions:

1 Is there a wound communicating with the fracture?

2 Is there evidence of neurovascular injury?

3 Is there evidence of associated soft tissue injury, e.g tendon or ligament?

Investigation

• Most hand fractures are adequately imaged with plain X-ray

• Complex intra-articular fractures may require a CT scan

• Ultrasound and MRI assess soft tissue detail

• To prevent displacement of the fragments

• To prevent movement that might interfere with bone union

• To relieve pain

– Immobilisation can be achieved by:

• External splint, e.g plaster of Paris or Zimmer splint

• Continuous traction

• External fixation

• Internal fixation

– Indications for fixation include:

• Irreducible fractures, particularly if malrotated

• Intra-articular fractures

• Subcapital fractures of the phalanges

• Open fractures

• Segmental bone loss

• Polytrauma with hand fractures

• Multiple hand or wrist fractures

• Fractures with soft tissue injury (vessel, tendon, nerve, skin).– Methods of internal fixation include:

– Rehabilitation is required for all fractures

– Begin as soon as possible, with supervision from a hand therapist.– Aims of rehabilitation:

1 Preserve hand function during fracture union.

2 Return hand function to normal once the fracture has united.

– It is unusual to immobilise a hand fracture for more than 3–4 weeks.– Prolonged immobilisation leads to stiffness

∘ Provide adequate exposure

∘ Preserve the skin’s blood supply

∘ Be extendable if necessary

∘ Avoid scar contracture

Dorsal approach

• Often used for metacarpals and phalanges

• Over the DIPJ they can be shaped like an H, Y or L

• Dorsal veins and sensory nerves are preserved if possible.

• The extensor tendon can be retracted over the metacarpal

∘ Juncturae tendinum may need to be divided, but should be repaired

• Over the proximal phalanx the central slip is freed on one side and retracted

∘ Alternatively, the central slip is split longitudinally

• The Chamay approach is a V-shaped incision through the extensor, allowing the centralslip to be reflected distally

∘ Gives excellent exposure of the head of the proximal phalanx

∘ Requires skill to repair the central slip to avoid extensor lag and boutonnière

Lateral approach

• Midaxial incision connects the centres of rotation of the IPJs

∘ Surface markings are the dorsal extremes of the IPJ flexion creases

∘ The digital NVB is volar to this incision

• Midlateral incision is halfway between the dorsal and volar surfaces

∘ It is slightly volar to the midaxial line

• The midaxial incision is generally preferred because it is ‘mechanically neutral’

Volar approach

• Few closed fractures are approached from the volar aspect

• Those that are include:

∘ Volar plate avulsion fracture of the middle phalanx base

∘ MCPJ collateral ligament avulsion fracture of the base of the proximal phalanx.– The collateral ligament travels from the metacarpal to the volar base of the proximalphalanx

Metacarpal fractures

• Rotational alignment is confirmed by asking the patient to make a fist

∘ Fingers should all point to the scaphoid tubercle

• If the fracture is stable, it is held for 3–4 weeks until union takes place

• Methods of non-operative fixation include:

∘ Buddy strapping to an adjacent non-injured finger

∘ Bedford gaiter

∘ Plaster of Paris, aiming for 3-point fixation, e.g ulnar gutter, Barton short hand cast,clam-digger cast

• Operative treatment is indicated for open fractures

∘ Some surgeons also elect to internally fix closed fractures

• Fixation can be achieved by:

∘ K wires: transverse, longitudinal, ‘bouquet’ wiring

∘ Lag screws

∘ Plates – newer low profile implants rarely require removal

∘ Interosseous wires

∘ External fixation

Fifth metacarpal neck fractures

• So-called boxer’s fracture; often over-treated

• Well tolerated due to mobility of the CMCJs

• Rarely requires treatment unless rotated or angulated>70∘.

• Usually impacted and stable if left unreduced

• Patients are told to mobilise their fingers immediately as pain allows

• A Bedford gaiter or buddy strapping prevents significant extensor lag

• No follow-up is required

Phalangeal fractures

• Rotational malalignment must be corrected

Distal phalanx

• Shaft fractures usually splinted; can be K wired if grossly unstable

• Bony mallet injuries: splint for 6 weeks

∘ Others advocate intervention if >30% of the articular surface is involved, but this is

arbitrary

∘ Operative fixation is indicated if the DIPJ is subluxed in a splint

Phalangeal shaft

• Most can be treated conservatively; some elect to treat them operatively

• Fixation should avoid the IPJs so they can be mobilised

• K wires are popular – phalanges are easily accessed percutaneously

Intra-articular fractures

• Aim of treatment is to restore joint congruity and subsequently:

1 Prevent deformity

2 Prevent OA

3 Restore early movement.

• Should be fixed with absolute stability if possible

• Some fractures require detailed assessment with pre-operative CT

• Unicondylar fractures of the phalanges are inherently unstable

∘ They require anatomical reduction

∘ Management is rarely successful with external splintage

∘ Percutaneous lag screws or K wires may be possible

– Otherwise open reduction is required

• Pilon fractures are comminuted intra-articular fractures

∘ Common at the base of the middle phalanx

∘ Result from axial loading – the head of the proximal phalanx is driven into the base ofthe middle phalanx

– Pilon is the French word for pestle (a heavy tool with a rounded end)

∘ The articular surface may be splayed

∘ Outcome is unpredictable; stiffness is expected

∘ For this reason, some favour dynamic external fixators over open reduction and internalfixation (ORIF):

– Examples: Hynes–Giddins device (K wires only) and Suzuki frame (K wires and ber bands)

rub-• ORIF usually requires bone graft to support the reduced articular fragments

• No method can repair the articular surface to its pre-injury state

Dislocations and subluxations

DIPJ

• Dislocations or subluxations are rare

• May be associated with avulsions of FDP or extensor tendon

• Integrity of the collateral ligaments is assessed after ring block

• Most (without tendon avulsion) are splinted for two weeks, then mobilised

PIPJ

• Often missed or poorly treated; a great source of litigation

• Eaton classifies volar plate injuries of the PIPJ as follows:

∘ Type I (hyperextension)

– Avulsion of the volar plate without fracture; collateral ligaments split

∘ Type II (dorsal dislocation)

– Complete dorsal dislocation; volar plate avulsion without fracture

∘ Type III (fracture subluxation)

– Fracture subluxation with a palmar fragment of variable size

• Palmar fragments<40% of the articular surface should leave enough collateral ligament

attached to the middle phalanx to provide joint stability when reduced

• Larger palmar fragments suggest the joint may re-sublux following reduction

∘ The ‘dorsal V sign’ on lateral X-ray indicates a subluxed joint

• Treatment: reduction and early mobilisation in an extension block splint

• Other options include transarticular K wire, ORIF of the palmar fragment or dynamicexternal fixator, e.g Suzuki frame

MCPJ

• Rare and easily missed

• Closed reduction may be impossible:

∘ The volar plate can flip into the joint

∘ FDP, FDS and lumbricals form a ‘noose’ around the metacarpal neck

• Open reduction requires particular care not to injure the digital nerves

CMCJ

• Uncommon in the radial four rays; indicative of high energy trauma

• Fifth CMCJ dorsal subluxation is relatively common

∘ Results from axial force on the fifth metacarpal

∘ Fracture of the metacarpal base is nicknamed a ‘reversed Bennett’s fracture’

∘ There may also be a dorsal avulsion from the hamate

• Treatment options include:

∘ Closed reduction and splint

∘ Closed reduction and K wire into an adjacent metacarpal or carpus

∘ ORIF

• Inadequate or lost reduction leads to weak grip

Thumb fractures

• More forgiving due to the greater range of motion in thumb joints

• Specific thumb fractures include:

Bennett’s fracture–subluxation

• Fracture–subluxation of the first carpometacarpal joint

∘ Does not refer to all fractures in the region of the first metacarpal base

• Mechanism of injury is axial loading of the flexed CMCJ

∘ The palmar oblique (‘beak’) ligament holds the fragment in the anatomical position

∘ The remainder of the metacarpal is adducted and supinated by adductor pollicis.– Also pulled proximally by APL

• The fracture–subluxation is reduced by a combination of:

1 Longitudinal traction

2 Pronation of the metacarpal

3 Pressure at the base of the metacarpal.

• The reduction can be held by applying a moulded below-elbow cast

• Persistent instability can be held with percutaneous K wires:

1 Transfixion of the metacarpal base to the trapezium.

2 Transfixion of the first metacarpal base to the second metacarpal.

3 Combination of both.

• ORIF is indicated for irreducible fractures

∘ Not usually feasible if the fragment is<20% of the articular surface.

Rolando fracture

• Three-part intra-articular fracture of the base of the first metacarpal

∘ Mistakenly used to describe all comminuted fractures of the first metacarpal base

• Non-operative treatment is unlikely to reduce the articular surface

• ORIF with a T-plate is usually done through a dorsal or radiopalmar approach

• More comminuted ‘Rolando’ fractures are difficult to ORIF

∘ External fixation can maintain a reasonable reduction and prevents metacarpalcollapse

• Rolando fractures are often more comminuted than shown on X-ray

∘ Some therefore routinely assess these injuries with CT scan

MCPJ UCL avulsion

• Frequently missed, leading to instability and weakness of pinch

• Commonly seen in skiers that fall onto their thumbs (especially while holding a ski pole)

∘ Colloquially known as ‘skier’s thumb’

– ‘Gamekeeper’s thumb’ refers to chronic attenuation of the UCL

• The avulsed ligament can displace dorsal to the adductor aponeurosis.

∘ Known as a Stener lesion

∘ The interposed adductor aponeurosis eliminates any chance of spontaneous bony orligamentous healing

• Incomplete injuries are managed conservatively in a cast for 4–6 weeks

• Complete injuries increase the likelihood of a Stener lesion, requiring surgical repair

∘ Stress testing of the UCL is done with the MCPJ in 30∘ of flexion

∘ Comparing with the uninjured side,>15∘ difference or a soft end-point suggests

com-plete rupture

• The UCL can be reattached using a Mitek bone anchor

∘ Repair is protected for 4 weeks; activity is gradually increased thereafter

Paediatric hand fractures

• The vast majority can be managed non-operatively

• The presence of a physis means that deformity can be remodelled with growth

• Greatest remodelling potential is seen with the following:

∘ When angulation occurs in the plane of adjacent joint motion

∘ When the fracture is in close proximity to the physis

∘ When the fracture is in a young child with many years of remaining growth

• Rotational and angular deformity has little remodelling potential

• The physis should be respected during surgery

• Salter–Harris classification of physeal fractures:

∘ Type I – fracture through the physis (6%)

∘ Type II – fracture through the physis and metaphysis (75%)

∘ Type III – fracture through the physis and epiphysis (8%)

∘ Type IV – fracture through the epiphysis, physis and metaphysis (10%)

∘ Type V – fracture compressing the physis (1%)

• Types III, IV and V are associated with physeal growth arrest

• Specific paediatric hand fractures include:

Seymour fracture

• Looks like a mallet ‘drop finger’, but is transepiphyseal rather than transarticular

• Usually open with nail bed involvement

• The fracture is distracted by the extensor tendon on the proximal fragment and FDP onthe distal fragment

• Requires debridement, reduction, nail bed repair and replacement of the nailplate as asplint

∘ An axial transarticular K wire can be passed if unstable

Phalangeal neck fractures

• Typically occur following trapping a finger in a door

• The distal fragment is usually angulated dorsally into extension

∘ Results in incomplete flexion at the PIPJ

• Minimally displaced fractures can be splinted, but require weekly X-rays

• Displaced fractures require closed reduction and K wire

Tendon injury

Flexor tendons

• Verdan described five zones of flexor tendon injury:

∘ Zone 1: distal to FDS insertion

∘ Zone 2: between proximal flexor sheath and FDS insertion

∘ Zone 3: between distal flexor retinaculum and proximal flexor sheath

∘ Zone 4: under the flexor retinaculum

∘ Zone 5: proximal to the flexor retinaculum

– Zone 2 repair is complicated by having two tendons in a tight sheath

• Thumb zones:

∘ Zone T1: distal to IPJ

∘ Zone T2: from A1 pulley to IPJ

∘ Zone T3: in the thenar eminence

∘ Zones T4 and T5 are the same as for the fingers

• FDP can be avulsed from its bony attachment

∘ Caused by a hyperextension force on an actively flexed DIPJ

∘ Known as ‘rugger jersey finger’ – a tackler grabs the opponent’s rugby shirt

∘ The ring finger is most commonly injured because it is the ‘longest’ flexed finger

• Leddy and Packer classify FDP avulsions:

∘ Type I: tendon retracts into the palm; rupture of both vincula

∘ Type II: tendon retracts to the PIPJ; long vinculum intact

∘ Type III: a large bony fragment avulsed with the tendon prevents retraction beyond theA4 pulley

Flexor tendon repair

Skin incision

• An extensile exposure is planned

• Popular approaches include the Brunner and midlateral

The flexor tendon sheath

• A synovial-lined fibro-osseous tunnel in the fingers and thumb

• Runs between the metacarpal neck and DIPJ

• Synovial portion contributes to tendon glide and nutrition

• Retinacular portion contributes mechanical efficiency

• Retinacular part consists of five annular (A) and three cruciform (C) pulleys:

∘ A1, A3 and A5 originate from the volar plates of MCPJ, PIPJ and DIPJ, respectively

∘ A2 and A4 originate from proximal and middle phalanx, respectively

∘ Cruciform pulleys are collapsible; they ‘concertina’ to allow flexion

• Pulleys are ordered from proximal to distal as follows:

∘ A1 – A2 – C1 – A3 – C2 – A4 – C3 – A5

• The thumb has two annular pulleys overlying the MCPJ (A1) and IPJ (A2)

• An oblique pulley runs between the two: from ulnar on the proximal phalanx to radial

on the distal phalanx

• The sheath usually needs to be opened for access to the tendon ends.

∘ As much sheath as possible should be preserved to maintain function

∘ Function is usually adequate if either A2 or A4 is preserved

• Closure of the sheath is controversial, particularly if it limits glide

∘ An alternative to venting zone II pulleys is excising a slip of FDS

The tendon repair

• Results are better when repair is done within the first few days of injury

• The following principles apply to most techniques:

∘ Handle tendon ends as little as possible

∘ Repair should be strong enough to allow early mobilisation

∘ Strength of repair is dependent on:

– Gauge of suture – 3/0 is stronger than 4/0

– Number of strands crossing the repair – four are stronger than two

– Configuration of the peripheral suture

– Tendon-suture interaction – grasping sutures pull through easily; locking sutures

‘lock’ a bundle of tendon fibres, minimising suture pullout

∘ Excessive suture bulk can increase resistance to tendon glide

∘ No gapping of the tendon ends on mobilisation

– A 2 mm gap increases gliding resistance significantly

– A 3 mm gap is unlikely to pass under the A2 pulley without rupture

∘ Avoid shortening FDP>1 cm – quadriga may ensue.

– The quadriga phenomenon was described by Verdan

– Occurs when FDP excursion in an unaffected finger is reduced as a result of decreasedFDP excursion in another finger due to stiffness, injury or adhesion

• Decreases global grip strength because all FDPs share a common muscle belly

• Most repairs use core and peripheral sutures

• No evidence that using ‘cutting’ needles gives a higher rupture rate

• Examples of core sutures include:

∘ 2-strand repair

– Kessler, with two knots on the outside of the tendon

– Modified Kessler, with a single knot within the repair site

• Peripheral sutures do the following:

∘ Align tendon ends prior to core suture (back wall first)

∘ Tidy up tendon ends following core suture

∘ Contribute significant strength to the repair

• Examples of peripheral sutures include:

∘ Strickland simple continuous suture

• Partial lacerations may cause triggering – the triggering part should be trimmed.

• Placing epitendinous sutures into partial lacerations doubles the gliding resistance

∘ This is unnecessary; may require sheath incisions for access

Rehabilitation following repair of flexor tendons

• Tendons were historically immobilised in the belief that adhesions were necessary forhealing

• Discovery of intrinsic healing allowed early mobilisation to improve glide

• Most regimes require a dorsal blocking splint to protect the repair

• The splint is maintained for up to 6 weeks

• Heavy use is avoided for 12 weeks total

• Common regimes are variations on the following:

Immobilisation

• Mainly for children or adults unsuitable for early mobilisation

Early passive mobilisation

• No active movement is permitted

Early active extension with passive flexion

• Advocated by Kleinertet al.

• Finger flexion is maintained by rubber-band traction

• Active extension is done against the recoil of the bands

• Passive flexion occurs by elastic recoil of the bands

• Critics state that PIPJ extension lag is a problem due to prolonged PIPJ flexion

• It is also regarded as a poor mobiliser of the DIPJ

Early active mobilisation

• Strength of repair is increased by early active flexion

• The ‘Belfast’ regime is widely used in the United Kingdom in modified forms

• Active mobilisation is started 48 hours after the operation

• Exercises are repeated two-hourly throughout the day:

∘ Two passive movements, then two active movements of the finger(s)

• The aim is full passive flexion in the splint within the first week

• Range of active motion is gradually increased

Outcomes

• Rupture and adhesion affect 5% of flexor tendon repairs