Phẫu Thuật Tái Tạo Bàn Tay Và Chi Trên

13/10/2026 • by Bs CKI Phẫu thuật tạo hình, tái tạo và thẩm mỹ Trương Hoài Anh •

Tài liệu chuyên sâu về vi phẫu và phẫu thuật tái tạo các khiếm khuyết vùng bàn tay, cánh tay do chấn thương hoặc dị tật bẩm sinh. Hướng dẫn chi tiết kỹ thuật khâu nối gân, thần kinh và ghép vạt da tự do.

📂 Chuyên mục: Tài liệu thẩm mỹ, Phẫu thuật tái tạo

🏷️ Từ khóa: phẫu thuật bàn tay, tái tạo chi trên, vi phẫu, khâu gân, hand reconstruction

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PROCEDURES IN RECONSTRUCTIVE SURGERY
Series Editor: Gregory R.D. Evans MD FACS
General Reconstructive Surgery
Gregory R.D. Evans MD FACS and Garret A. Wirth MD
ISBN: 978-0-7020-2925-7
Head and Neck Reconstruction
Charles E. Butler MD FACS
ISBN: 978-0-7020-2926-4
Hand and Upper Extremity Reconstruction
Kevin C. Chung MD MS
ISBN: 978-0-7020-2916-5
Cosmetic and Reconstructive Breast Surgery
Maurice Nahabedian MD FACS
ISBN: 978-0-7020-2915-8

Hand and Upper
Extremity
Reconstruction
Edited by
Kevin C. Chung MD MS
Professor of Surgery, Section of Plastic Surgery
Assistant Dean of Faculty Aff airs (Institutional Track)
The University of Michigan
Ann Arbor, MI, USA
Series Editor
Gregory R.D. Evans MD FACS
Professor of Surgery and Biomedical Engineering,
Chief, Aesthetic and Plastic Surgery Institute,
University of California, Irvine
Orange, CA, USA
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2009

An imprint of Elsevier Limited
© 2009, Elsevier Limited. All rights reserved.
Figures 19.1–9 © David J. Slutsky MD
No part of this publication may be reproduced, stored in a retrieval system, or transmitted
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‘Copyright and Permission’.
First published 2009
ISBN: 978-0-7020-2916-5
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Hand and upper extremity reconstruction. – (Procedures in reconstructive surgery series)
1. Surgery, Plastic 2. Hand – Surgery 3. Arm – Surgery
I. Chung, Kevin C.
617.5′750592
ISBN-13: 9780702029165
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notice
Neither the Publisher nor the Editors assume any responsibility for any loss or injury and/or
damage to persons or property arising out of or related to any use of the material contained in
this book. It is the responsibility of the treating practitioner, relying on independent expertise
and knowledge of the patient, to determine the best treatment and method of application for the
patient.
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Printed in China
Commissioning Ed itor: Sue H
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vii
SERIES PREFACE
When I was studying for my Plastic Surgery Oral Boards
and during my training, I was struck by the lack of a book
that would explain common procedures in plastic surgery
for speciﬁ c problems. This is probably due to the unique
and creative drive of our specialty and its emphasis on
multiple approaches. Spurred by this seeming lack of a one
volume book to carry to the operating room or utilize for
studying, we produced an atlas for plastic surgery that
would focus of common approaches to commonly seen
problems. Now eight years later, the continued interest in
such a book has produced this four volume set. The purpose
of these volumes is to allow the student, resident or plastic
surgeon to read and absorb common approaches to plastic
surgery problems seen routinely. It is our hope that the
procedures discussed in these volumes will allow quick in
depth approaches, proposing common indications, surgical
techniques, postoperative care and avoidance of pitfalls for
common surgical problems. The student, resident or plastic
surgeon should be able to utilize each of these volumes as
a quick and easy access to treatment options for their
patients. It is our desire that these volumes will become as
popular as our ﬁ rst volume eight years ago and that a new
generation of plastic surgeons will use, beneﬁ t and enjoy
the books for years to come.

G.R.D.E.

ix
VOLUME PREFACE
Various specialties are involved in taking care of patients
with hand injuries and conditions. The purpose of this
book is to provide a practical guide to the treatment of
common hand problems. I have recruited an international
list of authors who are established experts in this ﬁ eld to
give a fresh perspective on the ever-changing and advancing
specialty of hand surgery. This book is not meant to be a
comprehensive textbook on all aspects of hand and upper
limb surgery, but an economical and richly illustrated text-
book that minimizes the burden on the readers by distilling
the most important information. All of the chapters are
carefully edited to provide the most up-to-date materials
that are augmented by carefully illustrated pictures and
sketches. The most innovative part of this book is compre-
hensive video list in the accompanying DVD. There are
over 25 videos that include a scholarly discussion on the
examination of the hand and wrist, as well as carefully
produced videos by the editor to highlight the essence of
key operations in this text. I hope that I can continue to
update the DVD in future chapters to illustrate the most
innovative and practical surgical procedures in this
specialty.
This book could not be accomplished without my won-
derful Elsevier editors based in London, England. Claire
Bonnett worked tirelessly to organize all the materials in a
logical sequence, and the leadership of Sue Hodgson has
made this project possible. I would also like to personally
acknowledge my excellent assistants, Elizabeth Petruska
and Allison Pushman who organized the complexity of all
facets of this major textbook into a triumphant conclusion.
Most importantly, I would like to thank my colleagues in
all the surgical specialties who have embraced my effort in
producing this textbook to enhance the practice of hand
surgery for our patients. I hope that this textbook will serve
as a stimulus for other nations where hand and upper
extremity surgery is in its infancy. Hand and upper limb
diseases are prevalent throughout the world and our collec-
tive effort to share knowledge and expertise will fulﬁ ll our
obligations as physicians and surgeons to help those in
need.

K.C.C.
To Chin-Yin and William
DEDICATION

xi
CONTRIBUTORS
Roberto Adani, MD
Chief of Hand Surgery Unit
Policlinico G.B. Rossi
University of Verona
Verona
Italy
Brent Bickel, MD
MetroHealth
Columbus, OH
USA
Reuben A. Bueno, Jr., MD
Assistant Professor
The Plastic Surgery Institute
Southern Illinois University School of
Medicine
Springﬁ eld, IL
USA
Riccardo Busa, MD
Consultant of Hand Surgery
Hand Surgery and Microsurgery Unit
University of Modena and Reggio Emilia
Modena
Italy
Peter Carter, MD
Department of Orthopaedic Surgery
UT Southwestern Medical Center at
Dallas
Dallas, TX
USA
Victor W.T. Chee, MBChB, MMed,
FAMS
Director, Regional Anaesthesia Program
Tan Tock Seng Hospital
Singapore
Neal Chen, MD
Hand and Microvascular Fellow
MGH Orthopaedic Hand and Upper
Extremity Service
Boston, MA
USA
Winston Chew, MBBS, MMed, FRCS
Senior Consultant Orthopaedic Surgeon;
Chief of Hand Service
Department of Orthopaedic Surgery
Tan Tock Seng Hospital
Singapore
Kevin C. Chung, MD, MS
Professor of Surgery
Section of Plastic Surgery
Department of Surgery
Assistant Dean of Faculty Affairs
(Institutional Track)
University of Michigan School of
Medicine
Ann Arbor, MI
USA
Scott F.M. Duncan, MD, MPH
Assistant Professor of Orthopedic Surgery
Mayo Health System
Owatonna, MN
USA
Marybeth Ezaki, MD
Professor
Department of Orthopaedic Surgery
UT Southwestern Medical Center at
Dallas
Dallas, TX
USA
Grey Giddins, BA, MD, Bch, FRCS, MR
The Hand to Elbow Clinic
The Bath Clinic
Bath
UK
Robert M. Greenleaf, MD
Resident
Department of Orthopaedic Surgery
Allegheny General Hospital
Pittsburgh, PA
USA
Warren C. Hammert, MD
Associate Professor of Orthopaedic
Surgery and Plastic Surgery
University of Rochester Medical Center
Rochester, NY
USA
Harry A. Hoyen, MD
MetroHealth West Park Medical Building
Cleveland, OH
USA
Thomas B. Hughes, MD
Department of Orthopaedics
Division of Hand & Upper-Extremity
Surgery
Allegheny General Hospital
Pittsburgh, PA
USA
C. Scott Hultman, MD, FACS
Chief and Program Director
Ethel F. and James A. Valone
Distinguished Professor of Surgery
Division of Plastic Surgery
University of North Carolina
Chapel Hill, NC
USA
Jesse B. Jupiter, MD
Hansjorg Wyss Professor of Orthopaedic
Surgery
Harvard Medical School;
Chief, MGH Orthopaedic Hand and
Upper Extremity Service
Massachusetts General Hospital
Boston, MA
USA
Loree Kallianinen, MD, FACS
Assistant Professor
Department of Plastic and Hand Surgery
The University of Minnesota
Regions Hospital
St. Paul, MN
USA
Kenji Kawamura, MD, PhD
Assistant Professor
Department of Emergency and Critical
Care Medicine
Nara Medical University
Nara
Japan
Michael W. Keith, MD
Chief of Hand Surgery Service
MetroHealth Medical Center;
Professor of Orthopaedics and Biomedical
Engineering
Case Western Reserve University School
of Medicine
Cleveland, OH
USA

Ilana J. Langdon, MBChB, MSc, FRCS
Consultant Orthopaedic Surgeon
The Hand to Elbow Clinic
The Bath Clinic
Bath
UK
Tatsuya Masuko, MD, PhD
Assistant Professor
Department of Orthopaedic Surgery
Hokkaido University Graduate School of
Medicine
Sapporo
Japan
Akio Minami, MD, PhD
Professor and Chairman
Department of Orthopaedic Surgery
Hokkaido University Graduate School of
Medicine
Sapporo
Japan
Takaya Mizuseki, MD, PhD
Chairman, Medical Center;
Chief, Hand Service
Hiroshima Prefectural Rehabilitation
Center
Hiroshima
Japan
David P. Moss, MD
Associate
Washington Orthopaedics and Sports
Medicine;
Clinical Instructor
Department of Orthopaedic Surgery
The George Washington University
Medical Center
Washington, DC
USA
Chai Mudgal, MD
Instructor of Orthopaedic Surgery
Harvard Medical School;
Orthopaedic Hand and Upper Extremity
Service
Massachusetts General Hospital
Boston, MA
USA
Scott N. Oishi, MD
Hand Surgeon
Texas Scottish Rite Hospital for Children;
Clinical Assistant Professor
Department of Plastic Surgery
UT Southwestern School of Medicine
Charles E. Seay, Jr. Hand Center
Dallas, TX
USA
Kevin J. Renfree, MD
Department of Orthopedics
Mayo Clinic Arizona
Scottsdale, AZ
USA
David Ring, MD, PhD
Assistant Professor of Orthopaedic
Surgery
Harvard Medical School
Massachusetts General Hospital
Boston, MA
USA
Erika Davis Sears, MD
House Ofﬁ cer
Department of Plastic Surgery
University of Michigan Hand Center
Ann Arbor, MI
USA
Keith A. Segalman, MD
Attending Physician
The Curtis National Hand Center;
Assistant Professor of Orthopedic Surgery
Johns Hopkins University
Baltimore, MD
USA
David B. Shapiro, MD
Hand Surgeon
Cleveland, OH
USA
David J. Slutsky MD, FRCS(C)
Associate Professor of Orthopedics
David Geffen UCLA School of Medicine
Torrance, CA
USA
Thomas H. Tung, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive
Surgery
Washington University School of
Medicine
St. Louis, MO
USA
Sang-Hyun Woo, MD, PhD
President
Woo’s Institute for Hand &
Reconstructive Microsurgery
W Hospital
Daegu
South Korea
Lynda Yang, MD, PhD
Assistant Professor
Department of Neurosurgery
The University of Michigan
Ann Arbor, MI
USA
Elvin G. Zook, MD
Professor Emeritus
The Plastic Surgery Institute
Southern Illinois University School of
Medicine
Springﬁ eld, IL
USA
Contributors
xii

1
C H A P T E R
1
Anesthesia for Hand Surgery
Winston Chew and Victor Chee
Hand surgery is highly amenable to the use of various
regional techniques for the provision of prolonged anesthe-
sia in the distal limb. This chapter describes the practical
regional anesthesia approaches that the hand surgeon can
use independently to provide anesthesia in the surgical ﬁ eld
for operative intervention.
The use of distal regional anesthesia has many advan-
tages for hand surgery (Table 1.1). As with all regional
techniques, success with regional anesthesia for hand
surgery requires due consideration to the following points
and not solely the instillation of local anesthetics at the
various sites.
PATIENT FACTORS
● Comorbid conditions such as pre-existing neuropathy
● Anxiety
● Inability to keep still
● Patient refusal
SURGICAL FACTORS
● Duration of surgery
● Duration and location of tourniquet use
● Surgery outside the area of the hand
If patient and surgical factors cannot be addressed by
distal regional anesthesia and judicious sedation, then the
service of the anesthesiologist is required to provide surgical
anesthesia using proximal brachial plexus blockade or
general anesthesia.
The contraindications for distal peripheral nerve blocks
are listed in Table 1.2.
PERIOPERATIVE MANAGEMENT
If distal regional techniques are selected for use in hand
surgery, communication between surgeon and patient is
paramount. Preoperative patient selection and preparation
provide the foundations for success using these techniques.
This will involve a detailed explanation of the regional
anesthetic procedure (number and site of injections), what
to expect during surgery (as the patient is likely to be
awake), what alternative measures are available should the
patient feel discomfort or pain, and informed consent.
Management of these expectations will contribute to the
patient having a positive perioperative experience with
distal regional anesthesia.
Preanesthetic sedation may be required to provide anx-
iolysis as well as to improve regional block tolerance. This
can be achieved with a combination of drugs such as ben-
zodiazepines, narcotics and anticholinergics, depending on
the preferences of the individual surgeon.
In our practice, baseline assessments are made once the
patient arrives, and include blood pressure measurement
and pulse oximetry on room air. An intravenous cannula
is inserted in the non-operative arm and sedation achieved
using small doses of intravenous midazolam (0.5–1 mg
boluses titrated to effect). Most patients do not need more
than 5 mg. The endpoint for sedation is an awake, coopera-
tive patient who is calm, responsive to normal verbal stim-
ulation, and does not require airway control or respiratory
and cardiovascular support. Some patients may require nar-
cotics if there is pain due to hand trauma. For these patients
we normally use fentanyl 0.5–1 μg/kg boluses titrated to
effect. It is good practice to be mindful that drug combina-
tions for sedation tend to act synergistically when admin-
istered together, and their effects may be more than what
is expected when given individually.
During the procedure, periodic blood pressure measure-
ments are recorded together with continuous electrocardio-
gram and pulse oximetry monitoring. This practice is
especially critical when using intravenous regional anesthe-
sia (IVRA; Bier’s block), which requires the use of high
doses of local anesthetics.

Hand and Upper Extremity Reconstruction
2
One must remember that a successfully administered
distal regional anesthetic does not equate to good surgical
operating conditions and patient comfort. Attention must
also be paid to the other aspects of patient care, such as
body positioning, tourniquet use, preoperative emptying of
the bladder, and constant communication with the patient
regarding activities, to ensure immobility and tolerance
during the procedure.
LOCAL ANESTHETIC PHARMACOLOGY
Many local anesthetics are available for use in regional
anesthesia. Biochemically they fall into two major classes,
esters and amides. Clinically, knowledge of the various
agents by their pharmocodynamic properties, such as
potency, duration of action and speed of onset, gives prac-
titioners more relevant information for making decisions
regarding the selection of agents.
Potency and duration of action
The potency of local anesthetic agent increases with increas-
ing molecular weight and lipid solubility.1,2 Lipid-soluble
local anesthetics are also highly protein bound in blood and
removed more slowly from nerve membranes.
Speed of onset
The speed of onset of the various local anesthetics is thought
to be dependent on the aqueous diffusion rate of the anes-
thetic, which is inversely proportional to its molecular
weight.3 Even though increased lipid solubility and high pKa
are generally believed to delay onset of action, the fastest-
acting local anesthetic agents available are etidocaine,
which is highly lipid soluble, and chloroprocaine, which has
a pKa higher than that of other local anesthetics.
Information on commonly used local anesthetics for
regional anesthesia is summarized in Figure 1.1.
Additives to local anesthesia
Various additives have been used with local anesthetics for
regional anesthesia. Commonly used ones include epineph-
rine, clonidine, and alkalization with sodium bicarbonate.
Clinically, the addition of epinephrine (1 : 200 000–
1 : 400 000) is commonly used to cause vasoconstriction
and to serve as a marker of intravascular injection. However,
in the context of distal regional anesthesia techniques, addi-
tives play only a small role and are rarely used in our prac-
tice as the amount of drugs used rarely reaches maximum
limits, except when used in the context of IVRA. The use
of epinephrine for nerve block for areas supplied by end
arteries is also controversial. Although it is traditionally
avoided in these areas, recent data suggest that its use, for
example in digital blocks, is safe.4
TABLE 1.1
Advantages of distal regional
anesthesia
Advantages of proximal
regional anesthesia and
general anesthesia
Easily performed by surgeon
Area of anesthesia may involve
whole upper limb or in the
case of general anesthesia, the
whole body
Minimal physiological
disturbance
Tourniquet well tolerated
Area of anesthesia/analgesia
confi ned largely to hand
Can be used for prolonged
surgery
Does not require patient to fast
Tolerated well by most patients
Can be safely performed on an
outpatient basis
Does not require patient
cooperation intraoperatively
Reduced side eff ects
associated with general
anesthesia such as nausea and
vomiting
No prolonged paralysis of
proximal upper limb
musculature associated with
proximal brachial plexus
blockade
Can be used for prolonged
analgesia techniques via
catheters in the forearm
TABLE 1.2 Contraindications for peripheral nerve blocks
Absolute
Relative
Patient refusal
Preexisting neuropathy
Known allergy to local
anesthetic agent
Coagulopathy
Infection at site of injection
Prolonged surgery especially
involving proximal tourniquet is
used
Tumor surgery
Short duration
Long duration
Fast onset
Slow onset
Local anesthetic
Procaine
Chloroprocaine
Prilocaine
Lidocaine
Mepivacaine
Ropivacaine
Bupivacaine
LevoBupivacaine
Tetracaine
Relative potency
1
1
2
2
2
8
8
8
8
FIGURE 1.1 Properties of commonly used local anesthetics.

Anesthesia for Hand Surgery
3
Alkalization is another technique commonly used by
many practitioners. This usually involves the addition of
1 mL 8.4% sodium bicarbonate to each 10 mL of local
anesthetic. Data suggest that this practice reduces pain on
injection,5 although its effect in reducing onset time is more
equivocal.
In our practice, all the blocks described in this chapter
are performed without additives.
Toxicity
Toxicity from local anesthetics can occur either as a result
of direct neurotoxicity or of systemic toxicity. Although
neurotoxicity has been demonstrated in various animal
models, local anesthetics have a long history of safe clinical
use and the signiﬁ cance of the neurotoxic potential at clini-
cal concentrations is a topic of continued research.
The systemic toxicity of local anesthetics is related to
the serum concentrations achieved after drug deposition.
Although many textbooks continue to recommend maximal
local anesthetic doses, these data may not correlate well to
humans receiving nerve blocks in clinical conditions. Peak
plasma concentrations are related not only to the amount
of drug used, but also to the site of injection,6 and the cor-
relation to body weight is poor.
Among the local anesthetics, dose limits for lidocaine
remain important as it is a drug used commonly in IVRA.
Suggested dose limits for lidocaine for use in IVRA should
not exceed 4–5 mg/kg.
With less potent local anesthetics such as lidocaine and
mepivacaine, symptoms of toxicity are related to the pro-
gressive rise in serum plasma levels (Fig. 1.2).
Prevention remains key in the avoidance of local anes-
thetic toxicity. Prudent strategies include the use of tech-
niques with a low risk of intravascular injection, aspiration
before injection of local anesthetics, giving small fraction-
ated doses of local anesthetics, and constant communica-
tion during injection to elicit early signs of toxicity.
Management of toxicity is directed at two main aspects:
seizure control, usually with small doses of benzodiazepines
such as midazolam 2–5 mg, and supportive management
for cardiovascular collapse using advanced cardiac life
support algorithms. There is currently great interest in the
use of lipid infusions for the termination of refractory
arrhythmias secondary to local anesthetic toxicity.7
Increasing plasma concentrations
Cardiovascular instability
and collapse
Cardiac arrhythmias
Seizures
Somnolence
Muscular twitching
Nystagmus
Shivering
Dysphoria
Tinnitus
Dizziness
FIGURE 1.2 Systemic toxic eff ects of local anesthetics.
A
B
FIGURE 1.3 A Equipment for IVRA. B Double pneumatic tourniquet
used for IVRA.

Hand and Upper Extremity Reconstruction
4
INTRAVENOUS REGIONAL ANESTHESIA
(IVRA)/BIER’S BLOCK (Fig. 1.3)
Intravenous regional anesthesia was ﬁ rst described by
August Bier in 1908 and has remained largely unchanged.
Bier determined through cadaveric studies that the mecha-
nism of action of IVRA involved both direct local anesthesia
bathing local nerve endings and indirect local anesthesia
through conduction block, probably due to local anesthetic
transported to the substance of the nerves via the vasa
nervosa.
Indications
IVRA is suitable for all surgery below the level of the tour-
niquet. This technique is easily learnt and performed, and
its limitations are due mainly to tourniquet discomfort with
surgical procedures lasting more than 60 minutes. In addi-
tion, trauma at the surgical site may make this technique
unsuitable because of pain associated with arm manipula-
tion and application of the tourniquet during the exsangui-
nation process.
Technique (Fig. 1.4)
Obtain a functioning intravenous access in a non-operative
limb for sedation. The intravenous catheter is inserted into
the operative limb as far distally as possible. The double
pneumatic tourniquet is then applied, ensuring that there
is an adequate layer of soft cotton lining under it to protect
soft tissues around the arm. Always carry out a pre-use
check to ensure the tourniquet system is not faulty. The
arm is then elevated and exsanguinated using the Esmarch
compression bandage, wrapping the entire limb in a spiral
fashion from the hand to the edge of the distal pneumatic
tourniquet cuff. The proximal cuff is then inﬂ ated after
digitally occluding the axillary artery. The tourniquet pres-
sure is maintained at 100 mmHg above the systolic blood
pressure. The Esmarch bandage is then removed.
Local anesthetic solution is given via the cannula in the
operative limb. After delivery of the local anesthetic solu-
tion, the intravenous cannula on the operative arm is
removed and pressure applied over the site. After about 20
minutes, conﬁ rm that the operative block is successful. The
distal tourniquet is then inﬂ ated and the proximal tourni-
quet deﬂ ated to improve tourniquet tolerance.
NERVE BLOCKS IN THE MID-FOREARM WITH
ULTRASOUND GUIDANCE
The courses of the median, radial and ulnar nerves in the
forearm are well described and can readily be blocked for
both anesthesia and analgesia. Although open cutdown
techniques are widely used for placement of catheters to
provide prolonged analgesia, ultrasound-guided regional
anesthesia has enabled accurate and consistent success
rates with percutaneous nerve blocks8 and allowed place-
ment of catheters to provide prolonged analgesia. In the
case of surgery involving the little ﬁ nger the use of a single
catheter can provide sole analgesia, whereas in surgery
involving other parts of the hand, multiple catheters with
local anesthetic infusion can be used to meet the analgesic
requirements for postoperative active therapy.
Ultrasound imaging for regional
anesthesia techniques
Ultrasound imaging uses high-frequency sound waves (3–
17 mHz). For mid-forearm nerve blocks a high-frequency
linear probe (7.5–12 mHz) is ideal, as the target nerves are
generally not more than 3 cm deep to the skin. Common
nomenclature used to describe ultrasound-guided blocks
include a description of the target (long axis, longitudinal
view, or short axis, transverse view) and the needle approach
in relation to the imaging plane (out of plane or in plane).
Although combinations of long-axis, short-axis, in-plane
and out-of-plane approaches can be used, we commonly use
the short-axis view together with an out-of-plane needle
approach for mid-forearm nerve blocks.
Equipment
The equipment used for ultrasound-guided nerve blocks is
shown in Figure 1.5. For single-shot techniques, normal
hypodermic or short beveled nerve block needles may be
used. For catheter placement, various commercial sets are
available, such as the Contiplex A Set (Braun, Melsungen,
Germany).
Indications
Blockade of the various nerves in the forearm with ultra-
sound can be used instead of a wrist block for hand surgery.
These techniques can also be used as rescue blocks for
inadequate anesthesia or analgesia in the various nerve
distributions. The main indication for nerve blocks in the
forearm is to facilitate catheter placement to provide pro-
longed analgesia to enable painless hand therapy in the
early postoperative period.
MEDIAN NERVE BLOCK (Fig. 1.6)
Anatomy
The median nerve leaves the cubital fossa passing between
the two heads of the pronator teres. It continues distally
deep to the ﬂ exor digitorum superﬁ cialis and superﬁ cial to
the ﬂ exor digitorum profundus. Near the wrist, it emerges
from the lateral border of the ﬂ exor digitorum superﬁ cialis
and lies deep to the palmaris longus tendon.
Technique
The ultrasound probe footprint for use in the sterile ﬁ eld
is prepared with a sterile clear adhesive dressing (e.g. Tega-
derm, 3M Health Care, St Paul, MN, USA) (Figs 1.7A,B).
This is applied to ensure that there is no wrinkle or bubble
trapped between the footprint and the dressing, as these

Anesthesia for Hand Surgery
5
A
B
C
FIGURE 1.4 A Insertion of IV catheter. B, C Application of double
pneumatic tourniquet.

Hand and Upper Extremity Reconstruction
6
will cause artifacts. Sterile jelly is also used to couple the
interface between the probe footprint and the skin to
improve the ultrasound image.
With the forearm in a supinated position and shoulder
abducted, the linear ultrasound probe is placed in the volar
aspect of the mid-forearm to view the structures in the
short axis (Fig. 1.7C). Here the median nerve can be easily
visualized as a hyperechoeic structure with a honeycomb
appearance lying in the fascial plane between the ﬂ exor
digitorum superﬁ cialis and the ﬂ exor digitorum profundus
(Fig. 1.8). It can be conﬁ rmed by sliding the ultrasound
probe proximally and distally along the forearm to follow
the course of the median nerve. Once conﬁ rmed, the target
is centralized in the image and the depth of the target
ascertained. A needle is then placed at the center of the
ultrasound probe footprint and advanced to the appropriate
depth of the target. With this out-of-plane approach the
needle tip can only be visualized by tissue movements as
the needle traverses the various planes. Alternatively, the
needle tip can be conﬁ rmed by injection of saline and visu-
alization of the hydrodissection plane. Once the hydrodis-
section is conﬁ rmed to be in the plane of the median nerve,
D
E
FIGURE 1.4, cont’d D Exsanguination using Esmarch bandage. E IV lidocaine given.
FIGURE 1.5 Equipment for ultrasound-guided nerve block. (1)
Portable ultrasound machine with linear high-frequency probe.
(2) Catheter introduction set. (3) Extension tubing. (4) Sterile gel.
(5) Local anesthetic. (6) Syringe. (7) Sterile adhesive dressing.

Anesthesia for Hand Surgery
7
the syringe is switched to one with a local anesthetic and
3–4 mL of 1.5% lidocaine or 0.5% bupivacaine are deposited
around the nerve under direct vision. If placement of a
catheter is necessary, we use a Contiplex A set for the initial
deposition of local anesthetic around the nerve and subse-
quently thread the catheter through the cannula distally
towards the wrist, leaving not more than 5 cm of catheter
in the perineural space. Postoperative infusion of 2–3 mL/h
of 0.1% bupivacaine provides good analgesia in the median
nerve territory.
ULNAR NERVE BLOCK
Anatomy
The ulnar nerve passes behind the medial epicondyle of
the humerus and enters the forearm by passing between
the two heads of the ﬂ exor carpi ulnaris. It runs down
the forearm between the ﬂ exor carpi ulnaris and the
ﬂ exor digitorum profundus. In the lower third of the
forearm the ulnar artery lies on the radial side of the ulnar
nerve.
Technique
With the elbow ﬂ exed 90º and the shoulder externally
rotated, the medial aspect of the forearm can be easily
accessed for this block. The linear ultrasound probe is
placed in the medial aspect of the mid-forearm to view the
structures in the short axis (Fig. 1.9). Here, the ulnar nerve
is easily visualized beneath the ﬂ exor carpi ulnaris as a
hyperechoeic honeycomb structure. The nerve can be con-
ﬁ rmed again by sliding the probe along the forearm and
following the course of the nerve and visualizing the ulnar
artery next to it on the lateral side in the distal third of the
forearm (Fig. 1.10).
Once conﬁ rmed, a short-axis out-of-plane approached is
used for local anesthetic deposition and catheter placement,
as described previously.
RADIAL NERVE BLOCK (SUPERFICIAL BRANCH)
Anatomy
After piercing the lateral intermuscular septum in the lower
part of the arm, the radial nerve travels into the cubital
fossa lying between the brachialis on the medial side and
the brachioradialis and extensor carpi radialis longus on the
lateral side. At the level of the lateral epicondyle it divides
into the superﬁ cial and deep branches. The superﬁ cial
branch is the direct continuation of the radial nerve. It runs
under the brachioradialis muscle and lies on the supinator
and pronator teres muscles. In the middle third of the
forearm, it travels with the radial artery beneath the bra-
Palmaris Longus Muscle (PL)
Flexor Digitorum Superficialis
Muscle (FDS)
Median Nerve
Anterior Interosseous Artery
and Nerve (branch of median
nerve)
Ulnar Nerve and Artery
Flexor Carpi Ulnaris Muscle
(FCU)
Flexor Digitorum Profundus
Muscle (FDP)
Ulna
Extensor Pollicis Longus
Muscle (EPL)
Posterior Interosseous Artery
and Nerve (deep branch of
radial nerve)
Flexor Carpi Radialis Muscle (FCR)
Brachioradialis Muscle (B)
Flexor Pollicis Longus Muscle (FPL)
Radial Artery and Superficial Branch
of Radial Nerve
Radius
Extensor Carpi Radialis Longus
Muscle (ECRL)
Extensor Carpi Radialis Brevis
Muscle (ECRB)
Abductor Pollicis Longus Muscle (APL)
Extensor Digitorum Muscle (ED)
Extensor Digiti Minimi Muscle (EDM)
Extensor Carpi Ulnaris Muscle (ECU)
FCR
B
A
C
B
PL
FCU
FDS
FDP
ECU
EDM
ED
APL
EPL
ECRB
FPL
Cross Section of Mid Forearm
laid
e
M
lareta
L
A. Ultrasound Probe Placement for Superficial Radial Nerve Block
B. Ultrasound Probe Placement for Superficial Median Nerve Block
C. Ultrasound Probe Placement for Superficial Ulnar Nerve Block
FIGURE 1.6 Cross-sectional anatomy at the mid-forearm.

Hand and Upper Extremity Reconstruction
8
chioradialis before leaving the artery and passing dorsally
under the tendon of the brachioradialis in the distal
forearm.
Technique
With the forearm in a supinated position and the shoulder
abducted, the linear probe is placed on the lateral aspect of
the mid-forearm to visualize the structures in the short axis
(Fig. 1.11).
Identiﬁ cation of the radial artery as a pulsating round
hyperechoic structure with a hollow black center under the
brachioradialis will aid in the identiﬁ cation of the radial
nerve, which usually lies on the radial side of the artery and
appears as a hyperechoeic honeycomb structure (Fig. 1.12).
Once conﬁ rmed, a short-axis out-of-plane approach is used
for local anesthetic deposition and catheter placement, as
described previously.
WRIST BLOCK
Wrist blocks are easily performed by the surgeon and are
very useful for surgery of the ﬁ ngers and hand. There are
A
B
FIGURE 1.7 A, B Application of sterile adhesive dressing to obtain sterile ultrasound footprint.
ﬁ ve nerves that cross the wrist: three main nerves (median,
ulnar and superﬁ cial radial nerves), and two cutaneous
branches, the palmar cutaneous branch of the median nerve
and the dorsal sensory branch of the ulnar nerve. Any of
the ﬁ ve can be blocked according to the area of anesthesia
required for the surgery. It usually takes about 15–30
minutes for the onset of anesthesia. All injections use a
27G needle where possible.
MEDIAN NERVE BLOCK
Anatomy
In the forearm, the median nerve passes under the ﬂ exor
digitorum superﬁ cialis and emerges from the muscle on the
radial aspect in the distal forearm beneath the palmaris
longus tendon. Continuing distally, it then comes to lie
between the palmaris longus and the ﬂ exor carpi radialis
tendons, being partially covered by the palmaris longus
tendon just before entering the carpal tunnel.
The palmar cutaneous nerve branches from the median
nerve a few centimeters proximal to the carpal tunnel, on
the radial aspect of the nerve. It continues distally on the

Anesthesia for Hand Surgery
9
C
FIGURE 1.7, cont’d C Ultrasound-guided median nerve block.
FIGURE 1.8 Ultrasound image of median nerve.
FIGURE 1.9 Ultrasound-guided ulnar nerve block.
FIGURE 1.10 Ultrasound image of ulnar nerve. FCU, fl exor carpi
ulnaris; FDS, fl exor digitorum superfi cialis; FDP, fl exor digitorum
profundis.

Hand and Upper Extremity Reconstruction
10
ulnar aspect of the ﬂ exor carpi radialis tendon before becom-
ing subcutaneous at the level of the wrist and branching to
supply the skin over the thenar eminence.
Technique (Figs. 1.13A–D, 1.16)
With the hand in the supine position, the palmaris longus
and the ﬂ exor carpi radialis tendons are identiﬁ ed. The
needle is introduced from the ulnar side of the palmaris
longus, directing it at about 45º towards the index ﬁ nger.
Alternatively, the needle may be introduced between the
palmaris longus and the ﬂ exor carpi radialis, directing
towards the ring ﬁ nger.9 There is a higher risk of actual
needle-to-nerve contact with this technique, which may
be extremely painful for the patient. It is not necessary to
elicit paresthesia. Another alternative technique is to inject
directly into the carpal tunnel using a more ulnar
approach.9
Once the deep fascia is penetrated (usually about 1–
1.5 cm deep), observe the bulge deep to the fascia as the
anesthetic is injected (usually about 5 mL). There should
not be a subcutaneous wheal, which indicates that the
injection is too superﬁ cial.
FIGURE 1.11 Ultrasound guided radial nerve block.
FIGURE 1.12 Ultrasound image of superfi cial branch of radial nerve.
ECRL, extensor carpi radialis longus; FCR, fl exor carpi radialis.
If anesthesia over the thenar eminence is desired, the
palmar cutaneous nerve can be blocked at the same time.
The ﬂ exor carpi radialis tendon is identiﬁ ed at the wrist
crease. About 2 mL of anesthetic is inﬁ ltrated over the
ulnar aspect of the tendon in the subcutaneous plane. This
can be approached without withdrawing the needle fully
after a median nerve block.
ULNAR NERVE BLOCK
Anatomy
In the distal forearm the ulnar nerve lies deep and radial to
the ﬂ exor carpi ulnaris tendon. The ulnar artery lies radial
to the ulnar nerve at this level. The ulnar nerve then enters
Guyon’s canal before branching into the superﬁ cial and
deep branches.
The dorsal sensory branch of the ulnar nerve is given
off a few centimeters proximal to the wrist and travels along
the volar aspect of the ulna before winding around the ulnar
styloid tip towards the dorsal ulnar aspect of the hand in
the subcutaneous plane.
Technique (Figs. 1.14A–D, 1.16)
With the hand supine, the ﬂ exor carpi ulnaris tendon is
identiﬁ ed just proximal to the pisiform. Introduce the
needle in a horizontal plane just under the tendon until the
tip of the needle is just at its radial border, usually 1–1.5 cm
deep. An alternative technique is to introduce the needle
from the volar aspect, just radial to the tendon to a depth
of about 1–1.5 cm.
Observe a deep swelling of the tissues as about 5 mL of
anesthetic are injected. Evidence of a subcutaneous wheal
may suggest the deposition of local anesthetic in an inap-
propriate plane, increasing the risk of block failure.
If anesthesia of the dorsoulnar aspect of the hand is
required, the dorsal sensory branch of the ulnar nerve needs
to be blocked. The ulnar styloid is identiﬁ ed with the wrist

Anesthesia for Hand Surgery
11
A
B
C
D
FIGURE 1.13 A Identifi cation of the palmaris longus. B Approach to median nerve. C alternative approach to median nerve. D Blocking the
palmar cutaneous nerve.
resting over the chest or vertically. About 2–3 mL of anes-
thetic are inﬁ ltrated transversely around the level of the
ulnar styloid in the subcutaneous plane. This can be done
through the same needle puncture as the ulnar nerve block,
but redirecting the needle dorsally.
RADIAL NERVE BLOCK
Anatomy
At the distal forearm the superﬁ cial branch of the radial
nerve emerges from beneath the brachioradialis tendon,
passing dorsally to come to lie in the subcutaneous plane.
It travels towards the anatomical snuffbox, usually dividing
into two or more branches at the distal aspect of the
radius.
Technique (Fig. 1.15)
With the forearm in neutral rotation, the radial styloid and
anatomical snuffbox are identiﬁ ed. The needle is intro-
duced at the level of the styloid transversely, inﬁ ltrating
about 3 mL of anesthetic in a ring around the radial aspect
of the wrist in the subcutaneous plane.
DIGITAL BLOCK
Digital blocks are very useful for surgery involving the digits
only. It is easy to administer and effective. Surgery can be
performed using a ﬁ nger tourniquet and is usually well tol-
erated by the patient. For all digital blocks, a small, 27G
needle is usually used.
Due consideration should be given to the risks versus
the beneﬁ ts of digital blocks in patients with peripheral
vascular disease, because these blocks may compromise
digital circulation. In these patients, wrist and mid-forearm
blocks are preferred. Many techniques for digital blocks
have been described. The ones described here represent
those used commonly in our practice, in order of preference
(Fig. 1.20).
Anatomy
There are four digital nerves, two volar, which give out two
dorsal branches at the base of the digits.
Dorsal double injection
The whole digit can be adequately blocked, including the
base of the dorsal aspect of the digit. However, this has the
disadvantage of requiring two injections.

Hand and Upper Extremity Reconstruction
12
Technique (Fig. 1.17A–E)
The needle is inserted from the dorsal of the base of the
digit to be blocked, starting on either the radial or the ulnar
side at the level of the web space. Once in the subcutaneous
layer, about 1 mL of local anesthetic is inﬁ ltrated, raising
a wheal. The needle is then passed from the dorsal to the
volar direction until it starts to tent the volar skin. This
can be palpated with the surgeon’s index ﬁ nger. The needle
is then withdrawn about 1–2 mm and aspirated to avoid an
intra-arterial injection; 1–2 mL of anesthetic are then inﬁ l-
trated. A bulge on the volar aspect of the digit can be seen
and felt. The process is then repeated for the opposite side
of the digit.
Variations in technique
1. To reduce the pain from the second injection, redirect
the needle and inﬁ ltrate the skin across the dorsal aspect
of the ﬁ nger without withdrawing the needle completely
after the ﬁ rst injection. The second injection on the
other side of the digit will then be through anesthetized
dorsal skin.
A
B
C
D
FIGURE 1.14 A Identifi cation of the fl exor carpi ulnaris (FCU) tendon.
B Introduction of the needle horizontally. C Alternative approach to
the ulnar nerve. E Blocking the dorsal sensory branch.

Anesthesia for Hand Surgery
13
FIGURE 1.15 Blocking the superfi cial radial nerve.
Flexor carpi ulnaris muscle
A
C
B
D
Ulnar nerve
Ulnar
Palmaris longus tendon
Median nerve
Flexor carpi
radialis tendon
Radius
FIGURE 1.16 Summary of techniques of
nerve blocks at the wrist. Median nerve
block: A between fl exor carpi radialis (FCR)
and palmaris longus (PL); B, ulnar to
palmaris longus. Ulnar nerve block: C, volar
approach radial to fl exor carpi ulnaris (FCU),
and D, under FCU.
2. Directing the needle into the web space proximally will
result in blockade of the common digital nerve as it
branches at the intermetacarpal region.10
Single volar injection
A single subcutaneous injection of local anesthetic at the
level of the A1 pulley or metacarpal head is sufﬁ cient to
block the whole digit. The advantage of this over the double
dorsal injection technique is that only one injection is
required. However, the dorsal area over the base of the
proximal phalanx may not be blocked adequately. It is also
more painful, as volar skin is more sensitive.
Technique
At the level of the distal palmar crease, the needle is inserted
into the subcutaneous plane in line with the ﬂ exor sheath,
directed at about 45º distally. About 3 mL of local anes-
thetic are injected (Fig. 1.18). If anesthesia of the dorsal
skin over the proximal phalanx is required, a supplemen-
tary dorsal injection is required.
Variations in technique
1. Direct the injection towards two sides of the ﬂ exor
tendon to inﬁ ltrate the anesthetic more directly over the
digital nerves.9,10
2. Injection through the proximal digital crease.11 This is
reported to be less painful.
TRANSTHECAL BLOCK (Fig. 1.19)
Since Chiu12 ﬁ rst reported the use of the transthecal tech-
nique of digital block in 1990, there has been a surge of
interest, and it has been used successfully by many sur-
geons.13,14 An injection of local anesthetic into the ﬂ exor
sheath provides rapid onset in the whole digit. In the cadav-
eric work by Sarhdi and Shaw-Dunn,15 it was shown that
the solution injected intrathecally escapes from the ﬂ exor
sheath around the vincular vessels into the perivascular
loose areolar tissue. This occurs at the base and head of the
proximal phalanx. The solution then spreads along the
main digital nerve and vessels, and their volar and dorsal
branches.
The advantages of this technique are that only a single
injection is required, onset of anesthesia is rapid, the risk
of injuring the neurovascular bundle is minimal, and only
a small amount of anesthetic is required, usually 2 mL.
Owing to the extension of the ﬂ exor sheath to the wrist,
the thumb and little ﬁ nger require more volume, up to
4 mL.16 However, this may be overcome by applying digital
pressure just proximal to the site of injection.12 The main

Hand and Upper Extremity Reconstruction
14
A
B
C
D
E
FIGURE 1.17 A Dorsal entry point on ulnar side of digit. B Raising a
subcutaneous wheal. C Palpation of the needle on the volar aspect
with the index fi nger before withdrawing slightly and infi ltrating the
local anesthetic. D, E Repeating the process on the radial side.

Anesthesia for Hand Surgery
15
FIGURE 1.18 Single volar subcutaneous injection.
A
C
B
D
Flexor digitorum profundus tendon
P3
P2
P1
MC
Flexor digitorum superficialis tendon
Synovial (flexor tendon) sheath
Fibrous tendon sheaths
FIGURE 1.19 Diagram of longitudinal section of fi nger with various approaches of needles into the tendon sheath. A Chiu;12 B Whetzel et al.;20
C Bhatti;22 D Authors’. (MC = metacarpus, P1 = proximal phalanx, P2 = middle phalanx, P3 = distal phalanx).
disadvantage is that it is more painful than subcutaneous
injections.14,17–19
Technique
The ﬂ exor sheath is identiﬁ ed by palpation at the level of
the metacarpal head or A1 pulley. The needle is introduced
into the sheath just proximal to the A1 pulley, directing
about 45º distally. About 2–3 mL of local anesthetic are
then inﬁ ltrated into the sheath. Pressure is maintained in
the plunger until the anesthetic ﬂ ows easily. The ﬁ nger can
be seen and felt to distend along the course of the ﬂ exor
sheath, up to the blanching pulp.
Variations in technique (Fig. 1.19)
1. Introduce the needle into the sheath at the level of the
proximal digital crease from the distal to proximal direc-
tion, at about 45º, superﬁ cial to the ﬂ exor tendons. By
holding the ﬁ nger with the thumb over the ﬂ exor aspect,
the bulge of the tendon sheath caused by the anesthetic
can be easily palpated.
2. Perpendicular insertion of the needle at the level of the
proximal digital crease straight through the ﬂ exor
tendons to the bone, and withdrawing the needle slowly
while applying pressure to the plunger.20
3. Another method is to put the injection site midway
between the proximal and middle digital creases, which
is reported to be less painful.21
LOCAL INFILTRATION
Local inﬁ ltration of local anesthetic is useful for minor
surgery of the hand, including excision of lumps, ganglia,
carpal tunnel release and trigger ﬁ nger release.
Field block (Fig. 1.21)
The local anesthetic is inﬁ ltrated via a needle puncture just
proximal to the lump, fanning the needle out in a V-shaped
direction. This will cover the proximal area. The distal half
is covered by giving two more injections in a converging V
direction, with the needle puncturing the anesthetized skin.
For deeper structures such as ganglia, it is recommended
that local anesthetic be given in the deeper planes at the
level of the tendons and joint capsule.
Carpal tunnel release can be performed under general
anesthesia, regional anesthesia (brachial plexus block, nerve
blocks at the level of the forearm, or Bier’s block) or local
anesthesia. Local anesthetic is inﬁ ltrated in the subcutane-
ous plane over the carpal tunnel22 (Fig. 1.22) and the distal
forearm just proximal to the carpal tunnel. We ﬁ nd that it
is not necessary to give local anesthetic into the carpal
tunnel,23 although it has been reported that subcutaneous

Clinical Pearls
Success with distal regional
anesthesia techniques
●
Strict patient and procedure selection
●
Anticipation and management of perioperative
expectations
●
Attention to other potential areas of discomfort during
procedure
Clinical Pearls
Local anesthetic drug
selection
●
The eff ectiveness of a given local anesthetic is largely
determined by the dose (mass) and site of administration.
●
Recommendations for maximal doses of local anesthetics
are not directly applicable to regional anesthetic
techniques except for Intravenous regional anesthesia.
TABLE 1.3
Equipment for Intravenous Regional Anesthesia (IVRA) (See Figures 3A and B)
• 2 Intravenous Cannula (one for delivering IVRA, the other on the non operative arm, as a functional intravenous access for sedation and
emergency)
• Simple tourniquet for intravenous cannulation
• Esmarch bandage 60 inches in length, 4 inches wide
• Soft cotton lining
• Double pneumatic tourniquet systems
• Standard American Society of Anesthesiologists monitors (electrocardiography, blood pressure, pulse oximeter)
• Resuscitation equipment necessary for the conduct of resuscitation as per American Heart Association Advanced Cardiac Life Support
guidelines.
• Lidocaine ( 30–50 ml of 0.5% lidocaine or 20 ml of 1.5% lidocaine or 15 mls of 2% lidocaine)
Clinical Pearls
Intravenous Regional
Anesthesia (IVRA)
●
Excellent results have also been demonstrated in hand
surgery using more proximal sites of local anesthetic
delivery such as the distal forearm25 or cubital fossa.26
●
For patients with trauma in operative limb, some authors
have advocated the use of a third tourniquet in the forearm
for preliminary induction of anesthesia in the hand before
application of Esmarch30. Alternatively, eff ective venous
drainage of the extremity can be achieved by simply
elevating the arm for 5 minutes prior.
●
Usual dose of lidocaine is approximately 3mg/kg. Systemic
toxicity can occur due to leakage past the tourniquet,
accidental tourniquet defl ation, or intentional defl ation
after a brief period.
●
Intentional intermittent cuff defl ation at the end of surgery
may eff ectively prolong the time to achieve peak arterial
concentrations of the local anesthetic but may not be
reliable in minimizing the toxicity due to the release of
local anesthetic into the circulation.
●
The tourniquet should not be defl ated until at least 30
minutes have passed after the injection of the local
anesthetic in the operative limb.
Clinical Pearls
Nerve Blocks in the mid-
forearm with ultrasound
●
Short axis view with the ultrasound provides a transverse
view of the nerves and is easier to identify the nerve of
interest.
●
Out of plane needle approaches reduce the skin to nerve
travel distance, making the acquisition of targeting skills
easier.
●
Use of hydro-dissection techniques allow for visualization
of the various planes of needle tip travel to confi rm local
anesthetic delivery around the target nerves.
●
Catheter infusion rates should be kept as low as possible to
avoid leak problems in the post-operative period around
the catheter insertion point.
Clinical Pearls
Nerve Blocks at the wrist
1. Ensure an adequate period of time (about 15 mins) for the
blocks to work. Usually the nerve blocks are given fi rst
before scrubbing for surgery.
2. The local anaesthetic should be injected slowly to reduce
pain resulting from distension.
3. Avoid intra-arterial injections by aspirating before injecting.
4. Avoid intra-neural injections, especially in patients under
general anesthesia. Follow anatomical landmarks and
ensure that the local anesthetic fl ows smoothly during
injection without excessive force. In awake patients,
paresthesia during needle introduction, or severe pain
when infi ltrating the anesthetic should alert the surgeon,
and the needle should be repositioned.
5. Anatomical variations may result in inadequate cover for
the expected area of anesthesia. Block more than one
nerve if necessary, especially for median and ulnar nerves.
6. Although local pain control may be adequate, tourniquet
pain limits the duration of surgery.

A
C
B
Dorsal digital
nerve
Digital artery
Base of proximal
phalanx
Extensor tendon
Volar digital nerve
Flexor tendon sheath
FIGURE 1.20 Summary of digital block techniques. A Traditional
dorsal approach. B Volar subcutaneous approach. C Transthecal
approach.
1
Lesion
2
3
4
FIGURE 1.21 Diagram to show infi ltration of fi eld block, from steps 1
to 4 using three punctures.
FIGURE 1.22 Subcutaneous infi ltration over the carpal tunnel.
Clinical Pearls
Transthecal block
1. It is diffi cult to locate the space between the fl exor tendon
and the sheath. Applying steady pressure while
withdrawing the needle very slowly will result in a sudden
ease of injection when the needle tip is in the potential
space between the sheath and the tendon. The consolation
is that the digital block will still work if the local anesthetic
is deposited in the subcutaneous plane.
2. Strict sterile technique must be adhered to, as an infection
in the fl exor sheath can be disastrous.
Clinical Pearls
Digital blocks
●
Comparison of injection pain between dorsal and volar
subcutaneous techniques have yielded equivocal
results.28,29 Data suggest that the transthecal technique is
associated with increased injection pain.17,18,30,31 In our
practice, injection pain is reduced with the use of the
dorsal technique, small gauge needles and slow injection
rates.
●
The dorsal technique is preferred when anesthesia over the
base of the proximal phalanx is required as volar
techniques may spare this area.36
●
Although recent data suggest that the use of local
anesthetic with epinephrine is safe,4,32,33,34,35,36 this has not
been adopted in our practice as its reported benefi ts
(prolonged analgesia and temporary hemostatic eff ect) are
easily achieved with other alternatives. Its use is not
recommended in digits with vascular compromise.

inﬁ ltration alone may not be sufﬁ cient in some cases.24 For
endoscopy-assisted carpal tunnel release, local inﬁ ltration,
especially into the carpal tunnel, may obscure the view.
SUMMARY
A summary of the procedures discussed is shown in Table
1.3. The use of regional anesthesia techniques is associated
with risks common to all nerve block techniques. These
include vascular/neural injury, local anesthetic toxicity, and
infection. These risks can be minimized with the use of
proper technique and precautions. This, coupled with the
high success rates and efﬁ cacy, has resulted in the contin-
ued widespread use of regional anesthesia for hand
surgery.
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2. Strichartz GR, Sanchez V, Arthur GR, et al. Fundamental
properties of local anesthetics. II. Measured octanol : buffer
partition coefﬁ cients and pKa values of clinically used drugs.
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3. Brouneus F, Karami K, Beronius P, Sundelof L. Diffusive
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8. Liebmann O, Price D, Mills C, et al. Feasibility of forearm
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RN, Pederson WC, Wolfe SW, eds. Green’s operative hand surgery,
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11. Harbison S. Transthecal digital block. Flexor tendon sheath used
for anesthetic infusion. [Letter] J Hand Surg 1991; 16A: 957.
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10: 35–38.
15. Sarhadi NS, Shaw-Dunn J. Transthecal digital nerve block. An
anatomical appraisal. J Hand Surg 1998; 23B: 490–493.
16. Chevaleraud E. Flexor sheath anesthesia. In: Saffar P, Amadio PC,
Foucher G, eds. Current practice in hand surgery. London: Martin
Dunitz, 1997; 1–4.
17. Brutus JP, Baeten Y, Chahidi N, et al. Single injection digital
block: comparison between three techniques. Chir de la Main
2002; 21: 182–187.
18. Keramidas EG, Rodopoulou SG, Tsoutsos D, et al. Comparison of
transthecal digital block and traditional digital block for anesthesia
of the ﬁ nger. Plast Reconstruct Surg 2004; 114: 1131–1134.
19. Hill RG Jr, Patterson JW, Parker JC, et al. Comparison of
transthecal digital block and traditional digital block for anesthesia
of the ﬁ nger. Ann Emerg Med 1995; 25: 604–607.
20. Whetzel TP, Mabourakh S, Barkhordar R. Modiﬁ ed transthecal
digital block. J Hand Surg 1997; 22A: 361–363.
21. Bhatti AZ. Painless method of digital block. [Letter] Plast
Reconstruct Surg 2007; 119: 444–445.
22. Gale DW. Surgical decompression of the carpal tunnel using
inﬁ ltrative anesthesia: description of technique. J Roy Coll Surg
Edin 1991; 36: 341.
23. Altissimi M, Mancini GB. Surgical release of the median nerve
under local anesthesia for carpal tunnel syndrome. J Hand Surg
1998; 13B: 395–396.
24. Patil S, Ramakrishnan M, Stothard J. Local anesthesia for carpal
tunnel decompression: a comparison of two techniques. J Hand
Surg 2006; 31B: 683–686,.
25. Karalezli N, Karalezli K, Iltar S, et al. Results of intravenous
regional anesthesia with distal forearm application. Acta Orthop
Belg 2004; 70: 401–405.
26. Blyth M, Kinninmonth A, Asante D. Bier’s block: A change of
injection site. J Trauma 1995; 39: 726–728.
27. Tham CHJ, Lim BH. A modiﬁ cation of the technique for
intravenous regional blockade for hand surgery. J Hand Surg 2000;
25: 575–577.
28. Williams JG, Lalonde DH. Randomized comparison of the single-
injection volar subcutaneous block and the two-injection dorsal
block for digital anesthesia. Plast Reconstruct Surg 2006; 118:
1195–1200.
29. Yin ZG, Zhang JB, Kan SL, Wang P. A comparison of traditional
digital blocks and single subcutaneous palmar injection blocks at
the base of the ﬁ nger and a meta-analysis of the digital block
trials. J Hand Surg 2006; 31: 547–555.
30. Low CK, Vartany A, Engstrom JW, et al. Comparison of
transthecal and subcutaneous single-injection digital block
techniques. J Hand Surg 1997; 22A: 901–905.
31. Low CK, Wong HP, Low YP. Comparison between single injection
transthecal and subcutaneous digital blocks. J Hand Surg 1997;
22B: 582–584.
32. Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with
epinephrine: an old myth revisited. J Am Acad Dermatol 2004; 51:
755–759.
33. Andrades PR, Olguin FA, Calderon W. Digital blocks with or
without epinephrine. Plast Reconstruct Surg 2003; 111:
1769–1770.
34. Denkler K. A comprehensive review of epinephrine in the
ﬁ nger: to do or not to do? Plast Reconstruct Surg 2001; 108:
114–124.
35. Sylaidis P, Logan A. Digital blocks with adrenaline. An old dogma
refuted. J Hand Surg 1998; 23B: 17–19.
36. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look
at the evidence for and against elective epinephrine use in the
ﬁ nger. Plast Reconstruct Surg 2007; 119: 260–266.
Hand and Upper Extremity Reconstruction
18

19
C H A P T E R
2
Fingernail Reconstructive Techniques
Reuben A. Bueno Jr and Elvin G. Zook
INTRODUCTION TO RECONSTRUCTION
By virtue of its location at the most distal aspect of the digit,
the perionychium – the ﬁ ngertip and nail – is the most
frequently injured part of the hand. Successful reconstruc-
tion addresses both the appearance and the function of the
nail. A functional nail serves multiple purposes, including
protection of the tip, regulation of circulation, and contribu-
tion to the sensory feedback needed for the ﬁ ne motor
movements of the hand.
INDICATIONS AND CONTRAINDICATIONS
● Nail deformity secondary to trauma is the most common
indication for nail reconstruction.
● Soft tissue and bony support is necessary for optimal
reconstruction. Loss of these elements in severe crush
injury may prevent successful reconstruction.
● Nail absence after excision of benign neoplasm is another
indication for nail reconstruction.
● Nail reconstruction after excision of malignant neo-
plasm is contraindicated when treatment requires
amputation at the level of the PIP joint or more
proximally.
Defects of the nail requiring reconstruction are usually
secondary to traumatic injury. Restoration of normal nail
appearance is best achieved by treatment of the injured nail
matrix in the acute setting. For nail deformities that present
later, reconstructive techniques may be used to provide a
more normal-appearing nail. Post-traumatic deformities are
often a result of scarring or loss of nail matrix. Reconstruc-
tion of the nail requires replacement of the scarred nail
matrix with adjacent non-scarred matrix or nail graft. These
techniques can also be used in the acute setting.
Excision of benign and malignant tumors involving the
nail bed matrix may require techniques of nail bed repair
and reconstruction that are also used in the traumatic
setting. Optimal treatment is dependent on a thorough
understanding of the components of the perionychium (Fig.
2.1) – skin, sterile matrix, germinal matrix, eponychial fold,
and distal phalanx – and their anatomical relationships
with each other. In severe crush injuries in which there is
inadequate bony support or soft tissue coverage, nail recon-
struction may not be an option. In these situations, revision
amputation may be the preferred procedure to allow the
earliest return of function.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
Traumatic injury to the perionychium is usually due to the
digit being caught in a door hinge or crushed between two
objects.1,2 Features of acute nail bed injury that may be
present include subungal hematoma, avulsion of the nail
out of the fold, lacerations or abrasions of the hyponychial
and paronychial skin, laceration of the nail bed, and frac-
ture of the distal phalanx. Nail lacerations can be described
in one of four ways: simple laceration, stellate laceration,
severe crush, and avulsion.
In the acute setting, the status of the entire ﬁ ngertip
must be assessed: quality of the skin, the presence of a
subungual hematoma, quality of the nail matrix, capillary
reﬁ ll, sensory function, ﬂ exion and extension at the distal
interphalangeal (DIP) joint, and the presence of a distal
phalanx fracture. There is an associated distal phalanx frac-
ture in 50% of nail bed injuries. This type of injury should
be considered an open fracture and treated as such, with
irrigation and debridement, reduction of the fracture and
ﬁ xation if necessary, and repair of the nail bed (Fig.
2.2).1–4
Accurate repair in the acute period increases the chance
of a normal-appearing nail. Left untreated, traumatic injury
to the nail matrix may result in an abnormal appearance

Hand and Upper Extremity Reconstruction
20
of the nail. Post-traumatic nail deformities include nail
non-adherence, nail remnant, split nail deformity, and
hook-nail deformity. Reconstruction of the nail matrix after
traumatic injury or loss should be approached with realistic
expectations.
Benign tumors (glomus tumor, DIP joint ganglion), and
malignant tumors (squamous cell carcinoma (SCC), mela-
noma) can affect nail appearance. Reconstruction of the
nail matrix after tumor excision will depend on the amount
of nail bed excised and the amount remaining.3–6 Manage-
ment of malignant tumors involving the nail bed requires
an understanding of the safe level of amputation (usually
to the level of the more proximal joint) and the need for
sentinel node biopsy.
OPERATIVE APPROACH
Anatomy
The ‘perionychium’ includes the following structures: nail
plate, nail bed, hyponychium, eponychium and fold, and
paronychium (Fig. 2.1). The proximal portion of the nail
matrix is the germinal matrix. The distal portion and the
undersurface of the eponychial surface is the sterile matrix.
The germinal matrix produces approximately 90% of the
nail, and the sterile matrix produces the remaining 10%
plus the cells on the undersurface of the nail responsible
for nail adherence and shine. The hyponychium is the skin
distal to the nail bed, the paronychium is the skin on each
side of the nail, and the eponychium is the skin over the
nail fold. The nail bed is adherent to the distal phalanx.
The lunula is the white arc of the nail distal to the eponych-
ium and represents the distal aspect of the germinal matrix.
The nail grows at 0.1 mm/day. New nail growth is com-
pleted in 3–4 months, and nail appearance will improve for
9–12 months.
Exposure
To provide a bloodless ﬁ eld, use of a Penrose drain tourni-
quet secured by a clamp at the base of the digit is recom-
mended. Use of a portion of a surgical glove as a tourniquet
is discouraged because of the risk of leaving the tourniquet
in place after repair and placement of the dressing. The
dressing may then hide the tourniquet, and vascular com-
promise and subsequent necrosis of the ﬁ nger is possible
in the postoperative period. Incisions perpendicular to the
eponychial fold may be necessary for adequate exposure of
the germinal matrix during repair or reconstruction.
NAIL BED REPAIR (Figs 2.3–2.6)
Sterile preparation and draping is carried out and a digital
block using a maximum dose of 7 mg/kg 1% plain lidocaine
is administered. The use of surgical loupes (2.5× magniﬁ ca-
tion is sufﬁ cient) is recommended for the most accurate
repair. A Kleinert–Kutz elevator is used to separate the nail
plate from the matrix for adequate exposure of the nail bed
laceration. The nail plate is cleaned and soaked in Betadine
as the nail bed repair is done. If the nail plate is not avail-
able, a silicone sheet or non-adherent gauze can be used to
maintain the eponychial fold after repair. Minimal debride-
ment of the matrix is performed to preserve as much of the
nail bed as possible. The laceration is repaired with 7/0
chromic sutures under loupe magniﬁ cation. The cleaned
nail plate can be placed back into the eponychial fold to
maintain the space under the fold and to serve as a splint
for a distal phalanx fracture. A ﬁ gure-of-eight suture in 5/0
nylon or a simple stitch from nail to hyponychium can be
used to hold the nail in place. Split-thickness injury to the
nail bed does not require closure.
Paronychium
Perionychium is paronychium
plus nail bed
Nail fold
Nail wall
Lunula
Lunula
Hyponychium
Nail bed
Ventral floor
Eponychium
Eponychium
FIGURE 2.1 The perionychium and its associated structures.
FIGURE 2.2 Nail bed injury with concomitant distal phalanx fracture.
With a break in the periosteum there is communication of the distal
phalanx with the outside environment. There is a risk of osteomyelitis
if not treated appropriately.

Fingernail Reconstructive Techniques
21
NAIL BED RECONSTRUCTION (Figs 2.7–2.12)
A defect amenable to reconstruction may be present after
the excision of scar from a prior injury to the nail bed.
The scar may be causing non-adherence or a split nail
deformity.
Small areas <5 mm can be left to heal by secondary
intention but may result in scarring and nail deformity.
Defects measuring 3–5 mm can be closed with lateral
advancement ﬂ aps of the nail matrix, mobilized toward the
center after making releasing incisions in the lateral paro-
nychial folds. Defects >5 mm can be treated with a split-
thickness nail bed graft from one of the following donor
sites: adjacent non-injured nail bed, nail bed from another
digit, nail bed from a toe.3,6–8 The primary goal in nail
reconstruction is to restore the nail matrix to permit the
growth of a ﬂ at, smooth nail plate. In order to achieve
this, scar may need to be excised and the nail matrix
resurfaced.
In reconstruction with a split-thickness nail matrix
graft, the recipient and donor sites are prepared and draped
in standard surgical fashion. A digital block is administered
at both sites. The digit is exsanguinated, and a Penrose
drain tourniquet is placed at the base. The nail bed is
exposed at both recipient and donor sites, and the defect is
measured. Residual scar at the recipient site is excised. A
split-thickness nail bed graft to cover the defect is harvested
from the sterile matrix of the second toe using a #15
scalpel. To reduce the risk of donor site nail deformity, the
germinal matrix should not be used as a graft for a defect
of the sterile matrix. The graft is carefully harvested by
placing the blade parallel to the nail bed and taking it thinly
enough so that the blade can be seen through the graft. The
split-thickness graft is sutured in place using 7/0 chromic,
as for a laceration repair. Reconstruction of the germinal
matrix with subsequent growth requires full-thickness
germinal matrix graft from a toe (preferably the second toe)
to produce nail at the recipient site.9
FIGURE 2.3 Laceration with nail plate present. The nail plate is
cleaned and will be used later as a splint to maintain the eponychial
fold.
FIGURE 2.4 Repair of nail bed and surrounding skin after
debridement.

Hand and Upper Extremity Reconstruction
22
PINCER NAIL RECONSTRUCTION (Figs 2.13–2.16)
The goal of treatment is to ﬂ atten the excessive curvature
of the nail and correct the ‘pinched-in’ appearance of the
nail. The nail bed is exposed as previously described and
stab incisions are made in the ulnar and radial ﬁ ngertips.
The sides of the nail bed need to be elevated from the distal
phalanx using a Kleinert–Kutz elevator or ﬁ ne-pointed scis-
sors. Injury to the paronychium should be avoided as the
nail bed is elevated. Subcutaneous tunnels are created
on the radial and ulnar borders, and stab incisions are
made on the radial and ulnar eponychium. Dermal graft or
Alloderm is cut to the appropriate length and placed in
the tunnel. The graft can be pulled into the tunnel, distal
to proximal, with the aid of a suture to position it in the
desired position. Stab incisions are closed with 6/0 nylon.
EPONYCHIAL AND HYPONYCHIAL
DEFORMITIES
Reconstruction of the eponychium or the hyponychium is
challenging, and efforts should be made at the time of
initial repair to avoid these problems. Pterygium is the scar-
ring of the eponychium and nail fold to the underlying nail
bed, resulting in absent nail growth or a split nail deformity.
Despite attempts at the initial repair to maintain the
eponychial fold with the nail plate or silicone sheeting in
the postoperative period, scarring of the fold and the ger-
minal matrix, and subsequent nail deformity is a potential
complication. Release of the adherent scar and placement
of a silicone sheet into the nail fold to allow epithelializa-
tion of the undersurface of the fold may allow nail growth.10
Nonvascularized composite toe eponychial grafts have also
been described to reconstruct the eponychium.11
Closure of a ﬁ ngertip amputation with excessive tension
and/or inadequate bony support of the distal phalanx leads
to a hook nail deformity. The best treatment for this is
avoidance. The nail matrix should not be pulled over the
distal phalanx. If adequate soft tissue is present, bone loss
must be replaced with bone graft to provide distal support.
If adequate soft tissue is not present, or bone graft is not
a good option in the acute treatment, the nail bed should
be trimmed back and volar tissue advanced to cover the
exposed bone.
FIGURE 2.5 Nail plate being placed back into fold.
FIGURE 2.6 Completed nail bed laceration repair.

Fingernail Reconstructive Techniques
23
In terms of optimal reconstruction of the ﬁ ngertip –
including all the components of the perionychium, bony
support, and restoration of the volar pulp – the best option
is a microvascular second-toe transfer. Patient selection,
however, is often an issue in this most technically demand-
ing of nail reconstruction options. Patient desire, expecta-
tions, occupation and return to work, and compliance are
important factors to address if this option is to be
considered.
DIP JOINT GANGLION CYSTS
Ganglion cysts at the DIP joint can cause nail deformity.
The cysts often arise from an osteophyte at the joint, which
causes ridging or grooving of the nail. Normal appearance
of the nail is restored with excision of the osteophyte and
drainage of the ganglion cyst through a T- or H-shaped
incision over the DIP joint. Complete excision of the cyst
is not required to correct the nail deformity. Debridement
of the osteophyte is the more important step.10 In exposing
the DIP joint, the distal insertion of the extensor tendon
should be preserved to avoid an extensor lag.
FIGURE 2.7 Initial presentation of nail bed crush injury.
FIGURE 2.8 After repair with remaining nail matrix with defect and
exposed bone.
OPTIMIZING OUTCOME
● The primary goal in nail reconstruction is to restore
the nail matrix to permit growth of a ﬂ at, smooth nail
plate.
● With prompt treatment of nail bed injury, subacute and
chronic problems can be avoided and a more complex
reconstruction may be averted.
● An accurate repair of the nail matrix allows the nail
plate to grow out with a smooth, ﬂ at appearance.
● Whereas repair in the acute period provides the best
chance for a normal-appearing nail, scarring at the
site of injury may produce a nail deformity. Patients
should be reminded of this possibility at the time of
repair.8,9,12
● Results of nail bed repair are adversely affected by the
following factors: avulsion or crush injury of the ﬁ nger-
tip, the presence of a distal phalanx fracture, three or
more sites injured, and the need to use a silicone sheet
to replace the nail.1,2,8
● Late reconstruction of the nail bed is often not as
successful as surgeon or patient would desire.7

Hand and Upper Extremity Reconstruction
24
FIGURE 2.9 Harvest of split nail matrix graft from toe.
FIGURE 2.10 Harvested split nail matrix graft.
FIGURE 2.11 Graft inset into defect to cover exposed bone.
● Management plans must be individualized, and realistic
expectations discussed when treating patients with nail
bed injuries.
COMPLICATIONS
Complications in the acute or subacute setting include soft
tissue infection, osteomyelitis of the distal phalanx, non-
union of the distal phalanx fracture, and post-traumatic
stiffness and loss of motion at the DIP joint. Complications
or unfavorable outcomes in the chronic setting include
scarring in the sterile matrix leading to a split nail or
non-adherent nail, scarring at the eponychial fold that may
interfere with nail plate growth, and persistent nail growth
after unsuccessful attempt at ablation.
Inadequate treatment in the acute setting often leads to
a nail deformity. Scarring can lead to a split nail deformity.
Absence of the nail matrix can lead to detachment of the
nail. Lack of support from the distal phalanx leads to a hook
nail deformity. Failure to treat a nail bed laceration and
concomitant distal phalanx fracture as an open fracture
may result in osteomyelitis. Too much tension at the site
of nail bed repair or a lack of support from the distal

Fingernail Reconstructive Techniques
25
FIGURE 2.12 Appearance of nail 1 year after nail matrix
reconstruction using a split graft from the toe.
FIGURE 2.13 Pincer nail deformity with characteristic ‘pinched-in’
appearance.
FIGURE 2.14 Creation of subcutaneous tunnels through stab
incisions on the radial and ulnar sides.
phalanx may result in a hook nail deformity. Nail deformi-
ties are best avoided by following the principles of acute nail
repair: thorough irrigation, minimal or no debridement,
accurate placement of sutures to approximate nail matrix
edges, minimizing tension, and covering defects with adja-
cent matrix or with a split nail graft. It is better to close an
irregular edge than a straight edge under tension. Split nail
deformity and non-adherence can be treated by excision of
scar and the placement of a split-thickness nail matrix graft
from the toe.
POSTOPERATIVE CARE
The dressing is left on for 5–7 days and may need to be
soaked in a mixture of hydrogen peroxide and water or
normal saline for removal. The repaired nail is checked for
signs of infection, seroma, and hematoma. Non-adherent
gauze placed to maintain the eponychial fold should be
removed. Any suture used to hold the nail or silicone sheet
within the fold should also be removed 5–7 days after
surgery. Sutures placed in the skin of the hyponychium or
paronychium should be removed 10–14 days after repair.

Hand and Upper Extremity Reconstruction
26
FIGURE 2.15 Placement of Alloderm or dermal graft in subcutaneous
tunnel.
FIGURE 2.16 Postoperative appearance after pincer nail repair.
A ﬁ ngertip splint that does not include the proximal
interphalangeal (PIP) joint can be used for the ﬁ rst 3–5
weeks after injury to protect the nail bed repair and immo-
bilize a distal phalanx fracture if present. Early movement
of the PIP joint should be encouraged: the ﬁ ngertip splint
protects the tip and will allow PIP motion. Hypersensitivity
of the tip may be present 1–3 months post injury, and
desensitization exercises may be necessary to promote use
of the affected digit.
Repair in the acute period provides the best chance for
normal appearance of the nail.
The nail plate grows at approximately 0.1 mm/day or
2–3 mm/month. When the nail plate is removed for nail
bed repair, new nail growth is delayed for 3–4 weeks.7
If placed back on after repair, the old nail will remain
adherent for 1–3 months and then fall off as a new nail
pushes out the old one.13 After nail repair, it will take
approximately 12 months for the nail to achieve its ﬁ nal
appearance. Thickening of the nail proximal to the level of
injury is seen for approximately 50 days.7,8,13 Both surgeon
and patient should be aware of the stages of nail growth
and the characteristic appearance at different points in the
healing process as the nail grows out.
CONCLUSION
The goal of reconstruction is to restore the nail bed and
allow for more normal growth after loss due to trauma or
excision. Both appearance and function should be addressed
in any reconstructive effort. Reconstruction of the sterile
matrix can be accomplished with a split nail bed graft from
an adjacent nail bed, an adjacent digit, or a toe. Reconstruc-
tion of the germinal and sterile matrices can be accom-
plished with a graft from the second toe, if the donor site
is large enough. Adequate soft tissue and bony support is
necessary for an optimal result.
Pearls
●
Optimal appearance of the nail is most likely to occur with
prompt treatment of the nail bed injury in the acute
period.
●
Use of a fi nger tourniquet, loupe magnifi cation, and 7/0
chromic suture is recommended to achieve the most
accurate repair.
●
A Kleinert–Kutz elevator or a small periosteal elevator is
useful in separating the nail plate from the adherent nail
bed matrix.
●
Fractures of the distal phalanx are common with nail bed
injuries and should be treated if present.
●
After trauma to the nail bed and subsequent repair, it may
take up to a year for the nail to achieve its fi nal appearance.
●
As the nail grows distally, a heaped-up appearance is
present for 2–6 months before it fl attens.
●
Adequate soft tissue and bony support at the fi ngertip are
necessary for optimal nail reconstruction.

Fingernail Reconstructive Techniques
27
REFERENCES
1. Brown RE, Zook EG, Russell RC. Reconstruction of ﬁ ngertips with
combination of local ﬂ aps and nail bed grafts. J Hand Surg 1999;
24A: 345–351.
2. Kumar VP, Satku K. Treatment and prevention of ‘hook nail’
deformity with anatomic correlation. J Hand Surg 1993; 18A:
617–620.
3. Brown RE, Zook EG, Williams J. Correction of pincer-nail
deformities using dermal grafting. Plast Reconstruct Surg 2000;
105: 1658.
3. Guy RJ. The etiologies and mechanisms of nail bed injury. Hand
Clin 1990; 6: 9–21.
4. Shepard GH. Perionychial grafts in trauma and reconstruction.
Hand Clin 2002; 18: 595–614.
5. Shepard GH. Nail grafts for reconstruction. Hand Clin 1990; 6:
79–102.
5a. Shepard GH. Treatment of nail bed avulsions with split thickness
nail bed grafts. J Hand Surg 1983; 8: 49–54.
6. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of
acute ﬁ ngernail injuries. Hand Clin 1990; 6: 23–35.
7. Zook EG. The perionychium: Anatomy, physiology and care of
injuries. Clin Plast Surg 1981; 8: 21–31.
8. Zook EG, Van Beek AL, Russell RC, Beatty ME. Anatomy and
physiology of the perionychium: A review of the literature and
anatomic study. J Hand Surg 1980; 5: 528–536.
9. Zook EG. Reconstruction of a functional and aesthetic nail. Hand
Clin 2002; 18: 577–594.
10. Zook EG, Brown RE. The perionychium. In: Green DP, ed.
Operative hand surgery. New York: Churchill Livingstone, 1999;
1353–1380.
11. Lillie S, Brown RE, Zook EG, Russell RC. Free non-vascularized
composite nail grafts: An institutional experience. Plast
Reconstruct Surg 2000; 105: 2412–2415.
12. Brown RE. Acute nail bed injuries. Hand Clin 2002; 18:
561–575.
13. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries:
Causes, treatment and prognosis. J Hand Surg 1984; 9A: 247–252.

29
C H A P T E R
3
Surgical Techniques for Flexor
Tendon Repair
Kevin C. Chung
INTRODUCTION
Flexor tendon injury is devastating because the loss of
ﬂ exion of a digit renders that digit functionless. Unlike
the extensor system, where there are interconnections
between various tendon structures that may prevent retrac-
tion of the lacerated proximal tendon, the ﬂ exor tendon
system is under substantial tension. Laceration of a ﬂ exor
tendon needs to be repaired because the proximal tendon
will often retract, which will require its retrieval and suture
repair.
The physiology and healing of the ﬂ exor tendon are the
most common research topics in hand surgery. Research
on ﬂ exor tendon healing is one of the major advancements
in the ﬁ eld because the ﬁ ndings can be translated to other
regions of the body that require ligament and tendon repair.
At one time the ﬂ exor tendon was thought to have no
intrinsic healing ability, and researchers have hypothesized
that the only way ﬂ exor tendons can heal is extrinsically,
whereby nutrients and blood ﬂ ow from outside the tendons
and work to heal the repaired tendon. However, ﬂ exor
tendons do have an intrinsic healing ability. Classic research
studies have shown that repaired tendons immersed in
nutrient ﬂ uid have the ability to heal intrinsically by bridg-
ing of tenocytes between the lacerated tendon ends.1 This ﬁ nd -
ing is important because intrinsic healing will not have
the adhesions from the surrounding environment to limit
excursion of the healed tendons. Ongoing research projects
aim to enhance intrinsic healing while limiting healing
from extrinsic sources. It has also been shown that stress-
ing the tendon repair site will enhance intrinsic healing,
which lays the foundation for early mobilization exercises
after tendon repair. However, the amount of stress placed
on the healed tendon needs to be carefully coordinated to
prevent excess loading, which can rupture the repair. Out-
comes of ﬂ exor tendon repair may improve if surgeons can
improve the rate of healing through constant infusion of
growth factors to the repaired tendon ends, or by stronger
repair techniques to permit an active rehabilitation proto-
col. An active protocol provides much better excursion of
the repaired tendons, which theoretically will promote
intrinsic healing and limit the adhesions associated with
extrinsic healing. The current passive protocol has rather
modest excursion of the repaired tendons, and adhesions
limiting tendon mobility continue to be problematic.
ANATOMY OF THE FINGER FLEXOR
TENDON SYSTEM
The ﬂ exor tendon system is complicated and was divided
into ﬁ ve zones by Verdan (Fig. 3.1).2 Zone 1 is at the inser-
tion of the ﬂ exor digitorum profundus (FDP) tendon to the
distal phalanx. Zone 2 consists of the region of the middle
phalanx to the A1 pulley, where both the FDP and ﬂ exor
digitorum superﬁ cialis (FDS) tendons are intimately con-
tained within a tight ﬁ bro-osseous tunnel (Fig. 3.2). This
is a commonly injured area that was named the ‘no man’s
zone’ because laceration of tendons in this zone is associ-
ated with adhesions and loss of tendon excursion. Because
of the difﬁ culty associated with repairing and attaining
functional movement in this zone, early pioneers of hand
surgery, including Bunnell3 and Boyes,4,5 did not advocate
repair of tendons in zone 2, but rather excision and grafting
of the profundus tendon only. It was only in the 1970s that
Kleinert6 showed that primary repair of zone 2 ﬂ exor tendon
injury is feasible, and that patients who underwent judi-
cious early postoperative therapy could attain acceptable
function.
Zone 3 is the region between the proximal A1 pulley
and the carpal tunnel. This zone corresponds to the palmar
region and there is no sheath encasing the ﬂ exor tendons.
Therefore, injuries to this region generally have a much
better outcome.
Zone 4 is the region of the carpal tunnel. This region is
not commonly injured because the transverse carpal liga-

Hand and Upper Extremity Reconstruction
30
ment is attached to the trapezium and hamate. Laceration
in the carpal tunnel region will be blocked by these two
carpal bones, and the tendons dorsal to the transverse
carpal ligament typically will not be injured unless the
wound is longitudinally along the direction of the
tendons.
Zone 5 is the region proximal to the transverse carpal
tunnel and is a common region for tendon laceration. The
tendon injury may be self-inﬂ icted in suicide attempts, or
may be caused by trauma. There is no bony protection in
this region because the radius and ulna are dorsal to all the
vital structures. Lacerations to zone 5 will often have con-
comitant injuries to the median and/or ulnar nerves, and
perhaps the radial and ulnar arteries (Fig. 3.3). Flexor
tendon injuries at the wrist are often categorized as ‘spa-
ghetti wrist’ because the multiple lacerations may mimic
the appearance of cut spaghetti. Outcomes of ﬂ exor tendon
injuries in zone 5 are often quite favorable because each
tendon is shielded from the others by synovial tissue.
However, poor outcomes are often associated with con-
comitant nerve injuries involving the ulnar or median
nerves. Injury to these two nerves has a rather dismal
outcome, marked by incomplete sensory and motor
recovery and neuropathic pain.
THUMB FLEXOR TENDON SYSTEM ANATOMY
The thumb is divided into four zones (see Fig. 3.1). The
anatomy of the thumb ﬂ exor tendon is different from that
of the ﬁ ngers because it is powered by a single extrinsic
ﬂ exor tendon, the ﬂ exor pollicis longus (FPL). The tendon
sheath – comprising the A1, the obliques, and the A2
pulleys – contains only one tendon, and therefore tendon
excursion after repair is generally quite favorable, without
the adhesions commonly seen in zone 2. Inadequate excur-
sion of the repaired FPL may not be as troublesome as in
the ﬁ ngers because the thumb functions primarily as a post
to face the other ﬁ ngers, and full motion is generally not
necessary. For the ﬁ ngers, the most important pulleys are
A2 and A4 (see Fig. 3.2); for the thumb, the A1 and oblique
pulleys are the most important (Fig. 3.4), but one should
try to preserve all the pulleys during repair if possible.
ZONE 1 FLEXOR TENDON INJURY
Zone 1 consists of the insertion of the FDP onto the distal
phalanx. Lacerations to zone 1 are quite uncommon. Most
tendon injuries to this region involve an avulsion com-
ponent in which the distal interphalangeal (DIP) joint is
forcibly extended under great ﬂ exor tendon force. The
typical scenario is a ‘jersey ﬁ nger,’ when the middle or ring
ﬁ ngers grab onto the jersey of an opponent who pulls away
during a football game. The sudden, forcible DIP extension
against resistance causes rupture of the profundus tendon.
The tendon may be avulsed with a fragment of bone, which
can be seen on X-ray to determine the proximal location of
the avulsed tendon. Typically, the bone will be lodged at the
A3 pulley level at the decussation of the superﬁ cialis tendon.
However, when the tendon is avulsed without an accompa-
nying fracture fragment, it may retract proximally to the
level of the A1 pulley, depending on whether the vincula
supplying the FDP is avulsed as well. The vincula provides
blood supply to the tendon system and consists of a vincula
longus and a vincula brevis (Fig. 3.5). Occasionally, the
vincula may hold the profundus tendon more distally.
Leddy7 divided profundus tendon avulsion injury into three
categories: type 1 is when the tendon retracts to the palm,
type 2 is when it retracts to the proximal interphalangeal
(PIP) joint, and type 3 is when it retracts to the level of the
distal A4 pulley.
Indications for treating zone 1 avulsion injury
Typically after about 3 weeks of no treatment, the FDP may
be quite edematous and cannot be guided through the
pulley system to be attached into the distal phalangeal
bone. In selected cases the tendon is lodged at the level of
the A2 pulley, and the tendon can still be passed through
FIGURE 3.1 The fi ve zones of the fl exor tendon system.

Surgical Techniques for Flexor Tendon Repair
31
A5
A5
C3
A4
C2
A3
A2
A1
C1
A5
A5
C3
A4
C2
A3
A2
A1
C1
Pronator
quadratus
muscle
Ulnar nerve
Ulna
Palmaris longus tendon
Median nerve
Flexor carpi
radialis tendon
Radius
Flexor pollicis
longus tendon
Radial artery
Ulnar artery
Flexor carpi
ulnaris tendon

Palmar carpal
ligament
Flexor digitorum
superficialis tendons
Flexor digitorum
profundus tendons
FIGURE 3.2 Anatomy of the zone 2 fl exor tendon system.
FIGURE 3.3 Cross-sectional anatomy of
zone 5.
the tendon system and be attached to the distal phalanx.
Therefore, the 3-week period is not the absolute criterion
for not performing primary repair. To determine the pro-
ximal extent of the avulsed FDP tendon, radiography (if
associated with a fracture) or ultrasound may be helpful.
Myostatic contraction associated with a retracted tendon
may also prevent the tendon from being able to be inserted
into the distal phalanx without undue tension.
Contraindications for treating zone 1
avulsion injury
Profundus tendon laceration or avulsion injury occurs more
than 3 weeks after injury, and if the proximal retraction of
the tendon is at the level of the A1 pulley.
If the avulsion injury is not detected for several months,
then primary repair of the tendon is not possible. One

Hand and Upper Extremity Reconstruction
32
the quadriga effect, in which a checked ruptured FDP
tendon prevents the other FDP tendons from full excursion
because of a shared common muscle belly (Fig. 3.7). Preop-
eratively, an X-ray is necessary to evaluate whether the bone
is avulsed, which can help determine the proximal extent
of the avulsed tendon (Fig. 3.8). If the X-ray does not show
bone fragments, ultrasound can be helpful to determine the
proximal location of the avulsed tendon, but is not neces-
sary because exploration of the tendon system will deter-
mine this. A zigzag incision is made to explore the tendon
system (Fig. 3.9). In this case, there is bone attached to the
ruptured profundus tendon, which is held by the pickup.
The Keith needle skewers the profundus tendon proximally
to prevent its retraction (Fig. 3.10A,B).
When the profundus tendon is retracted more proxi-
mally, a transverse A3 pulley incision is made to identify
the tendon. On rare occasions the A1 pulley will need to
be opened with an incision in the palm, and a small red
Robinson catheter can be threaded distal to proximal
through the tendon sheath to retrieve the proximal tendon.
Once the tendon is sewn to the end of the catheter, the
catheter can be gently pulled through the sheath (Fig. 3.11).
It is quite important to place the catheter gently through
the FDS decussation so that the FDP tendon can go through
its original path. If the tendon is rerouted through a new
path, adhesions may form, which can cause problems with
excursion.
The ﬂ exor tendon is then pulled through the A5 pulley.
By ﬂ exing the ﬁ nger, one can lessen the tension on the
tendon and allow it to advance to the distal phalanx. Even
though the bone is avulsed, the fragment is usually too
small to accommodate bone ﬁ xation using a screw. Occa-
sionally the bone component can be large enough that a
single screw ﬁ xed to the distal phalanx is sufﬁ cient to sta-
bilize the avulsed tendon. In most cases the tendon will
need to be advanced and secured within the bone of the
distal phalanx using a Bunnell criss-cross suture with 2/0
Prolene. Prolene sutures are used because they can slide and
can be pulled off the bone after healing. It would be a
mistake to use a braided suture because braided sutures do
not slide and will be partially retained under the nail bed
after attempted removal, which may lead to infection. The
cortex of the distal phalanx is partially removed using a
curette (Fig. 3.12). Two Keith needles are placed through
the mid-portion of the dorsal nail (Fig. 3.13). It is important
Oblique
A2
A1
VBP
VBS
VLP
VLS
FIGURE 3.4 Pulley system of the thumb.
FIGURE 3.5 Vincula system that
provides blood to the tendons.
should resist the temptation to place a tendon graft within
an intact FDS tendon. The functional limitation of an
immobile DIP joint is not great and patients can generally
tolerate this. If there is volar laxity of the DIP joint, then
the joint can be fused or volar capsule advancement can be
performed to maintain DIP stability. Placing a tendon graft
through an intact FDS tendon may cause tendon adhesions,
and the prolonged rehabilitation may cause an even greater
functional problem.
Operative approach
The ring ﬁ nger is often involved in FDP avulsion injury
(Fig. 3.6). It may be difﬁ cult to make a full ﬁ st because of

Surgical Techniques for Flexor Tendon Repair
33
not to puncture the germinal matrix at the nail fold to avoid
causing nail deformity. The two ends of the Prolene suture
are inserted into the Keith needles and pulled through the
nail. The Keith needles are used again to pass the Prolene
sutures through folded Xeroform gauze and are tied over a
button (Fig. 3.14). One should watch the entry of the pro-
fundus tendon into the bone when tying the suture so that
the tendon will contact the distal phalanx to achieve better
healing.
The wrist and ﬁ ngers are ﬂ exed to take the tension off
the tendon, and the sutures are tied down using at least
10–15 ties to avoid loosening. Once the suture is secured,
the ﬁ nger posture should show the natural ﬂ exion cascade
of the DIP joint (Fig. 3.15). The bone fragment (Fig. 3.16,
FIGURE 3.6 Functional picture showing the inability to fl ex the right
ring fi nger due to a profundus tendon rupture.
FIGURE 3.7 Functional picture showing the diffi culty of fl exing the
other fi ngers because of the quadriga eff ect from the checked FDP
tendon to the ring fi nger.
FIGURE 3.8 Lacerated profundus tendon with the arrow pointing to
the attached bone chip.

Hand and Upper Extremity Reconstruction
34
FIGURE 3.9 A zigzag incision is used to expose the fl exor tendon
system.
A
B
FIGURE 3.10 A The pick-up is holding the bony attachment to the
profundus tendon. B The Keith needle is used to prevent retraction of
the avulsed tendon.
Red Robinson catheter
A1
(opened)
A2
Distal phalanx
Middle phalanx
A3
A4
A5
Proximal phalanx
Retracted profundus
tendon sutured to
catheter
FIGURE 3.11 Diagram showing a catheter threaded through the
pulley system and sewn to the avulsed tendon for retrieval.
arrow) has healed to the distal phalanx. The wound is
closed using 5/0 nylon sutures and the patient is placed in
a dorsal blocking splint with the wrist ﬂ exed at about 60º
and the MCP joints at about 90º. Gentle passive motion of
the DIP joint will be initiated 1 week after surgery. The
button is left in place for 8 weeks, and the Prolene suture
will be pulled through the tendon and bone at that time.
Strengthening exercises are not started until 8 weeks after
surgery.
Optimizing outcomes
●
Early recognition of the injury and repair
●
Atraumatic handling of the avulsed tendon in order to guide
it through the pulley system
●
Strong attachment of the tendon into a bone tunnel in the
distal phalanx
●
Judicious passive therapy to prevent joint contracture and
enhance tendon excursion

Surgical Techniques for Flexor Tendon Repair
35
Complications
The most common complication from this injury is inade-
quate tendon excursion and ﬁ nger stiffness. Many of
these injuries are not recognized immediately. The avulsed
tendons may become edematous and be difﬁ cult to pull
through the pulley system. The tight interface between the
pulley system and the edematous tendon may cause
postoperative adhesions, resulting in incomplete ﬁ nger
ﬂ exion.
A less common complication is tendon rupture. If this
is the case, it may be difﬁ cult to retrieve the tendon and
repair it again. However, one should explore the tendon and
evaluate whether reattaching it can still be useful. It is
generally not a good idea to place a tendon graft through
the intact FDS tendon system because of the technical
difﬁ culty and potential problems with adhesions, which
may severely affect ﬁ nger movement (Fig. 3.17A,B). When
tendon repair is not possible because of delay, DIP fusion
is an effective operation that will position the ﬁ nger in a
good functional posture of about 10–15º of ﬂ exion without
the need for a complicated tendon grafting procedure.
ZONE 2 FLEXOR TENDON INJURY
Zone 2 ﬂ exor tendon injuries are often accompanied by
digital nerve or artery lacerations. Typically, the surgeon has
about 4 weeks to repair a lacerated zone 2 ﬂ exor tendon.
After this time the tendon may have retracted and short-
ened, which makes repair much more difﬁ cult and out-
comes less favorable; for delayed presentation when primary
repair is not suitable, one should consider excising the FDS
and FDP and reconstruct using a tendon graft. Depending
on the tendon graft available, there are two options for the
procedure. One is to repair the proximal tendon in zone 3,
another to repair the tendon in zone 5. Typically, the pal-
maris longus tendon can reach the palm easily, and in some
cases is long enough to reach the distal end of the wrist
crease. If the patient has a plantaris tendon, this is long
enough to bridge between the distal phalanx and the proxi-
mal wrist. Proximal repair at the wrist is favorable because
there is sufﬁ cient space between tendons, which minimizes
adhesions at the wrist.
Operative approach
Physical examination will demonstrate the extended ﬁ nger
posture typical of lacerated zone 2 ﬂ exor tendons (Fig. 3.18).
The patient may complain of sensory loss if the digital
nerves are injured. Occasionally the ﬁ ngers may be isch-
emic, and one must prepare for digital artery reconstruc-
tion. The exposure incision needs to be creative to
incorporate the laceration into the ﬂ ap design (Fig. 3.19).
If the laceration is transverse, the exposure can be extended
into a mid-axial incision and a zigzag incision both distally
and proximally. A zigzag incision at the laceration site will
make the tip of the ﬂ ap very narrow; this may lead to ﬂ ap
Curette
A1 (opened)
A2
Distal phalanx
A3
A4
A5
Middle phalanx
Profundus tendon
FIGURE 3.12 Diagram showing a curette removing the distal portion
of the distal phalanx.
Two Keith needles
A1
A2
A3
A4
A5
Profundus tendon
with Prolene sutures
FIGURE 3.13 Two Keith needles are
placed through the nail and used to
pull the sutures through the bone to
secure the tendon to the distal
phalanx.

Hand and Upper Extremity Reconstruction
36
A
B
FIGURE 3.17 A Severe PIP contracture after failed tendon grafting through an intact FDS tendon. B Improved fi nger posture after tendon graft
excision and PIP fusion.
FIGURE 3.15 Flexion cascade of the DIP joints after surgery.
FIGURE 3.16 X-ray showing the healed bony fragment that was
pulled off when the tendon became avulsed.
Xeroform gauze pad
Flexor tendon
Button
FIGURE 3.14 The sutures are then tied over a button to secure the
end of the profundus tendon to the distal phalanx.
necrosis, which can be problematic because the underlying
ﬂ exor tendon and nerve repairs will be exposed.
The ﬂ aps are tagged and retracted using 4/0 nylon
sutures and sharp dissection is carried out using a no. 15
blade to expose all the vital structures relatively atraumati-
cally. Digital nerves and vessels are identiﬁ ed and a portion
of the A2 pulley is opened to expose the lacerated ﬂ exor
tendons. The superﬁ cialis tendons are repaired ﬁ rst because
they lie more dorsally, and each slip of the FDS tendon can
be repaired using horizontal mattress 4/0 braided sutures
(Fig. 3.20). The superﬁ cialis tendons are ﬂ at at the level of
zone 2, and a core stitch repair is usually not possible. The
proximal profundus tendon should be brought through the
decussation of the superﬁ cialis tendon and secured using a

Surgical Techniques for Flexor Tendon Repair
37
Back of
circumferential
sutures
Outer core
locking suture
Horizontal mattress
inner core suture
Complete
circumferential
suture
A
B
C
D
FIGURE 3.18 Finger posture typical of lacerated zone 2 fl exor
tendons.
FIGURE 3.19 Flap design and incision that incorporates the
laceration.
FIGURE 3.20 Repaired zone 2 lacerated tendons using horizontal
mattress 4/0 braided sutures.
FIGURE 3.21 Sequence of four-stranded suture repair for the
lacerated tendon.
Keith needle to prevent its proximal migration. The pro-
fundus tendon has a round conﬁ guration, and a four-strand
suture repair augmented by an epitendinous 6/0 Prolene
locking repair is preferable. The sequence of repair is to
place a 6/0 Prolene epitendinous circumferential suture
onto the dorsal half of the profundus tendon (Fig. 3.21A).
This outer locking suture will complete the volar epitendi-
nous repair after tying the core sutures (Fig. 3.21B). Next,
a grasping locking core suture is placed, followed by a
central core horizontal mattress 4/0 Ethibond suture to
bring the tendon ends together (Fig. 3.21C). The suture

Hand and Upper Extremity Reconstruction
38
knot can either be within the tendon or outside it, which
avoids having too much suture material within the tendon
substance that can hinder healing. The ﬁ nal step is to close
the anterior tendon gap using a locking 6/0 Prolene suture
tied to itself (Fig. 3.21D). This suture not only adds strength
to the repair, but also tidies up the rough edges of the
tendon to make it a smooth, gliding surface (Fig. 3.22).
Once the tendon is repaired, there is less tension on the
nerves and vessels. The nerves can be repaired using 9/0
nylon epineurial stitches under microscopic guidance. Vein
grafts are harvested from the volar wrist to repair the digital
arteries of the ring and little ﬁ ngers (Fig. 3.23). The wound
is closed (Fig. 3.24) and the ﬁ ngers now have a normal
cascade.
A dorsal blocking splint is placed with the wrist ﬂ exed
at about 60º and the MCP joints at about 90º to take the
tension off the tendon repair. When the tendon repair is not
accompanied by nerve or vessel repairs, the patient can start
passive mobilization exercises 2 or 3 days after the opera-
tion. However, when there are digital nerve or vessel repairs,
the author delays therapy for about a week to allow the
edema to settle and to prevent avulsion of the nerve or the
arterial repairs.
Therapy
It is quite important that the therapist treating the patient
is aware of the strength and type of repair used as well as
the number of structures repaired. Typically, patients are
started on passive mobilization exercises with passive ﬁ nger
ﬂ exion and active extension with rubber band traction for
3.5 weeks. After this period the wrist is extended to the
neutral position and the patient is gently started on active
exercises for another 4 weeks. Eight weeks after surgery the
patient begins strengthening exercises (Fig. 3.25A,B).
Complications
The most disastrous complication after ﬂ exor tendon repair
is tendon rupture. If this occurs the patient will need to
return immediately to the operating room for repeat repair.
Otherwise, reconstruction with a tendon graft will be neces-
sary. In most situations the repair can be salvaged by an
immediate return to the operating room. Tendon rupture
complications typically occur about 1 week after surgery,
when the patient begins therapy, and after the 3.5-week
period when they begin active exercises. The nadir of tendon
repair strength is typically between weeks 1 and 2, after
which time the repair starts to gain more strength as the
tendon heals (Fig. 3.26). Many have demonstrated that an
increased number of sutures crossing the tendon repair site
will add more strength to the repair. The six-strand repair
will allow the patient to start active exercises, but the bulki-
ness of the tendon at the repair site may hinder excursion.
The increased strength at the tendon repair to allow an
active therapy protocol is an ambitious and promising
direction for the future.
FIGURE 3.22 This picture shows how the use of 6/0 Prolene sutures
can clean up the tendon ends, allowing for smoother gliding.
FIGURE 3.23 Repaired digital arteries and nerves.
FIGURE 3.24 Closure of wound, showing the natural cascade of the
fi ngers.

Surgical Techniques for Flexor Tendon Repair
39
Outcomes
Tendon outcomes are based on measurement of the ﬂ exion
arc at the MCP, PIP, and DIP joints minus the extension
lag. The MCP joint range of motion is 0–110º, that of the
PIP joint is 0–90º, and of the DIP is 0–90º. Therefore, a
normal total active motion (TAM) will give the ﬁ nger a
maximum of 280º. However, it is quite unlikely that this
goal will be achieved after ﬂ exor tendon repair. A poor result
is when the total active motion is less than 150º, a fair
result is between 150º and 180º, a good result is between
180º and 220º, and an excellent result is over 220º. If the
patient is able to achieve results in the good range, it will
be difﬁ cult to advise them to undergo tenolysis to achieve
outcomes in the excellent range. There are inherent com-
plications with tenolysis, such as tendon rupture, more
scarring to reduce tendon excursion, pulley injury, nerve
A
B
Force in grams
Time in weeks

Repair
1
3
6
8000
6000
4000
2000
0
Strong grip
Light grip
Passive
6-Strand
4-Strand
2-Strand
FIGURE 3.25 Postoperative functional pictures showing the ability to fl ex and extend the fi ngers.
FIGURE 3.26 Flexor tendon repair: strength versus force. Two-, four-
and six-strand repairs plotted against passive light active fl exion and
strong grip, adjusted for friction, edema and stress.
and vessel injuries in a scarred ﬁ eld, and the technical dif-
ﬁ culty of the operation. Therefore, the author does not
advocate tenolysis if the patient has attained outcomes in
the good range. However, if the results are in the poor range,
tenolysis is worthwhile. I will perform tenolysis at 6 months
after the initial repair, by which time the tendon has healed
sufﬁ ciently to withstand the trauma of the procedure.
Tenolysis is one the more complicated procedures in
hand surgery because the scar can be quite unyielding, and
it is difﬁ cult to separate the tendons from the tightly adher-
ent pulley system. The patient should understand the risks
of the procedure, which can be an occasional tendon rupture
due to devascularization and weakening of the tendon repair
site. The therapist must also be involved in the decision
regarding tenolysis. If the patient is continuing to improve
in therapy, the tenolysis should be delayed until they have
reached maximum improvement. Equally importantly, the
condition of the tendon during tenolysis must be conveyed
to the therapist, so that they can design a program based
on the surgeon’s impression of the strength of the healed
tendons.
TWO-STAGE TENDON RECONSTRUCTION
Stage 1
For a patient who presents with an unrepaired tendon, a
tendon rupture, or a severely scarred ﬂ exor tendon system
after repair, it may not be possible to perform a single-stage
graft because the tendon sheath can be quite scarred and
the newly placed graft will be bound down in scar tissue
rather quickly. In addition, the scarred tendon system will
limit joint motion to cause chronic joint contracture, which
needs to be released to achieve good passive motion prior
to insertion of a graft (Fig. 3.27A,B). In these situations a
two-stage repair strategy is more appropriate. In the ﬁ rst
stage, the scarred tendon is excised entirely while preserv-
ing the crucial A2 and A4 pulleys, but all viable pulley
systems should be preserved. A stump of the profundus

Hand and Upper Extremity Reconstruction
40
tendon is preserved to suture to the silicone rod distally.
The silicone rod is made up of a silicone outer core and a
central fabric material that can hold sutures.
The joint capsule must be released to achieve good
passive motion of the ﬁ ngers. The silicone rod is then
threaded through the pulley system and the distal end sewn
to the distal profundus tendon using a horizontal mattress
4/0 Ethibond suture (Fig. 3.28). Proximally, the silicone rod
is placed next to a potential donor tendon in preparation
for the second-stage reconstruction. If the palm is severely
scarred and no donor tendon in the vicinity is suitable for
reconstruction, the silicone rod can be passed into the wrist
in preparation for using an expendable tendon at the wrist,
such as the proximal FDS or FDP tendon from the injured
ﬁ nger, to power the graft (Fig. 3.29). At the ﬁ rst-stage recon-
struction the surgeon may ﬁ nd associated nerve injuries
that need to be repaired with either nerve graft or nerve
tube. The anatomy of repair in this region must be drawn
out in preparation for the second-stage procedure, so that
the surgeon can avoid injuring these critical structures that
may be embedded in scar tissue. Over the next 3 months
the patient will engage in passive exercises to the ﬁ nger
joints in order to prepare for the second stage of
reconstruction.
Stage 2
Once the patient has achieved supple joint motion, the
second-stage reconstruction is planned. If the proximal sili-
cone rod is at the palm, then the palmaris longus has suf-
ﬁ cient length for tendon grafting. A V-shaped incision is
made at the level of the DIP joint to expose the distal sili-
cone rod and a proximal palmar incision is made to expose
the proximal rod (Fig. 3.30). If the location of the rod
cannot be ascertained preoperatively, intraoperative ﬂ uoros-
copy can identify it. Occasionally, the rod may have been
dislodged distally. In this situation it is tricky to retrieve
the rod and place it into the tendon sheath, but this problem
A
B
FIGURE 3.27 A, B Chronic joint contracture due to unrepaired fl exor
tendon laceration.
FIGURE 3.28 Stage 1 fl exor tendon repair using a silicone rod
threaded through the pulley system.
FIGURE 3.29 Stage 1 fl exor tendon repair showing no palmar donor
tendon available. Therefore, the rod is inserted into the wrist so the
proximal FDS or FDP tendons can be used.

Surgical Techniques for Flexor Tendon Repair
41
FIGURE 3.30 Incisions for the stage 2 repair. A V-shaped incision is
made at the level of the DIP joint to expose the distal silicone rod and
a proximal palmar incision is made to expose the proximal rod.
FIGURE 3.31 Once the rod is removed from the distal end of the
tendon, a mosquito is used to prevent the rod from migrating into
the palm.
FIGURE 3.32 A curette is used to remove the cortical window over
the volar distal phalanx to allow for tendon insertion into the bone.
is not common because there is no tension placed on the
rod during ﬁ nger motion. The silicone rod is found distally
and detached. A mosquito clamp is used to secure the distal
end of the rod to prevent its migration (Fig. 3.31). It is
crucial to have proximal and distal control of the silicone
rod so that it cannot be accidentally dislodged from the
tendon sheath. However, if the rod is dislodged within the
tendon sheath during exposure, it can be inserted through
the established tendon sheath.
The distal profundus tendon is partially elevated from
the bone. A curette is used to remove a cortical window
over the volar distal phalanx so that the tendon can be
inserted into the bone using a pull-out button (Fig. 3.32).
The proximal donor tendon is found by retrieving the suture
tag on the tendon for ease of identiﬁ cation (Fig. 3.33). The
palmaris longus tendon graft (Fig. 3.34) is then sutured to
the proximal silicone rod and gently guided into the tendon
sheath. The distal tendon is woven using a 2/0 Prolene
suture in a Bunnell stitch, and the graft is secured to the
distal phalanx as described earlier. The slightly redundant
distal profundus tendon is sutured to the tendon graft using
4/0 Ethibond suture for additional support. Excursion of the
tendon graft is evaluated by pulling the graft to assure that
the distal insertion is strong enough to withstand motion
and to check whether the ﬁ nger has good passive movement
(Fig. 3.35A,B). The proximal tendon graft is woven to the
donor profundus tendon, which has excellent excursion
(Fig. 3.36A,B). The tension is set sufﬁ ciently so that the
ﬁ nger has slightly more ﬂ exion than the normal cascade
(Fig. 3.37A–C). A dorsal blocking splint is placed, and the
patient is started on gentle passive mobilization exercises
for the next 4 weeks, followed by 4 weeks of active exercises.
FIGURE 3.33 Identifi cation of the proximal donor tendon by
retrieving the suture tag on the donor tendon that was placed in the
stage 1 repair.

Hand and Upper Extremity Reconstruction
42
The button is removed 8 weeks after surgery and strength-
ening exercises are begun.
Outcomes
The results of two-stage tendon reconstruction may not be
ideal given the length of recovery and the amount of scars
within the tendon sheath. However, patients usually have
satisfactory improved function with this approach, and will
retain a useful ﬁ nger that can participate in most activities.
A
B
A
B
FIGURE 3.34 Palmaris longus tendon graft.
FIGURE 3.35 A, B Checking the tendon excursion to ensure the graft
is strong enough.
FIGURE 3.36 Pulvertaft weave of the tendon graft to donor tendon.
Optimizing outcomes
●
Ensure that the pulley system is preserved.
●
If a critical pulley is absent, one can recreate a pulley by
using a cuff of the extensor retinaculum sutured to the
pulley remnant, or by using the discarded profundus or
superfi cialis tendon from the excised tendon system. The
tendon is looped around the bone to recreate a pulley
system overlying the silicone rod.
●
The distal tendon–bone repair must be secure to achieve
healing. The proximal donor tendon must have at least 3 cm
of excursion in order to provide adequate movement of the
tendon graft.

Surgical Techniques for Flexor Tendon Repair
43
FLEXOR POLLICIS LONGUS TENDON
FPL lacerations will often be accompanied by digital nerve
injuries. Both the radial and ulnar digital nerves have an
intimate relationship with the proximal A1 pulley of the
thumb (Fig. 3.38). The proximal FPL tendon retracts by
muscular contraction after laceration, and the tendon is
often found at the wrist level. One may ﬂ ex the wrist and
milk the FPL tendon into the sheath, and occasionally the
proximal tendon can be retrieved by passing a tendon
retriever down the sheath to grasp the tendon. In most
cases a separate incision is needed at the wrist over the
radial border of the FCR tendon, and the FPL can be found
dorsal to the FCR tendon. A Robinson catheter can be
passed down the tendon sheath from distal to proximal,
and the FPL tendon is sutured to the catheter and retrieved
to the laceration site by ﬂ exing the wrist to take the tension
off the tendon. A Keith needle is used to secure the FLP
tendon to the A1 pulley to prevent proximal retraction. The
tendon is repaired using a standard four-strand repair aug-
mented with an epitendinous 6/0 Prolene locking suture.
The therapy protocol is similar to that for zone 2 ﬂ exor
tendon injuries.
ZONE 3 FLEXOR TENDON INJURY
Injury in this zone is quite easy to repair. The tendon ends
are quite close to each other and a proximally retracted
lacerated tendon is not too difﬁ cult to retrieve. However,
given hematomas and edema are associated with traumatic
A
B
C
Flexor pollicis
longus tendon
A1 of thumb
Proper palmar
digital nerves
of thumb
FIGURE 3.37 A, B, C Cascade of the fi ngers showing slightly more
fl exion than normal.
FIGURE 3.38 Anatomy of the thumb showing the intimate
relationship between the digital nerves and the proximal A1 pulley.