Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

102
SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
aiming medially. The infiltration is then extended laterally,
using an additional 5 mL of local anesthetic.
Intravenous regional anesthesia (Bier block)
A Bier block is indicated for brief surgery of the hand or
forearm (up to 1 h). This technique relies on diffusion of
local anesthetic from the venous system to nearby nerves.
The operative extremity is exsanguinated using an Esmarch
bandage. A double tourniquet is inflated sequentially from
distal to proximal. The distal tourniquet is then deflated to
allow local anesthetic to penetrate that area. Local anesthetic
solution is then injected through a small IV catheter placed in
the hand of the arm to be anesthetized. A total of 50 mL of
0.5% lidocaine is commonly used. Of note, the patient should
have a separate IV on the nonoperative limb to be available
for sedation and/or emergency access. Anesthesia onset is
within minutes. Patients may complain of tourniquet pain
after 30 min, at which time the distal cuff is inflated and the
proximal cuff is released. At the conclusion of surgery, the
tourniquet is deflated, and there is a rapid resolution of
anesthesia. To prevent local anesthetic toxicity, the tourniquet
should not be deflated before 30 min have elapsed after drug
infusion. Advantages of a Bier block include its safety profile,
simplicity and reliability. However, its use is limited to short
procedures due to tourniquet discomfort, and it offers no
postoperative analgesia.
Interscalene block
Indications for an interscalene block include surgery of the
shoulder, distal clavicle, acromioclavicular joint, and proximal
humerus. The block is performed at the level of C5–C7 nerve
roots, providing anesthesia to the shoulder and upper arm.
Proximal spread of local anesthetic to C3–4 will also anesthe­
tize the cape of the shoulder. Ulnar nerve distribution is
usually spared with this technique. The nerve roots lie in a
groove between the anterior and middle scalene muscles,
posterolateral to the sternocleidomastoid muscle and phrenic
nerve.
To perform the block, the patient is placed in a semi-
recumbent position. When using the nerve stimulation tech­
nique, the interscalene groove is palpated at the level of C6
and the needle is advanced in a slight posterocaudad direc­
tion. A twitch of the bicep, tricep, or distal muscle is sought.
When using ultrasound, the C5–7 roots form a characteristic
“stoplight” appearance as they lie sequentially between the
scalene muscles. The nerves are identified, and local anesthetic
is deposited circumferentially around the nerves (Fig. 4.4).
Complications and side effects specific to this block are
ipsilateral phrenic nerve palsy, Horner’s syndrome, hoarse­
ness from blockade of the recurrent laryngeal nerve, and
vascular puncture or injection; the carotid artery, internal and
external jugular veins, and vertebral artery are in close prox­
imity to the nerves of interest.
Supraclavicular block
The supraclavicular approach to the brachial plexus pro­
vides more reliable and effective regional anesthesia to the
upper extremity than other approaches.27 Indications for
the supraclavicular approach include surgery of the upper
extremity including the arm, elbow, and hand. Though the
supraclavicular block can also be used for shoulder surgery,
it may require some supplementation of the supraclavicular
nerve (C3–C4).2
With ultrasound assistance, it is easy to appreciate the
continuum that exists within the brachial plexus. Moving
the ultrasound probe up or down, the brachial plexus will
change a block from an interscalene block to a supracla­
vicular block. With the gain in popularity with ultrasound,
there has been a resurgence in the supraclavicular block
as the concerns of pneumothorax have diminished. In a
recent study of 510 patients who underwent ultrasound-
guided supraclavicular blocks, none were found to have a
pneumothorax.28
The supraclavicular block is performed with the probe
placed in the supraclavicular fossa (Video 4.1
). The sono­
anatomy includes the subclavian artery, which is the primary
landmark in this block. The brachial plexus (trunks and/or
divisions of the plexus) lies superior (posterior) and lateral to
the artery in a majority of patients and appears as a “bunch
of grapes” or several round structures with a dark interior
(hypoechoic) and a bright outline (hyperechoic outer circle).
Once an adequate view is identified, the area is prepped and
draped in a sterile fashion. The needle is then aligned with
the probe in what is referred to as an “in-plane” technique.
The needle appears on screen to move in a lateral to medial
fashion. Once the needle is seen, placement should be care­
fully done with frequent aspiration. It may take 2–3 needle
placements to ensure adequate coverage of the brachial plexus
(Fig. 4.5).
The most common side effects include hemi-diaphragmatic
paresis secondary to phrenic nerve block, ipsilateral Horner’s
syndrome, and ipsilateral nasal congestion. Other risks include
infection, bleeding, nerve injury, and pneumothorax.
Nerve stimulation technique of the supraclavicular block
is less frequently performed due to the concerns and risk of
pneumothorax. There are other suitable alternatives if the
ultrasound view is difficult to obtain.
Infraclavicular block
Indications for an infraclavicular block are the same as for
the supraclavicular approach. The main difference is that
the infraclavicular approach generally preserves pulmonary
function by avoiding a block of the diaphragm, which is pos­
sible with the supraclavicular approach. The infraclavicular
approach is a block of the brachial plexus at the level of the
lateral, medial and posterior cords. These cords are named for
their relationship to the axillary artery, although this relation­
ship can have many variations.29 In the United States, the most
common approach for the infraclavicular block is using the
coracoid process as a landmark, both with ultrasound guid­
ance, as well as with peripheral nerve stimulation. Ultrasound-
guided infraclavicular blocks are performed with the probe
placed just medial to the coracoid process and below the
clavicle. Important sonoanatomy includes the axillary artery
with the three cords surrounding the artery in a U-shaped
fashion. The approach includes an in-plane technique with
the needle aligned with the probe in a 45° angle aiming
in a cephalad to caudad direction. The needle is placed
just posterior to the axillary artery, which, when the LA is
injected, provides coverage to all three cords in a U-shaped
spread (Fig. 4.6).

103
Regional anesthesia techniques
Fig. 4.4  (A,B) Interscalene block, functional anatomy and (C) technique.
A
B
Thyroid cartilage
Sternocleidomastoid
(cut)
Phrenic nerve
Cricoid cartilage
External jugular vein
Subclavian vein
Subclavian artery
Anterior scalene
Anterior scalene
Middle scalene
Middle scalene
Clavicle
Clavicle
1st rib
C
Cricoid cartilage

104
SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
Use of the nerve stimulator with the infraclavicular
approach is quite common and may be considered to be less
difficult by some than ultrasound-guided infraclavicular
block. In order to perform the infraclavicular block, the cora­
coid process is identified and marked. Once this is achieved,
the physician will measure 2 cm medial and 2 cm inferior –
this marks the nerve stimulator needle entry point. The nerve
stimulator is turned to 1.0 mA. The needle is advanced in a
direction that is perpendicular to the floor. It is important to
note, as with other blocks, that there should be frequent
aspiration throughout the block in order to minimize the risk
of intravascular injection. As the needle is advanced, stimula­
tion of the posterior cord is sought (extension of the elbow,
wrist or fingers) and maintained at 0.5 mA. If the correct
stimulation of muscle groups is not achieved, the needle’s
direction should be redirected by 5° at a time. Some anesthe­
siologists may seek both the medial and lateral cord if the
posterior cord is difficult to find in order to improve success
rates. The risks of the infraclavicular block include infection,
bleeding, nerve injury, and pneumothorax.
Axillary block
An axillary block is indicated for surgery of the hand and
forearm. It is performed at the level of the terminal branches
of the brachial plexus. The radial, median, and ulnar nerves
are positioned around the axillary artery, and the musculocu­
taneous nerve resides in the coracobrachialis muscle, lateral
to the neurovascular bundle. The distribution of anesthesia
includes the entire arm, except for the medial strip of skin in
Fig. 4.5  Functional anatomy of supraclavicular block.
Middle scalene
Anterior scalene
1st rib
Clavicle
Sternocleidomastoid (cut)
Vertebral artery
Sternocleidomastoid (cut)
C4
C3
C5
C6
Phrenic nerve
Accessory phrenic nerve
Fig. 4.6  Functional anatomy of infraclavicular block.
Sternocleidomastoid (cut)
Anterior scalene (cut)
T1
C7
C6
C5
C4
Pectoralis minor (cut)
Clavicle (cut)
First rib
Subclavian vein
Musculocutaneous nerve
Axillary nerve
Axillary artery
Ulnar nerve
Median nerve
Radial nerve

105
Regional anesthesia techniques
A
B
Radial nerve
Ulnar nerve
“Gentle pressure”
Median nerve
Musculocutaneous nerve
Radial nerve
Ulnar nerve
Median nerve
Musculocutaneous nerve
Axillary artery
Humerus
C
Fig. 4.7  (A,B) Functional anatomy and (C) technique of axillary block.
the upper arm, which is supplied by the intercostobrachial
nerve from T2 (Fig. 4.7).
For this block, the arm is abducted and the elbow flexed.
When using the nerve stimulation technique, the axillary
artery is palpated high in the axilla and the needle is directed
lateral, medial, and posterior to the artery to stimulate the
median, ulnar, and radial nerves, respectively. Obtaining
two or more separate twitches, and therefore injecting local
anesthetic near two or more nerves, improves block success.30
The musculocutaneous nerve is then blocked by directing
the needle laterally into the coracobrachialis muscle, obtain­
ing a twitch of the bicep muscle, and depositing additional
local anesthetic. When using ultrasound, the probe is placed
transversely on the upper arm near the axilla, perpendicular
to the axillary artery. The artery and nerves of interest are
visualized. The needle is advanced in a lateral to medial
direction, and local anesthetic is deposited around each nerve.
The axillary approach to the brachial plexus has potential
benefits for certain patient populations, such as patients
with pulmonary disease, because the phrenic nerve will
not be affected. This block may also be superior in patients
with coagulopathies, since the area is superficial and easily
compressible if vascular puncture occurs. One disadvantage
of this block is that the needle must be repositioned mul­
tiple times to adequately block all of the nerves, potentially
increasing the risk of vascular puncture or causing more
patient discomfort. Additionally, the arm must be abducted
in order to have adequate access to the upper arm and axilla,
which may be difficult in some patients such as those with
injuries.

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SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
reports from the first advisory, the incidence of peripheral
nerve injury has remained stable regardless of the localization
technique used. The reported range of long-term injury is 2–4
per 10 000 blocks. Long-term injury is rare, but transient
postoperative neurologic symptoms are common in the first
days to month following peripheral nerve blocks and decrease
over time. The current advisory continues to advise against
placing blocks in deeply sedated or anesthetized adults, as
paresthesias reported by patients are considered a valuable
warning sign for potential nerve injury.33
Local anesthetic toxicity
Local anesthetics used for peripheral nerve blocks have the
potential to cause serious harm. Systemic absorption of local
anesthetic from an appropriately placed and dosed nerve
block may result in mild symptoms, while an unintentional
intravascular injection can lead to severe neurologic or
cardiac toxicity causing major disability or even death. Risk
factors that increase the potential for local anesthetic systemic
toxicity (LAST) include local anesthetic potency and dose,
peripheral nerve block location and technique, and patient
risk factors such as age, pre-existing disease, and medica­
tions. Methods to prevent LAST revolve around avoiding
intravascular injection and limiting the total dose of local
anesthetic. Intravascular injection can be limited or avoided
by incrementally injecting local anesthetic to monitor for
symptoms of systemic absorption, aspirating prior to injec­
tion, and using an intravascular marker such as epinephrine.
If systemic toxicity does occur, the classic symptoms present
as auditory changes, circumoral numbness, metallic taste,
and agitation. Symptoms may then progress to seizures,
CNS depression and, finally, cardiac excitation followed by
depression. However, cardiac toxicity may occur simultane­
ously or even before neurological symptoms. The treatment
of LAST is circulatory and airway support to minimize
hypoxia and acidosis. Seizures can be controlled with ben­
zodiazepines, although succinylcholine may be necessary for
persistent seizures. Cardiac arrest requires rapid restoration
of cardiac output and oxygen delivery. If standard ACLS mea­
sures such as epinephrine or amiodarone fail to provide an
adequate response, lipid emulsion therapy should be adminis­
tered. Cardiac arrest refractory to vasopressor and lipid emul­
sion therapy should prompt institution of cardiopulmonary
bypass.34
Vascular injury
Vascular complications include hematomas, vasospasm from
arterial puncture or local anesthetic-induced vasoconstriction,
and arterial dissection from intramural injection. Hematomas
have the potential to cause ischemic injury to nearby neural
structures from compression, although they are usually small
and inconsequential.35 The severity of symptoms and progres­
sion are related to the rate and duration of hematoma forma­
tion. Risk factors include the extent of arterial injury (number
of needle punctures), intrinsic vascular elasticity, and pres­
ence of diabetes, hypertension, or anticoagulation.36 The
presence of a hematoma should prompt evaluation of neuro­
logical function. Surgical decompression and evacuation may
be necessary for severe cases, although conservative manage­
ment is often appropriate.
Complications
Complications associated with regional anesthesia present a
rare but significant risk to patients undergoing surgery of the
upper extremity. Serious complications include neurologic
injury, seizures, and cardiac arrest. Other risks associated
with regional anesthesia are hematoma, infection, and block-
specific complications such as pneumothorax. A large French
prospective study reported an incidence of severe complica­
tions related to peripheral nerve blocks to be <5/10 000 and
an incidence of serious neurologic injury to be 2.4/10 000.31
Neurologic complications
Peripheral nerve injury can present as pain, sensory distur­
bances, or motor deficits. Most of these are transient, with 95%
resolving within 4–6 weeks and over 99% resolving within 1
year.2,30 The pathophysiology and mechanisms of peripheral
nerve injury are mechanical, injection, ischemic, and neuro­
toxic. Recovery and prognosis are related to the location of
injury. If the axon is damaged, recovery is slow and often
incomplete, relying on collateral reinnervation or axonal
regrowth. Damage to the myelin sheath disrupts the nerve
action potential and tends to have faster recovery and a better
prognosis. Mechanical injury from needles or catheters can
disrupt the axon, although nerves tend to move away from
approaching needles.32 Needle to nerve contact or intraneural
injection can result in ischemia and neurotoxicity if the peri­
neurium is disrupted. Local anesthetics can cause acute
inflammatory reactions and be neurotoxic to exposed axons
via cellular cytotoxic effects, dependent on the concentration
and duration of exposure.31 Finally, ischemic injury may be
caused by vascular injury, prolonged tourniquet use, or the
use of vasoconstrictors. Intraneural injection can result in
elevated pressure leading to ischemia. Ischemia causes meta­
bolic stress and is associated with axonal damage and a poorer
prognosis.
Peripheral nerve injury
A suspected peripheral nerve injury warrants an immediate
evaluation, including a complete history and physical exami­
nation to screen for any pre-existing problems and to deter­
mine the location of the lesion. The 2008 American Society of
Regional Anesthesia and Pain Medicine (ASRA) Practice
Advisory on Neurologic Complications recommends that a
complete or progressive deficit should be evaluated immedi­
ately by a neurologist or peripheral nerve surgeon. Mild or
resolving symptoms without evidence of a neural deficit
can be monitored and may only require patient reassurance.
However, if symptoms fail to improve, a neurological consul­
tation is recommended. Incomplete lesions with evidence of
a neural deficit should initially be evaluated by a neurologist
and may require referral to a peripheral nerve surgeon if
symptoms persist or worsen.32 Neurologic tests such as
nerve conduction studies, electromyography, and MRI may
be helpful in establishing the degree of nerve damage, loca­
tion, and prognosis.
The Second ASRA Practice Advisory on Neurologic
Complications Associated with Regional Anesthesia and Pain
Medicine provides updates to the 2008 advisory. Similar to

107
Outcomes
group had significantly less postoperative pain before hospital
discharge, but on postoperative days 1, 7, and 14, there were
no differences in pain, opioid consumption, adverse effects,
pain–disability index, or satisfaction.43 Improved functional
capacity has been demonstrated in patients having lower
extremity surgery with continuous RA techniques. A study of
patients undergoing outpatient shoulder and foot surgery
under RA with continuous outpatient perineural infusions of
local anesthetics demonstrated optimized functional recovery,
analgesia, and patient satisfaction for 3 days postoperatively.45
Further studies are necessary to determine if RA for upper
extremity surgery has a benefit after the immediate postop­
erative period in terms of pain control, adverse effects, and
functional capacity.
Patient satisfaction, although difficult to define, is usually
high, with both regional and general anesthesia. Improved
patient satisfaction with RA techniques may be a result of
improved analgesia and fewer side effects.46 Studies showing
lower patient satisfaction with RA techniques often cite tour­
niquet pain and discomfort during the nerve block placement
as causes of dissatisfaction.47
When considering peripheral nerve blocks in the
anticoagulated patient, significant blood loss, rather than
neural deficits, may be the most serious complication. The
expansile nature of the neurovascular sheath may decrease
the chance of irreversible neural ischemia. Although neur­
axial regional anesthesia presents significant risk to the
anticoagulated patient, the risk after peripheral techniques
remains undefined. Published case reports of clinically
significant bleeding after peripheral regional anesthesia
techniques demonstrate that all patients presenting with
neurodeficits had complete recovery within 6 months to 1
year.37 The 2010 ASRA Guidelines on Regional Anesthesia
in the Anticoagulated Patient suggest that brachial plexus
blockade in this patient population is not contraindicated, but
should be evaluated on a case-by-case basis with increased
caution.2
Infection
Infectious complications associated with regional anesthesia
of the upper extremity are rare. Localized infection and bac­
teremia have been reported after both single-shot and continu­
ous catheter techniques. One study reported catheter tip
colonization in 29% of peripheral catheters, with 3% resulting
in local inflammation.38,39 Patient risk factors for infectious
complications include underlying sepsis, diabetes, immuno­
compromised status, steroid therapy, localized bacterial
infection, chronic catheter maintenance (>48 h), and ICU
admission.40,41 A careful evaluation of the risk-to-benefit ratio
should be made prior to placing nerve blocks in infected or
immunocompromised patients.2,39
Outcomes
Upper extremity surgery can be performed successfully under
both general anesthesia (GA) and regional anesthesia (RA).
The potential benefits of RA techniques in outpatient surgery
include improved clinical outcomes, patient satisfaction,
efficiency, and reduced cost.42 However, GA is still widely
used for outpatient surgery, and many of the newer anesthetic
agents are short-acting with fewer side effects and better
recovery profiles as compared with older agents. Addition­
ally, many anesthesiologists are more familiar and comfortable
with providing GA compared with RA.43,44
Clinical outcomes and patient satisfaction
Several studies comparing regional anesthesia to general
anesthesia for upper extremity surgery have demonstrated
more favorable clinical outcomes with regional anesthesia, in
terms of improved pain control, less nausea and vomiting,
and fewer opioid-related side effects. Other benefits include
patients feeling more alert, tolerating oral intake sooner, and
ambulating sooner.42,43
While improved clinical outcomes have been shown for RA
in the immediate postoperative period, long-term benefits are
still undefined. In a study comparing RA to GA in patients
undergoing outpatient hand and wrist surgery, patients
having RA had better initial analgesia and faster recovery but
both groups had a similar degree of pain and need for oral
analgesics 48 h postoperatively.42 In another study comparing
RA to GA in ambulatory hand surgery, patients in the RA
Clinical tip: benefits of a regional anesthesia
service and outpatient clinic
A 24-hour regional anesthesia service can expand care to
patients who present during off-hours with traumatic injuries.
Blocks are placed in the emergency department for patients
with fractures, traumatic amputations, and other injuries hours
prior to their scheduled surgery. This offers the benefit of
decreased opioid use during admission and decreased side
effects such as delirium.
A regional anesthesia outpatient clinic permits walk-ins from
home or from their surgeon’s office to be evaluated for
postoperative neuropathies, catheter management, or other
related concerns. The benefits of a regional anesthesia clinic
include reduced emergency department admissions, early
diagnosis and management of neuropathies, and improved
patient satisfaction.
Operating room cost and efficiency
Several investigators have sought to determine if regional
anesthesia is superior to general anesthesia in terms of operat­
ing room (OR) efficiency and costs. Some potential areas to
improve efficiency and reduce costs are OR utilization time
and recovery room time.
Some studies suggest that in order to save OR time through
the use of regional anesthesia techniques, nerve blocks must
be performed outside the operating room. In this case, the cost
of valuable OR time is spared and efficiency is maximized
because patients are ready for surgery as soon as they enter
the operating room.43 Others have reported similar OR times
for RA versus GA techniques even when the blocks were
performed in the operating room. This was attributed to the
combination of fast-acting local anesthetics, the ability for
surgeons to prepare the patients while the nerve blocks
took full effect, and faster emergence time compared
to GA.42

108
SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
the block must take into consideration the possibility of an
increased likelihood of bleeding during a nerve block with a
resultant hematoma and nerve compression.
Pediatric patients
The pediatric population warrants special considerations when
considering the type of anesthetic for surgery. These include
anatomic and physiologic differences when compared with
adult counterparts. Regional anesthesia offers the advantage
of intraoperative and postoperative analgesia for the pediatric
population. While still receiving a general anesthesia in most
cases, the pediatric patient may benefit from a regional anes­
thetic as a result of decreased requirements for inhalational
agents, leading to improved respiratory status.51 Improved
respiratory status decreases the chance of laryngospasm on
emergence. There are additional benefits of comfort for the
patient’s family, observing a more comfortable and pain-free
child in the recovery room. Overall, there is less stress for
all involved.52
The types of blocks performed on pediatric patients are
generally performed with the patient under GA. It is not
until the child is older and demonstrating a level of matu­
rity that the block can be performed on the awake patient.
When a block is performed on an asleep patient, there is
an elevated risk of nerve injury as the patient cannot relay
the sensation of paresthesias and pain from the rare event
of neural trauma. Overall, regional anesthetic techniques
are considered safe with an extremely low incidence of
complications.53
Ultrasound guidance is strongly recommended when
considering regional anesthesia as part of the anesthetic in
infants and children. The increased assistance provided in
locating sonographic landmarks and nerve targets are of great
benefit.54–56
Perioperative pain management
For upper extremity surgery, the use of regional anesthesia
with local anesthetics is primarily motivated by the desire to
avoid general anesthesia. It has resulted in lower postopera­
tive opiate usage and therefore alleviation of opiate-related
side effects.57 This approach has become, in many ways, the
standard of care in upper extremity cases.
Peripheral catheters
Peripheral nerve blockade is safe and provides postop­
erative analgesia through the use of long-acting local
anesthetics and/or continuous infusions through peripheral
nerve catheters.58 Outpatient catheters have become very
common. Catheters provide longer acting pain relief over
single shot techniques and benefit patients who undergo
more painful surgical procedures, patients with chronic
pain, and patients who are unable to tolerate opioids for
various reasons. Peripheral nerve catheters are usually
placed preoperatively by the anesthesiologist when the initial
nerve block is performed. Alternatively, a catheter may be
placed in the postoperative period if the patient experiences
severe pain. Continuous catheters do not delay discharge in
outpatient surgery as they can be managed at home by the
patient.
Patients having RA for upper extremity surgery who
experience superior pain control and fewer side effects may
potentially have a shorter PACU stay. A meta-analysis of RA
versus GA for ambulatory anesthesia showed that patients
receiving RA had an increased ability to bypass the PACU
and/or a decreased PACU time.46
To date, studies demonstrating an overall cost reduction for
intraoperative and postoperative care during upper extremity
surgery have compared GA to intravenous regional anesthesia
(Bier block). The IVRA group had significant cost-savings
attributed to lower anesthetic drug and equipment costs,
shorter OR times, shorter PACU times, and shorter nursing
times.48,49 In contrast, a retrospective comparison of costs for
RA and GA techniques demonstrated a cost disadvantage for
brachial plexus regional anesthesia, although recovery room
costs were not included in this analysis.50 More research is
needed to determine if RA techniques for upper extremity
surgery show a significant cost reduction when compared
with other anesthetic techniques.
Special considerations
Cardiac patients
Patients with cardiac disease, including those with cardiac
dysfunction and low ejection fractions, conduction abnormali­
ties or ongoing ischemia, should be given consideration for
regional anesthesia for upper extremity cases when indicated.
Regional anesthesia allows patients the usual advantages of
perioperative analgesia and possibly avoidance of general
anesthesia.20 General anesthesia, while very safe, can cause
hemodynamic variations during the induction of anesthesia,
intubation, emergence from anesthesia and possibly during
surgical stimulation or bleeding. In this patient population,
variations in blood pressure and heart rate can have signifi­
cant consequences. The prospect of regional anesthesia and
analgesia allows the patient to avoid hemodynamic fluctua­
tions, thus minimizing risk.
Patients with cardiac disease may be anticoagulated for a
variety of reasons. In these patients, the risks and benefits of
Clinical tip: benefits of an out-of-OR regional team
Having a separate, out-of-OR regional anesthesia team offers
several benefits. Efficiency is improved when blocks are
placed in the preoperative holding area rather than the
operating room. An out-of-OR team has the freedom and
availability to place rescue blocks in the recovery room and
bolus, reposition, or replace catheters placed preoperatively.
Additionally, blocks can be placed in the emergency
department, hospital ward, or intensive care unit for patients
with acute pain such as dressing changes and other non-
operative pain.
The addition of a block nurse to the regional anesthesia
service improves efficiency. The block nurse assists the team
by placing IVs, applying monitors to the patients, preparing
drugs and supplies, and directing the pre-procedure “time-
out”. Other responsibilities include assisting with
documentation and patient follow-ups.

109
Perioperative pain management
significant improvement occurred in patients who received
the NSAID when compared to those in the placebo group.
The treated patients consumed significantly less opiates and
therefore were less likely to develop narcotic side effects
such as sedation, nausea, constipation, or urinary retention.
Nociceptive afferent transmission is known to be sensitive
to inflammation and NSAIDs are postulated to have this
effect via their anti-inflammatory action. Another study retro­
spectively reviewed a multimodal, preemptive pathway for
patients undergoing major knee or hip surgery featuring
peripheral nerve blocks, and found that patients were better
able to participate in postoperative rehabilitation, were eligible
for hospital discharge sooner, initiated earlier ambulation,
experienced lower perioperative pain scores, and experienced
reduced postoperative nausea and vomiting when compared
with more traditional PCA measures.63 These findings advo­
cate for the preemptive multimodal analgesic regimen.
Inflammatory neuropathies
Since the 2008 ASRA advisory, new knowledge has emerged
regarding postsurgical inflammatory neuropathies.33 These
neuropathies appear to be immune-mediated and precipitated
by stressors such as infection or surgery. The clinical presenta­
tion may be delayed, usually within the first month after
surgery, followed by a period of normal recovery. Patients
complain of intense pain that is out of proportion to that
expected from surgery, which resolves, and is then followed
by weakness. Symptoms are outside of the expected location
of the anesthetic block or surgery. The neurologic deficits may
be focal, multifocal, or diffuse. Patients presenting with this
combination of symptoms should be promptly referred for
neurologic consultation, as many neurologists recommend
treatment with steroids or immunoglobulin, and most
postsurgical inflammatory neuropathies improve with early
diagnosis and treatment.
Patients with persistent postsurgical pain may suffer from
perioperative nerve injury related to their nerve block or
surgical procedure. Patients with persistent pain, pain out of
proportion to that expected from surgery, pain limiting func­
tion, or signs and symptoms concerning for chronic regional
pain syndrome should be referred to a pain specialist. The
pain physician plays an important role in providing symp­
tomatic treatment and coordinating patient care, education
and therapy.
Chronic postoperative pain
The development of postoperative pain after surgery is due
to complex pathways – endocrine, metabolic, and inflamma­
tory – that trigger a prolonged state of excitation of the spinal
cord.64 Various chemicals released during and soon after
surgical incision may induce conversion of high threshold
nociceptors into low threshold receptors, via a process called
peripheral sensitization. This complex process eventually
leads to release of cellular mediators in the recuperative
period resulting in central sensitization and chronic pain.65
Chronic pain is, among other factors, linked to patients with
severe postoperative pain.15,66 While the development of
chronic pain following surgery has lacked a spotlight in the
medical literature, it is a reality that needs to be considered
particularly in patients who may be at higher risk of
Preemptive analgesia
Preemptive analgesia is a pain management technique initi­
ated prior to incision, which continues during the surgical
procedure to reduce ongoing changes that occur in the body
as a result of surgical incision and stimulation.59 The rationale
is that by preemptively blocking the nociceptive transmission
onslaught that occurs with surgical incision, there will be less
pain in the postoperative period and thus less need for con­
sumption of opiates with fewer side effects. The duration of
treatment includes the entire time that the noxious stimula­
tion of surgery and its inflammatory injuries occur (intra­
operative and early postoperative period).59
Opiate-related side effects of sedation, nausea, respiratory
depression, ileus and urinary retention can impact patient
safety and satisfaction, discharge or patient admission, par­
ticularly in the outpatient setting, thereby affecting cost issues.
Multimodal analgesic regimens have been developed featur­
ing the peripheral nerve block in order to improve periopera­
tive outcomes for minimally invasive procedures.
There has been much controversy surrounding the relevance
and effectiveness of preemptive analgesia. Although the
benefits have been established to some degree in animal
studies, it has had questionable effect in human studies to
date.60 Many physicians practice with the belief that there is
some preemptive analgesic effect. Some suggest that there is
greater complexity in pain pathways than our understanding,
and that studies are too simplistic. However, there is little
doubt that excellent pain management in the pre- and post­
surgical area contributes to an overall improved pain experi­
ence. A meta-analysis demonstrated that analgesia in the
preoperative period lowered opiate consumption when the
preemptive treatment was epidural analgesia, local infiltra­
tion, and systemic non-steroidal anti-inflammatory drugs
(NSAIDs).61 The findings were equivocal with opioids and
NMDA receptors alone. Certain studies go further to demon­
strate that the preemptive analgesia associated with ketamine
or a cox-2 analgesic gives additional benefit pre-incision.
One such study looked at patients about to undergo upper
limb surgery under axillary brachial plexus blockade.62
The study examined the addition of a long-acting NSAID,
ampiroxicam, versus placebo given 3 h prior to surgery. A
Clinical tip: use and protocols for ambulatory
catheters and pain pumps
For upper extremity procedures, the infraclavicular approach is
preferred over the supraclavicular approach because there is
less catheter migration at this location, possibly due to the
anchoring of the catheter by the pectoralis muscles or the
decreased amount of skin movement with activity. Patients are
sent home with a catheter and an elastomeric pain pump with
an on-demand button function. The pumps are set at a basal
rate at 6 mL/hour (on average) with a bolus option of 5 mL
every 30 minutes. The pumps are filled to 550 mL and usually
last roughly three days, depending on the number of boluses
activated by the patient. Patients remove the catheters
themselves at home. The patients are instructed on the use
and care of the catheter and pump prior to discharge and are
sent home with an instruction pamphlet and a 24-hour number
to call for any questions or concerns.

110
SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
bloodless field. Mitigation of tourniquet discomfort is usually
achieved with the use of sedation, regional anesthetic blocks
or general anesthesia. An alternative to this traditional
approach is the wide awake local anesthesia no tourniquet
(WALANT) technique, under which hand surgery is per­
formed only with lidocaine for anesthesia combined with
epinephrine for hemostasis.
The use of epinephrine permits adequate hemostasis and
visibility; it effectively eliminates the need for a tourniquet in
most types of hand surgery. Epinephrine is now considered
to be safe for use in the upper extremity, specifically the hand
and fingers.71 There have been no reported cases of digital
infarction directly attributable to the use of epinephrine.
There are multiple recognized benefits of wide awake hand
surgery. The risks of sedation or general anesthesia can be
avoided, particularly in patients with complicated medical
histories. Wide awake surgery has been shown to be cost
effective as the charges related to the anesthesiologist, preop­
erative testing and postanesthesia recovery monitoring can be
avoided.72 In the absence of sedation, patients can actively
demonstrate intraoperative range of motion during tenolysis
and flexor tendon repair surgery. Gapping in tendon repairs
can be assessed and corrected immediately. During tendon
transfer surgery, patients can activate transfers and demon­
strate tensioning; transfers that are too tight or loose can be
adjusted prior to skin closure.73 For these reasons, wide awake
surgery can improve results after hand surgery, particularly
with respect to tendon repairs and tendon transfers. Wide
awake hand surgery is gaining traction and is expected to be
increasingly utilized as more surgeons are trained in the
technique.
developing chronic pain.67 Inadequately treated postoperative
pain is a major source of patients’ dissatisfaction with their
overall surgical experience.68 Severe pain in the postoperative
period correlates to a greater likelihood of developing chronic
pain.69 There are a number of risk factors70 for developing
severe postoperative pain (Table 4.3).
It is imperative that postoperative pain be treated effec­
tively, possibly with a multimodal approach which considers
preemptive analgesia and its potential benefits. It is crucial to
identify those patients that have a greater likelihood of devel­
oping severe postoperative pain, not only to minimize the
likelihood of developing chronic pain, but also to improve the
patient’s experience in the perioperative period.
Future directions
Wide awake upper extremity surgery
Most upper extremity surgery is performed with the use of a
tourniquet, which allows improved visibility offered by a
Table 4.3  Risk factors for severe postoperative pain
Preoperative pain
Prior use of opiates
Female gender
Nonlaparoscopic surgery
Knee and shoulder surgery
Psychosocial vulnerability
Repeat surgery
Intensity of early postoperative pain
Surgical approach with risk of nerve damage
2. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional
anesthesia: essentials of our current understanding, 2008. Reg
Anesth Pain Med. 2009;34:134–170. This article provides a comprehensive
review of upper extremity regional anesthesia, including relevant anatomy,
pharmacology, techniques, and complications. This review also
summarizes the essential scholarly works available on upper extremity
regional anesthesia and identifies informational gaps where further study
is warranted.
6. Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of
the brachial plexus and surrounding compartments, and their
possible significance for plexus blocks. Anesthesiology.
2008;108:299–304.
8. Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors
associated with ultrasound-guided regional anesthesia. Part I:
understanding the basic principles of ultrasound physics and
machine operations. Reg Anesth Pain Med. 2007;32:412–418. This
article presents the basics of ultrasound used for regional anesthesia. By
understanding basic ultrasound physics most relevant to regional
anesthesia and recognizing brachial plexus ultrasound anatomy,
physicians can improve their ability to visualize target nerves, position of
needles, and real-time spread of local anesthetic, thus improving nerve
block efficiency, success, and safety.
15. Bridenbaugh PO, Cousins MJ. Neural Blockade in Clinical Anesthesia
and Management of Pain. 3rd ed. Philadelphia: Lippincott-Raven;
1998:xxii, 1177. This book chapter presents a review of the clinical
pharmacology of local anesthetics, including factors that influence their
usefulness and toxicity. Additionally, the various local anesthetics are
reviewed for their specific activity, physiochemical structure, and
applicability in clinical practice. These drugs, integral to the practice of
regional anesthesia, are presented in a totality essential to the
understanding of their role in practice.
18. Raj PP. Textbook of Regional Anesthesia. New York: Churchill
Livingstone; 2002:xix, 1083.
19. Klein SM, Evans H, Nielsen KC, et al. Peripheral nerve block
techniques for ambulatory surgery. Anesth Analg.
2005;101:1663–1676.
21. Neal JG, Cox MJ, Drake DB, et al. The ASRA evidence-based
medicine assessment of ultrasound-guided regional anesthesia and
pain medicine: Executive summary. Reg Anesth Pain Med.
2010;35:S1–S9.
30. Sorenson EJ. Neurological injuries associated with regional
anesthesia. Reg Anesth Pain Med. 2008;33:442–448. This article
provides a concise review of neurological injuries associated with regional
anesthesia, including mechanisms, diagnosis, and management. Although
neurologic injury is rare, every anesthesiologist and surgeon employing
regional anesthesia techniques for their patients must be able to recognize
a potential injury and institute treatment if necessary.
46. Liu SS, Strodtbeck WM, Richman JM, et al. Comparison of regional
versus general anesthesia for ambulatory anesthesia: a meta-
analysis of randomized controlled trials A. Anesth Analg.
2005;101:1634–1642.
62. Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal
pathway featuring peripheral nerve block improves perioperative
outcomes after major orthopedic surgery. Reg Anesth Pain Med.
2008;33:510–517.
Access the complete reference list online at

110.e1
References
References
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2. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional
anesthesia: essentials of our current understanding, 2008. Reg
Anesth Pain Med. 2009;34:134–170. This article provides a comprehensive
review of upper extremity regional anesthesia, including relevant anatomy,
pharmacology, techniques, and complications. This review also
summarizes the essential scholarly works available on upper extremity
regional anesthesia and identifies informational gaps where further study
is warranted.
3. Thompson GE, Rorie DK. Functional anatomy of the brachial
plexus sheaths. Anesthesiology. 1983;59:117–122.
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the brachial plexus and surrounding compartments, and their
possible significance for plexus blocks. Anesthesiology.
2008;108:299–304.
7. van Geffen GJ, Moayeri N, Bruhn J, et al. Correlation between
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8. Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors
associated with ultrasound-guided regional anesthesia. Part I:
understanding the basic principles of ultrasound physics and
machine operations. Reg Anesth Pain Med. 2007;32:412–418.
This article presents the basics of ultrasound used for regional anesthesia.
By understanding basic ultrasound physics most relevant to regional
anesthesia and recognizing brachial plexus ultrasound anatomy,
physicians can improve their ability to visualize target nerves, position of
needles, and real-time spread of local anesthetic, thus improving nerve
block efficiency, success, and safety.
9. Schafhalter-Zoppoth I, Gray AT. The musculocutaneous nerve:
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1998:xxii, 1177. This book chapter presents a review of the clinical
pharmacology of local anesthetics, including factors that influence their
usefulness and toxicity. Additionally, the various local anesthetics are
reviewed for their specific activity, physiochemical structure, and
applicability in clinical practice. These drugs, integral to the practice of
regional anesthesia, are presented in a totality essential to the
understanding of their role in practice.
16. Bernards CM, Kopacz DJ. Effect of epinephrine on lidocaine
clearance in vivo: a microdialysis study in humans. Anesthesiology.
1999;91:962–968.
17. Spiegel DA, Dexter F, Warner DS, et al. Central nervous system
toxicity of local anesthetic mixtures in the rat. Anesth Analg.
1992;75:922–928.
18. Raj PP. Textbook of Regional Anesthesia. New York: Churchill
Livingstone; 2002:xix, 1083.
19. Klein SM, Evans H, Nielsen KC, et al. Peripheral nerve block
techniques for ambulatory surgery. Anesth Analg.
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20. Pierce EC Jr. The 34th Rovenstine Lecture. 40 years behind the
mask: safety revisited. Anesthesiology. 1996;84:965–975.
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pain medicine: Executive summary. Reg Anesth Pain Med.
2010;35:S1–S9.
22. Koff MD, Cohen JA, McIntyre JJ, et al. Severe brachial plexopathy
after an ultrasound-guided single-injection nerve block for total
shoulder arthroplasty in a patient with multiple sclerosis.
Anesthesiology. 2008;108:325–328.
23. Zetlaoui PJ, Labbe JP, Benhamou D. Ultrasound guidance for
axillary plexus block does not prevent intravascular injection.
Anesthesiology. 2008;108:761.
24. Lalonde D, Bell M, Benoit P, et al. Multicenter prospective study of
3,110 consecutive cases of elective epinephrine use in the fingers
and hand: the Dalhousie Project clinical phase A. J Hand Surg Am.
2005;30:1061–1067.
25. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine
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393–397.
26. Gill HS, Prausnitz MR. Does needle size matter? J Diabetes Sci
Technol. 2007;1:725–729.
27. Winnie AP, Collins VJ. The subclavian perivascular technique of
brachial plexus anesthesia. Anesthesiology. 1964;25:353–363.
28. Perlas A, Lobo G, Lo N, Brull R, et al. Ultrasound-guided
supraclavicular block: outcome of 510 consecutive cases. Reg Anesth
Pain Med. 2009;34:171–176.
29. Sauter AR, Smith HJ, Stubhaug A, et al. Use of magnetic resonance
imaging to define the anatomical location closest to all three cords
of the infraclavicular brachial plexus. Anesth Analg.
2006;103:1574–1576.
30. Sorenson EJ. Neurological injuries associated with regional
anesthesia. Reg Anesth Pain Med. 2008;33:442–448. This article
provides a concise review of neurological injuries associated with regional
anesthesia, including mechanisms, diagnosis, and management. Although
neurologic injury is rare, every anesthesiologist and surgeon employing
regional anesthesia techniques for their patients must be able to recognize
a potential injury and institute treatment if necessary.
31. Auroy Y, Benhamou D, Bargues L, et al. Major complications of
regional anesthesia in France: The SOS Regional Anesthesia Hotline
Service. Anesthesiology. 2002;97:1274–1280.
32. Neal JM, Bernards CM, Hadzic A, et al. Practice advisory on
neurologic complications in regional anesthesia and pain medicine
ASRA. Reg Anesth Pain Med. 2008;33:404–415.
33. Neal JM, et al. The Second ASRA Practice Advisory on Neurologic
Complications Associated with Regional Anesthesia and Pain
Medicine, Executive Summary 2015. Reg Anesth Pain Med.
2015;40:401–430.
34. Neal JM, Bernards CM, Butterworth JF 4th, et al. Practice advisory
on local anesthetic systemic toxicity ASRA. Reg Anesth Pain Med.
2010;35:152–161.
35. Ben-David B, Stahl S. Axillary block complicated by hematoma and
radial nerve injury. Reg Anesth Pain Med. 1999;24:264–266.
36. Zipkin M, Backus WW, Scott B, et al. False aneurysm of the axillary
artery following brachial plexus block. J Clin Anesth. 1991;3:
143–145.
37. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia
in the patient receiving antithrombotic or thrombolytic therapy:
American Society of Regional Anesthesia and Pain Medicine
Evidence-Based Guidelines, 3rd edn. Reg Anesth Pain Med.
2010;35:64–101.
38. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve
blocks in hospital wards after orthopedic surgery: a multicenter
prospective analysis of the quality of postoperative analgesia and
complications in 1,416 patients. Anesthesiology. 2005;103:1035–1045.

110.e2
SECTION I
CHAPTER 4 • Anesthesia for upper extremity surgery
39. Hebl JR, Neal JM. Infectious complications: a new practice advisory.
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40. Horlocker TT, Wedel DJ. Regional anesthesia in the
immunocompromised patient. Reg Anesth Pain Med.
2006;31:334–345.
41. Wedel DJ, Horlocker TT. Regional anesthesia in the febrile or
infected patient. Reg Anesth Pain Med. 2006;31:324–333.
42. Hadzic A, Arliss J, Kerimoglu B, et al. Comparison of
infraclavicular nerve block versus general anesthesia for hand and
wrist day-case surgeries A. Anesthesiology. 2004;101:127–132.
43. McCartney CJ, Brull R, Chan VW, et al. Early but no long-term
benefit of regional compared with general anesthesia for
ambulatory hand surgery. Anesthesiology. 2004;101:461–467.
44. Epple J, Kubitz J, Schmidt H, et al. Comparative analysis of costs of
total intravenous anaesthesia with propofol and remifentanil vs.
balanced anaesthesia with isoflurane and fentanyl. Eur J
Anaesthesiol. 2001;18:20–28.
45. Capdevila X, Dadure C, Bringuier S, et al. Effect of patient-
controlled perineural analgesia on rehabilitation and pain after
ambulatory orthopedic surgery: a multicenter randomized trial.
Anesthesiology. 2006;105:566–573.
46. Liu SS, Strodtbeck WM, Richman JM, et al. Comparison of regional
versus general anesthesia for ambulatory anesthesia: a meta-
analysis of randomized controlled trials A. Anesth Analg.
2005;101:1634–1642.
47. De Andrés J, Valía JC, Gil A, et al. Predictors of patient satisfaction
with regional anesthesia. Reg Anesth. 1995;20:498–505.
48. Chan VW, Peng PW, Kaszas Z, et al. Comparative study of general
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Analg. 2001;93:1181–1184.
49. Chilvers CR, Kinahan A, Vaghadia H, et al. Pharmacoeconomics of
intravenous regional anaesthesia vs general anaesthesia for
outpatient hand surgery. Can J Anaesth. 1997;44:1152–1156.
50. Schuster M, Gottschalk A, Berger J, et al. retrospective comparison
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51. Shandling B, Steward DJ. Regional analgesia for postoperative
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477–480.
52. Leak WD, Winchell SW. Regional anesthesia in pediatric
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53. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of
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54. Lönnqvist PA. Is ultrasound guidance mandatory when performing
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63. Sai S, Fujii K, Hiranuma K, et al. Preoperative ampiroxicam reduces
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Reconstr Surg. 2007;119:1507–1512.

SECTION I • Introduction and Principles
5 
Principles of internal fixation as applied to
the hand and wrist
Jason R. Kang, Christopher Cox, and Jeffrey Yao
SYNOPSIS
■ Careful preoperative planning facilitates safe and expeditious surgery.
■ Ligamentotaxis relies on the application of linear traction to indirectly
reduce fragments via the intact periosteum, ligaments and soft tissues.
■ The most appropriate method of fracture fixation depends on a careful
assessment of the fracture characteristics and patient-related factors.
■ Postoperative care should generally allow for early mobilization if
fixation permits.
Introduction
Fracture care was significantly advanced in the twentieth
century with the introduction of new techniques and instru­
mentation for internal and external fixation.1 Today’s capable
hand surgeon must be well versed in the spectrum of avail­
able techniques of fracture fixation to provide optimum care
for the myriad of bony injuries that occur within the purview
of a hand surgery practice. Fixation of fractures in the hand
is notoriously difficult given the relatively small size of the
osseous structures and complexity of the surrounding
anatomy.2 The aim of this chapter is not to review every pos­
sible technique of fracture fixation in the hand, but rather,
to present basic concepts and general techniques useful in
routine fracture care.
Much of the credit for these advances in fracture manage­
ment should go to the Arbeitsgemeinschaft für Osteosynthe­
sefragen (AO), who devised a set of principles (Table 5.1) that,
in its modified form, provides the basic tenets that underlie
appropriate fracture care.3
Patient selection
Fracture assessment
Any consideration of fracture fixation must begin with a
careful, complete history and physical examination. Was the
mechanism of injury high or low energy trauma? How
much time has elapsed since the fracture and the current
presentation? Does the patient require early return to func­
tional activities or are their daily demands limited? Does
the patient have multiple injuries, or is this an isolated
injury? Are there open wounds or soft tissue damage? Is
there angular or rotational displacement? The vast majority
of fractures that are non- or minimally displaced are ame­
nable to treatment with immobilization and non-operative
methods.
Patient-specific considerations
The treatment of fractures requires a commitment from the
patient to observe potential activity restrictions and to partici­
pate in appropriate rehabilitation. Failure to comply with
immobilization, follow-up care, therapy recommendations,
or weight-bearing restrictions may result in compromised
outcomes.
Certain host factors can increase susceptibility to fracture
and/or surgical wound healing problems. Systemic risk
factors for poor healing potential include: diabetes mellitus,4
an immunocompromised state, advanced age, and smoking.
Local risk factors include: skin quality, volume/quality of soft
tissues available for closure, type of hardware utilized, and
tension across the wound. Failure to recognize and address
these factors may result in poor outcomes. Patients with an
elevated risk for wound problems should be counseled
accordingly and managed with alternative strategies where
appropriate. Non-modifiable risk factors should be recognized
and taken into consideration during treatment decision-
making. Modifiable risk factors should be addressed and
optimized before, during, and after fracture treatment.
Preoperative imaging
Proper radiographic assessment requires a minimum of 2
orthogonal views with the X-ray beam centered near the
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112
SECTION I
CHAPTER 5 • Principles of internal fixation as applied to the hand and wrist
fracture to minimize distortion. Factors to carefully evaluate
include:
1. Location of fracture (articular, metaphyseal, diaphyseal)
2. Pattern (transverse, oblique, spiral)
3. Presence of comminution
4. Displacement
5. Angulation (sagittal, coronal, and axial/rotational
planes)
6. Potential deforming forces acting across the fracture site
Occasionally, advanced imaging with computed tomography
(CT) scans or magnetic resonance imaging (MRI) may be
indicated to further characterize complex fracture patterns or
to evaluate for occult injuries to the bones or soft tissue. After
careful consideration of the fracture pattern in the context of
the injured patient, a decision must be made regarding non-
operative versus operative treatment.
Treatment/surgical technique
Preoperative planning
Once a decision has been made to treat a fracture operatively,
the surgeon begins the planning phase. Similar to the “recon­
structive ladder” concept for management of soft-tissue
defects, the surgeon should, in general, use the simplest
method that will reliably produce excellent clinical results.
Planning should include every detail of the proposed opera­
tion. This includes patient positioning, operating room setup,
type of imaging (fluoroscopy) desired, implants needed,
surgical approach, fracture fixation constructs, and consider­
ation of backup plans. Time spent planning will save operative
time, decrease staff frustration, and ensure that the appropri­
ate tools are present for the safest, most successful and most
efficient surgery possible.
Fracture reduction
Fracture reduction may be obtained by closed or open means.
For closed reductions, pulling linear traction across the frac­
ture site is usually required. This utilizes the phenomenon
of ligamentotaxis,5,6 whereby intact periosteum, soft tissue
attachments, and ligaments help realign bony fragments as
they are stretched. For open reductions, the fracture site is
exposed and reduction is obtained through a combination of
external manipulation and instruments placed within the
fracture site. The reduction can be provisionally held with
reduction forceps or Kirschner wires. The concept of reducing
the number of fragments by temporary or final fixation of
fragments to other fragments is critical in achieving a satisfac­
tory reduction in the face of comminution. Forceps or wires
used for temporary fixation should be carefully thought out
so as to not interfere with the planned definitive fixation.
Table 5.1  AO principles
1. Anatomical fracture reduction
2. Appropriate stability of the fixation construct
3. Preservation of blood supply and soft-tissue attachments to
fracture fragments
4. Early and safe mobilization
Reduction hints and tips: reduction forceps
Reduction forceps may be useful to attain and maintain
fracture reduction in fixation of larger fragments. One tine of
the forceps is introduced firmly onto a fragment and the other
tine is used to tease another fragment into the appropriately
reduced position. Careful pronation and supination
movements while applying the forceps may allow for the
restoration of length to difficult fractures. One has to take care
not to crush or shatter the fragments with excessive
compression of the clamps.
Reduction hints and tips: Kirschner wires (K-wires)
These are discussed in a separate section below in detail. In
fracture reduction, K-wires can be used to temporarily secure
fractures that are already reduced. Alternatively, they may be
applied in a unicortical fashion and utilized as “joysticks” or
“handles” to manipulate pieces into the appropriate position.
After attaining this position, they are often advanced across
the fracture to transition them from a reduction aid into a tool
of temporary or definitive fixation.
Reduction hints and tips: Kapandji (intrafocal)
pinning7–11
This is a special type of application of a K-wire utilized
commonly in distal radius fractures. The wire is introduced
through the fracture site (intrafocally). The pin is then tilted in
the desired direction of the reduction, then advanced through
the far cortex. This has particular applicability to the restoration
of volar tilt and radial inclination in distal radial fracture. This
may be employed as either temporary or definitive fixation.
Reduction hints and tips: temporary/supplemental
external fixation
For select, extremely difficult fractures, an external fixator may
be utilized to hold traction, neutralize shortening and apply
ligamentotaxis to assist with fracture reduction.
Intraoperative imaging
Fluoroscopy provides a valuable adjunct to many fracture
fixation surgeries. A complete review of the physics and
principles of fluoroscopy is beyond the scope of this chapter,
but a few points are worth mentioning. For upper extremity
surgery, either an image intensifier or a “mini” fluoroscopic
unit may be employed. For the vast majority of hand surgery
cases a “mini” fluoro provides adequate visualization with
greater mobility and less radiation.12–15
Many different operating room setups may be employed,
but patient positioning should be confirmed preoperatively to

113
Intraoperative imaging
Relative stability
Relative stability is important when treating comminuted
fractures where anatomical reduction is not possible or in
cases where closed reduction is elected. With relative stability,
the primary focus is on restoring the anatomic relationship of
the neighboring articular surfaces in length, alignment and
rotation. Some micromotion occurs at the fracture site, and, in
fact, is conducive to this type of healing (secondary bone
healing). Stability, however, must be adequate to maintain
alignment and prevent excessive motion at the fracture sites.
In contrast to primary bone healing via absolute stability,
secondary bone healing occurs via progression through carti­
laginous intermediaries and fracture callus is typically
observed. Relative stability is typically achieved with external
fixation, bridge plating, or intramedullary fixation. This
concept, in general, is not commonly applied to articular
fractures.
Methods of fixation
Kirschner wires
Kirschner wires (K-wires) are inexpensive and simple, yet
versatile tools to assist with fracture fixation. They may be
inserted in either a percutaneous or open fashion and appro­
priate insertion causes minimal tissue trauma. They may be
implemented either as provisional or definitive fixation (Fig.
5.2).19 When used for definitive fixation, relative stability is
generally obtained and healing occurs with callus formation.
Insertion of K-wires may be either directly across a fracture
site or in an intramedullary fashion. The main limitation of
K-wires is that they do not allow for interfragmentary com­
pression and may loosen over time, leading to implant
migration.
Sizes of Kirschner wires are usually reported either in
terms of inches or millimeters. For instance, a 0.062-inch
K-wire is the same caliber as a 1.6-mm K-wire. Sizes typically
utilized in hand surgery range from 0.035 inches (0.9 mm) to
0.079 inches (2.0 mm), although larger wires may be used for
select indications. Most wires are available in either smooth
or threaded varieties. Smooth wires allow for easy removal in
a clinic setting, but are also more prone to unintended migra­
tion. Threaded wires have a tendency to follow prior tracts
within bone; advancing them with the drill on reverse some­
what negates this tendency.
Tension band constructs
When bone is subjected to eccentric axial forces, one side of
the bone is subjected to compression forces and the opposite
side to tensile forces. A tension band,20–23 either in the form of
a wire construct or a plate, aims to convert this eccentric
tensile force into compression to assist with fracture compres­
sion and healing (Fig. 5.3). This concept is most applicable to
simple, transverse fractures in the diaphyseal region and
requires an intact cortex (no comminution) on the compres­
sion side.
To accomplish this conversion of eccentric forces into
compression, the tension band must be placed on the tension
surface. Fortunately, in the hand, this is on the dorsal side of
the metacarpals and the phalanges, allowing easier surgical
access. As the patient actively flexes the fingers, the force of
allow for adequate fluoroscopic visualization during surgery.
We typically position the mini fluoroscopic unit parallel to the
bed, oriented from the foot toward the axilla, so that the
patient’s arm can be adducted off of the hand table to provide
unobstructed views.
The region being examined should always be centered on
the detector of the fluoroscopic unit to minimize the distortion
from the “parallax” effect. Multiple views are helpful to
determine fracture reduction or hardware position in all
planes. It may also be helpful to orient the beam directly down
a placed K-wire or screw to precisely visualize its placement.
Specific knowledge of certain anatomic regions may also be
helpful. For instance, when imaging the distal radius, inclin­
ing the wrist approximately 20–30 degrees from a true lateral
can provide better visualization of the cortex of the lunate
facet to evaluate for screw penetration into the radiocarpal
joint.16 Live, dynamic fluoroscopy may be useful to examine
for stability across a fracture site with controlled motion or to
evaluate for intra-articular screw penetration.
Fixation principles
Absolute stability and interfragmentary
compression
Absolute stability is employed when fracture fragments are
reduced anatomically and secured with rigid fixation. Inter­
fragmentary compression is a critical component of fixation
when the surgeon attempts to achieve absolute stability.17,18
This compression, when combined with anatomic reduction,
leads to microscopic interdigitation of fracture ends, thus
minimizing the distance required for cells to travel from one
side of the fracture to the other. The fracture heals by primary
bone healing and histologically with “cutting cones” that
facilitate direct healing of one fragment to another (Fig. 5.1).
Minimal to no fracture callus is observed. This may be
achieved via a variety of methods discussed below, including
lag screws, compression plates, and tension bands. Interfrag­
mentary compression should be avoided in highly commi­
nuted fractures, as overzealous compression may lead to
excessive shortening.
Fig. 5.1  Compressed osteotomy site. Note the migration of osteocytes across the
fracture line, an example of contact healing. (Hematoxylin and eosin: magnification
×100.)

114
SECTION I
CHAPTER 5 • Principles of internal fixation as applied to the hand and wrist
Fig. 5.3  Tension band technique. (A) Transverse midshaft proximal phalangeal
fracture with volar angulation and displacement. (B) Reduction without fixation
allows compression of the volar cortex during digital flexion but unacceptable
dorsal cortical instability, causing an unacceptable gap. (C) A figure-of-eight
tension band wire is applied dorsal to the central axis of the proximal phalanx.
(D) The loops on either side of the tension band are tightened simultaneously to
achieve symmetric tension on both sides of the fracture. After the tension band wire
is applied, the compressive forces created during digital flexion are evenly
distributed across the entire fracture site. The tension band wire absorbs an amount
of tension equal to the compression at the fracture site. (E) Dorsal view of the
tightened tension band wire. Holes may be drilled in the bone, and the ends of the
wire loops may be inserted into these holes to minimize soft-tissue irritation. (After
Freeland AE. Hand Fractures: Repair, Reconstruction and Rehabilitation.
Philadelphia: Churchill Livingstone; 2000:42.)
A
B
C
D
E
Fig. 5.2  This 75-year-old had multiple injuries after being run over by a truck. He
sustained fractures of all metacarpals. Relative stability through usage of multiple
K-wires was elected to minimize further soft-tissue disruption.
A
B
flexion on the annular pulleys is transmitted directly to
the attached bone, and the vectors of force are through the
volar cortex toward one another. Because the tension band
fixes the dorsal cortex stably, the effect is to force the volar
cortices against each other and, by this process, produce
further compression of the fragments, thus attaining absolute
stability.
The exact configuration of the wires may vary with
the individual fracture, but most commonly consists of a
“figure-of-8” construct with dorsally crossed wires (Fig. 5.4).
Typically, this is employed by passing the wire either
through a drill hole or under a tendinous origin/insertion on
each side of the fracture. The wire can then be twisted to
reduce and compress the fracture. Depending on the specific
situation, one may use a twist on either side of the bone,
combine K-wires with the intraosseous wires, or many other
techniques.
In the hand, 28-gauge wire is adequate for a tension band
in small phalanges; 26-gauge wire serves in larger phalanges
and metacarpals. Rotation may be controlled and stability
augmented by accurately interdigitating the jagged edges of
fracture fragments together (Table 5.2).

115
Intraoperative imaging
Fig. 5.4  (A) A displaced transverse fracture of the mid-diaphysis of the
middle phalanx resulting from a glancing blow to the dorsum of the long finger.
(B) Application of a tension band wire resulting in good interdigitation of the
fracture so that it was held securely against rotational forces. (From Freeland AE,
Jabaley ME, Hughes JL. Stable Fixation of the Hand and Wrist. New York:
Springer-Verlag; 1985:89.)
A
B
Table 5.2  Techniques for internal fixation
Interosseous
wire (gauge)
Kirschner wire
(diameter inches)
Interosseous
(lag) screw (mm)
Plate (mm)
Distal phalanx
28
0.028/0.035
1.3/1.5
N/A
Middle phalanx
28
0.035
1.3/1.5
1.3/1.5
Proximal phalanx
26/28
0.045
1.5/2.0
1.5/2.0
Metacarpal
26
0.045/0.062
1.5/2.0
2.0
Carpal
24/26
0.045/0.062
1.5/2.0/2.4
2.0/2.4
A specific form of intraosseous wiring,24 the 90-90 technique
(Fig. 5.5), is useful, especially for arthrodesis, replantation,
and transverse fractures. Although not a tension band strictly
speaking, it is a rigid enough construct that it will permit
immediate motion.
External fixation
External fixation provides a useful, versatile option for frac­
ture stabilization. This typically consists of pins placed on
either side of the fracture with the pins connected to each
other through an external apparatus. This may be employed
as either temporary or definitive fixation. Reduction is
achieved through ligamentotaxis.5,25,26 While this may be used
with any fracture, it serves a particular purpose when there
is severe fracture comminution (Fig. 5.6) and/or an element
of soft tissue loss requiring reconstruction, thus increasing the
risk of infection with internal implants. External fixators can
typically be inserted through small incisions away from the
fracture site and zone of injury, thus avoiding violation of the
fracture hematoma. Knowledge of local anatomy together
with proper techniques of pin insertion should be used to
avoid damage to neurovascular structures. For instance, when
placing an external fixator for a distal radius fracture, great
care should be used to avoid damage to the radial sensory
nerve. Most authors advocate using an open approach and
identifying the radial sensory nerve in this instance although
others have advocated percutaneous placement of the pins in
a more dorsal position.27
Two main categories of external fixators exist: non-bridging
and bridging. Non-bridging fixators28 only span the fracture
site, while bridging fixators also span a joint. Bridging fixators
are more often used with metaphyseal fractures. Bridging
fixators may also be combined with limited K-wire or internal
fixation for comminuted articular fractures.11,29 When bridg­
ing joints, care must be taken to avoid unwanted overdistrac­
tion.30 Some specialized bridging fixators are hinged to
allow mobilization of the spanned joint.31 Relative stability is
achieved with any method of external fixation and healing
occurs with abundant callus via secondary bone healing.
Interfragmentary lag screws
Lag screws (Figs. 5.7 & 5.8) provide compression between two
fragments to achieve absolute stability. These may be used
alone, in combination with another method of fixation, or
through a plate. Lag screws are most useful in simple oblique
or spiral fractures,32 but also may be used to piece together
comminuted fractures. The utility of lag screws is very limited
in the fixation of transverse fractures as proper orientation
perpendicular to the fracture is difficult. If the trajectory of the
lag screw is not perpendicular to the plane of the fracture, a
shear force is introduced.
Key concepts: lagging by technique vs lagging  
by design
Insertion of a lag screw can be accomplished in two ways.
Lagging by technique relies on screw placement technique
to achieve interfragmentary compression, whereas lagging by
design applies the design features of the screw to achieve
compression.
When placing a lag screw by technique, a proper site of inser­
tion is selected first (see Fig. 5.7 and Video 5.1
). Ideally, lag
screws should be positioned perpendicular to the plane of the
fracture. Long spiral fractures may be fixed with lag screws

116
SECTION I
CHAPTER 5 • Principles of internal fixation as applied to the hand and wrist
Fig. 5.6  A spanning external fixator has
been applied to this highly comminuted 5th
metacarpal shaft fracture.
A
B
Fig. 5.5  This 37-year-old male had a saw injury to the palm of the hand. In addition to multiple tendon injuries, he sustained a severe injury to the cartilage of the thumb
metacarpophalangeal joint. A primary fusion was elected with usage of 90-90 interosseous wires and a supplemental K-wire.
A
B
C
in different planes, but perpendicular to the fracture at each
position. Screws placed too close to fracture edges may lead
to fracture propagation.
Second, the near cortex is overdrilled with a drill size
equivalent to or slightly larger than the outer thread diameter
of the planned screw. This allows the screw to “glide” through
the near cortex as the screw is tightened.
Next, the far cortex is drilled with a smaller drill size
equivalent to the core diameter of the planned screw. Tapping
may be done at this stage. However, most modern screws are
self-tapping.
Next, the near cortex is countersunk. This increases the
contact area of the screw head on the near cortex, thus
distributing the forces more evenly and avoiding the high
contact pressure that may lead to fracture propagation from
the drill site into the fracture site. Countersinking also
decreases the prominence of the screw head, decreasing irrita­
tion of the overlying soft tissues.
Finally, the screw length is measured with a depth gauge
and the appropriate length screw is inserted. Visible compres­
sion across the fracture site is frequently observed. Care
should be taken to avoid overcompression.
Lagging by design may be achieved by utilizing specially
designed implants. Two types of screws commonly employed
are partially threaded screws (Fig. 5.9) and headless compres­
sion screws. Partially threaded screws have threads at the

117
Intraoperative imaging
Compression plating
Compression plating is a method of obtaining absolute stabil­
ity and interfragmentary compression through a specific
method of plate application. This particular plating method
is typically employed for oblique or transverse fractures.
For transverse fractures (Fig. 5.12), the fracture is provi­
sionally reduced and the plate is affixed to one side of the
fracture in a neutralization fashion (holes drilled centrally
within the screw holes of the plate). Next, a hole is drilled
eccentrically (the portion of screw hole farthest away from the
fracture) on the opposite side of the fracture. As the screw
head engages the plate, it slides down the incline of the screw
hole in the plate, thus causing the screw/plate interface to
tip of the screw but no threads below the screw head that
allows the screw to glide through the near cortex. They may
be placed after drilling bicortically with the core-diameter
drill and then placing the screw, which saves time intraopera­
tively. The utility of partially threaded screws may be limited
by the relatively large size of the implant in many regions
of the hand and wrist. Another type of compression screw
is the headless compression screw (Fig. 5.10 and Video 5.2
). This screw has threads of varying pitches. The threads
with greater pitch within one fragment lead to more travel
per turn within that fragment compared to the finer pitch
threads in the other fragment (Fig. 5.11). Thus, compres­
sion is achieved as the screw is advanced (Fig. 5.10 and see
Video 5.2
).
Fig. 5.7  Lag screw technique. A long oblique
metacarpal fracture (A) is reduced and secured with a
pointed reduction forceps. (B) A glide hole is drilled
perpendicular to the fracture in the near cortex with a
2.4 mm drill bit. A drill guide is used to protect adjacent
soft tissue and to prevent skating of the drill bit on the
bone. (C) The opposite end of this double-ended drill
guide inserts into the 2.4 mm gliding hole. It has an
internal diameter of 1.8 mm. A concentric 1.8 mm core
hole is drilled in the opposite cortex (D). A countersink
fashions an area in the proximal half of the dorsal cortex
to correspond to and seat the screw head (E). A depth
gauge determines the appropriate screw length (F). A
2.4 mm tap threads the core hole of the opposite cortex
(G). A tap sleeve is used to protect the adjacent soft
tissues. (This step may be omitted for self-tapping
screws.) A 2.4 mm screw is inserted. As the screw
glides through the proximal hole, its head engages the
proximal cortex (H). A second screw is applied in a
manner similar to the first but in a plane perpendicular
to the long metacarpal axis, thus satisfying the need for
a neutralization screw (I). (Redrawn after Freeland AE.
Hand Fractures: Repair, Reconstruction and
Rehabilitation. Philadelphia: Churchill Livingstone;
2000:42.)
A
B
C
D
G
I
E
H
F
2.4
1.8
2.4

118
SECTION I
CHAPTER 5 • Principles of internal fixation as applied to the hand and wrist
translate toward the fracture site, leading to interfragmentary
compression.
In oblique fractures (Fig. 5.13), the plate should be affixed
first to the side of the fracture that allows for an acute angle
(or axilla) to be created between the undersurface of the plate
and the fragment. This allows for the second fragment to be
compressed into the axilla, thus entrapping the fragment and
assisting with reduction and compression. If the opposite
sequence was done and an obtuse angle was created, further
compression would lead to shortening and displacement of
the fracture. An angled lag screw through the plate placed
perpendicular to the fracture may be added to provide further
interfragmentary compression.
Bridge plating
Bridge plating (Fig. 5.14) is a useful method of relative
stability for stabilization of comminuted metaphyseal and
Fig. 5.8  This 34-year-old woman sustained an oblique fracture of the ring finger
proximal phalanx. Absolute stability was achieved through usage of multiple lag
screws. Note that the screws are placed in different planes, but perpendicular to the
fracture at each site.
A
B
Fig. 5.9  Anatomy of a partially threaded screw.
Shaft
Core diameter
Pitch
Length
Head
Fig. 5.10  A 20-year-old woman fell onto her wrist and sustained a left scaphoid
fracture. A headless compression screw is used for fixation. This device allows for
interfragmentary compression while avoiding screw-head prominence when treating
intra-articular fractures.
A
B
Fig. 5.11  Headless compression screw. Headless compression screws have
threads with variable pitch so that the screw advances at a different rate in the
proximal and distal bone fragments as the screw is advanced. This achieves
compression at the fracture site without the prominence of a screw head at an
articular surface.

119
Intraoperative imaging
Fig. 5.12  Compression plate. This illustration demonstrates the
application of a mini compression plate to a reduced transverse
fracture of the mid-metacarpal shaft. The straight miniplate has a
graduated bend of about 5 degrees centered at the middle of the
plate. (A) Two neutral (centered) screws secure the plate to the
left (distal) of the fracture. (B) A drill hole is placed eccentrically
away from the fracture site in the first plate hole to the right
of the fracture. (C) A screw is inserted in the eccentric drill hole.
(D) As the screw is tightened and the screw head engages the plate,
translation of the plate and bone in opposite directions causes
compression at the fracture site. (E) After compression is obtained,
a neutral drill hole is centered in the remaining plate holes. If further
compression is desired a second offset hole may be used instead.
(F) A neutral screw is inserted, completing the fixation. (Redrawn
from Freeland AE. Hand Fractures: Repair, Reconstruction and
Rehabilitation. Philadelphia: Churchill Livingstone; 2000:53).
A
B
C
D
E
F
Plate
Bone
Plate
Dorsal view
Lateral view
Bone
Fig. 5.13  Compression plate – compression screw (CS) within the plate. (A) Lateral view of a short oblique mid-diaphyseal metacarpal fracture in the coronal plane.
(B) The fracture is reduced and a tension band plate is applied, compressing the fracture. It is essential to place the offset mini compression screw (OS) eccentrically away
from the triangle of bone that is compressed into the “axilla” of the miniplate. (C) A large screw is placed across the fracture site, adding compression and stability.
(Redrawn from Freeland AE. Hand Fractures: Repair, Reconstruction and Rehabilitation. Philadelphia: Churchill Livingstone; 2000:55).
A
B
2
NS
1
NS
3
OS
4
NS
C
2
NS
1
NS
5
CS
3
OS
4
NS

120
SECTION I
CHAPTER 5 • Principles of internal fixation as applied to the hand and wrist
Locked plates may be applied in a variety of methods,
depending on the particular fracture pattern. Compression, if
desired, may be achieved through lag screws (either outside
or through the plate) or usage of non-locked eccentrically
placed compression screws (depending on plate selected).
Postoperative care
Immobilization following fracture fixation may be done for
several reasons including: need to protect the soft tissues
during initial wound healing, desire to mitigate the possibility
of secondary loss of reduction, and as treatment for associated
injuries in the polytrauma patient. Immobilization, however,
is not without risks. Certain joints, such as the proximal inter­
phalangeal joints of the fingers and the elbow, are notoriously
prone to problematic stiffness following immobilization.
Joint immobilization following fracture fixation may result
in increased stiffness due to either tendon adhesions or cap­
sular contraction. In the setting of articular fractures, unwanted
alterations in cartilage physiology occur with immobilization.
Several studies have showed a protective effect of early
motion on cartilage following articular injury.34,35 Furthermore,
some degree of micromotion across the fracture site may be
beneficial for fracture healing, as illustrated in the examples
of bridge plating and external fixation. This micromotion
facilitates callous formation through the secondary bone
healing pathway.
Where possible, fixation should be stable enough to allow
for early postoperative motion without allowing unintended
motion across the fracture site. The decision whether to add
supplemental splint or cast immobilization following fracture
fixation should consider the need for soft-tissue protection,
level of stability achieved, and presence of associated
injuries.
Summary
The hand surgeon must be familiar with various aspects of
proper fracture care and fixation. Decisions regarding optimal
treatment rely heavily on careful consideration of patient
related factors and on a detailed analysis of fracture morphol­
ogy. Once operative management is chosen, a myriad of
options are available. Comprehensive preoperative planning
should be done to shorten operative times and ensure that
adequate instrumentation is available. The type of stability
desired, planned operative sequence, and desired implants
should all be included in the preoperative plan. A thorough
understanding of the key concepts underlying proper opera­
tive fracture care aids the hand surgeon in optimizing surgical
outcomes.
diaphyseal fractures where anatomic reduction is either not
possible or would require extensive dissection.33 Ideally, the
fracture site should not be opened with this technique to
avoid unnecessary surgical trauma to the surrounding soft
tissues and allow for the preservation of vascularity to the
comminuted fragments. Bridge plates are used in a similar
manner to that of an external fixator. The principal goal is to
restore length, alignment, and rotation of the proximal and
distal articular surfaces. Healing is indirect via callus forma­
tion. Alternatively, if inadequate bone is thought to be present
to allow healing, this technique may be supplemented with a
staged bone grafting procedure to stimulate healing.
Locked plating
Locking plates allow for the creation of angular stable con­
structs to share load across a healing fracture (see Video 5.3
). Special threads on the screw heads themselves allow for
interdigitation with threads located within the screw hole of
the plate. The resultant angular stable construct is no longer
reliant on screw thread purchase within bone and may present
an advantage in osteoporotic bone or in low-density meta­
physeal bone. Failure of this construct is not at the screw/
plate interface, but rather would represent catastrophic
failure of the entire construct from the bone. Furthermore,
because purchase within the far cortex is not mandatory,
screws may be used in a unicortical fashion, thus avoiding
soft-tissue irritation in the tissues overlying the far side of the
fracture.
Fig. 5.14  Bridge plate. A complicated fracture in the first metacarpal with
comminution and bone loss has been excised and filled with an autogenous graft.
This plate provides a modicum of compression and screws through it further
stabilize the graft. (Reproduced with permission from Freeland AE, Jabaley ME,
Hughes JL. Stable Fixation of the Hand and Wrist. New York: Springer-Verlag;
1986:248.)

121
Summary
2. Henry MH. Fractures of the proximal phalanx and metacarpals in
the hand: preferred methods of stabilization. J Am Acad Orthop
Surg. 2008;16:586–595. This is a concise, recent review article which
summarizes many options for fracture fixation in the proximal phalynx
and metacarpals with case examples.
5. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand
Clin. 1993;9:577–585. This classic article describes the use of
ligamentotaxis in multiple planes to achieve optimal reduction of distal
radius fractures. The author has developed innovative external fixators
that use the concepts described in this article.
9. Kapandji A. [Intra-focal pinning of fractures of the distal end of the
radius 10 years later]. Ann Chir Main. 1987;6:57–63. This is a report of
some refinements to the author’s originally published technique of
intrafocal pinning for distal radius fractures. This is a useful technique to
understand, even in this era of volar plate fixation of the distal radius.
32. Horton TC, Hatton M, Davis TR. A prospective randomized
controlled study of fixation of long oblique and spiral shaft
fractures of the proximal phalanx: closed reduction and
percutaneous Kirschner wiring versus open reduction and lag
screw fixation. J Hand Surg [Br]. 2003;28:5–9. In this prospective,
randomized clinical trial , K-wiring and lag screw fixation of proximal
phalangeal fractures were compared. The series is limited by the
uniqueness of each fracture, nevertheless, worthwhile conclusions may be
drawn from this study.
33. Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius
fractures: the Harborview method. Clin Orthop Relat Res.
2006;445:91–99. In this retrospective study, the authors describe their
method of bridge plating of the distal radius including a summary of
indications for this technique. Their experience is derived from patients in
an extremely busy trauma center.
Access the complete reference list online at

121.e1
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summarizes many options for fracture fixation in the proximal phalynx
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10. Silverman AT, Paksima N. Biplanar Kapandji intrafocal pinning of
distal radial fractures. Am J Orthop (Belle Mead NJ). 2004;33:40–41.
11. Trumble TE, Wagner W, Hanel DP, et al. Intrafocal (Kapandji)
pinning of distal radius fractures with and without external
fixation. J Hand Surg Am. 1998;23:381–394.
12. Athwal GS, Bueno RA Jr, Wolfe SW. Radiation exposure in hand
surgery: mini versus standard C-arm. J Hand Surg Am.
2005;30:1310–1316.
13. Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR 2nd. Patient
and surgeon radiation exposure: comparison of standard and
mini-C-arm fluoroscopy. J Bone Joint Surg Am. 2009;91:297–304.
14. Giordano BD, Ryder S, Baumhauer JF, DiGiovanni BF. Exposure
to direct and scatter radiation with use of mini-c-arm fluoroscopy.
J Bone Joint Surg Am. 2007;89:948–952.
15. Sinha S, Evans SJ, Arundell MK, Burke FD. Radiation protection
issues with the use of mini C-arm image intensifiers in surgery in
the upper limb. Optimisation of practice and the impact of new
regulations. J Bone Joint Surg Br. 2004;86:333–336.
16. Soong M, Got C, Katarincic J, Akelman E. Fluoroscopic evaluation
of intra-articular screw placement during locked volar plating of
the distal radius: a cadaveric study. J Hand Surg Am.
2008;33:1720–1723.
17. Bagby GW, Janes JM. The effect of compression on the rate of
fracture healing using a special plate. Am J Surg. 1958;95:761–771.
18. Perren SM, Huggler A, Russenberger M, et al. The reaction of
cortical bone to compression. Acta Orthop Scand Suppl.
1969;125:19–29.
19. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal
fixation of proximal phalangeal fractures. J Hand Surg Am.
1984;9:725–729.
20. Allende BT, Engelem JC. Tension-band arthrodesis in the finger
joints. J Hand Surg Am. 1980;5:269–271.
21. Jupiter JB, Sheppard JE. Tension wire fixation of avulsion fractures
in the hand. Clin Orthop Relat Res. 1987;113–120.
22. Safoury Y. Treatment of phalangeal fractures by tension band
wiring. J Hand Surg [Br]. 2001;26:50–52.
23. Pehlivan O, Kiral A, Solakoglu C, et al. Tension band wiring of
unstable transverse fractures of the proximal and middle phalanges
of the hand. J Hand Surg [Br]. 2004;29:130–134.
24. Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg
Am. 1978;3:427–435.
25. Agee JM. External fixation. Technical advances based upon
multiplanar ligamentotaxis. Orthop Clin North Am. 1993;24:265–274.
26. Agee JM. Application of multiplanar ligamentotaxis to external
fixation of distal radius fractures. Iowa Orthop J. 1994;14:31–37.
27. Emami A, Mjoberg B. A safer pin position for external fixation of
distal radial fractures. Injury. 2000;31:749–750.
28. Eichenbaum MD, Shin EK. Nonbridging external fixation of distal
radius fractures. Hand Clin. 2010;26:381–390, vi–vii.
29. Weil WM, Trumble TE. Treatment of distal radius fractures with
intrafocal (kapandji) pinning and supplemental skeletal
stabilization. Hand Clin. 2005;21:317–328.
30. Loebig TG, Badia A, Anderson DD, Baratz ME. Correlation of wrist
ligamentotaxis with carpal distraction: implications for external
fixation. J Hand Surg Am. 1997;22:1052–1056.
31. Hove LM, Krukhaug Y, Revheim K, et al. Dynamic compared with
static external fixation of unstable fractures of the distal part of the
radius: a prospective, randomized multicenter study. J Bone Joint
Surg Am. 2010;92:1687–1696.
32. Horton TC, Hatton M, Davis TR. A prospective randomized
controlled study of fixation of long oblique and spiral shaft
fractures of the proximal phalanx: closed reduction and
percutaneous Kirschner wiring versus open reduction and lag
screw fixation. J Hand Surg [Br]. 2003;28:5–9. In this prospective,
randomized clinical trial , K-wiring and lag screw fixation of proximal
phalangeal fractures were compared. The series is limited by the
uniqueness of each fracture, nevertheless, worthwhile conclusions may be
drawn from this study.
33. Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius
fractures: the Harborview method. Clin Orthop Relat Res.
2006;445:91–99. In this retrospective study, the authors describe their
method of bridge plating of the distal radius including a summary of
indications for this technique. Their experience is derived from patients in
an extremely busy trauma center.
34. Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of
continuous passive motion on the healing of full-thickness defects
in articular cartilage. An experimental investigation in the rabbit.
J Bone Joint Surg Am. 1980;62:1232–1251.
35. Salter RB. The physiologic basis of continuous passive motion for
articular cartilage healing and regeneration. Hand Clin.
1994;10:211–219.

SECTION II • Acquired Traumatic Disorders
6 
The fingertip, nail plate and nail bed:
Anatomy, repair, and reconstruction
Brian Mailey and Michael W. Neumeister
SYNOPSIS
■ Fingertip and nail bed injuries are the most common injuries of the
hand.
■ Large subungual hematomas should be drained to relieve pressure and
pain; small and asymptomatic hematomas (<50%) can be observed;
trephination of a subungual hematoma is performed to relieve the
throbbing pain associated with this injury.
■ When the nail plate is intact, not all nail bed lacerations need to be
repaired.
■ Common secondary nail deformities seen after nail bed injury include
nail ridging, splitting, nonadherence, absence, cornified nail bed, hook
nails and spikes, or nail cysts.
■ Knowledge of the anatomic arterial branching patterns of the fingertip
allows creation of flaps to preserve length after distal fingertip
amputation injuries, including the volar and lateral V–Y advancement
flaps.
■ In the appropriate patient, subungual melanoma in situ can be safely
treated without amputation.
■ The purpose of the current chapter is to provide the reader with a
comprehensive review of the pathophysiology, diagnosis, and
treatment of nail and fingertip injuries and their management.
Introduction
The fingertip serves many functions in our everyday interac­
tions with the world. The sensation provided by the complex
unit of the highly specialized immobile, glabrous skin and soft
tissue pulp with the rigidity and counter pressure created by
the distal phalanx, nail plate and nail bed produces tactile
feedback allowing detailed sensation, proprioception, and
fine object manipulation. The perionychium consists of the
nail bed, nail fold, eponychium, paronychium and hypo­
nychium. Embryologically, these structures develop near the
end of the first trimester1 as a thickened area of epidermis on
the dorsal distal phalanx of each finger and toe that proximally
invades the underlying dermis to form the nail groove. The
deep layer of epidermal cells proliferates to form the nail
matrix. Cells within the superficial layer of the nail matrix
differentiate into hard keratin, forming the nail. At approxi­
mately 14 weeks, proliferation of the deeper layers of the nail
matrix pushes the nail distally across the nail bed while firm
attachment is maintained between the nail and nail bed.2
Folds of epidermis lateral and proximal to the developing nail
form the nail folds. Nails reach the tips of the fingers and toes
at about 32 and 36 weeks of intrauterine life, respectively.3
Anatomy
Surface anatomy
The topography of the nail was first described by Zaias in
1963.4 In this landmark study, fingers and toes of human
embryos from 9-weeks to full term were sectioned and exam­
ined; and the development of the human nail was detailed.
This paper began to clarify terminology of nail structures and
embryology with a glossary of various fingernail structures.
Later, in 1980, a standardized nomenclature for the anatomy
of the nail was proposed by Zook et al.5 to improve commu­
nication between physicians regarding nail pathology, injury,
and treatment (Fig. 6.1A,B). The entire nail structure, includ­
ing the nail fold, paronychium, hyponychium, nail bed (ger­
minal and sterile matrices), and nail, is referred to as the
perionychium. The paronychium refers to the lateral skin
surrounding the nail bed and nail. The skin over the dorsum
of the nail fold is referred to as the nail wall. Extension of the
nail wall distally onto the dorsum of the nail forms the
eponychium. The eponychium is attached to the nail by a
cornified material known as the nail vest, or cuticle. The
white, convex opacity extending distally from beneath the
eponychium is the lunula, which is the distal visible extent of
the germinal matrix. The white color remains after removal of
the nail and is thought to be secondary to retention of nuclei
of the germinal cells to this level in the nail. The mass of

123
Anatomy
the nail fold, drains in a random fashion over the dorsum
of the digit, and becomes large enough for vessel anastomosis
at the level of the distal interphalangeal joint.7
Lymphatics roughly parallel the veins and are most numer­
ous at the free edge of the nail (hyponychium). The density
of hyponychial lymphatics is greater than in any other dermal
area of the body.8 This explains the low subungual infection
rate, considering the heavy exposure of the hyponychial
region to pathogenic organisms with use of the nails and
fingertips to scratch frequently contaminated areas.
Knowledge of the anatomic arterial branching patterns
allows creation of fingertip flaps to preserve length after distal
fingertip amputation injuries. These local flaps will be dis­
cussed in detail later in the chapter.
Nerve supply
The common volar digital nerves branch dorsally, just distal
to the distal interphalangeal joint, to supply the perionychium.
Zook et al.5 reported the most common distribution of branch­
ing (70%) to be a proximal fascicle into the deep nail bed at
the level of the lunula and a distal branch to the hyponychial
area. Wilgis and Maxwell9 reported innervation by three nerve
keratin beneath the distal aspect of the nail and at the distal
edge of the nail bed is the hyponychium (Fig. 6.1C), which
forms from a thickening of stratum intermedium known in
the embryo as the distal ridge.
The nail bed consists of the germinal and sterile
matrices. The germinal matrix makes up the ventral floor of
the proximal nail fold. The sterile matrix consists of the soft
tissue immediately beneath the nail distal to the germinal
matrix.
Vascularity
The nail unit is supplied by branches of the common volar
digital arteries. As described by Flint,6 the digital arteries form
three arterial anastomoses over the dorsal surface of the distal
phalanx. A superficial arcade supplies the nail fold, and
proximal and distal arcades wrap around the waist of the
distal phalanx to supply the sterile matrix and the pulp space.
On dissection of 10 amputated digits, Zook et al.5 found two
consistent dorsal arterial branches of the digital arteries. The
first branch was seen at the base of the nail fold and the
second branch at the level of the lunula. Venous drainage of
the perionychium coalesces laterally and dorsally, proximal to
A
Dorsal roof
Nail fold
Eponychium
Hyponychium
Lunula
Nail bed
Ventral floor
B
Fig. 6.1  (A) The nail, the sterile and germinal matrices, and the surrounding tissue marked in blue compose the perionychium. (B) A lateral view of the nail bed showing
the ventral floor (germinal matrix), the nail bed (sterile matrix), and the dorsal roof of the nail fold. (C) Histologic section of the keratinous plug at the hyponychium.
(© Southern Illinois University School of Medicine.)
C

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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
their habitation upon our bodies and to allay the uneasy titilla­
tion by scratching”.13 Accordingly, fingernails are used for
scratching and in defense. The nail protects the fingertip and
contributes to tactile sensation.16 Counterforce between the
nail and the volar skin and pulp aids in delicate and precise
touch. Picking up small objects is difficult if the nail is absent.
Two-point discrimination will frequently double when the nail
is lost. However, incompletely attached or split nails are often
painful, especially in individuals who work with their hands
and may be worthy of removal in select situations.
Acute injury
Epidemiology
Injury to the fingertip and nail bed is the most common
injury of the hand because of its prominent position.17 The
long finger is most commonly injured, followed by the ring,
index, small finger and the thumb, with equal frequency
bilaterally. The majority of injuries occur between the ages
of 4 and 30 years, with 75% occurring in males.17 Fractures
of the distal phalanx are present in 50% of nail bed injuries,
and most injuries occur to the middle or distal third of the
nail bed.
The mechanism of injury generally constitutes a deforming
force, which compresses the nail bed between the nail and the
distal phalanx. A subungual hematoma results from injury
to the nail bed, causing bleeding beneath the nail. Most
commonly injury to the nail bed is a simple laceration (Fig.
6.3A
), especially17 when the object causing the injury is
small or sharp. A stellate laceration (Fig. 6.3B) occurs after
compression with larger objects causing a bursting injury.
Severe crush of the nail bed (Fig. 6.3C) is commonly caused
by a wider, greater force of compression. Avulsion injuries
(Fig. 6.3D) are the least common.17
Fig. 6.3 appears online only.
Subungual hematoma
Subungual hematoma formation causes separation of the nail
from the nail bed. The pressure of bleeding in this closed
space frequently results in throbbing pain. Hematoma drain­
age is thus indicated for pain relief.
Treatment
Drainage is performed with a heated (red-hot), sterile paper
clip, battery-operated cautery,18-gauge needle,18 or 2-mm
punch biopsy19,20 or in children, an insulin-syringe needle may
be used.21 The heated object burns a hole through the nail and
is cooled by the underlying hematoma. The hole is made large
enough to ensure prolonged drainage of the hematoma. A
small hematoma will be incorporated into the nail and travel
distally with nail growth. The decision to perform trephina­
tion is made by the size of hematoma and symptoms; not all
hematomas require drainage.
The extent of underlying nail bed injury is difficult to assess
with a subungual hematoma. Some advocate the use of ultra­
sound to detect nail bed injuries.22 If there is minimal disrup­
tion of the nail bed, normal nail growth is expected. However,
if a significant disruption of the nail bed is present, there is
higher risk of nail deformity if the nail bed is not repaired.
branches including two dorsal branches, as well as a branch
to the pulp.
Physiology
The hard and elastic structure of the nail plate is produced
continuously by the nail matrix. The nail is transparent,
however appears pink due to the presence of vessels of the
underlying nail bed. Keratinization of nail matrix cells occurs
along an oblique axis. As a result, the proximal part of nail
matrix produces the dorsal portion of the nail plate and, when
damaged, gives rise to the development of nail plate surface
abnormalities, whereas the distal part of nail matrix produces
the ventral portion of the nail plate.9 The nail plate is firmly
attached to the nail bed and it detaches at the hyponychium,
where its color becomes white due to the presence of air
underneath.
Nail growth continues throughout life. The speed of growth
increases with age until 10–14 years, at which point it becomes
similar to adults, which averages about 0.1 mm a day,4,10 and
is a rate 4× faster than toenails.11 The rate of growth changes
by season, with growth increased during summer months and
by age. Nail growth is twice as rapid before the age of 30 years
than after 80 years.11 Nail growth is also affected by comorbid
conditions of the individual, including endocrine, vascular,
infectious, and nutritional disorders.12 The rate of complete
nail progression from the nail fold to the free margin has been
reported to be between 70 and 140 days.4 Baden10 described a
21-day delay in growth after injury, during which time the
nail thickens proximally but does not grow distally. Distal
growth of a thicker than normal nail proceeds for the next 50
days; followed by growth of a thinner than normal nail for 30
days. Therefore, it is normal for an injury-induced lump to be
present on the growing nail. Nail growth is not normal for
approximately 100 days after injury. The nail is fixed to under­
lying tissues by virtue of being a continuous chain of cells
from the germinal layer into the nail, each cell attached to the
one in front, behind, and beside it.
The nail is produced by cells from three areas of the peri­
onychium: the germinal matrix, the sterile matrix, and the
dorsal roof of the nail fold (Fig. 6.2
). The germinal matrix
produces the majority of the nail volume (90%) by gradient
parakeratosis.4 The sterile matrix and the dorsal roof of the
proximal nail fold produce the remaining nail cells. The sterile
matrix adds cells to the volar surface of the nail, accounting
for the attachment of the nail to the matrix. The addition of
ventral nail during distal growth usually results in a thicker
nail distally and compensates for the dorsal wear.13,14 There
are longitudinal ridges in the sterile matrix increasing the
surface for attachment and accompany the rich, longitudinally
oriented vascularized capillary network. The dorsal roof of
the nail fold adds flattened cells to the dorsal surface of the
nail, producing the shine of the nail.15 Loss of the dorsal roof
causes a dull-appearing nail. Proximally and laterally, the nail
plate is surrounded by the nail folds that are responsible for
the protection of the nail matrix.
Fig. 6.2 appears online only.
Function
The function of nails was described in 1724 as “weapons to
defend us from trouble … from small creatures, that often make

124.e1
Acute injury
Fig. 6.2  Components of the nail are produced in three areas. (© Southern Illinois
University School of Medicine.)
Dorsal nail
Ventral nail
(sterile matrix)
Intermediate nail
(germinal matrix)
Either dorsal or
intermediate
Fig. 6.3  Of nail bed injuries: (A) 36% are classified as simple lacerations; (B) 27% as stellate lacerations; (C) 22% as crushing injuries of the nail bed; (D) 15% as
avulsions of the germinal or sterile matrix. (© Southern Illinois University School of Medicine.)
A
B
C
D

125
Acute injury
Lacerations
Avulsion of the nail, or nonadherence of the nail to the nail
bed, is an indication for nail removal. Any loose nail should
be trimmed and only enough of the nail that allows adequate
exposure and repair of the nail bed laceration should be
removed. Complete removal of the nail is not always neces­
sary. With middle to distal nail bed injuries, it may be possible
to leave the proximal nail undisturbed within the nail fold.
Treatment
Exploration of the nail bed is performed with digital block,
anesthesia, and tourniquet (e.g., a half-inch Penrose drain or
cut-out from a sterile glove). The nail plate is gently removed
from the nail bed with a small periosteal elevator or iris scis­
sors. Careful removal of the nail is important to avoid further
injury to the nail bed. Once removed, the nail is scraped to
remove residual soft tissue, then soaked in povidone-iodine
(Betadine) solution. The nail bed is examined with loupe
magnification. It is better to leave ragged edges and allow the
replaced nail to mold the edges than to debride and cause
tension on closure. Careful undermining of the edges may
assist in reducing tension on closure. A double-armed 7-0
chromic suture on an ophthalmic needle is recommended.
Therefore, whether a subungual hematoma should be
drained with the nail left intact or the nail removed and the
nail bed repaired is debatable. In the past, removal of the nail
for inspection of the nail bed with repair, as needed, was
advocated for hematomas undermining more than 25% of the
nail. Simon and Wolgin23 examined the nail beds of 47 patients
presenting to the emergency department with a subungual
hematoma and found that a hematoma >50% had a 60%
incidence of laceration requiring repair. Repair of the nail bed
was advocated with a hematoma >50% and an associated
distal phalanx fracture. At the University of Pittsburgh, a
2-year prospective, observational study was designed to
examine the outcome of 48 patients with subungual hemato­
mas treated with drainage alone. No complications of nail
deformity were found with this treatment, regardless of the
size of hematoma or presence of fracture.24 Roser and
Gellman25 compared three treatment groups in a prospective
study of 52 children with subungual hematomas. A total of 26
fingers were treated with nail removal and repair of the nail
bed. Drainage only was performed in 11 fingers, and 16 of 27
fingers were observed. No notable difference in outcome was
found between the groups, regardless of hematoma size. It
was concluded that nail removal and nail bed exploration are
not justified in children with subungual hematoma with an
intact nail and nail margin. A systemic review in 2012 evalu­
ated four articles comparing nail bed repair with simple
decompression and concluded the outcome of nail cosmesis
did not differ by the mode of treatment.26 Leaving the nail in
place is recommended for most subungual hematomas with
an intact nail. Exceptions may include children or patients
with concern for an optimally aesthetic nail. If the nail is
broken or the edge disrupted, removal of the nail and explora­
tion of the nail bed are advised (Fig. 6.4). The acutely painful
subungual hematoma should be decompressed, whether
done by trephination or nail removal.
Fig. 6.4  11-year-old male crushed his left index finger in a fence and suffered (A) an avulsion injury of the nail plate with a stellate laceration of the nail bed in the sterile
matrix with an intact germinal matrix. (B) The nail was taken off with a Freer elevator, the nail bed and hyponychium were repaired and the nail plate replaced. (C) 4 months
after injury and repair (left index finger) compared to the uninjured right index fingernail.
A
B
C
Hints and tips
Nail bed repair
The nail bed handles like wet tissue paper; each suture should
be thrown with two bites. Be conservative with the placement
of sutures. The goal is simple – re-approximation. Tension on
the nail bed suture line will lead to excessive scarring.

126
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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
This will secure the nail bed within the nail fold. The
eponychial incisions are then re-approximated with 5-0 or 6-0
nylon after nail bed repair.
Loss of small areas of nail bed may be replaced with split-
thickness nail bed grafts from adjacent uninjured nail bed,
harvested carefully with a No. 15 scalpel blade (Fig. 6.6A,B). A
split-thickness nail bed graft may be harvested from an adjacent
noninjured finger (risky) or an amputated finger. A split toenail
bed graft may also be used acutely and avoids the possible
deformity of an adjacent nail (Fig. 6.6C–H).27 With exception of
the great toe, the nail bed from the other toes are not large enough
to supply enough graft for an entire finger nail bed.
On completion of the nail bed repair, the nail is removed
from the povidone-iodine solution and a hole made in the nail
away from the site of injury. The hole allows drainage of the
subungual space after reinsertion of the nail into the nail fold.
The nail is placed within the nail fold to mold the edges of
the repair, to act as a splint for tuft or phalangeal fractures, to
prevent formation of synechiae between the nail fold and the
injured nail bed, and to protect the tender fingertip. The nail
is held in place with a 5-0 nylon suture placed distally through
the nail and hyponychial region. On rare occasions with
severe injury to the fingertip, a mattress suture may be placed
proximally through the nail fold. If the nail is not available or
is in small fragments, a piece of silicone sheeting (reinforced
0.020-inch-thickness silastic) may be shaped to fit beneath the
nail fold and secured proximally through the nail fold (Fig.
6.7
). Unlike the nail, the silastic sheet is soft and easily slips
from beneath the nail fold if it is secured only distally. Non-
adherent gauze may also be placed within the nail fold if no
nail or silicone sheet is available.
Fig. 6.7 appears online only.
The suture is cut in half to provide a second stitch because the
small needle is commonly bent during the repair.
Re-approximation of the more complex stellate laceration
and crush injury is more difficult. In these types of injuries, it
may appear to be missing fragments. However, they are often
present, attached to the undersurface of the nail. Small frag­
ments should be gently removed with a periosteal elevator
and used as a nail bed graft. A split- or full-thickness nail bed
graft up to 1 cm in diameter will usually survive, even when
it is placed directly on the distal phalanx cortex.6 Blood supply
to the graft is established by inosculation and vascular
ingrowth from the periphery.
The scenario with nail bed fragments attached to the nail
commonly occurs in avulsion type of injuries. To avoid further
insult to the nail bed, leaving the large nail bed fragment on the
nail is recommended. The edges of the nail are trimmed a few
millimeters to expose the nail bed for suturing into the defect.
Avulsion of the bed often occurs at the level of the germinal
matrix and proximal nail fold, leaving a distally based nail
bed flap of germinal or sterile matrix (Fig. 6.5A). The nail bed
remains attached to the nail, avulsing the germinal matrix off
the bone and out of the nail fold (Fig. 6.5B). The nail and
germinal matrix must be separated and the germinal matrix
replaced and sutured back into the nail fold (Fig. 6.5C). The
nail fold is exposed with unilateral or bilateral incisions per­
pendicular to the lateral corners of the eponychium. The
incisions should be made at a 90° angle to the eponychium to
prevent a notch deformity (Fig. 6.5D). If the laceration occurs
at the junction of the ventral and dorsal roof of the nail fold,
suture approximation may not be possible. In this case, a
horizontal mattress stitch is placed through the proximal end
of the avulsed nail bed and brought out through the nail wall.
Fig. 6.5  (A) When the proximal nail is flipped out of the nail fold and is lying on top of it, one must remove the nail and explore the nail bed. (B) There is almost always a
nail bed laceration with stripping of the germinal matrix up with the nail or a Salter fracture of the distal phalanx. (C) The laceration must be replaced and repaired.
(D) Radial incisions are made in the eponychium to access the nail fold. It is almost impossible to replace the nail in the nail fold without its total removal and then sliding
it back. (© Southern Illinois University School of Medicine.)
A
B
C
D

126.e1
Acute injury
Fig. 6.7  An example of a stitch in the silicone sheeting to hold it in place.
(© Southern Illinois University School of Medicine.)

127
Acute injury
left in place longer than 7–10 days. If not disturbed, the nail
will frequently adhere to the nail bed for 1–3 months as the
new nail forms beneath. Fingertip tenderness is usually less
with the nail replaced.
Distal phalanx fractures
Initial evaluation
Distal phalanx fractures are found in approximately 50% of
nail bed injuries and result in a higher incidence of secondary
nail deformities.17 Therefore, multiple-view radiographs of
the distal phalanx are recommended. A Seymour fracture
presents in children with the appearance of an elongated nail.
The fracture occurs through the physis with interposed soft
tissue, usually consisting of nail bed matrix but can include
other tissues, like eponychial fold.
Postoperative care
The fingertip is dressed with nonadherent gauze, 2-inch roll
gauze, and a four-prong splint to protect the repair. At 3–7
days after repair, the holding suture is removed, especially if
it is in the proximal nail fold position. The authors have
observed stitch track formation in the nail fold if the stitch is
Fig. 6.6  (A) A crushing injury to the tip of the finger with laceration of the surrounding skin. (B) After the skin is sutured, an area of cortex is seen. (C) A split-thickness
sterile matrix graft is removed from an adjoining area on the finger or toe. Back-and-forth sawing with a scalpel blade will remove a small fragment of nail bed, which is
slightly curved after the nail has been removed. The white line of the sharp edge of the blade should always be able to be seen so that the graft is not taken too thick with a
resultant deformity. (D) The fragment of nail bed taken. (E) If a larger piece of nail bed graft is needed, it may be taken from proximal to distal; the tip of the knife blade is
used to dissect up the split-thickness layer of nail bed. (F) The large toe after removal of the split-thickness nail bed graft. (G) A split-thickness nail bed graft is sutured
into place over the periosteum without any manipulation of the cortex. (H) One year later, good regrowth of the nail and adherence are shown. (© Southern Illinois University
School of Medicine.)
A
B
C
D
E
F
G
H
Hints and tips
Nail plate replacement
Trim the nail plate of sharp contours. Place the nail plate under
the eponychial fold for a distance of 2–3 mm. An absorbable
suture can be used to hold the nail plate in place as an
alternative to nylon. This will avoid painful suture removal.

128
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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
of the dorsal roof matrix to detach from the nail, and scar
formation between the dorsal roof and ventral floor of the
nail fold. Although longitudinal splits are most common, a
horizontal split has been reported; it caused a diagonal scar
in the matrix and formation of a portion of the nail on each
side (Fig. 6.10
). The nail was produced within both folds,
forming a horizontally split nail.
Figs. 6.9 and 6.10 appear online only.
Treatment
Scar must be minimized to allow normal nail production. Scar
within the sterile matrix can occasionally be treated with exci­
sion and primary closure. The excised defect is frequently too
wide to be approximated without tension and requires repair
with a split-thickness sterile nail bed graft from the same digit
or a toe. In germinal matrix injuries, Johnson28 recommended
releasing incisions in the lateral paronychial folds with bilat­
eral central advancement of the germinal matrix, but our
experience with this technique has been disappointing in
traumatic deformities. Replacement of germinal matrix with
sterile matrix will not be successful because sterile matrix
grafts do not produce a nail. Split-thickness germinal matrix
grafts also do not produce hard nail growth. The germinal
matrix defect requires repair with a full-thickness germinal
matrix nail bed graft.27,29 The second-toe germinal matrix is a
good option with its similar shape and size; the large toe is a
second choice (Fig. 6.11). The patient is warned that use of the
toenail germinal matrix will eliminate hard nail growth on the
toe. This second-toe nail defect is frequently more acceptable
to patients than a defect of the great toenail. In the case of an
existing bone spur, the nail bed is lifted free and the spur is
removed with rongeurs to produce a flat surface, and the nail
bed is replaced.
Pterygium
Splitting of the nail may also be caused by a pterygium. A
pterygium of the eponychium results from adherence of the
eponychium or dorsal roof of the nail fold to the nail plate or
nail bed during healing. A web between the eponychium and
nail bed will result in splitting of the nail as it grows distally
from the nail fold (Fig. 6.12
).
Fig. 6.12 appears online only.
Treatment
Simple pterygia are amenable to warm water soaks until the
eponychium can be bluntly separated from the nail. Sharp
dissection of the eponychium from the dorsal nail is per­
formed if blunt dissection is unsuccessful. Separation between
the dorsal roof and nail is then maintained with nonadherent
gauze or a silastic sheet. This allows epithelialization of the
undersurface of the nail fold. If adherence persists between
the dorsal roof and the ventral floor (matrix) of the nail fold,
it must be divided surgically. Once the nail fold has been
redesigned, maintenance of the separation must be achieved
with nail, silicone sheet, or gauze until healing occurs. If a
large raw surface is present after freeing, a split-thickness
sterile matrix graft can be placed on the raw surface of the
dorsal roof. If the scar has completely replaced the normal
germinal matrix, a full-thickness germinal matrix graft is
necessary.
Treatment
Treatment of nondisplaced distal fractures consists of nail bed
repair and replacement of the nail. The nail acts as an excellent
splint for the fracture. Small, displaced tuft fractures and most
stable distal fractures can be reduced with reapproximation
of the nail bed and replacement of the nail. Larger displaced
fractures or unstable fractures require longitudinal or cross
K-wire fixation. Care must be taken to put the pin in the
medullary cavity of the bone. K-wires traversing the nail bed
can cause a painful ridging deformity.
Secondary procedures
Reconstruction
The painful non-adherent, split, or hooked nail, may hinder
work productivity in the laborer. For others, nail deformities,
such as nail ridges, grooves, or absence of the nail may create
self-consciousness or an unsightly appearance. Goals for
reconstruction should be based on concerns and wishes of the
individual patient. Surgical measures often improve function
and appearance but often do not produce a normal nail. The
best chance for restoring a normal nail is at time of the initial
repair.
Most nail deformities are secondary to scarring of the nail
bed with subsequent disruption of nail growth. Similar to
other scars, it is recommended to wait at least 8–12 months
after injury before consideration of reconstruction. With scar
remodeling, small nail deformities may resolve significantly
or completely. Common secondary nail deformities seen after
nail bed injury include nail ridging, splitting, non-adherence,
absence, cornified nail bed, hook and spikes, or cysts.
Nail ridge
Nail ridges are secondary to an irregularly healed distal
phalanx fracture or scar within the nail bed. Nail ridges may
also occur secondary to a K-wire placed between the sterile
matrix and the periosteum on reduction of a phalanx fracture
(Fig. 6.8
). Longitudinal irregularities result in longitudinal
ridges or grooves. Transverse irregularities beneath the nail
bed result in corresponding transverse grooves or ridges or
distal nonadherence. Correction of this deformity requires
excision of the scar or irregular bone edge to form a flat,
smooth nail bed surface.6,16 A defect that cannot be reapproxi­
mated primarily requires use of a nail bed graft.
Fig. 6.8 appears online only.
Transverse nail ridges may develop secondary to hypoxia
from ischemic injury or tourniquet hemostasis. The ridges
resolve with correction of the inciting factor and subsequent
new nail growth.
Split nail
A split nail is often secondary to longitudinal scarring of the
germinal or sterile matrix. Unlike the germinal and sterile
matrices, the scar does not produce nail cells, resulting in
splitting of the nail. Scar within the germinal matrix can
split the nail from its most proximal aspect. Scar within the
sterile matrix disrupts the progressive addition of nail cells to
the volar nail, leading to detachment of the nail plate (Fig.
6.9
). Other causes of split nails include bone spurs beneath
the nail bed, eponychial pterygium resulting from failure

128.e1
Acute injury
Fig. 6.8  A longitudinal pin was placed to maintain fracture reduction but was
between the periosteum and sterile matrix, causing scarring in the ridge.
(© Southern Illinois University School of Medicine.)
A
Fig. 6.9  (A) A split nail may occur within the sterile matrix with minimal problems. (B) An injury to the germinal matrix can cause a split in the entire nail, causing
significant pain secondary to trauma and disfigurement. (© Southern Illinois University School of Medicine.)
B

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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
Fig. 6.10  (A) A horizontal laceration in the sterile matrix with a resultant transverse scar can cause a separation so that two nails grow out. If the volar nail is adequate,
surgical removal of the dorsal nail-producing matrix will correct the problem. (B) The patient’s index finger postoperatively. (© Southern Illinois University School of
Medicine.)
A
B
A
B
C
Fig. 6.12  (A) A split of the nail due to scarring between the dorsal roof and the ventral floor of the nail fold. (B) End-on view of the nail deformity. (C) With the two
portions of nail removed, the cicatrix between the dorsal roof and the ventral floor of the nail fold can be seen. (D) The cicatrix is divided with the resultant defect on the
dorsal roof. (E) A split-thickness sterile matrix graft is removed from the sterile matrix and sutured in place on the dorsal roof of the nail fold. (F) One-year follow-up with
an improved appearance and reduced functional problems. (G) An end-on view of the nail demonstrating the improved contour. (© Southern Illinois University School of
Medicine.)
D
E
F
G

129
Acute injury
reconstruction of absent nails. Both germinal and sterile
matrices are needed for total reconstruction of a nail bed.
Zook recommended a full-thickness second-toe germinal and
sterile matrix graft to approximate the width of the fingernail.
To match the length of the fingernail, a split-thickness sterile
matrix graft from another toe is placed distal to the free
composite graft. The large toenail is used for thumbnail
reconstruction. Results can be unpredictable and at times
unsuccessful secondary to nontake or shrinkage of the graft.
Patients should be informed of the risk of toenail deformity
and a possible suboptimal outcome.
The most reliable and normal-appearing nail is constructed
with a free vascularized dorsal tip of the toe.35–38 This proce­
dure can be technically difficult, requiring microsurgical
expertise, and produces scarring of the foot from harvest of
the vascular pedicle.
Skin grafts, as opposed to nail bed grafts, have been used
with some success to mimic the nail. This method has been
advocated for treatment of traumatic nail absence and con­
genital nail absence in which multiple digits are involved
(Fig. 6.13). The scar is excised from the fingertip in the shape
of a larger than normal nail (10% larger), and replaced
with a similarly shaped split- or full-thickness skin graft.
Full-thickness grafts can be placed proximally and distally
to simulate a white lunula and hyponychia, respectively.
An artificial nail can then be fixed to the healed skin with
glue, but patients may have difficulties maintaining the nail
in place with glue alone. To aid in nail adherence, Bunke
and Gonzales39 reconstructed the proximal fold using a
prosthesis wrapped in split-thickness skin graft and buried it
under the dorsal finger skin. Artificial nails were then secured
beneath the new fold. Unfortunately, the fold was only tem­
porary and slowly disappeared with time. Baruchin et al.40
described an osseointegrated anchorage device to secure the
artificial nail.
Cornified nail bed
With ablation of the germinal matrix, nail production ceases.
However, an intact sterile matrix will continue to produce
Fig. 6.11  (A) Avulsion of a portion of the germinal matrix with a split nail. (B) The sterile matrix has been reapproximated after resection of the scar, and a toe germinal
matrix graft is shown before insertion in the germinal matrix. (C) Insertion of the germinal matrix graft as a free graft into the sterile matrix. (D) At 6 months, the graft of
germinal matrix is shown to be growing nail. (© Southern Illinois University School of Medicine.)
A
B
C
D
Nonadherence (onycholysis)
Nonadherence of the nail is the most common post-traumatic
nail deformity. This occurs secondary to nail bed scarring and
is often found immediately distal to transverse or diagonally
oriented nail bed scars or bone irregularities. The scar inter­
rupts the progressive addition of nail cells from the sterile
matrix to the volar nail plate, causing detachment of the nail.
The nail is unable to reattach to the nail bed distally.30
Distal nonadherence may lead to problems with subungual
hygiene, an unstable nail when picking up small objects, pain
from repeated avulsions when catching the nail on objects, or
may simply be an aesthetic concern.
Treatment
Nonadherence secondary to a nail bed scar is corrected with
scar excision and primary closure or closure with a split-
thickness sterile matrix graft from the adjacent nail bed or
toenail bed.30–32
Malalignment of distal phalanx fractures may cause non-
adherence. Prevention begins with accurate alignment of the
fracture at initial repair. Secondary deformities caused by
bone exostosis, bone angulation, or nonunion will require
revision. The exostosis should be removed to form a flat
surface for the sterile matrix and subsequent nail adherence.
Bone angulation may require osteotomy of the distal phalanx
to re-form a flat surface.
Nail absence (anonychia)
Any process, including trauma, infection, and burn, which
destroys the nail matrix will lead to an absent nail. Frequently,
small nail remnants will remain that can cause other second­
ary deformities. Nail absence is also rarely seen as a congenital
deformity known as anonychia.
Treatment
Free partial and composite nonvascularized nail grafts
have been described by McCash33 and Lille et al.34 for

130
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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
seen more commonly after revision amputations performed
in the emergency department.
Hooked nail
The hooked nail is a nail that hooks volarly during distal
growth. This deformity is commonly seen after tight closure
of tip amputations. On closure, the nail bed is pulled around
the tip of the finger. Healing of a distal amputation site by
secondary intention may also pull the nail bed volarly over
the tip. Because the growing nail follows the direction of the
nail bed, the nail grows in a hooked fashion, curving around
the fingertip.
Treatment
This deformity can be avoided during repair of the acute
injury by following two rules. The nail bed should never be
pulled over the tip of the distal phalanx. If bone support
beneath the nail bed is missing, it must be replaced or the nail
bed shortened to match the length of the remaining distal
phalanx.
Correction of the hooked nail secondary to the distal nail
being pulled over the tip comprises release of contracted soft
tissue, return of the nail bed to its normal position, and
replacement of fingertip soft tissue. A full-thickness skin graft,
V–Y advancement flap, cross-finger flap, or proximal thenar
crease flap can be used to augment the tip and reposition the
nail bed on the dorsum of the distal phalanx.41 When bony
support is missing, the options are either to shorten the nail
bed or add bony support to maintain length. Non-vascularized
bone grafts have been placed distally with successful initial
support of the nail bed. However, they often resorb with time,
and the correction is lost.6 Osteotomy and distraction of the
distal phalanx with placement of a bone graft between the
distracted segments has been proposed to decrease the inci­
dence of graft resorption but may be technically difficult.
Bubak et al.42 described a repair of a hooked nail deformity
using a composite second-toe graft for tip support. A fish­
mouth incision is made in the hyponychium and carried
proximally on the lateral aspects of the digit until the nail bed
is released. An elliptical, transverse wedge of skin and pulp
is excised from the second toe and placed beneath the released
nail bed. Good results were reported with a 2-year follow-up.
Free vascularized second-toe tip (bone, soft tissue, and nail
bed) transfer has been presented as a more permanent yet
more complex option.36
Eponychial deformities
Eponychial deformities occur as sequelae after trauma, burns,
tumor, infection or any process causing direct destruction of
the nail fold tissue. As the tissues heal, scar contractures create
the final deformity. Loss of eponychium causes more of an
aesthetic defect than a functional one. Notching or loss of the
eponychium exposes more of the proximal nail and results in
loss of nail shine. Despite this change in appearance, there is
no effect on nail growth.
Treatment
The three-dimensional structure of the nail fold makes recon­
struction difficult. Multiple local rotation flaps have been
varying amounts of keratinous material, resulting in a corni­
fied nail bed.
Treatment
Treatment for a cornified nail bed includes excision of the
sterile matrix and replacement with a split-thickness skin
graft. Overproduction of keratinous material from the sterile
matrix can also occur beneath a nail from chronic repetitive
partial avulsion, allowing build-up beneath the distal nail,
leading to nonadherence. Treatment includes removal of the
nail to a point just proximal to this area of overproduction.
The keratinous material is scraped from the nail bed with a
scalpel blade. The nail is then able to adhere to the nail bed
during distal growth. The process may need to be repeated if
overproduction on the exposed nail bed occurs more quickly
than nail growth (Fig. 6.14
). Sterile matrix grafts may be
necessary if scraping is unsuccessful (Fig. 6.15
).
Figs. 6.14 and 6.15 appear online only.
Nail spikes and cysts
On elimination of the nail bed or amputation of the distal
phalanx, care must be taken to excise the germinal matrix
completely. Any residual matrix allows continued production
of nail cells. These cells produced within a closed space form
nail cysts and the cells that are able to grow distally form nail
spikes.
Treatment
Treatment consists of complete surgical removal of the cyst or
spike along with the residual matrix. These deformities are
Fig. 6.13  A nail-shaped split-thickness skin graft is placed on the dorsum of the
finger to mimic a nail. (© Southern Illinois University School of Medicine.)

130.e1
Acute injury
A
B
FPO
Fig. 6.14  (A) Nonadherence of nail to the sterile matrix thought to be due to an episode of pulling the nail free
from the nail bed traumatically and then repeated attempts to clean under the nail. The area of nonadherence is
marked on the nail. (B) That area of nail is removed, showing the hyperkeratinous sterile matrix. The
hypertrophic keratinous material is scraped off with a scalpel blade to bare the vascular sterile matrix. (C) The
patient 1 year later with improved adherence of the nail. (© Southern Illinois University School of Medicine.)
C

130.e2
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
Fig. 6.15  (A) Nonadherence of the nails to the nail bed after a crushing injury and then application of artificial nails. The cause of the detachment could be either of these.
(B) A split-thickness sterile matrix graft from the large toe donor site is placed over the defect. (C) The patient 1 year later with much improved attachment. (© Southern
Illinois University School of Medicine.)
A
B
C

131
Acute injury
nails trimmed. Alternatively, further shortening of the digit or
nail bed ablation would be required.
Fig. 6.17 appears online only.
Treatment
Treatment for the hypertrophic hyponychium requires deter­
mination of the inciting activity, which is often something that
causes acute or chronic irritation. Initial management consists
of avoidance of process producing the pathology. If irritation
cannot be avoided or if symptoms persist despite avoidance,
excision of the hypertrophic hyponychium and coverage with
a split-thickness sterile matrix graft have resulted in a high
incidence of symptom relief. The split-thickness sterile matrix
graft is carried out in the same manner as with replacement
for avulsion of a portion of the sterile matrix or scar
excision.
Pigmented lesions
The differential diagnosis for pigmentation of the nail bed is
complex; it includes subungual hematoma, foreign body,
onychomycosis nigricans, junctional nevi, pyogenic granu­
loma, paronychia, vascular lesion, melanonychia striata, mela­
noma in situ, and malignant melanoma.48 Although most
pigmented lesions of the nail are benign, they should be
evaluated carefully to rule out malignancy.
Patient presentation
The history of the pigmentation is generally the most valuable
aspect to making the diagnosis. Trauma may cause bands of
pigment, especially in darkly pigmented individuals. Devel­
opment of pigment in adults, even without a known history
of trauma, is often secondary to a subungual hematoma, but
the differential diagnosis of malignant melanoma must be
considered. These suspicious areas can be monitored by
scratching the nail at the proximal and distal edges of the
pigment with a scalpel blade or 18-gauge needle (Fig. 6.18).
described. Reconstruction of a nail fold with both inner and
outer surfaces has been described with use of rotation flaps
lined with split-thickness skin grafts.16 Hayes43 used distally
based ulnar finger flaps for creation of the nail fold without
reconstruction of the inner surface. Kasai and Ogawa44 modi­
fied Hayes’ technique of distally based ulnar finger flaps by
using the local tissue to reconstruct the inner surface. The
scarred eponychial tissue is incised proximally and turned
over distally to form the nail roof. An ulnar, dorsal flap is then
raised on a distal base and placed on top of the new roof to
form the new eponychium, with split-thickness skin grafting
of the donor site. Achauer and Welk45 described a one-stage
reconstruction of the burn-scarred eponychium with dorsal
transposition of bilateral proximally based lateral digit flaps.
A composite eponychial graft of skin and dorsal roof from
the first or second toe to the eponychial defect is recom­
mended. This eponychial graft has been found to improve
appearance and restore the shine to the nail (Fig. 6.16).
The eponychial flap is a technique used for fingertip inju­
ries when the eponychium is intact. This flap lengthens the
appearance of the visible nail. It was first presented in 1998
by Bakhach46 and is indicated for fingertip injuries with a
resultant small stump of intact nail and nail bed. The proce­
dure consists of incising the dorsal eponychium with two
radial incisions, elevating the dorsal eponychium as a flap and
suturing it down in a more proximal location. This can be
done at the time of acute injury or as a later reconstructive
procedure.47
Hyponychial defects
The keratinous plug of the hyponychium may hypertrophy
secondary to acute or chronic trauma to the distal nail and
hyponychium. When this occurs, it may protrude beyond the
nail and cause pain when it is bent or pressed with use of the
finger. It may also produce an unsightly protrusion from
under the nail (Fig. 6.17
). Loss of the hyponychium results
in lack of support of the nail and a hook nail deformity. To
prevent hygiene and cosmetic issues, patients must keep their
Fig. 6.16  (A) Loss of eponychium secondary to trauma with resultant irregularity and roughness of the nail. (B) One year after a full-thickness composite graft of
second-toe dorsal roof transfer to the finger. Note the improvement in the contour and shine of the dorsum of the nail. (C) The eponychial graft was taken from the second
toe and here shows essentially no deformity. (© Southern Illinois University School of Medicine.)
A
B
C

131.e1
Acute injury
A
B
Fig. 6.17  (A) A hypertrophic hyponychium (arrowhead) causing pain and discomfort with upper traction on the nail. (B) Dorsal view of the same patient. (C) Same patient
with relief of pain after resection of the hypertrophic hyponychium and a split-thickness sterile matrix graft in its place. (D) Same patient, dorsal view with hyponychial
attachment. (© Southern Illinois University School of Medicine.)
C
D

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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
drugs or pregnancy, endocrine disorders and frictional mela­
nonychia. Next, the appearance of the nail itself can provide
diagnostic information, including trauma, psoriasis and
nail tumors (onychopapilloma, onychomatricoma, Bowen’s
disease). Nail clippings can also be used to assist in the diag­
nosis. Finally, if the diagnosis has not be determined then
removal of the nail plate and a histopathologic evaluation of
tissue is required.51
Subungual melanoma represents only 1–2% of all cutane­
ous melanoma and usually affects the thumb or big toe.52 An
Distal migration of pigmentation over 3–4 weeks, together
with the scratch marks suggests a hematoma. However, if the
scratch marks move distally, away from the pigment, this
suggests foreign body, nevus, or melanoma. The evaluation
of nail clippings can also provide some diagnostic value.49 To
do this, a sample at least 4 mm in length is required and can
be used to diagnose a number of conditions, including mela­
nonychia, subungual hematoma, onychomycosis and others.49
Melanonychia striata is defined as any linear tan–brown–
black pigment of the nail bed that is carried into the nail as
growth occurs. This pigmentation is caused by focal increase
in the number or function of melanocytes. Melanonychia
striata is common in individuals with darkly pigmented skin
but uncommon in those with fair skin (Fig. 6.19).
Subungual nevi produce pigmentation within the nail bed
and the ventral nail (Fig. 6.20). These pigmented nevus cells
are derived from neural crest cells and are frequently present
at birth or shortly thereafter. The nail is frequently pigmented
with elevation and ridging (Fig. 6.21).
Fleegler and Zeinowicz50 recommended nail bed biopsy of
dark streaks present at or shortly after birth because of the
danger of malignant degeneration at puberty. Melanocytic
hyperplasia without atypia can be observed. However, com­
plete excision with reconstruction of the nail bed is advised if
atypical cells are found.
Subungual melanoma
Nail melanoma is an infrequent cause of brown–black nail
color compared to other melanocytic and nonmelanocytic
pigmentations. More common causes of nail discoloration are
subungual hematoma, exogenous pigmentations and melano­
nychia, which are all benign. In a review of 100 patients seen
at a dermatology clinic for nail discoloration, 25 required
additional evaluation, but only one had a melanocytic pig­
mentation that required a surgical evaluation.51 Most lesions
can be diagnosed by history alone. The first determination is
to decide if the pigment is due to melanin within the nail. This
step can help exclude exogenous pigmentations, fungal mela­
nonychia and subungual hematoma. Examining the other
digits can reveal racial melanonychia, effects of systemic
Fig. 6.18  (A) A swollen, inflamed paronychium known as a paronychia. (B) The side of the nail, which is undermined by the infection, is separated from the nail bed and
the lateral aspect of the dorsal roof of the nail fold. (C) This fragment of nail is removed, giving adequate drainage to the infection. (D) A piece of water-soluble gauze is
placed as a drain. (© Southern Illinois University School of Medicine.)
A
B
C
D
Fig. 6.19  Scratching of the nail proximal and distal to the pigment to determine
whether the pigment is in the nail or in the nail bed. (© Southern Illinois University
School of Medicine.)

133
Acute injury
superficial, radial growth under the nail plate, followed by a
vertical growth. At this stage, the lesion begins to develop a
more dramatic change in appearance.
Treatment
The historic standard treatment recommendation for subun­
gual melanoma has been en bloc partial or complete digit
amputation. This strategy was considered the safest means of
obtaining clear margins, preventing recurrence and metasta­
sis. This rationale, however, was not based on clear scientific
evidence, but rather the principles of wide excision for what
was thought to be an aggressive malignancy. Current evidence
suggests this disease is not more aggressive than their more
common cutaneous counterpart of similar depth.53,54 The
original evidence to support these recommendations came
from Das Gupta et al. in 1965.55 They presented 34 patients
with subungual melanoma treated with amputation at differ­
ent levels. Three patients who underwent a less aggressive
form of amputation recurred and subsequently died from
their disease. On the basis of these findings, it was determined
that local amputation was not an adequate resection. However,
it should be noted that they did not present the depth of these
lesions and half of the patients in the study were being treated
for recurrent melanoma or already had regional lymph node
metastases at time of treatment. Therefore, the conclusions
derived from Hutchinson’s and Das Gupta’s findings regard­
ing aggressive amputation are not appropriately supported
by their evidence.
Today, interphalangeal joint amputations are the most com­
monly performed treatments for this disease. However, digit
sparing procedures in appropriately selected cases have also
been successfully performed. The precedent for digit sparing
came from a study in 1992 by Park et al.56 In this manuscript,
the authors treated subungual melanoma in situ without
amputation. This was followed by a number of series in the
literature presenting similar experiences with variable results,
but not infrequent recurrence. Today, it seems wide excision
can be an option for patients with melanoma in situ. However,
they should be followed closely for signs or disease recur­
rence. For a complete discussion and further in-depth review
of available literature, a manuscript presented by Cochran
et al. in the August 2014 issue of Plastic and Reconstructive
Surgery is available for the reader.57
Pincer nail
Pincer nail deformity is described as lateral hooking or exces­
sive transverse curvature of the nail plate, unilaterally or
bilaterally (Fig. 6.22). The progressive tubing of the nail even­
tually pinches off the nail bed and hyponychium, resulting in
an unaesthetic, painful nail. Pincer nail is most commonly
seen in middle-aged to elderly women. The cause of the
pincer nail is not known.
Treatment
Previous treatments have included resection of a wedge of the
phalanx to flatten the nail edges and release of the nail bed
with a medial longitudinal nail bed incision and split-thickness
skin graft coverage of the resultant triangular defect.58 They
have been largely unsuccessful. Brown et al.59 have advocated
the use of dermal graft strips between the lateral nail bed and
important clinical clue to subungual melanoma is character­
ized by extension of brown or black pigment from the nail
bed, matrix and nail plate to the adjacent cuticle and proximal
or lateral nail folds; this is known as Hutchinson’s nail sign.
There are two stages to melanoma growth. The first stage is
Fig. 6.21  A newly occurring pigmented streak that originates in the germinal
matrix or proximal to the observable pigment. (© Southern Illinois University School
of Medicine.)
Fig. 6.20  The melanocytic streaks in an African American patient after trauma to
the perionychium (arrowhead). (© Southern Illinois University School of Medicine.)

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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
size, shape, location and availability of donor sites. Age,
occupation and individual attributes of the patient ultimately
play the largest role in appropriate selection of the reconstruc­
tive plan. The final decision is made by the patient, however
the surgeon may affect this choice. A recent survey sent out
to American Association for Hand Surgery members revealed
US and private practice physicians were less likely to perform
replantations than academic or international centers.60 For
soft-tissue fingertip injuries, local flaps were preferred over
secondary intention or skin grafts more commonly in surgeons
with a plastic surgery background or with more than 30 years
of experience.60 Younger surgeons were also more likely to
perform skeletal shortening than those with more than 5
years’ experience.60
The Allen classification61 is commonly used to describe the
level of fingertip injury, as thought of in a transverse amputa­
tion. Type 1 injuries involve the pulp only. A type 2 injury also
involves the nailbed. Concomitant distal phalangeal fractures
with associated pulp and nail represents a type 3 injury and
the type 4 injury occurs more proximal with involvement at
the level of the lunula.
Reconstructive principles
The principles of wound management in the traumatized
digit or hand are the same basic guidelines that apply to the
rest of the body and include irrigation, debridement, and
the distal phalanx periosteum for elevation of the lateral
borders of the nail bed. The nail is removed, and incisions are
made at the tip of the digit to allow freeing and elevation of
the paronychial folds from the periosteum. The dermal grafts
are placed within this space to maintain the elevation and to
flatten the nail bed. Our preferred technique is a modification
of this, using human acellular dermal matrix in place of
autologous dermal strips. We have achieved equally good
correction of pincer nail without the addition of an additional
donor defect.
In more severe cases, the pain from a pincer nail deformity
may be severe enough to warrant surgical ablation of the
nail bed, especially if other forms of reconstruction are
unsuccessful.
Reconstruction of fingertip injuries
Reconstructing defects on the fingers requires thorough
knowledge of a variety of coverage options. Treatment pos­
sibilities range from simple, including an occlusive dressing
to allow healing by secondary intention, to extremely complex,
including free pulp transfer. As the surgeon considers each
possibility to obtain definitive closure, one must also integrate
the priorities of function, contour, stability, and the anticipa­
tion for further reconstructive surgery. The reconstructive
decision is based on characteristics of the defect, including
A
B
Fig. 6.22  (A) Unilateral pincer nail deformity. (B) The perionychium is freed from
the bone, and a graft of dermis or dermal substitute is placed into the tunnel to
flatten the nail bed. (C) One year after correction. (© Southern Illinois University
School of Medicine.)
C

135
Reconstruction of fingertip injuries
Flap selection
A multitude of available flaps can produce good outcomes for
both the recipient and donor site. Each flap has inherent
advantages and drawbacks. Ultimately, flap selection is
dependent upon variables such as size, shape, location of the
defect, and the characteristics of the tissue lost. The hand
surgeon must select the most ideal flap to restore as many of
the native skin characteristics present prior to the defect, and
to provide the quickest means of wound closure. Efficient
wound closure becomes a higher priority to prevent finger
stiffness and maximize hand function.
Fingertip injuries should be thoroughly irrigated and
debrided of foreign material and nonviable tissue before
closure is attempted. If the entire defect cannot be closed
primarily, the wound can be partially closed and the remain­
der allowed to heal by secondary intention. Suture selection
varies by surgeon preference. If possible, the wound should
be closed with a chromic or other resorbable suture. Nylon
sutures in the fingertip are not usually necessary; they are
uncomfortable to remove in the early follow-up periods. The
wound is covered with a non-stick dressing like Xeroform or
other minimal adherence dressing. Daily dressing changes
permits rapid wound healing. Early motion is encouraged
to prevent stiffness at the DIP or PIP joints. Larger wounds
can heal by secondary intention if bone, tendon or neuro­
vascular structures are not exposed. Wounds up to 2–3 cm
may be allowed to heal by re-epithelialization, but both
surgeon and patient must be aware that closure may take
4–6 weeks (Fig. 6.23). Previously, authors advocated that
defects >1 cm should be closed with local flaps.62 However,
secondary intention offers many advantages over flap closure,
including improved contour, sensation, and lack of donor site
morbidity.63
restoration of vascularity. Stabilization of fractures and repair
of specialized tissues such as nerve and tendon become the
second priority, followed by the definitive soft-tissue cover­
age. The skin of the hand and the fingers varies from palmar
to dorsal sides. The palmar aspect is covered with glabrous
skin notable for its limited sheer, high friction coefficient and
papillary ridges, which create the characteristic fingerprint.
Numerous fibrous septae compartmentalize subcutaneous
tissue of the palm with fibers from the underlying dermis to
the musculoskeletal structures below. The midaxial line of
each digit is formed by connecting the lateral volar finger
crease at the distal interphalangeal joint (DIP), proximal
interphalangeal joint (PIP) and metacarpal phalangeal (MCP)
joint. It is at this line that the transition from the glabrous to
non-glabrous skin of the hand occurs. The midaxial line cor­
responds to the midline of the phalanx. Whereas the true
midlateral line of the finger corresponds to the location of the
neurovascular bundle. The dorsal skin is relatively soft,
pliable, and thin. It is devoid of the fibrous septae observed
in the volar skin.13 The importance of understanding the dif­
ference of glabrous and non-glabrous skin comes to light
when one observes one of the dictums of reconstructive sur­
geons to replace “like with like”. Local flaps that include
glabrous skin should be considered first for glabrous defects.
The relative limited and inelastic quality of glabrous skin on
the body prevents reconstruction of large glabrous defects
with similar tissue. In such cases, alternative strategies must
be employed, including using spare parts in a multi-digit
injury, use of multiple grafts for a single defect, allow wounds
with non-vital structures exposed to heal by secondary inten­
tion or coverage with non-glabrous skin. Dorsal skin more
closely resembles skin on the anterior trunk and defects of the
dorsal hand and fingers can readily be closed with other
similar quality skin.
Fig. 6.23  (A) Large soft tissue defect of the volar aspect of the thumb allowed to heal by secondary intent. (B) 4-year follow-up of healed thumb showing good contour.
A
B

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CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
lateral aspect of the digits (Fig. 6.26).64 Often bilateral flaps are
required to get sufficient closure of the of the fingertip defect.
The lateral V–Y flaps are elevated in a similar fashion as to
the volar V–Y flap; however, they are based laterally and
medially instead of volar. Unlike the Atasoy counterpart, this
flap’s advancement has limited mobility and can only reliably
close defects of 0.5 cm, but no more than 1 cm. The flap
is elevated in the plane of the deeper musculoskeletal
structures.70
Visor flap
Described by Neumeister et al., the visor flap is indicated
for closure of transverse distal fingertip amputations with
exposed bone.70,71 This flap utilizes skin on the dorsal aspect
of the finger to preserve length and close defects on the most
distal aspect of the finger amputation site. The visor flap is a
bipedicled rectangular-shaped flap from the dorsal aspect of
the finger. It is raised at the level of the paratenon immediately
proximal to the defect (Fig. 6.27). The width of the flap is
approximately that of the fingertip defect. The flap is sensate
and vascularized by branches of the volar lateral and medial
digital arteries and nerves, respectively.71 Back cuts in the
dorsal aspect of the skin may be required for transposition of
the flap. The donor site requires a skin graft. If dog ears are
present, they are left in place and should flatten over a period
of months. The visor flap provides acceptable sensation, good
cosmetic appearance and preservation of length of the digit
without violating adjacent normal digits or creating volar
scars.
Homodigital flaps
Reverse homodigital flap
The reverse homodigital flap, originally described by Lai
et al.,72 takes advantage of the dual vascularity of the digit, as
the finger can remain viable on a single digital artery. The
other artery can provide blood supply for an axial flap that
can be based proximally or distally (Fig. 6.28). The digital
nerve remains in situ to preserve sensation to the finger,
however small nerve branches can be used for coaptation to
improve sensation of the transferred flap. These arterial per­
forator flaps involve small perforators arising from the digital
artery. The skin island can be isolated on the perforator while
the remaining aspect of the artery provides length to the
pedicle, ultimately creating an arc of rotation of up to 180°
(Fig. 6.29A–D
).73,74 The donor site may be closed with a
skin graft if primary closure is not possible. Distally based
homodigital flaps take advantage of the communication with
the contralateral digital artery.75 These flaps may be somewhat
precarious as they require retrograde venous flow and may
have limited communication with the contralateral vessels.
This reverse homodigital flap can also be taken as an adipo­
fascial flap.76 This technique can provide a slightly broader
and larger flap and reduces donor site morbidity.76
Fig. 6.29 appears online only.
Alternative modifications described islandize a dorsal–
lateral skin paddle on a volar perforating branch from
the digital vessel. This digital artery perforator propeller
flap is innervated and can be used to reconstruct lateral
oblique fingertip defects and prevent further skeletal
shortening.77
Skin grafting
Patient selection
When the extent of the defect is limited to skin, a split- or
full-thickness skin graft may be used for coverage of a well-
vascularized bed. Graft contraction is expected. Although
re-innervation is poor with split-thickness grafts, protective
sensation may be possible if full-thickness grafts are used.62,64
Dermal substitutes (Integra, Intera LifeSciences Co., Plains­
boro, NJ) over tendons can provide an interface that accepts
a skin graft and prevents scar adhesion formation that pre­
vents motion (Fig. 6.24). Distal fingertip amputations often
comprise skin, subcutaneous fat and a portion of the nail bed.
The amputated part may be replaced as a composite graft
after defatting, called a cap graft.65 The overall success rate of
composite grafts is poor in the adult population and better in
children <10 years of age. A recent review of pediatric patients
treated with cap grafts revealed a relatively poor rate of
complete take (7.7%).66 The majority of patients had a partial
take (38.5%) and 33% had total loss of the graft. Despite this
seemingly poor overall success of composite grafts, only 10%
of patients went on to require a secondary procedure.66 It can
be concluded that a composite graft placed on a fingertip that
does not revascularize should be left as a biologic dressing to
allow healing from below the eschar. This often leads to an
adequately contoured fingertip. These injuries do, however,
take many weeks to months to completely heal and in the
adult laborer needing to return to work, a revision amputation
may be a preferred method for treatment of these types of
injuries.
An evaluation by Allen level concluded that cap grafts are
most successful for Zone I and II sharp or blunt-cut injuries,
but Zone III or IV injuries regardless of mechanism should be
treated by another method (e.g., revision amputation, local
flap, micro-anastomosis, etc.).67
Treatment: Local flaps
Volar V–Y advancement (Atasoy, Kleinert)
Fingertip defects less than one centimeter and oriented in a
dorsal oblique or transverse fashion may be closed with a
volar V–Y advancement flap.64 Originally described by Atasoy
et al. in 1970, this flap is oriented as a triangle and closed in a
V–Y fashion. The base of the triangle sits at the wound edge
and the apex at the DIP crease (Fig. 6.25).68,69 This skin is
incised down through the dermis and then scissor dissection
is used to release fibrous septae that anchor glabrous skin to
the deeper musculoskeletal structures.64 The most distal
corners of the flap must be freed by 2–3 mm in order to allow
adequate release of the flap distally. Similarly, the apex of the
flap at the DIP joint must be released significantly to permit
distal migration of the flap.70 The flap is elevated with its
neurovascular pedicles on either side of the flap in the plane
of flexor tendon sheath; 0.75–1 cm of length can be obtained
with a volar V–Y advancement flap. Functional and cosmetic
results are extremely good as this flap remains one of the most
important tools in treatment of fingertip injury closure.62,64,68,69
Lateral V–Y advancement flaps (Kutler)
Transverse and lateral oblique defects can be covered with
sensate vascularized skin using V-Y advancement flaps on the

136.e1
Reconstruction of fingertip injuries
A
Flap with digital artery
Digital nerve
Skin graft
B
C
D
Fig. 6.29  (A) Homodigital flaps are based on the nondominant digital artery to the
fingers and used to transpose either in a retrograde or an antegrade fashion.
(B) Exposed PIP joint necessitates closure, the homodigital flap is elevated, care is
taken to incorporate the digital artery proper into the flap. (C,D) The flap is
transposed and the donor site closed with a full-thickness skin graft. The flap can be
elevated without transecting the skin paddle proximally. This improves the venous
outflow of the flap. (E) Healed flap, dorsal aspect of finger.
E

137
Reconstruction of fingertip injuries
A
B
C
D
Fig. 6.24  54-year-old male suffered occupational avulsion injury as an elevator repairman. (A) The
neurovascular bundles were intact, but there was exposed flexor tendon sheath. (B) The wound was debrided
and Integra (indicated by the scissor tips) was placed over the tendon sheath and (C) immediately covered
with a full-thickness skin graft from the volar forearm. (D) Some areas of purplish discoloration are seen
during the immediate postoperative period. (E) At 4 weeks postoperative, he healed completely and with
good motion.
E

138
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
A
B
C
Fig. 6.25  (A–D) Distal defects of the fingertip that require flap coverage can be closed with volar V–Y flaps.
The flap is designed with the apex at the DIP flexion crease. Flaps can be transposed distally to cover defects
up to 1 cm in length.
D
A
Fig. 6.26  Distal fingertip injuries are sometime more amenable to laterally V–Y flaps. The limited length gained is more limited reaching only up to 0.75 cm.
B

139
Reconstruction of fingertip injuries
Heterodigital flaps
The cross-finger flap
The cross-finger flap utilizes skin from the dorsal aspect of the
adjacent finger as part of a two-stage technique. The inner
cross-finger flap is most applicable for volar defects of the
distal aspect of an adjacent finger. The flap is normally taken
from the dorsal radial surface over the middle phalanx of the
adjacent digits.62,64,70,77 The flap is designed slightly larger than
the defect to ensure complete coverage. Vascularity of the flap
arises from the digital artery and vena comitantes that send
branches dorsally beyond the PIP joint. The flap is elevated
superficial to the extensor paratenon and flipped over like
a page in a book to cover the volar defect of the adjacent
finger (Fig. 6.31). The base of the flap remains intact with
the donor finger while the donor defect on the dorsal aspect
of the middle phalanx is covered with a full-thickness or
Moberg flap
The homodigital volar advancement flap, also known as a
Moberg flap, can be used to reconstruct defects on the thumb
(Fig. 6.30A–C). A volar oblique injury to the tip of the thumb
is the classic indication for this flap. However, this flap’s uses
have expanded to include a wider range of defects. The
unique dorsal and volar blood supplies to the thumb allow
creation of a volar skin paddle with both neurovascular
bundles. Flap elevation is performed in a plane just volar to
the tendon sheath. The flap can be completely islandized on
the neurovascular structures, with a variety of proximal inci­
sions used to close the defect in the palm, including a V–Y
design (Fig. 6.30D) or transverse incisions at the base with
excision of Burow’s triangles. The Dellon modification of the
flap allows closure of defects up to 3 cm. This requires dissec­
tion of the flap into the palm past the base of the thumb.
A
A
B
C
D1
B
C
Fig. 6.27  (A) The visor flap is designed over the dorsum of the digit. The height of the defect (A to B) is equal to the height of the flap (A to C). The proximal incision is
carried down to the midaxial line on either side of the dorsum of the finger. A back cut to D1 can be made but only through the dermis in order to protect the neurovascular
structures supplying the flap. (B) Clinical picture of the design of the visor flap. (C) The flap was transposed over the distal aspect of the amputated stump. The donor
defect is closed with a split thickness skin graft or a full thickness graft. (D,E) Lateral and AP view of the visor flap after it is transposed and healed.
D
E