Operative Technique in Plastic Surgery – Kevin C.Chung

■ Inject slowly to decrease pain.
Local
anesthetic
dosage
■ The maximum adult dose of plain lidocaine is 4–5 mg/kg.7
■ The maximum adult dose of plain bupivacaine is 2.5 mg/kg.7
POSTOPERATIVE CARE
■ Postoperative care will depend on the procedure performed.
OUTCOMES
■ A systematic review compared six local anesthetic preparations (lidocaine,
lidocaine with epinephrine, bupivacaine, bupivacaine with epinephrine,
lidocaine with bupivacaine, and ropivacaine). All provided benefits in digital
nerve blocks.3
■ Lidocaine demonstrated the shortest mean onset of anesthesia (3.1 minutes),
whereas bupivacaine was the longest (7.6 minutes).
■ Lidocaine also had the shortest mean duration of anesthesia (1.8 hours),
whereas ropivacaine had the longest duration (21.5 hours).
COMPLICATIONS
■ Amino esters (chloroprocaine, procaine, tetracaine, cocaine) are more likely to
cause allergic reactions than amino amide compounds (lidocaine, bupivacaine,
ropivacaine, mepivacaine).
■ Systemic toxicity is extremely rare with hand and wrist local anesthesia but
can occur with intravascular injection.
■ Central nervous system manifestations can include facial numbness, metallic
taste, light-headedness, tinnitus, and seizure.
■ Cardiac depression can culminate in cardiovascular collapse (ventricular
tachycardia or fibrillation).
■ Primary therapy in the setting of cardiac arrest involves advanced
cardiovascular life support (ACLS).
■ Consider intravenous lipid emulsion therapy in the treatment of local
anesthetic systemic toxicity.8,9
■ Although the authors have never encountered digital infarction with use of
epinephrine, it is important to know that local phentolamine injection reverses
epinephrine-induced vasoconstriction.10
REFERENCES

1. Puna R, Poon P. The anatomy of the dorsal cutaneous branch of the ulnar
nerve. J Hand Surg Eur Vol. 2010;35E(7):583-585.
2. Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve:
an anatomic study with surgical implications. J Hand Surg [Am].
1992;17(6):1037-1041.
3. Vinycomb TI, Sahhar LJ. Comparison of local anesthetics for digital nerve
blocks: a systematic review. J Hand Surg [Am]. 2014;39(4):
744-751.
4. Hung VS, Bodavula VK, Dubin NH. Digital anaesthesia: comparison of the
efficacy and pain associated with three digital nerve block techniques. J Hand
Surg Eur Vol. 2005;30B(6):581-584.
5. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg
2013;131:811-814.
6. Lalonde DH, Martin A. Tumescent local anesthesia for hand surgery:
improved results, cost effectiveness, and wide-awake patient satisfaction. Arch
Plast Surg. 2014;41(4):312-316.
7. Katz RD, LaPorte DM. Use of short-acting local anesthetics in hand surgery
patients. J Hand Surg [Am]. 2009;34(10):1902-1905.
8. Cordell CL, Schubkegel T, Light TR, Ahmad F. Lipid infusion rescue for
bupivacaine-induced cardiac arrest after axillary block. J Hand Surg [Am].
2010;35(1):144-146.
9. Neal JM, Mulroy MF, Weinberg GL. American Society of Regional
Anesthesia and Pain Medicine checklist for managing local anesthetic systemic
toxicity: 2012 version. Reg Anesth Pain Med. 2012;37(1):
16-18.
10. Nodwell T, Lalonde D. How long does it take phentolamine to reverse
adrenaline-induced vasoconstriction in the finger and hand? A prospective,
randomized, blinded study: the Dalhousie project experimental phase. Can J
Plast Surg. 2003;11(4):187-190.

2
CHAPTER
Fasciotomy for
Compartment Syndrome of
the Hand and Forearm
John R. Lien and Kevin C. Chung
DEFINITION
■ Compartment syndrome occurs when interstitial tissue pressure rises to levels
that impair blood flow and cellular function.
ANATOMY
■ The hand contains 10 muscular compartments as well as the carpal tunnel and
digital compartments (Table 1, FIG 1).
■ The forearm consists of three myofascial compartments: volar, dorsal, and the
mobile wad (Table 2, FIG 2).
PATHOGENESIS
■ If there is swelling within the fascial compartments, intracompartmental
pressure will rise.
■ Increased compartment pressure can result in tissue ischemia and necrosis.
■ Causes of compartment syndrome:
■ Intracompartmental swelling: Bleeding/soft tissue injury from trauma,
anticoagulation, infection, high-pressure injection injury, reperfusion injury,
intravenous fluid infiltration.
■ External compression: Burn eschar, prolonged syncope with pressure on the
limb, tight dressings or casts.
■ Major limb replantation/revascularization requires prophylactic fasciotomy
due to risk of reperfusion injury and compartment syndrome.
NATURAL HISTORY
■ Irreversible muscle damage occurs within 6 to 8 hours of ischemia.

■ Rhabdomyolysis from myonecrosis can result in acute renal failure and
electrolyte abnormalities.
■ Left untreated, permanent nerve deficit and muscle fibrosis of the forearm can
result in secondary Volkmann contracture.
Table 1 Head Compartments
Compartment
Muscle
Nerve
Thenar
Abductor pollicis brevis,
opponens pollicis, flexor
pollicis brevis
Recurrent motor
Hypothenar
Abductor digiti minimi,
opponens digiti minimi, flexor
digiti minimi
Ulnar
Adductor
Adductor pollicis
Ulnar
Interosseous (7)
4 dorsal and 3 palmar
interossei
Ulnar
Carpal tunnel
Flexor digitorum superficialis,
flexor digitorum profundus,
flexor pollicis longus (tendons)
Median
Digit

Digital
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Understand the mechanism of injury and have a high clinical suspicion—
compartment syndrome is a clinical diagnosis.
■ Remove any constrictive dressings or clothing.
■ Physical exam findings:
■ Tense, swollen compartment, blistering (FIG 3)
■ Pain with passive stretch of the compartment muscles
■ Paresthesias
■ Paralysis of the involved compartment muscles develops after nerve
paresthesias.
■ Pallor and pulselessness are late findings.
DIAGNOSTIC STUDIES
■ Compartment syndrome is usually a clinical diagnosis; diagnostic studies may

complement the diagnosis.
■ If there is a history of trauma, plain radiographs are indicated to assess for
fracture or dislocation.
■ Other advanced imaging (ultrasound, MRI) is rarely indicated. Time-
consuming studies should not preclude emergent fasciotomy if there is high
clinical suspicion for compartment syndrome.
■ Laboratory studies (complete blood count, coagulation panel, basic metabolic
panel, creatine phosphokinase, serum and urine myoglobin) are obtained.
FIG 1 • Midpalmar cross-section of hand compartments.
Table 2 Forearm Compartments
Compartment
Muscle
Nerve
Volar


Superficial
Flexor digitorum superficialis,
pronator teres, palmaris
longus, flexor carpi radialis,
flexor carpi ulnaris
Median, ulnar
Deep
Flexor digitorum profundus,
flexor pollicis longus, pronator
quadratus
Anterior interosseous

Dorsal


Superficial
Extensor digitorum communis,
extensor digiti minimi,
extensor carpi ulnaris
Posterior
interosseous
Deep
Abductor pollicis longus,
extensor pollicis brevis,
extensor pollicis longus,
extensor indicis proprius,
supinator
Posterior
interosseous
Mobile wad
Brachioradialis, extensor carpi
radialis brevis, extensor carpi
radialis longus
Radial
■ If clinical diagnosis is equivocal or the patient is obtunded, compartment
pressure measurements should be obtained. We use a commercially available
Stryker manometer.
■ An acute compartment syndrome is assumed if the compartment pressure is
within 30 mm Hg of the diastolic blood pressure.1 If the compartment
measurement is measured under anesthesia, the pressure should be compared
to the preinduction diastolic blood pressure.
■ If measurements are not consistent with compartment syndrome, close
monitoring and repeat clinical examination with serial compartment pressures
may be indicated.

FIG 2 • Cross-sectional anatomy of forearm.
FIG 3 • Forearm gunshot wound with dorsal
compartment swelling and skin blistering.
SURGICAL MANAGEMENT
■ If there is high clinical suspicion or objective manometric evidence supporting
the diagnosis of compartment syndrome, perform emergent fasciotomy.
■ The goal of fasciotomy is to reduce compartment pressure and allow for tissue
perfusion.
Preoperative Planning
■ In the setting of trauma, review radiographs and prepare for skeletal
stabilization if necessary.
■ Consider reversal of anticoagulation if indicated.
Positioning
■ Patient is positioned supine with a hand table.
■ A tourniquet is applied to the arm; we do not inflate the tourniquet unless there
is difficulty with visualization.
Approach
■ The standard approach for the volar forearm involves a curvilinear incision
extending from the medial epicondyle to the proximal wrist crease, creating a
flap of skin over the distal forearm to cover the flexor tendons and median
nerve (FIG 4A).

FIG 4 • A. Volar forearm curvilinear approach. B. Dorsal
forearm longitudinal approach. C. Alternative parallel
forearm incision approach.
■ The dorsal forearm and mobile wad are decompressed through a longitudinal
dorsal forearm incision (FIG 4B).
■ An alternative forearm fasciotomy with two parallel longitudinal incisions
(FIG 4C)
■ A volar radial incision allows access to the volar compartment and mobile
wad without exposure of the median nerve or flexor tendons.
■ An ulnar incision allows access to the dorsal compartment.
T E C H N I Q U E S
■ Fasciotomy of the Hand
Dorsal Hand Compartment Release
■ Identify the second and fourth metacarpals dorsally.
■ Perform longitudinal incisions on the radial border of the second and fourth
metacarpal down to the level of the extensor tendons (TECH FIG 1A). Avoid
incisions directly over the metacarpals; if the wound is left open, the tendon
will desiccate. Avoid injury to the sensory branches of the radial and ulnar
nerves.
■ The incision over the fourth metacarpal is used to decompress the third and
fourth dorsal interossei (TECH FIG 1B).

■ The incision over the second metacarpal is used to decompress the first and
second interossei.
■ Dissect bluntly through the dorsal interossei to decompress the three palmar
interosseous muscles.
■ Release the adductor compartment through the incision over the second
metacarpal.
Thenar Compartment Release
■ Palpate the radial border of the first metacarpal and make an oblique
longitudinal incision (TECH FIG 2, line A).
■ Identify the thenar fascia overlying the abductor pollicis brevis (APB) and
incise it longitudinally.
Hypothenar Compartment Release
■ Make a longitudinal incision just volar to the ulnar border of the fifth
metacarpal and hypothenar eminence (see TECH FIG 2, line B).
■ Identify the hypothenar fascia overlying the abductor digiti minimi (ADM)
and incise it longitudinally.
Carpal Tunnel Release
■ Make an incision over the carpal tunnel in line with the radial border of the
fourth ray between the thenar and hypothenar compartments (see TECH FIG
2, line C).
TECH FIG 1 • A. Dorsal hand compartment release
incisions. B. Decompression of the fourth dorsal
interosseous compartment.

TECH FIG 2 • Palmar hand fasciotomy incisions:
hypothenar (a), carpal tunnel (b), and thenar (c).
■ Identify the longitudinal fibers of the palmar aponeurosis and split them
longitudinally.
■ Longitudinally divide the transverse fibers of the transverse carpal ligament
from the level of the sentinel fat pad to the antebrachial fascia, taking care to
protect the median nerve and its motor branch.
■ This incision may be incorporated into a volar forearm fasciotomy.
Digital Compartment Decompression
■ Approach the digit on its noncontact side (ulnar incision for the index, long,
and ring fingers, radial incision for the thumb and small finger).
■ Make a midaxial incision (dorsal to the neurovascular bundles) and divide
Cleland ligaments.
Wound Management

■ Place loose tagging sutures as indicated over the carpal tunnel incision and
over any areas with concern for tendon exposure.
■ Apply a bulky dressing and splint in a functional position.
■ Fasciotomy of the Volar Forearm with Curvilinear
Incision
■ Design a curvilinear incision from the ulnar wrist crease to the medial
antecubital fossa (TECH FIG 3A).
■ If a carpal tunnel release is performed, extend the proximal carpal tunnel
incision ulnarly at the wrist flexion crease.
■ This creates a radially based flap that prevents desiccation of the median
nerve and flexor tendons.
■ Curve the incision radially in the mid forearm and then toward the medial
elbow.
■ Release the forearm fascia overlying the superficial and deep compartments of
the volar forearm (TECH FIG 3B).
■ Release the lacertus fibrosus at the medial elbow (TECH FIG 3C).
■ Inspect each muscle and release individual muscle fascia if necessary.
■ Debride any devitalized muscle.
■ The mobile wad can be released through the volar or dorsal incision.
■ Loose sutures may be placed to secure skin flaps over the median nerve and
flexor tendons. Leave the rest of the wound open, as significant swelling will
usually prevent skin closure (TECH FIG 3D).
■ Apply a loose bulky dressing and splint.

TECH FIG 3 • A. Volar forearm curvilinear incision. B.
Exposure of deep volar muscle compartment. FCR,
flexor carpi radialis; FDS, flexor digitorum superficialis;
FDP, flexor digitorum profundus; FPL, flexor pollicis
longus; MN, median nerve. C. Identification of lacertus
fibrosus at medial elbow. LF, lacertus fibrosus; PT,
pronator teres; BR, brachioradialis. D. Clinical image
after volar forearm fasciotomy, with significant swelling
preventing primary wound closure.
■ Fasciotomy of the Dorsal Forearm
■ Re-evaluate for the need for dorsal fasciotomy. After volar forearm and mobile
wad compartment release, the dorsal forearm may have been indirectly
decompressed.
■ Make a longitudinal dorsal incision starting 3 to 4 cm distal to the lateral
epicondyle extending toward Lister tubercle (TECH FIG 4A).
■ Release the fascia over the dorsal compartment and the mobile wad.
■ Inspect each muscle and release individual muscle fascia if necessary (TECH
FIG 4B).
■ Debride any devitalized muscle.
■ Perform any secondary procedures such as skeletal fixation.
■ The wound is left open. A loose dressing and splint are applied.

TECH FIG 4 • A. Dorsal forearm compartment incision.
B. Dorsal forearm compartment release and
debridement. In this case, devitalized extensor muscle
from gunshot wound was debrided.
■ Fasciotomy of the Forearm with Two Longitudinal
Incisions
■ Make a longitudinal incision on the volar radial forearm along the ulnar border
of the brachioradialis (TECH FIG 5A).
■ Undermine the ulnar aspect of the incision to gain access to the superficial
volar forearm fascia.
■ Release the underlying volar forearm fascia longitudinally.
■ Access to the deep volar compartment is through a volar Henry approach
between FCR and brachioradialis (TECH FIG 5B).
■ Undermine the proximal ulnar aspect of the incision to gain access and release
the lacertus fibrosis.
■ The mobile wad can be released from the radial aspect of the incision.
■ Make a longitudinal incision along the ulnar forearm and release the dorsal
forearm compartment (TECH FIG 5C).
■ Inspect each muscle and release individual muscle fascia if necessary.
■ Debride any devitalized muscle.
■ The wound is left open and a loose dressing and splint are applied.
■ This double incision allows decompression without exposure of the median
nerve or tendons at the distal forearm.

TECH FIG 5 • A. Alternative volar radial longitudinal
incision. B. Access to superficial and deep volar
compartments. BR, brachioradialis; RA, radial artery;
FCR, flexor carpi radialis; FDS, flexor digitorum
superficialis. C. Ulnar longitudinal approach for dorsal
forearm compartment release.
PEARLS AND PITFALLS
Indications
■ Have a low threshold to proceed with compartment release.
Examination
■ Pain out of proportion to injury an early finding in patients with
compartment syndrome.2
Technique
■ Attempt to preserve cutaneous nerves and veins whenever
possible.
■ Debride any devitalized muscle.
■ Release any restrictive epimysium that can subcompartmentalize
muscle groups (flexor digitorum profundus).
■ Do not close fascia.
■ Loose sutures can be used to hold skin flaps over exposed nerve or
tendon—initial wound closure should prioritize coverage of
neurovascular structures and tendons.
■ Wounds generally should be left open in the acute setting; return
for delayed primary closure vs skin grafting or flap coverage as
clinically indicated.

Postoperative
management
■ If there is concern for delayed presentation and muscle necrosis,
serial debridement may be necessary.
POSTOPERATIVE CARE
■ After initial fasciotomy the limb should be splinted in a functional position.
■ Intravenous antibiotics are administered while the wound is open.
■ Monitor electrolyte and renal function closely; myoglobinemia can result in
acute renal failure.
■ Return to operating room is planned within 48 hours for interval debridement
and assessment of the wound bed.
■ Once the wound bed is stabilized, perform delayed primary closure or split-
thickness skin graft (FIG 5). Rarely, flap coverage is indicated for exposed
tendon or nerve.
■ Edema management with elevation and loose dressings proximal to the
involved site
■ Begin range of motion as soon as reasonable to prevent joint contractures and
decrease swelling.
OUTCOMES
■ Patient outcomes are dependent on the timing of fasciotomy.
■ Early recognition and expedient treatment generally results in favorable
outcomes.
■ Late recognition and delayed treatment may result in irreversible nerve and
muscle injury with limited functional recovery.
■ The mechanism and severity of initial injury also influence prognosis.
COMPLICATIONS
■ Untreated compartment syndrome will result in nerve dysfunction as well as
Volkmann ischemic contracture (FIG 6).
■ Rhabdomyolysis can result in acute renal failure.
■ Incomplete release of the deep volar compartment can result in extrinsic flexor
contractures.

FIG 5 • Split-thickness skin graft application to volar
forearm.

FIG 6 • Untreated compartment syndrome with
Volkmann contracture.
REFERENCES
1. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG III. Compartment syndrome
of the upper extremity. J Hand Surg [Am]. 2011;36(3):
544-560.
2. Codding JL, Vosbikian MM, Ilyas AM. Acute compartment syndrome of the

hand. J Hand Surg [Am]. 2015;40(6):1213-1216.

3
CHAPTER
Revision Amputation and
Shortening of the Digit
John R. Lien and Kevin C. Chung
DEFINITION
■ Fingertip injuries involve trauma to the digit distal to the insertion of the flexor
and extensor tendons.
■ The primary goal of treatment is a painless fingertip with supple and sensate
skin coverage.
■ The method of treatment should be individualized to the patient and injury
pattern.
■ This chapter will focus on revision amputation and shortening of the digit. The
principles discussed can be applied to finger amputations more proximal than
the fingertip.
■ Refer to Chapter 60 for flap coverage options of fingertip injuries.
ANATOMY
■ The nail complex (perionychium) consists of the nail plate and surrounding
tissues1 (FIG 1):
■ Eponychium: Skin proximal to the nail plate, covering the nail fold
■ Paronychium: Skin lateral to the nail plate
■ Hyponychium: Skin immediately distal and palmar to nail
■ Nail bed: Germinal matrix and sterile matrix
■ Germinal matrix: Soft tissue deep and proximal to nail plate, responsible for
majority of nail growth. Distal margin is the lunula.
■ Sterile matrix: Tissue distal to lunula, responsible for nail adherence
■ Nail fold: Consists of dorsal roof matrix and proximal germinal matrix.
■ Lateral matrix horns: The proximal lateral corners of the matrix, formed by
the confluence of the germinal matrix, dorsal roof matrix, and lateral nail

fold.
■ The terminal extensor tendon insertion on the distal phalanx is approximately
1.2 mm proximal to the germinal matrix.2
■ The pulp of the fingertip consists of fibrofatty tissue stabilized by septae
extending from the dermis to the palmar periosteum of the distal phalanx.
■ The proper digital nerve lies palmar to its corresponding digital artery. The
nerve trifurcates at the level of the distal interphalangeal (DIP) joint (FIG 2).
PATHOGENESIS
■ Traumatic mechanisms of injury: sharp, crush, avulsion
FIG 1 • Sagittal and dorsal views of the distal phalanx
and nail complex.

FIG 2 • Digital nerve anatomy. The nerve arborizes at
the level of the distal interphalangeal joint.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History:
■ Age
■ Handedness
■ Occupation
■ Medical comorbidities
■ Mechanism of injury
■ Timing of injury
■ Tobacco use
■ Tetanus status
■ Physical exam:
■ Identify the level of amputation; fingertip vs more proximal.
■ Assess for nail bed injury.
■ Assess for exposed bone. If there is significant exposed bone, healing by
secondary intention will not be successful.
■ Morphology of fingertip injury: transverse, dorsal oblique, palmar oblique,
radial/ulnar oblique.
■ Assess residual soft tissue: Can it be closed primarily with minimal tension?
IMAGING
■ Radiographs of the digit
NONOPERATIVE MANAGEMENT
■ Fingertip injuries without exposed bone will heal by secondary intention with
local wound care.
■ Irrigation and primary closure can be considered only if there is adequate skin
resulting in a tensionless closure.

SURGICAL MANAGEMENT
Preoperative Planning
■ Fingertip and amputations distal to the metacarpophalangeal joint with
exposed bone and inadequate soft tissue coverage are candidates for bone
shortening and primary closure.
■ Amputations at the level of the eponychium and proximal are usually best
suited for revision amputation.
■ For fingertip injuries with exposed bone involving the midportion of the nail
bed, consider flap coverage depending on injury morphology and patient
factors (see Chapter 60).
■ For finger amputations presenting with an amputated piece, consider
replantation (see Chapter 68).
■ Uncomplicated finger amputation can be performed in the emergency
department.
■ If there is a nail bed injury, prepare to repair the nail bed with chromic suture
or Dermabond (Ethicon, Inc., Somerville, NJ).3
■ If the revision amputation will result in removal of over two-thirds of the nail
matrix and/or its underlying bony support, prepare to ablate the nail bed.
■ Perform a digital block and gather instruments and dressings prior to starting
the procedure.
Positioning
■ Patient is positioned supine with hand table or Mayo stand.
Approach
■ Goals of this procedure are a painless, sensate fingertip, preservation of as
much length as possible and avoidance of nail dystrophy.
■ The decision to proceed with bone shortening and primary closure should take
injury characteristics and patient factors into account. For example, if a patient
with a volar oblique fingertip amputation is a smoker and a laborer who must
return to work as soon as possible, we would recommend revision amputation
with shortening and primary closure as opposed to a homodigital island flap or
cross-finger flap.

T E C H N I Q U E S
■ Revision Amputation With Primary Closure
■ Administer a digital block prior to sterile preparation.
■ Apply a finger tourniquet.
■ Debride contaminated or devitalized tissue sharply.
■ If there is nail matrix involvement, consider ablation vs nail bed repair.
■ Mobilize the soft tissue around the level of bony exposure (TECH FIG
1A,B).
■ Use a rongeur to shorten and contour the bone (TECH FIG 1C).
■ Bone should be shortened for tension-free closure.
■ Remove articular cartilage if performing a disarticulation.
■ If the amputation is through or proximal to the DIP joint, identify the radial
and ulnar digital nerves and shorten them to prevent neuroma being caught in
the incision that will be painful (TECH FIG 1D,E).
■ Reassess skin flaps to ensure tension-free closure and round fingertip by
removing the dog ear over either side of the incision to create a round tip
rather than a boxy tip.
■ Close skin flaps with 5-0 nonabsorbable suture (TECH FIG 1F).
■ Release the finger tourniquet to ensure adequate perfusion of the skin flaps.
If the flaps appear tight or ischemic, consider additional bony shortening.
■ Apply a sterile dressing.

TECH FIG 1 • Revision amputation through middle
phalanx. A,B. Mobilization of the viable soft tissue
around the amputation site. C. Bone contouring of
middle phalanx head at amputation site. D,E. Digital
nerve identification and shortening to prevent
symptomatic neuroma. F. Amputation wound closure
without tension. The boxy appearance should be
rounded by removal of dog ears as marked.
■ Nail Ablation
■ If the revision amputation will result in removal of over two-thirds of the

nail matrix and/or its underlying bony support, prepare to ablate the nail bed
(TECH FIG 2A).
■ Administer a digital block prior to sterile preparation.
■ Apply a finger tourniquet.
■ Remove the nail plate (if it remains) with a Freer elevator and hemostat.
■ Make periungual incisions, perpendicular to the radial and ulnar margins of
the eponychium, but do not incise through the dorsal roof matrix (TECH FIG
2B,C).
■ Use methylene blue or a surgical marker to stain the germinal matrix and
dorsal roof matrix from within the nail fold4 (TECH FIG 2D).
■ Use a scalpel to raise the eponychial skin from the dorsal roof matrix.
Separate these layers to the proximal extent of the germinal matrix (TECH
FIG 2E,F).
■ Avoid injury to the terminal extensor tendon. It inserts on the distal phalanx
1.2 mm proximal to the germinal matrix.2
■ Identify the radial and ulnar lateral horns of the matrix, as these define the
radial and ulnar limits of ablation.
■ Excise the germinal and sterile matrix from the underlying periosteum of the
distal phalanx (TECH FIG 2G,H).
■ The proximal confluence of the lateral nail fold, germinal matrix, and dorsal
roof matrix forms a pocket of tissue (lateral horns of the matrix) that should
be excised en bloc. All marked tissue should be contained within this pocket.
■ Perform bony shortening as indicated.
■ Close with 5-0 nonabsorbable suture (TECH FIG 2I,J).

TECH FIG 2 • A. Fingertip amputation with significant
loss of sterile matrix and bony support. B,C. Incisions
for nail ablation. D. Use of a surgical marker or
methylene blue helps define the extent of the nail fold
for ablation. DRM, dorsal roof matrix. E,F. Elevation of
the eponychial skin from the dorsal roof matrix. G,H.
Nail ablation completed. I,J. Wound closure after nail
ablation and bone shortening. The closure is
contoured by removing dog ears as marked.

PEARLS AND PITFALLS
Preparation
■ Gather all instruments and dressings prior to starting the procedure.
■ Perform the digital block prior to gathering supplies. This allows
time for the anesthetic to take effect.
Revision
amputation
technique
■ If the flexor or extensor tendon insertion is injured, strongly consider
DIP joint disarticulation. The residual digit will be more stable with
little sacrifice of length.
■ Ensure shortening of digital nerves to prevent painful neuroma
formation at the fingertip.
Nail
ablation
technique
■ Complete removal of the germinal matrix is easier if the dorsal roof
matrix is left in continuity with the germinal matrix. This allows for a
“pocket” of matrix to be removed en bloc.
■ Handle the thin dorsal eponychial skin with care when elevating
from the underlying dorsal matrix.
Wound
closure
■ Tension-free closure is a necessity. Shorten bone further if needed.
■ Contour skin edges to minimize dog ears.
POSTOPERATIVE CARE
■ A nonadherent soft dressing is applied over the digit.
■ Oral antibiotics may be routinely prescribed postprocedure.
■ Nonabsorbable sutures are removed 2 weeks postprocedure.
■ After revision amputation, hand therapy is useful for fingertip desensitization,
contouring, and early motion.
OUTCOMES
■ Average static two-point discrimination after revision amputation is 3.8 mm.5
■ Overall, revision amputation results in better static two-point discrimination
when compared to local flaps.
■ Good functional outcomes can be expected, with 95% of total active motion
preserved.5
■ Cold intolerance is common after revision amputation, with a 77% incidence.5
COMPLICATIONS

■ Infection
■ Cold intolerance and hypersensitivity are common.
■ Painful neuroma
■ Poor wound healing may be a result of closure under tension.
■ Stiffness can result if early motion is not encouraged.
■ Nail remnants may grow at the site of incomplete nail ablation.
REFERENCES
1. Peterson SL, Peterson EL, Wheatley MJ. Management of fingertip
amputations. J Hand Surg [Am]. 2014;39(10):2093-2101.
2. Shum C, Bruno RJ, Ristic S, et al. Examination of the anatomic relationship
of the proximal germinal nail matrix to the extensor tendon insertion. J Hand
Surg [Am]. 2000;25(6):1114-1117.
3. Strauss EJ, Weil WM, Jordan C, et al. A prospective, randomized, controlled
trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand
Surg [Am]. 2008;33(2):250-253.
4. Baran R, Haneke E. Matricectomy and nail ablation. Hand Clin.
2002;18(4):693-696.
5. Yuan F, McGlinn EP, Giladi AM, et al. A systematic review of outcomes after
revision amputation for treatment of traumatic finger amputation. Plast
Reconstr Surg. 2015;136(3):99-113.

4
CHAPTER
Drainage of Septic Flexor
Tenosynovitis
John R. Lien and Kevin C. Chung
DEFINITION
■ Pyogenic flexor tenosynovitis is a bacterial infection in the flexor tendon
sheath of the fingers or the thumb.
ANATOMY
■ The flexor tendon sheath extends from the A1 pulley to the distal
interphalangeal joint (FIG 1).
■ The thumb flexor tendon sheath and radial bursa are contiguous.
■ The small finger flexor tendon sheath and ulnar bursa are contiguous.
■ The radial and ulnar bursae communicate through the space of Parona, which
lies between the fascia of the pronator quadratus and flexor digitorum
profundus tendon sheath.
PATHOGENESIS
■ Most infections are caused by a penetrating injury to the tendon sheath.
■ The most common organism responsible for disease is Staphylococcus
aureus.1

FIG 1 • Flexor tendon sheaths of the hand. There is
potential communication between the thumb and small
finger sheaths with the radial and ulna bursae,
respectively.
■ Hematogenous disease can be caused by disseminated gonococcal infection.
■ Inoculated bacteria use the synovial fluid within the sheath as nutrition.
■ Bacterial growth leads to increased volume and pressure within the tendon
sheath.
■ Horseshoe abscess: Thumb or small finger flexor tenosynovitis can extend
proximally into the space of Parona and track back up distally the opposite side
flexor sheath.
NATURAL HISTORY
■ Left untreated, the infection creates adhesions within the tendon sheath,

resulting in stiffness and loss of tendon gliding.
■ Increased pressure obstructs extrinsic vincular blood supply to the tendon,
contributing to tendon necrosis and rupture.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History of penetrating trauma. Evaluate for puncture wound on the palmar
aspect of the digit.
■ Assess the timing of injury and onset of symptoms.
■ Diagnosis is clinical. Kanavel’s four cardinal symptoms and signs are useful in
diagnosis1:
■ Exquisite tenderness along the flexor tendon sheath
■ Semiflexed position of the digit
■ Fusiform swelling of the digit
■ Pain with passive extension of the digit
■ Examine the thenar and hypothenar eminences to assess for proximal
extension of thumb or small finger tenosynovitis.
■ Examine the distal forearm; tenderness or fullness of the volar wrist may
indicate extension to the space of Parona (FIG 2).
IMAGING
■ Radiographs should be obtained to assess for foreign body, pyarthrosis, or
osteomyelitis.
■ Laboratory evaluation with CBC, ESR, and CRP is helpful to monitor the
disease process.
DIFFERENTIAL DIAGNOSIS
■ Felon
■ Paronychia
■ Herpetic whitlow
■ Gout
■ Local abscess
■ Septic arthritis
■ High-pressure injection injury

FIG 2 • Thumb flexor tenosynovitis with extension into
the space of Parona. Note swelling and erythema in
radial volar forearm.
■ Nonseptic acute flexor tenosynovitis from an inflammatory process such as
rheumatoid arthritis
NONOPERATIVE MANAGEMENT
■ Early infection (less than 24–48 hours after inoculation) in immunocompetent
patients with mild symptoms may be treated with intravenous antibiotics,
immobilization, and elevation.1
■ If symptoms do not improve within the first 12 to 24 hours of antibiotic
therapy, surgical treatment is warranted.
SURGICAL MANAGEMENT
■ Indications for surgical management:
■ Patients presenting with symptoms for more than 24 to 48 hours
■ Immunocompromised or diabetic patient

■ Failure of symptom improvement with nonoperative management.
Preoperative Planning
■ Plan for carpal tunnel decompression and extension to the distal forearm if
there is concern for proximal involvement.
Positioning
■ Supine with hand table
■ General anesthesia
■ Tourniquet without Esmarch exsanguination
Approach
■ Closed tendon sheath irrigation is preferred for acute infections.2 The limited
incisions prevent tendon desiccation and minimize postoperative scarring.
■ Extensile open debridement of the flexor tendon sheath through a longitudinal
midlateral incision is used in the setting of subacute or chronic infection with
thick purulence and phlegmon. The volar skin should not be disturbed to avoid
wound separation, leading to exposure of the flexor tendon sheath that will
require flap coverage to avoid tendon desiccation.
T E C H N I Q U E S
■ Closed Tendon Sheath Irrigation (Acute
Presentation)
Debridement and Exposure
■ Thoroughly irrigate and debride any wounds.
■ Distal exposure of the flexor tendon sheath
■ Make a 1-cm midaxial skin incision on the noncontact side of the digit
overlying the A5 pulley (TECH FIG 1A).
■ Deepen the incision by dividing Cleland ligaments, dorsal to the
neurovascular bundle.
■ Bluntly elevate the volar flap of the incision in order to visualize the A5
pulley of the flexor tendon sheath (TECH FIG 1B).

■ Incise the A5 pulley longitudinally and send any purulent or cloudy material
for culture and sensitivity.
■ Proximal exposure of the flexor tendon sheath
■ Make a chevron or oblique incision in the palm overlying the A1 pulley (see
TECH FIG 1A).
■ Bluntly dissect the soft tissue overlying the flexor tendon sheath, taking care
not to injure the neurovascular bundles.
TECH FIG 1 • A. Incision markings for index finger
tendon sheath exposure. B. Distal portal exposure of
A5 pulley. The incision is dorsal to the neurovascular
bundle and away from the contact surface of the distal
pulp.
■ Identify the A1 pulley.
■ The A1 pulley does not have to be incised to perform tendon sheath
irrigation. However, if there is thickened tenosynovium at this level, debride
and send cultures.
■ In the thumb, proximal exposure is performed through a thenar crease
incision with release of the distal centimeter of transverse carpal ligament.
The irrigation catheter is inserted along the flexor pollicis longus tendon.
Tendon Sheath Irrigation
■ Place a 16-gauge intravenous catheter or 5F pediatric feeding tube in the
proximal flexor sheath under the A1 pulley.
■ From the proximal catheter, irrigate the tendon sheath with sterile saline until
the effluent is clear (TECH FIG 2). We typically irrigate at least 500 mL of

fluid.
■ If resistance is met, place a second catheter distally to facilitate irrigant egress.
■ If irrigant is exiting through a debrided wound proximal to the distal catheter,
irrigate thoroughly and then replace the proximal catheter in the distal aspect of
the debrided wound to complete distal irrigation of the tendon sheath. Be sure
that the saline is not injected into the subcutaneous tissue to avoid pressure
necrosis of the soft tissue.
Wound Management
■ Release the tourniquet and achieve hemostasis.
■ Place small drains such as a 0.25 in. Penrose in the proximal and distal
incisions.
TECH FIG 2 • Irrigation of flexor tendon sheath with
pediatric feeding tube.
■ Loose sutures are placed only to prevent tendon exposure and desiccation. The

wounds should be left open otherwise.
■ Apply a forearm-based splint with the hand in resting position.
Open Debridement of Flexor Tendon Sheath
(Subacute or Chronic Presentation)
■ Thoroughly irrigate and debride any wounds.
■ Make a midlateral incision from the distal interphalangeal flexion crease to the
metacarpophalangeal flexion crease.
■ Elevate a full-thickness palmar flap over the flexor tendon sheath. Extend the
incision with oblique Bruner incisions distally and proximally if necessary.
■ Identify the proximal extent of the flexor sheath system at the A1 pulley either
through a separate chevron incision or by oblique proximal extension of the
midlateral incision (TECH FIG 3A).
■ Debride purulent and unhealthy appearing tenosynovium. Typically, this tissue
cannot be washed away with closed sheath irrigation.
TECH FIG 3 • A. Extensile exposure of flexor tendon
sheath in setting of extensive purulence. B.
Debridement of ruptured necrotic flexor digitorum
profundus tendon.
■ Necrotic tendon and/or pulley may need to be debrided (TECH FIG 3B).
■ Send tissue for culture and sensitivities.
■ Thoroughly irrigate the wound.
Wound Closure

■ Release the tourniquet and obtain hemostasis.
■ The palmar flap may be loosely closed over the flexor tendon sheath;
compared to a standard Bruner approach, the midlateral approach minimizes
the risk of tendon desiccation (TECH FIG 4).
■ Leave drains in place to allow for fluid egress.
■ Apply a forearm-based splint with the hand in resting position.
TECH FIG 4 • Wound closure to cover the flexor
tendons.
PEARLS AND PITFALLS
Diagnosis
■ Prompt clinical diagnosis is essential to initiate early treatment.
Incision
placement
■ Plan incisions so they may be incorporated into extensile
exposures if needed.
■ Avoid injury to the neurovascular bundle. The digital nerve
trifurcates at the distal interphalangeal joint crease.
■ Inadequate exposure may fail to drain the infection.
Culture
■ Obtain stains, cultures, and sensitivities for aerobic, anaerobic,
fungal, acid-fast bacillus, and atypical mycobacterial organisms.

■ If a hematogenous source is suspected, obtain blood cultures and
gonococcal tests.
Tendon
sheath
irrigation
■ Avoid high-pressure injection if there is resistance to syringe
irrigation. Reposition the entrance and egress catheters if
necessary.
■ If there is extensive infection, indicated by thick phlegmon or
viscous drainage from the tendon sheath, extensile exposure may
be necessary.
■ Continue irrigation until there is clear effluent.
Postoperative
■ Return for interval irrigation and debridement if there is no
clinical improvement within 24–48 h.
POSTOPERATIVE CARE
■ Elevate the extremity.
■ Continue empiric antibiotics while cultures are pending. Include methicillin-
resistant S aureus coverage.
■ Remove the dressing postoperative day one and begin soaks 3 times daily.
■ Initiate early motion of the digits to minimize stiffness.
■ If symptoms do not improve within the first 24 to 48 hours, return to the
operating room for additional irrigation and debridement.
■ In the setting of severe infection with persistent infection and/or tendon
necrosis, discuss amputation with the patient.
OUTCOMES
■ Patients average 70% to 80% recovery of total active motion.3
■ Risk factors for failure of surgical treatment resulting in amputation include3:
■ Age over 43 years
■ Diabetes mellitus, peripheral vascular disease, or renal failure
■ Presence of subcutaneous purulence
■ Ischemic changes at presentation
■ Polymicrobial infection
COMPLICATIONS
■ Finger stiffness
■ Persistent infection
■ Digital nerve injury
■ Tendon desiccation and rupture

REFERENCES
1. Draeger RW, Bynum DK. Flexor tendon sheath infections of the hand. J Am
Acad Orthop Surg. 2012;20(6):373-382.
2. Neviaser RJ. Closed tendon sheath irrigation for pyogenic flexor
tenosynovitis. J Hand Surg [Am]. 1978;3(5):462-466.
3. Pang HN, Teoh LC, Yam AT, et al. Factors affecting the prognosis of pyogenic
flexor tenosynovitis. J Bone Joint Surg Am. 2007;89(8):
1742-1748.

5
CHAPTER
Section II: Hand Fractures
and Dislocations
Distal Phalanx Fractures
John R. Fowler and Thomas B. Hughes
DEFINITION
■ Distal phalanx fractures can be divided into several main categories (FIG 1):
■ Extensor tendon injuries, including soft tissue–only extensor tendon
avulsions and “bony mallet” injuries that involve avulsion of a fragment of
the distal phalanx. Bony mallet injuries may cause volar subluxation of the
distal phalanx.
■ Distal phalanx fractures without involvement of the ligaments or tendons
■ Open epiphyseal fracture with nail bed laceration (Seymour fracture)
■ A fracture is present in one-third of all mallet fingers.1
■ Mean age is 30, and the middle finger is most commonly involved.2
■ Mallet injuries may be classified using the Wehbe and Schneider
classification2
■ Type I: No subluxation at DIP joint
■ Type II: DIP joint subluxation
■ Type III: Epiphyseal injury
■ The types are further subdivided based on the amount of articular surface that
is involved:
• Type A involves less than 1/3 of the articular surface.
• Type B involves 1/3 to 2/3 of the articular surface.
• Type C involves greater than 2/3 of the articular surface.

FIG 1 • Type of distal phalanx fractures. A. Bony mallet
fractures. B. Jersey finger—avulsion of the flexor
digitorum profundus from the base of the distal phalanx.
C. Distal phalanx shaft/epiphyseal fracture or tuft
fracture.
ANATOMY
■ The terminal tendon inserts on the distal phalanx articular edge and has a
footprint of approximately 12 mm.3
■ The terminal tendon insertion is, on average, 1.4 mm proximal to the leading
edge of the germinal matrix.3
■ The extensor tendon inserts on the epiphysis, and flexor tendon inserts on the
metaphyseal portion of the distal phalanx.4 This results in a flexed posture for
epiphyseal fractures.

PATHOGENESIS
■ The classic mechanism for a mallet injury is a ball striking the tip of the finger,
causing eccentric flexion, resulting in tendon rupture and/or distal phalanx
fracture.
■ Subluxation of the joint may occur with large fracture fragments as the
collateral ligaments are attached to the fracture fragment and the flexor
digitorum profundus then has unopposed pull.1
■ Biomechanical studies have found that fractures involving less than 43% of
the joint surface do not result in joint subluxation, whereas fractures involving
over 52% of the joint surface do result in joint subluxation.5
■ Seymour fractures are more commonly caused by a crushing mechanism
resulting in distal phalanx epiphyseal fracture with nail bed laceration.4 This is
an open fracture that requires immediate debridement, reduction, nail bed
repair, and pinning.
NATURAL HISTORY
■ Bony mallet injuries without volar subluxation of the joint have excellent
healing rates.
■ The average extensor lag with nonoperative treatment is 7 degrees.
■ Seymour fractures that are not treated with formal irrigation and debridement
historically have a high infection rate and risk for osteomyelitis.4
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically present after a “jamming”-type injury of the finger with a
chief complaint of inability to extend the finger at the distal interphalangeal
joint.
■ The distal interphalangeal joint is often swollen and erythematous. There is a
variable amount of nail plate ecchymosis depending on the specific fracture
type.
IMAGING
■ AP and lateral radiographs of the finger are obtained.
NONOPERATIVE MANAGEMENT
■ Conservative treatment in a DIP extension splint is indicated for soft tissue
mallet fingers and bony mallet injuries involving less than 40% of the articular
surface and injuries without volar subluxation.

■ The DIP extension splint is worn continuously for 6 weeks and then only at
night for an additional 2 weeks.
■ The vast majority of fractures without volar subluxation of the distal phalanx
should be treated nonoperatively. K-wire fixation is a secondary solution.
SURGICAL MANAGEMENT
■ Indications for surgical management
■ Open fracture (Seymour fracture or open bony mallet)
■ More than 40% articular surface involvement
■ Volar subluxation of the distal phalanx
■ A relative indication is a patient who is a professional (such as a surgeon)
who cannot wear an extension splint continuously for 6 weeks. They require
pinning, with the pin buried under the skin and removed after 6 weeks.
Positioning
■ The patient is placed in the supine position with the arm on a radiolucent table.
■ The surgeon sits so that the dominant hand can drill the K-wires retrograde
into the finger. For right-handed surgeons, this is at the head of the table.
Approach
■ Mallet fingers are treated percutaneously. Seymour fractures require open
debridement and pinning.
T E C H N I Q U E S
■ Closed Reduction and Pinning
■ First, a closed reduction is performed under live fluoroscopy by
hyperextending the distal interphalangeal joint by 5 to 10 degrees.
■ If this results in apposition of the bony mallet fragment and distal phalanx, a
0.045 in. K-wire is placed from the fingertip, through the distal phalanx, and
across the distal interphalangeal joint (TECH FIG 1).
■ The pin can be cut and bent above the skin for removal in the office or buried
and removed at a later time.
■ If the dorsal bony fragment remains significantly displaced, the finger is

flexed, and under live fluoroscopy, a 0.045 in. K-wire is placed 1 to 2 mm
proximal to the avulsion fragment and then drilled into the head of the middle
phalanx.6

TECH FIG 1 • A. Oblique radiograph demonstrating
bony mallet fractures of the small and ring finger distal
phalanges. The joint reduced with extension of the
distal phalanx, and the avulsion fragments became
closely opposed. Postoperative (B) and lateral (C) AP
demonstrate near anatomic overall alignment.
■ The finger is then fully extended (TECH FIG 2A), and a second 0.045 in. K-
wire is placed from the fingertip, through the distal phalanx, and across the
distal interphalangeal joint (TECH FIG 2B).6

TECH FIG 2 • A. After a K-wire is placed just proximal
to the avulsion fragment, the distal phalanx is extended
to reduce the avulsion fragment to the distal phalanx. B.
A second K-wire is placed across the DIP joint to hold
the distal phalanx in extension.6
■ The starting point for this K-wire is just volar to the nail bed. One must be
careful not to be too dorsal because nail deformities can occur if the K-wire
is driven through the nail bed.
■ Open Reduction and Internal Fixation
■ An H-shaped incision is made dorsally, over the distal interphalangeal joint.
■ Thick flaps are raised proximally and distally to expose the terminal tendon.
■ The fracture is reduced and held in place with a 0.035 in. K-wire.
■ Depending on the size of the fragment, two 1.3- to 1.5-mm mini-fragment
screws are placed to stabilize the fracture.
■ The reduction is indirect as visualization is blocked.

■ Open Treatment of Seymour Fractures
■ The nail bed is carefully removed using a combination of a Freer elevator and
a hemostat. Care is taken to not injure the underlying nail bed.
■ There is usually a transverse laceration in the nail bed at the level of the
germinal matrix.
■ It may be necessary to make a longitudinal incision on either edge of the
eponychium to lift the eponychium up “like a car hood” to allow better
visualization of the germinal matrix.
■ The finger is flexed to expose the open epiphyseal fracture. The interposed
soft tissue is carefully removed and the bone is well irrigated. Excessive
debridement of the bone is not performed as this would risk epiphyseal closure.
■ The fracture is reduced and a 0.045 in. K-wire retrograde across the fracture
and then across the DIP joint (TECH FIG 3).
■ The nail bed is repaired using 5-0 chromic suture. The eponychial fold
incisions are repaired using 5-0 chromic as well.
■ The nail plate is trimmed, washed, and replaced under the eponychial fold to
prevent scarring to the nail bed. Alternatively, the foil wrapper from the
chromic suture package is cut in the shape of a nail and placed under the
eponychial fold.

TECH FIG 3 • Preoperative AP (A) and lateral (B)
radiographs demonstrating an open distal phalanx
epiphyseal fracture. The fracture site was debrided and
reduced. C,D. Two 0.045 in. K-wires were then drilled

retrograde across the fracture and across the DIP joint
for stability.
PEARLS AND PITFALLS
Indications
■ Classic indications include volar subluxation of the distal phalanx
and/or a fracture involving more than 40% of the joint surface.
Seymour
fractures
■ Early irrigation, debridement, and pinning are essential to successful
outcomes. These fractures have a high risk of osteomyelitis if not
appropriately treated.
Treatment
■ Attempt to avoid skin incisions and treat percutaneously, if possible,
to avoid dorsal skin necrosis.
POSTOPERATIVE CARE
■ Patients are immobilized in a DIP extension splint, leaving the PIP joint free.
■ Early active motion of the PIP joint is encouraged to prevent stiffness and
contracture.
OUTCOMES
■ Hofmeister et al.7 reported on 24 fingers that underwent extension block
pinning at a mean follow-up of 74 weeks.
■ Mean time to union was 35 days.
■ Mean extension was −4 degrees.
■ Mean flexion was 78 degrees.
■ Three fingers had a superficial pin site infection that resolved with oral
antibiotics.
■ Two fingers had loss of reduction less than 2 mm.
■ Darder-Prats and colleagues8 reviewed 22 mallet fractures that underwent
extension block pinning at mean follow-up of 25 months. All patients reported
a good or excellent result.
■ Krusche-Mandl et al.9 reviewed 24 patients with Seymour fractures and noted
that 23/24 obtained full range of motion and there were no chronic infections.
However, 5 patients had distal phalanx growth disturbances and 6 had limited
nail dystrophies.