Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

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Which nerves orm the brachial plexus?
T e union o the anterior primary divisions o C5–8 and 1 orms the brachial plexus with variable contributions
rom C4 and 2.

Brief y describe the organization o the brachial plexus.
1. Robert-roots (f ve o them, C5– 1)
2. aylor-trunks (three o them, superior, middle, and in erior)
3. Drinks-divisions (six o them, an anterior and posterior division or each trunk)
4. Co ee-cords (three o them, posterior, lateral, and medial)
5. Black-branches or named peripheral nerves

Which peripheral nerve originates rom the lateral, medial, and posterior cords?
1. Lateral cord: musculocutaneous nerve and contribution to medial nerve
2. Medial cord: ulnar nerve, medial antebrachial and medial brachial cutaneous nerves, contribution to median nerve
3. Posterior cord: radial and axillary nerves

Name the our types o brachial plexus blocks to the upper extremity.
1. Interscalene block
2. Supraclavicular block
3. In raclavicular block
4. Axillary blockade

What are the advantages and disadvantages o the interscalene brachial plexus block (ISB)?
Indications:
Shoulder surgery, upper arm surgery
Advantages:
E ective analgesia or surgery or arthroscopy o the shoulder
Disadvantages:
Frequently misses:
1. Medial cutaneous nerve o the arm
2. Intercostobrachial nerve
3. Ulnar nerve
Not suitable or hand anesthesia (sparing o C8 and 1) ulnar nerve
Failure rate 8.7%
Complications:
1. 100% ipsilateral phrenic nerve block (C3–5)
2. Horner syndrome
3. Hoarseness, dysphagia, blurred vision
4. Involvement o recurrent laryngeal and cervical sympathetic nerves can occur

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What are the advantages and disadvantages o the supraclavicular brachial plexus block?
Indications:
Surgery o the arm, elbow, and hand
Advantages:
Well suited or long surgery or prolonged postoperative pain relie
Complete, prompt, long-acting block
Arm can be in a com ortable position (modif ed Brown’s plumb-bob approach)
Disadvantages:
Pneumothorax 0.4% to 6%
Ipsilateral phrenic nerve paralysis 60%
Occasional Horner syndrome

What are the advantages and disadvantages o the in raclavicular brachial plexus block?
Indications:
Surgery o the arm, elbow, and hand
Advantages:
Long-acting hand and arm anesthesia
Reliable block o musculocutaneous and axillary nerves
Lower risk o pneumothorax compared to supraclavicular block (SCB)
Uses more obvious landmarks then SCB
Disadvantages:
Increased risk o intravascular puncture as the plexus surrounds the subclavian artery at this level.

What are the advantages and disadvantages o the axillary brachial plexus block?
Indications:
Most widely used brachial plexus block in hand surgery
Advantages:
Simple, sa e, and reliable technique
Well suited or outpatient surgery
Remote rom neck and thorax
Disadvantages:
Can miss the musculocutaneous nerve and thus the lateral antebrachial cutaneous nerve
Complications:
Intravascular injection
Soreness or bruising o the axilla, persistent numbness

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Describe the relationship o the radial, ulnar, and median nerves to the axillary artery.
1. T e radial nerve is posterior to the axillary artery.
2. T e ulnar nerve is in erior to the axillary artery.
3. T e median nerve is superior to the axillary artery.

What is a Bier block and how is it per ormed?
1. An intravenous catheter is placed as distally as possible in the operated limb and the upper extremity is elevated
and exsanguinated with an Esmarch bandage starting rom distal to proximal.
2. A dual tourniquet is placed on the operated arm and the proximal cu is in ated prior to removal o the
Esmarch bandage.
3. Lidocaine 0.5% (40–50 mL) without preservatives is injected slowly (smaller doses o 30 mL can be used i a
orearm tourniquet is used).
4. T e proximal tourniquet cu can be de ated a ter 20 minutes a ter conf rming that the distal tourniquet cu
has been in ated to avoid escape o intravascular local anesthetic into the central circulatory system.
5. T is distal cu is in ated over an anesthetized area and can be tolerated or an additional 40 minutes.
6. A minimum occlusion time o 20 minutes is recommended based on peak plasma values o local anesthetics.

What are the advantages and disadvantages o a Bier block?
Advantages:
Ease o administration
Rapid onset
Rapid recovery o motor unction
Suitable or outpatient surgery
Disadvantages:
ourniquet pain when procedure longer than 1 hour
Accidental or early release o tourniquet can lead to toxic intravascular injection
Loss o anesthesia ollowing cu de ation
Exsanguinations o pain ul extremity
Postoperative pain

What are contraindications to using a Bier block (IVRA)?
1. Any condition which precludes the use o a tourniquet:
a. Sickle cell anemia
b. Severe peripheral vascular disease
c. Established so t tissue in ection
d. umors

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What are some causes o postoperative neuritis?
1. ourniquet pressure above 250 mm Hg
2. Limb position during surgery (e.g., pressure over ulnar nerve at the elbow)
3. Duration o tourniquet time > 2 hours
4. Regional blocks:
a. Sharp needles instead o bevel block needles
b. Intraneural injection
c. Perineural hematoma
d. Seeking paresthesia
e. Higher concentrations than necessary o local anesthetics

Name our types o peripheral nerve blocks.
1. Elbow block
2. Wrist block
3. Metacarpal block
4. Digital block

Elbow block
1. Rarely per ormed because o variations and overlapping o the distribution o the nerves.
2. Only allows or 20 to 30 minutes o tourniquet time.
3. Individual elbow blocks most use ul or supplementing anesthesia ollowing incomplete brachial plexus blocks.

Describe the landmarks or per orming ulnar, median, radial, and medial and lateral antebrachial cutaneous
nerve blocks at the elbow.
Ulnar: posterior to the medial epicondyle, 3 to 5 cm proximal
Median: medial to brachial artery, medial to biceps tendon, slightly above line between epicondyles
Radial: anterior aspect o the lateral epicondyle, lateral to the biceps tendon
Medial and lateral antebrachial cutaneous nerves: subcutaneous ring block around the elbow

What are the advantages and disadvantages o using wrist blocks?
Advantages:
Simple to per orm
Retained motor unction (except intrinsics)
Disadvantages:
Surgery time limited because o tourniquet pain a ter 20 to 30 minutes

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Describe the landmarks or per orming ulnar, median, and super cial radial nerve blocks at the wrist.
Ulnar: radial to the exor carpi ulnaris tendon, at the level o proximal wrist crease and in the direction o the
pisi orm bone. (Can also be injected dorsally at the same point to block the dorsal ulnar cutaneous nerve.)
Median: between the palmaris longus and exor carpi radialis tendons at the level o the proximal wrist crease.
Superf cial branch o radial nerve: base o the extensor pollicis longus tendon and across the anatomical snu box
lateral to the radial artery.

How many nerve branches supply the digits?
Four nerve branches supply digital sensation: two volar and two dorsal branches along the respective sides o each digit.

How does the ulnar nerve distribution di er rom the median nerve distribution distal to the DIP joint?
In the small f nger, the dorsal digital nerve extends up to the end o the f nger, whereas in the median nerve
distribution the volar digital nerve supplies a dorsal branch that comes o distal to the PIP joint. Dorsal branches
need also to be blocked or complete f nger anesthesia.

What kind o approaches can be used or a digital nerve block?
1. Volar approach:
a. Common digital nerve
b. Proximal to the common digital arterial communications
c. Skin wheal made over the exor tendon proximal to the distal palmar crease, and 2- to 3-mL lidocaine
without epinephrine is injected on each side o the exor tendons
d. More pain ul than the dorsal approach
2. Dorsal approach:
a. Less pain ul
b. Allows simultaneous blockade o dorsal branches without a second stick
c. Injection to the side o the extensor tendons proximal to the web and then palmar to block the volar digital
nerves
3. Intrathecal or exor tendon sheath approach:
a. Single injection o 2 mL into the exor tendon sheath at the level o the distal palmar crease or
metacarpophalangeal exion crease
b. Rapid onset

What should be avoided during digital blockade?
1. Circum erential ring blocks
2. Excessive or prolonged digital tourniquet
3. Excessive local anesthetic volume injection

Is epinephrine injection into the nger sa e?
Generally yes, there are no cases o f nger death associated with high-dose epinephrine (1:1,000) in spite
o hundreds o case reports. In patients who have poor per usion to the f ngertips, and slow capillary ref ll
epinephrine should still be avoided.

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How do you reverse the e ects o epinephrine in the nger?
1 mg o phentolamine is diluted in 20 cc o saline, and injected subcutaneously at the same site as the epinephrine.

What is the acidity o 1% lidocaine with 1:100,000 epinephrine?
pH = 4.2, which is 1,000 times more acidic than physiologic pH.

How does bicarbonate quicken the onset time o lidocaine?
Local anesthetics work by blocking nerve transduction, but f rst must di use into the nerve. Bu ering the local
anesthetic accelerates the passage o more uncharged molecules through the cell membrane, which is lipophilic.

What is minimally invasive anesthesia or wide awake hand surgery?
T e only medications given are lidocaine and epinephrine inf ltrated at the surgical site. T e local anesthetic results
in an extravascular “bier block.” T e other term used to describe this approach is tumescent local anesthesia.

What are the advantages o wide awake hand surgery?
1. No tourniquet is required or the procedure
2. Procedure can be done in a minor care setting at where there is no sedation
3. Active mobility can be used intraoperatively to determine:
a. T e strength o a tendon repair
b. T e degree o release with a tenolysis
c. Adjust the tension on a tendon trans er accurately
d. T e amount o malrotation on a racture

When is this approach contraindicated?
1. Patients with high anxiety
2. Patients with P SD
3. Patients with cognitive impairment

When does maximum vasoconstriction occur a ter injecting lidocaine with 1:100,000 epinephrine?
Maximum vasoconstriction occurs 26 minutes post injection.

What are nine principles o decreasing pain during local anesthetic injections?
1. Bu er lidocaine 10:1 with 8.4% bicarbonate
2. Warm the local anesthetic
3. Distract the patient (touch, pressure, pinch, ice)
4. Use a 27-gauge needle
5. Stabilize the syringe to avoid needle wobble
6. Inject 0.5 cc perpendicularly and sub-dermally, then pause until the patient states that the needle pain is gone
7. Inject an additional 2 cc be ore moving the needle, then move antegrade slowly
8. Reinsert needles within 1 cm o blanched areas
9. Learn rom patients, by asking them to score the number o times they elt pain during the injection

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What does a stellate ganglion block interrupt?
Sympathetic innervation o the upper extremity.

What are the two types o central nerve blockade available?
1. Epidural anesthesia: this occurs when a local anesthetic is injected into the epidural space and generally requires
a large volume o anesthetic. Mostly used to block sensory unction, not motor unction, and o ten per ormed
as a continuous block; or example, obstetrics.
2. Spinal anesthesia: this occurs when a local anesthetic is injected into the subarachnoid space cerebrospinal uid
(CSF) and requires smaller volumes o anesthetic compared to epidural anesthesia. Used to block sensory and
motor unctions.

List ve potential complications rom central nerve blockade.
1. Hypotension: results rom vasodilation; risk: patients who are hypovolemic
2. High spinal: spinal anesthetic migrates cephalad; 1–4: blocks sympathetic innervation to heart (bradycardia,
decreased cardiac output), above C4 (phrenic nerve, apnea)
3. Spinal headache: because o continued CSF leak through the dura; treatment: ca eine, uids, blood patch.
4. Urinary retention: common
5. Spinal cord injury
GENERAL ANESTHESIA

What is balanced anesthesia?
Uses several di erent categories o drugs to achieve desired anesthesia, results in less o each drug and less toxicity.

What are the di erent stages o anesthesia?
Stage 1: amnesia ( rom induction to loss o consciousness)
Stage 2: delirium (most dangerous stage, can have injurious pain response, e.g., N&V, laryngospasm,
hypertension, tachycardia, uncontrolled movements)
Stage 3: surgical anesthesia (target point, no pain response)
Stage 4: overdose (shallow or absent respirations, hypotension, dilated and nonreactive pupils)

Which muscle relaxant is not recommended or induction in burn patients and why?
Succinylcholine. An increase in the number o muscle receptor sites or acetylcholines has been documented in
burn patients. Succinylcholine is an agonist o acetylcholine and can be responsible or a large and sometimes atal
release o potassium up to 2 years a ter the initial burn injury. Nondepolarizing muscle relaxants as well as care ul
monitoring with a nerve stimulator are recommended.

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Describe the patient American Society o Anesthesiologists (ASA) classi cation or anesthesia.
T e ASA scale is the ollowing:
ASA1: patient is a healthy individual with no major systemic disease
ASA 2: patient has a one-system, well-controlled disease
ASA 3: patient with multisystem disease or well-controlled major system disease
ASA 4: patient with severe, incapacitating, poorly controlled, or end-stage disease
ASA 5: patient with imminent danger o death with or without surgery
“E”: patient who qualif es or emergency surgery

Which general anesthetic is most commonly associated with cardiac arrhythmias?
Halothane.

What are the eatures o sleep apnea?
S OP
S. Snoring Loudly
. iredness or daytime hypersomnolence
O. Observed pauses in breathing during sleep
P. Pressure = history o hypertension

What can be done to minimize the risk to patients with known sleep apnea who are undergoing plastic
surgery procedures?
1. Preoperative anesthesiologist evaluation
2. Bring CPAP or BIPAP machine to the hospital, or use in the PACU and overnight
3. Consider 23 hours observation post op, with oxygen saturation monitoring
4. minimize opioids and sedatives
5. Use NSAIDs
6. Use local or regional anesthesia, i possible

What are the clinical e ects o clonidine?
1. Analgesia
2. Sedation
3. Hypotension

What is the mechanism o action o clonidine?
It acts centrally, and stimulates the alpha-2 adrenergic receptors to treat hypertension. T e sedating and analgesic
e ects are not ully understood, but are likely related to action in the pre rontal cortex.

Under what circumstances is clonidine used in plastic surgery procedures?
It is primarily used as an adjuvant in patients undergoing acial plastic surgery, such as a aceli t. T e analgesic
and sedating aspects o the medication complement the local anesthesia and sedation approach. Also, the mild
hypotension decreases intraoperative bleeding, and reduces the risk o a postoperative hematoma.

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What is the dose o clonidine?
T e recommended dose or hypertension is 0.1 to 0.3 mg po BID as a starting dose. For operative procedures
typically 0.1 to 0.2 mg po is given immediately prior to the procedure.
NEW DEVELOPMENTS

What are the advantages o local aesthetics delivered via elastomeric pumps?
1. Reduced narcotic use
2. Reduced hospital stay
3. Reduced post-op nausea and vomiting
4. High patient satis action rate or a variety o procedures

What are the potential complications rom local aesthetics delivered via elastomeric pumps?
1. Inconsistent in usion rates
2. Clogging or leaking
3. Premature emptying o medication
4. echnical pump ailure

What is the trade name or liposomal bupivacaine or in ltration anesthesia?
EXPAREL

What is the mechanism o action or EXPAREL?
T e bupivacaine is encapsulated in multi-vesicular liposomal particles which then releases the drug over a desired
period o time.

What is the dosage o EXPAREL?
T e drug is supplied as 1.3% in 20 cc vial. T is is 266 mg o medication, and is the maximum dosage.

What are the precautions with EXPAREL?
1. Lidocaine can cause an immediate release o bupivacaine rom EXPAREL. T ere ore, i administered together,
wait 20 minutes be ore administering EXPAREL a ter lidocaine.
2. Bupivacaine HCl may a ect the pharmacokinetics o EXPAREL when the bupivacaine dose is > 50% o the
EXPAREL dose in milligrams.
3. Sur actant containing topical anesthetics (betadine and chlorhexidine) should be allowed to dry prior to
administration o EXPAREL as the sur actant can destabilize the liposomes.

What is the duration o action o standard bupivacaine, compared to liposomal bupivacaine?
Standard bupivacaine has a duration o action o 6 to 8 hours, while liposomal bupivacaine has a duration o
action o up to 24 to 72 hours.

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REFERENCES
Ben-David B. Complications o regional anesthesia: an overview. Anesthesiol Clin North America. 2002;20(3):665–667.
Gerancher JC. Upper extremity nerve blocks. Anesthesiol Clin North America. 2000;18(2):297–317.
Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1–6.
Lin YC, Krane EJ. Regional anesthesia and pain management in ambulatory pediatric patients. Anesthesiol Clin North America.
1996;14(4):803–816.
Morales R Jr, Mentz H, Newall G, Patronella C, Masters O. Use o abdominal f eld block injections with liposomal bupivacaine to
control postoperative pain a ter abdominoplasty. Aesth Surg J. 2013;33(8):1148–1153.
Ramamurthy S, Hickey R. Anesthesia. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed.
Philadelphia, PA: Churchill Livingstone; 1999:22–47.
Richards BG, Schleicher WF, Zins JE. Putting it all together: recommendations or improving pain management in plastic surgical
procedures: surgical acial rejuvenation. Plast Reconstr Surg. 2014;134(4S-2):108S–112S.
Stephan PJ, Mercier D, Coleman J, Rohrich RJ. Obstructive sleep apnea: implications or the plastic surgeon and ambulatory surgery
centers. Plast Reconstr Surg. 2009;124(2):652–655
etzla JE. T e pharmacology o local anesthetics. Anesthesiol Clin North America. 2000;18(2):217–233.

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Trenton M. Morton, MD and
Jeffrey B. Friedrich, MD, FACS

What is the role o computed tomography (CT) in assessing upper extremity tumors?
C is used to evaluate extent o bone destruction as well as calci ed lesions.

What is the role o magnetic resonance imaging (MRI) in assessing upper extremity tumors?
MRI is used or evaluation o lesions involving bone and so t tissue.

How is clonality used to di erentiate between neoplasms and benign tissue growths (i.e., Dupuytren
disease)?
Benign and in ammatory conditions are typically polyclonal, whereas neoplasms are monoclonal.

In which direction should the incision be oriented when obtaining a biopsy o an upper extremity mass?
Orient the incision longitudinal (rather than transverse or zigzag) so as to incorporate the biopsy site within the
de nitive excision or amputation.

When per orming a biopsy on a lesion, should one dissect around muscle planes or split the muscle sharply?
Split the muscle sharply (to avoid seeding other muscle compartments).

Should drains be placed a ter per orming an open biopsy?
No, drains can seed tumor cells along their tracts. T us, use diligent hemostasis to prevent hematoma ormation.

Should a tourniquet be used when operating on a neoplasm o the upper extremity?
Yes, a tourniquet should be used, but exsanguination o the arm should be done through elevation. Do not use an
Esmarch bandage.
Hand Tumors
CHAPTER 31

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BENIGN TUMORS

What is the usual etiology o epidermal inclusion cysts?
Epidermal cells become embedded in the dermis, which is usually the result o trauma.

Where do epidermal inclusion cysts usually occur?
In the glabrous, non–hair-bearing skin o the palms and ngertips (especially perionychium).

What is the treatment o epidermal inclusion cysts?
Complete excision along with the skin puncture wound (or punctum, i present).

What is a glomus tumor?
A glomus tumor is a benign hamartomatous neoplasm ormed rom the thermoregulatory neuromyoarterial
apparatus in the stratum reticulare.

What are the clinical f ndings seen with a subungual glomus tumor?
Severe pain, cold sensitivity, tenderness, nail de ormity, or discoloration.

What is the treatment o a subungual glomus tumor?
Removal o nail plate and complete excision o the tumor.

What is the most likely diagnosis in a patient with a subcutaneous elevation just proximal to the eponychial
old and associated nail grooving?
Mucous cyst. Mucous cysts are uid- lled ganglia o the distal interphalangeal joint associated with bony spurs
and nail grooving.

What is the treatment o mucous cysts?
Cyst excision and removal o bone spurs.

What is a pyogenic granuloma? What demographic does it a ect most commonly?
Pyogenic granuloma is a rapidly growing vascular, riable nodule. It is requently seen on ngertips in young
adults, and notably most common a ter pregnancy.

What is a Keratoacanthoma?
Keratoacanthoma is a lesion commonly ound on the dorsal hand that is round, elevated, and usually has a central
crater. T is lesion usually resolves spontaneously and only occasionally progresses to squamous cell carcinoma.

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What is the natural history o keratoacanthomas?
T ey undergo three phases:
1. Proli eration
2. Maturation
3. Involution
T e history and clinical presentation will usually include the rapid growth o a pre-existing lesion that then
gradually gets smaller as the central crater expels a keratin plug.

What is the recommended treatment or keratoacanthomas?
Surgical excision or intralesional injection using 5- uorouracil (5-FU) or methotrexate.

What are the f rst and second most common tumors or masses o the hand?
Ganglions and giant cell tumors (GC s), respectively.

What is the predominant cell type in GCTs (aka localized nodular synovitis)?
Histiocytes.

What is the usual site o origin o GCTs?
Flexor tendon sheath.

What is the treatment o GCTs?
Complete excision along with stalk (i present).

How is a lipoma diagnosed?
Physical examination demonstrating a so t, mobile, nontender mass that does not transilluminate along with a
consistent clinical history o slow growth.

What is the di erence between a neurof broma and a neurilemmoma?
Neuro broma: tumor arising within the nerve ascicles. Neurilemmoma (also known as schwannoma): tumor o
Schwann cells on the nerves sur ace.

How does this di erence impact treatment?
Neurilemmoma can be “shelled out” easily leaving the nerve intact, while neuro broma requires transection at the
proximal and distal ascicles.

Are these common tumors?
Neurilemmomas are the most common benign nerve tumors in the upper extremity.

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A patient presents with multiple neurof bromas o the upper extremity and cutaneous ca é-au-lait spots.
What is your diagnosis?
Von Recklinghausen disease or neuro bromatosis type 1.

A patient presents with bilateral acoustic schwannomas. What is the likely diagnosis?
Neuro bromatosis type 2. O note, these patients rarely have neuro bromas.

What diagnostic studies can be used to di erentiate between neurof broma and neurilemmoma?
Magnetic resonance (MR) and nerve conduction studies.

What is the treatment o f bromatosis and juvenile aponeurotic f bromas?
reatment involves wide excision with skin gra ting or ree tissue trans er. Despite this approach there remains a
high potential or recurrence.

What is in antile digital f bromatosis (IDF)?
IDF is a benign condition presenting in children between 5 months and 6 years in which broad-based, rm, and
nontender nodule(s) develop on the dorsal or lateral aspects o the ngers.

What are the histologic f ndings associated with IDF?
Histologic examination demonstrates interlacing broblasts and intracytoplasmic eosinophilic inclusion bodies.
T ese inclusion bodies distinguish IDF rom other bromatosis.

What is the recommended treatment or IDF?
Wide excision o the lesion(s) with ull-thickness skin gra ting i the de ect warrants.

What is the chie problem seen with desmoid tumors?
High rate o recurrence (especially in emale patients).

In general, what is the treatment or upper extremity arteriovenous mal ormations (AVM)?
AVMs are treated with ligation o eeding vessels and complete excision o the mal ormation. Preoperative
embolization o the mal ormation may be per ormed prior to excision.

Are vascular mal ormations considered neoplasms?
No, they are simply an abnormal collection o blood vessels.

What is the most common benign bone tumor?
Enchondroma.

What are the common locations o enchondromas?
T e most common location o an enchondroma is in the proximal phalanx, ollowed second by the metacarpal,
and third by the middle phalanx (as per 2010 In-service examination question).

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What is Ollier’s disease?
A nonhereditary disease o multiple enchondromas that usually presents unilaterally.

What is Ma ucci syndrome?
A condition characterized by multiple enchondromas and hemangiomas.

What is the li etime chance o a solitary enchondroma undergoing malignant trans ormation?
Less than 5%.

What can enchondromas degenerate into?
Chondrosarcomas.

How do enchondromas requently present?
Enchondromas are o ten discovered as the cause o a pathologic racture presenting with pain.

What is the treatment o enchondromas?
Curettage and bone gra ting. In cases o pathologic racture, it is optimal to allow racture healing prior to
de nitive resection.

What is a periosteal chondroma?
Periosteal chondroma is a benign cartilaginous tumor that is similar to an enchondroma and most commonly
ound at the metaphyseal–diaphyseal junction o the phalanges.

What is the peak age range o unicameral bone cysts (UBCs)?
5 to 10 years. In act, it is seen almost exclusively in children.

What is the typical presentation o UBC?
An incidental nding on radiography or a pathologic racture through the cyst.

What nonsurgical treatment is used or UBCs?
Intralesional corticosteroid injection.

What is the name o a blood-f lled cyst that typically occurs in the metaphysis o a metacarpal and then
grows toward the physis?
Aneurysmal bone cyst (ABC).

What is the peak age range o ABC?
Second decade o li e.

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What is the typical presentation o ABC?
Swelling and pain, o ten ollowing an injury.

What is the treatment o ABCs?
Curettage and bone gra ting is recommended as ABCs are erosive, although benign, lesions that must be removed.

What is the usual structure o an osteochondroma?
Osteochondromas have a bone stalk and cartilaginous cap growing rom the metaphysis in skeletally immature
patients.

Is excision necessary or osteochondromas?
Excision is not necessary unless they are symptomatic as osteochondromas rarely undergo malignant degeneration.

What are the symptoms o an osteoid osteoma?
Pain at night that is generally relieved by nonsteroidal anti-in ammatory drugs.

How do osteoid osteomas present on imaging studies?
Sclerotic nidus with a lucent halo, less than 1.0 cm in diameter (by de nition).

What is the histology o osteoid osteomas?
Hypervascular nidus o osteoblasts with surrounding cortical reactive bone ormation.

What is the treatment o osteoid osteomas?
Curettage and bone gra ting.

What is an osteoblastoma?
Same as an osteoid osteoma, but these are larger than 1 cm in diameter. T ey have unlimited growth potential and
all should be resected.

What is the clinical presentation o a GCT o bone?
Gradual swelling, pain, sometimes with pathologic racture, most o ten in the distal radius.

Why do some classi y GCTs as low-grade malignancies?
T ey are capable o metastasizing.

Where do GCTs o bone typically metastasize?
T e lungs (2%).

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How do GCTs look on radiographs?
Lytic lesion without new bone ormation; the lesion encroaches on, but does not penetrate joint sur ace.

What is the surgical treatment o GCTs?
Wide excision and joint reconstruction, i necessary.

What is the pathophysiology o f brous dysplasia?
Bone marrow o involved bone(s) lled with noncalci ed collagen.

What is the x-ray appearance o f brous dysplasia?
Ground-glass opacity.

Is treatment o f brous dysplasia o the hands required?
Not usually. Surgical treatment is only per ormed or pathologic ractures, or “impending” ractures.

What are some other common so t-tissue masses in the upper extremity?
Ganglia, lipomas, oreign-body granulomas, retinacular cysts, palmar bromatosis, or nodules (Dupuytren).
MALIGNANT TUMORS

What is the staging system or malignant musculoskeletal tumors?

What is the most common malignant tumor o the hand?
Squamous cell carcinoma.
Stage

Grade

Site

Metastasis
IA

Low (G1)

Intracompartmental (T1)

M0
IB

Low (G1)

Extracompartmental (T2)

M0
IIA

High (G2)
Intracompartmental (T1)

M0
IIB

High (G2)
Extracompartmental (T2)

M0
III

Any
Any
M1 (regional or distant)
Known as the Enneking Classif cation and originally described in 1980 by WF Enneking.

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What is the most common type o melanoma among A rican Americans and Asians?
Acral lentiginous melanoma, generally presenting on hands and eet.

When treating melanoma o the hand, how is the amputation level determined?
Amputate proximal to the nearest joint (i.e., or a subungual melanoma, amputation would be through the middle
phalanx).

What role does sentinel node biopsy play in the treatment o subungual melanoma, and why?
Sentinel node biopsy is use ul with subungual melanoma because depth o the tumor is di cult to determine in
the nail bed.

What is Dermatof brosarcoma protuberans (DFSP)?
A so t-tissue neoplasm arising in the dermis that presents as a purple-red plaque or nodule.

Has Mohs surgery been shown to be an e ective treatment o DFSP?
Yes.

Name a strong risk actor associated with malignant peripheral nerve sheath tumor?
Neuro bromatosis type 1 (Von Recklinghausen disease).

What is a synovial cell sarcoma?
Synovial cell sarcoma is a high-grade sarcoma that grows in proximity to (but not in) joints. Size o the lesion is
proportional to the mortality.

What is the treatment o synovial cell sarcoma?
Synovial cell sarcoma is treated with wide excision with lymph node sampling (and dissection i nodes involved),
and consideration o adjuvant radiation therapy.

What other sarcoma is similar to synovial cell sarcoma and usually arises rom muscle?
Epithelioid sarcoma.

What pattern o spread does epithelioid sarcoma demonstrate that makes it particularly dangerous?
It spreads proximally along ascial planes, tendons, and lymphatics.

Where is malignant f brohistiocytoma usually ound in upper extremities?
Malignant brohistiocytomas are ound on the deep muscle mass o adductor pollicis or within exor muscles.

What is the most common malignant primary bone tumor o the hand seen in children and teens?
Osteogenic sarcoma.

CHAPTER 31 Hand umors
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How does osteogenic sarcoma look on plain radiograph?
Bone growth outside normal skeletal boundaries with hazy “cloud-like” bone ormation into so t tissues.

Is there a role or external beam radiation in treatment o osteogenic sarcoma?
T ere is no role or external beam radiation in the treatment o osteogenic sarcoma, but chemotherapy has greatly
improved survival and limb salvage.

What is the most common malignant primary bone tumor o the hand in adults?
Chondrosarcoma.

Is chondrosarcoma sensitive to chemotherapy or radiation?
No.

What is the benign predecessor that can rarely degenerate into a chondrosarcoma?
Enchondroma.

What is a rare bone tumor o the metacarpals and phalanges that consists o abnormal endothelial cells?
Angiosarcoma.

What is a typical presentation o a Ewing sarcoma o the hand?
Pain, swelling, so t-tissue mass; generalized symptoms such as ever, elevated WBC and/or ESR may also be
present.

What is the radiographic presentation o Ewing sarcoma?
Large lytic lesion o bone with a so t-tissue component.

What is the periosteal reaction on radiographs called in Ewing sarcoma?
“Onion skin” appearance or “sunburst” pattern.

What are the common sites o Ewing sarcoma o the hand?
Metacarpals, phalanges.

What is the treatment o Ewing sarcoma?
reatment o Ewing sarcoma includes surgical excision, systemic chemotherapy, and/or external beam radiation.

What percentage o patients with primary cancers in other parts o the body will develop a metastasis to the
hands or eet?
0.3%.

What is the most common primary carcinoma that metastasizes to the hand?
Bronchogenic carcinoma ( ollowed by breast and kidney).

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When primary carcinoma metastasizes to the hand, where does it go?
T e distal phalanx.
REFERENCES
Altay M, Bayrakci K, Yildiz Y, Erekul S, Saglik Y. “Secondary chondrosarcoma in cartilage bone tumors: report o 32 patients.” J Orthop
Sci. 2007;12(5):415–423.
Athanasian EA. Bone and so t tissue tumors. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed.
Philadelphia, PA: Churchill Livingstone; 1993:2223–2253.
Athanasian EA, Wold LE, Amadio PC. Giant cell tumors o the bones o the hand. J Hand Surg Am. 1997;22(1):91–98.
Bednar MS, Weiland AJ, Light R. Osteoid osteoma o the upper extremity. Hand Clin. 1995;11:211–221.
Enneking WF, Spanier SS, Goodman MA. Current concepts review. T e surgical staging o musculoskeletal sarcoma. J Bone Joint Surg
Am. 1980;62(6):1027–1030.
Falco NA, Upton J. In antile digital bromas. J Hand Surg Am. 1995;20(6):1014–1020.
Floyd WE 3rd, roum S. Benign cartilaginous lesions o the upper extremity. Hand Clin. 1995;11:119–132.
Mankin HJ, Lange A, Spanier SS. T e hazards o biopsy in patients with malignant primary bone and so t tissue tumors. J Bone Joint
Surg Am. 1982;64(8):1121–1127.
O’Leary JA, Berend KR, Johnson JL, Levin LS, Seigler HF. Subungual melanoma. A review o 93 cases with identi cation o prognostic
variables. Clin Orthop Relat Res. 2000;(378):206–212.
Scaglietti O, Marchetti PG, Bartolozzi P. T e ef ects o methylprednisolone acetate in the treatment o bone cysts. Results o three years
ollow-up. J Bone Joint Surg Br. 1979;61-B(2):200–204.
Simon MA, Finn HA. Diagnostic strategy or bone and so t tissue tumors. J Bone Joint Surg Am. 1993;75(4):622–631.
rumble E, Berg D, Bruckner JD, et al. Benign and malignant neoplasms o the upper extremity. In: rumble E, ed. Principles of
Hand Surgery and T erapy. 1st ed. Philadelphia, PA: WB Saunders; 2000:529–578.

293
Emily Cushnie, MD, PhD and
César J. Bravo, MD

What organism is ound in all the hand in ections?
Staphylococcus aureus. Seen in 50% to 80% o in ections.

What are the most common bacteria involved in acute hand in ections?
Staphylococcus aureus (up to 60%) and beta-hemolytic streptococci.

What proportion o hand in ections are polymicrobial?
Over hal .

What is the basic treatment principle when dealing with in ections o the hand?
DICE. Drainage and Debridement. Immobilization. Chemotherapy (antibiotics). Elevation.

What is the most common site o hand in ections?
Dorsal subcutaneous tissue. Followed by tendon, joint, bone, and the sub ascia.

What is the most common mechanism o hand in ections?
rauma, such as penetrating injuries or bites.

How do super cial hand in ections tend to be treated? Exception?
With antibiotics, which can be supplemented with splinting depending on severity. ypical course i 14 to 21 days.
Exception is necrotizing asciitis, which requires early surgical intervention.

How do deep hand in ections tend to be treated?
Surgical irrigation and debridement in conjunction with antibiotics and splinting as indicated.
Infections of the Hand
CHAPTER 32

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What patient risk actors predispose them to hand in ections?
Immunocompromised state, Intravenous (IV) drug abuse, diabetes mellitus, and steroid use. Microvascular disease
and damage to blood supply, as in trauma, also impairs host immune response.

What are the common pathogens ound in diabetic patients with hand in ections?
Gram–negative and polymicrobial in ections. Subepidermal abscesses are unique to this patient population.

How do hand in ections in immunocompromised patients behave?
Hand in ections in this population tend to run a virulent course; or example, herpetic whitlow will not resolve
spontaneously and require antiviral agents.

What characterizes cellulitis in the hand?
Characterized by erythema, swelling, and tenderness. Associated lymphangitis may indicate a more severe
in ection.

What is the most commonly involved organism in cellulitis o the hand?
Group A β-hemolytic Streptococcus.

What other organism is also involved, speci cally in less severe cases o cellulitis?
S. aureus.

What are the oral antibiotics o choice in cellulitis o the hand?
Na cillin, dicloxacillin, and cephalexin; erythromycin, i allergic to penicillin.

How do subcutaneous abscesses typically occur in the hand?
A ter a puncture wound or as a response to a retained oreign body.

What are the most commonly isolated pathogens in human-bite in ections?
α-Hemolytic Streptococcus and S. aureus.

What is the area most commonly involved in human bites?
T e metacarpophalangeal joint, commonly re erred to as “ ght bites.”

Where is the most common topography or occurrence o hand in ections?
Flexor tendon zone injury II.

What organism is commonly isolated in one-third o human bite wounds?
Eikenella corrodens. Cultured in 7% to 29% o human bites. Must be cultured in 10% carbon dioxide. Destroys
articular cartilage quickly.

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What is the recommended treatment o a human bite injury?
Surgical extension and debridement with arthrotomy and culture acquisition. T e wound is le t open.

What organism commonly in ects animal bites and scratch wounds?
Pasteurella multocida.

Why do you need an x-ray i the patient had a simple animal bite?
o rule out a retained oreign body like a broken tooth.

How should animal bites be treated?
Irrigation and oral amoxicillin-clavulanate, or IV ampicillin-sulbactam.

What are the common cultures requested in hand in ections?
Aerobic cultures, anaerobic cultures, cultures Löwenstein–Jensen medium or atypical Mycobacterium
(Mycobacterium marinum at 32°C, Mycobacterium tuberculosis at 37°C).

What are the common stains needed in hand in ections?
Gram stain, Ziehl–Neelsen stain (atypical Mycobacteria), zanck smear (herpes simplex virus).

When evaluating a hand in ection and a ungus is suspected, what preparation should be done or
examination?
Potassium hydroxide preparation.

What is the most common in ection in the hand in human immunode ciency virus (HIV)–positive patients?
Herpes simplex in ection.

When using an aminoglycoside (e.g., gentamicin) or gram-negative coverage, what adverse e ects are
commonly overlooked?
Nephrotoxicity and ototoxicity.

What is the drug o choice or methicillin-sensitive S. aureus (MSSA) in ections o the hand?
Cephalexin, amoxicillin clavulanate (orally).

What is the drug o choice or methicillin-resistant S. aureus (MRSA) in ections o the hand?
Vancomycin.

What is the current reported incidence o MRSA hand in ections, and is it rising?
34–73% o all hand in ections, Yes.

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What is the recommended empirical oral antibiotic or MRSA?
Sul amethoxazole/trimethoprim (Bactrim) covers 90% community-acquired MRSA, current recommendation is
or 2 double-strength Bactrim tablets twice a day. Clindamycin and cipro oxacin are also appropriate, however
they have 50% and 40% resistance to community-acquired MRSA, respectively. T e mecA gene, which codes or
penicillin-binding protein 2A, provides its resistance to methicillin.

Which is the most common hand in ection?
Paronychia. It is an in ection beneath the eponychial old or along the paronychial old and nail plate. Not to be
con used with perionychium, which is the skin around the nail margin (see Fig. 32-1).
Figure 32-1 Paronychial in ection.
Pus beneath
eponychial fold

Which is the area around the ngertip most resistant to in ection?
T e hyponychium is the most resistant area to in ection.

How do you treat an acute paronychia without abscess?
Warm water soaks with or without povidone or chlorhexidine and oral antibiotics. With and abscess in place,
incision and drainage is recommended, routinely with removal o the nail plate.

What is a runaround abscess?
A paronychial in ection that orms an abscess that tracks around beneath the entire nail old super cial to the nail
plate.

In what type o patient population is chronic paronychial in ection o ten seen?
Patients exposed to constant moisture such as dishwashers, swimmers, or medical pro essionals. Also, children who
requently dig in dirt.

What organism is commonly implicated in chronic paronychial in ection and how is it treated?
Candida albicans. Marsupialization and nail removal.

What adjunct treatment or chronic paronychial in ections is recommended?
opical corticosteroid—anti ungal ointment (3% clioquinol in a triamcinolone-nystatin ointment). (Mycolog)

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In what subset o diabetic patients with hand in ections is morbidity particularly high?
Renal transplant patients.

What is a elon?
Closed-space in ection o the digital pulp.

What is the most common organism ound in elons?
S. aureus, with MRSA being more common.

What are the pre erred incisions or draining a elon?
Midvolar and high lateral incisions (see Fig. 32-2). Longitudinal incisions rom distal exion crease to pulp apex
allows or incision o septal compartments while protecting neurovascular bundles.
Figure 32-2 Midvolar and high lateral incision or drainage o elon.

What type o incision used or draining a elon is associated with vascular compromise o the digital pad?
Fish-mouth incisions.

What are the consequences o untreated elons?
Deep-space in ections, septic arthritis, osteomyelitis, amputation, acute exor tenosynovitis, and pain ul/insensate
pulp scars.

How long does viral shedding and ability to in ect others persist in people with herpetic whitlow?
Until lesion epithelialization is complete.

What is the natural course o herpetic whitlow?
A sel -limiting disease resolving over a period o 3 to 4 weeks. Presents initially with prodromal throbbing pain,
tingling, swelling, and erythema o the af ected nger ( rst 48–72 hours). T is is ollowed by erythema and
tenderness around clear vesicles which coalesce to orm ulcers over 10 to 14 days. wenty percent recurrence rate
reported.

Is surgical irrigation and debridement indicated?
No, this could cause a bacterial superin ection to develop, surgical intervention is contraindicated.

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What is pyogenic f exor tenosynovitis o the hand?
A bacterial in ection o the exor sheath between the visceral epitenon layer and the outer parietal layer. S. aureus
is the most common causative organism.

What are the our cardinal signs described by Kanavel characteristic o pyogenic f exor tenosynovitis?
1. Flexed resting position o the involved digit.
2. enderness over the exor sheath.
3. Severe pain o passive extension (commonly proximally along the nger tendon sheath).
4. Fusi orm swelling o the nger.
All signs may not be present, especially early in the course o in ection.

What laboratory values are help ul in diagnosis o f exor tenosynovitis?
White blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Elevation o at least one o these
markers, plus a positive clinical examination was shown to be 100% speci c (although not nearly as sensitive) in
diagnosing exor tenosynovitis.

What type o bacterial f exor tenosynovitis usually results rom hematogenous spread?
Gonococcal in ections.

Which two digital f exor sheaths communicate with bursae in the palm and thus can propagate proximal
extension o tenosynovial in ections?
T e exor sheath o the thumb (radial bursa) and the small nger (ulnar bursa). T e ulnar and radial bursae
extend proximally in 50% to 80% o persons into carpal tunnel.

What is a horseshoe abscess?
In ection o either small nger or thumb exor sheath with contiguous spread through communication o the
radial and ulnar bursae.

What has happened i a patient with suppurative f exor tenosynovitis o the small nger suddenly develops
acute carpal tunnel symptoms?
Extensive proximal spread o in ection into Paronas space (the quadrilateral potential space at the wrist bordered
by the pronator quadratus, digital exors, pollicis longus, and exor carpi ulnaris).

Can contiguous spread rom the index- nger sheath cause in ection o thenar space?
Yes.

How do you treat early in ections o suppurative f exor tenosynovitis (within 24 hours)? Late?
Elevation, splinting, and intravenous antibiotics. Surgical irrigation o the tendon sheath and IV antibiotics.

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I limited incision and catheter irrigation are used, why is it important to make sure catheter is within
digital sheath?
Digital compartment syndrome can occur. T e presence o uid in the interstitial tissue.

What is the avored exposure or severe tenosynovitis in ections with subcutaneous purulence or necrotic
tendon?
Open exposure o the sheath and irrigation through windows sparing the A2 and A4 pulleys, midaxial approach is
pre erred over Bruner to limit postoperative tendon exposure.

What is the recommended empiric choice and duration o treatment or antibiotics in pyogenic f exor
tenosynovitis?
Vancomycin and piperacillin/tazobactam or 2 to 3 weeks.

What deep spaces o the hand can be involved in in ection?
Dorsal subaponeurotic, thenar, midpalmar, Parona’s quadrilateral, and interdigital sub ascial web spaces
(see Fig. 32-3).
Figure 32-3 Reproduced, with permission, rom intinalli JE, Kelen GD, Stapczynski JS, et al. intinalli’s Emergency Medicine: A
Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004. Fig. 268–8.
Palmar aponeurosis
Digital arteries
and nerves
Hypothenar
muscles
Fifth metacarpal
Flexor tendon
on sheath
Midpalmar
space
Extensor
tendons
Opponens muscles
First metacarpal
Thenar space
Palmar interosseous
muscles
Dorsal subaponeurotic
space
Dorsal interosseous
muscles

Name the ascial spaces o the hand and its possible pertinent in ecting area.
Fascial Space

Infected Area
Middle palmar space

In ection o ring- or middle- nger f exor tendon sheath
Thenar space

In ection o index f exor tendon sheath
Dorsal subaponeurotic space Aponeurosis o extensor tendons (deep)
Dorsal subcutaneous space
Entire dorsum o hand

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What are the most common in ectious agents in deep-space hand in ections?
Streptococcus, S. aureus, and coli orm organisms.

What is the name used when the interdigital sub ascial web space is in ected?
Collar button abscess. reated with incision and drainage/broad-spectrum antibiotics.

Why are they called collar button abscesses?
T ey typically orm two swellings—one volarly and one dorsally with each on one end o a narrower stalk. T e
shape is like a dumbbell or the collar buttons used on shirts years ago. uxedos still come with collar buttons
requently.

In contrast to a simple dorsal subcutaneous abscess, a collar button abscess is characterized by:
Abducted resting posture o the adjacent digits.

An in ection o the thenar space, rst web space, and dorsoradial aspect o the hand is known as?
Dumbbell or pantaloon in ection.

T e boundaries o the thenar space are:
Volar: Index- nger exor tendon.
Dorsal: Adductor pollicis musculature.
Radial: Insertion o adductor pollicis into the proximal phalanx o thumb and thenar muscle ascia.
Ulnar: Midpalmar space or oblique septum extending rom palmar ascia to the volar ridge to the third metacarpal
(midpalmar septum).

Why is the thumb held in marked abduction in thenar-space in ections?
T is posture reduces pressure (and thus pain) within the thenar space.

What are the mimickers o hand in ection?
Gout, pseudogout, pyogenic granuloma, pyoderma gangrenosum, and neoplasia.

What is the most common algae in ection seen in shermen?
Prototheca wickerhamii ( x: etracycline).

What are the recommended incisions or drainage o thenar-space in ections?
Combined volar and dorsal incisions (see Fig. 32-4).

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Why are incisions that parallel the rst-web commissure not recommended in thenar-space in ection?
o avoid web space contracture.

What is the only in ection resulting in loss o palmar concavity?
Midpalmar space in ection.

What are the boundaries o the midpalmar space?
Volar: Flexor tendons and lumbricals
Dorsal: Middle- and ring- nger metacarpals and second and third palmar interosseous muscles
Radial: Midpalmar septum
Ulnar: Hypothenar muscles

Exposure to what virus causes milker’s node in the hand (or granuloma)?
Poxvirus. Handling a cow’s udder.

What is an interdigital pilonidal cyst?
When a oreign piece o hair enters the web space and becomes secondarily in ected. Seen in barbers and
sheep shearers.
Figure 32-4 Incisions or thenar-space hand in ections.
A

B

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What is the usual rate o in ections a ter elective hand surgery?
1% to 7%; 0.47% deep in ection rate a ter carpal tunnel release.

What are the recommended incisions or midpalmar space in ections?
Figure 32-5.
Figure 32-5 Incisions or midpalmar space hand in ections.
A
B
C
D

Name organisms ound in hand in ections associated with river or seawater?
Vibrio vulni cus—coastal and brackish water ( x: tetracycline, chloramphenicol)
Mycobacterium marinum— resh water ( x: ri ampin, ethambutol trimethoprim-sul amethoxazole)
Aeromonas hydrophila— resh water ( x: cipro oxacin, tetracycline, trimethoprim-sul amethoxazole)

What is sporotrichosis?
A chronic granulomatous in ection caused by the saprophytic ungus Sporothrix schenckii. Most common
subcutaneous ungal lesion in North America seen mostly in the upper extremities.

What is the treatment o choice or sporotrichosis? I allergic to iodine?
Oral potassium iodide. Itraconazole.

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What organisms are commonly ound in septic arthritis o the hand? Cause?
S. aureus and Streptococcus. Haemophilus inf uenzae (young). Gonococcus (young adult with monoarticular
nontraumatic septic arthritis). Penetrating trauma.

What is the most common cause o osteomyelitis in the hand?
Open ractures.

Where is the most common location o osteomyelitis in the hand?
Distal phalanx.

What is necrotizing ascitis? What is it usually caused by?
Lique action necrosis o the ascia with selective spread along ascial planes with involvement o skin and muscle
during later stages o in ection with bullae ormation, myonecrosis, and skin slough. Group A Streptococcus.

Gas gangrene is requently caused by?
Clostridium per ringens.

Are there pathognomonic physical ndings in mycobacterial in ections o the hand?
No, but deep in ections are requently associated with abundant tenosynovitis or joint synovitis.

What unique in ection can occur in the hands o a patient receiving axol?
Subungual abscess o multiple digits (including the toes) with pain ul onycholysis or nail plate separation.

How is septic arthritis o the hand transmitted?
Commonly by penetrating trauma or spread o in ection rom contiguous structures

What are the physical ndings in hand septic arthritis?
Fusi orm swelling o the joint with erythema and pain upon active or passive motion.

How is septic arthritis diagnosed?
Joint aspiration or de nitive diagnosis, with analysis o cultures, cell count, and crystal content. Cell count o
50,000 cells with > 75% polymorphonuclear leukocytes is traditionally thought to be diagnostic o septic arthritis,
however more recent studies suggest lower cell count values as being more accurate.

What is the treatment or hand septic arthritis?
Irrigation and debridement with antibiotics.
1. Wrist septic arthritis can be addressed either open through longitudinal incisions between the third and ourth
extensor compartments, or via arthroscopy.
2. MCP joints should be entered through a longitudinal, dorsal incision with at least partial preservation o the
sagittal bands to prevent extensor tendon subluxation.
3. IP joints approached through midaxial incisions.

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What duration o antibiotics is recommended or septic arthritis o the hand?
Between 1 and 4 weeks o IV antibiotics.
REFERENCES
Abrams RA, Botte MJ. Hand in ections: treatment recommendations or speci c types. J Am Acad Orthop Surg. 1996;4:219–230.
Arons MS, Fernando L, Polayes IM. Pasteurella multocida—the major cause o hand in ections ollowing domestic animal bites. J Hand
Surg Am. 1982;7:47–52.
Bishop GB, Born . Kakar S, Jawa A. T e diagnostic accuracy o in ammatory blood markers or purulent exor tenosynovitis.
J Hand Surg Am. 2013;38(11):2201–2211.
Burkhalter WE. Deep space in ections. Hand Clin. 1989;5(4):553–559.
Canales FL, Newmeyer WL 3rd, Kilgore ES Jr. T e treatment o elons and paronychias. Hand Clin. 1989;5:515–523.
Chuinard RG, D’Ambrosia RD. Humanbite in ections o the hand. J Bone Joint Surg Am. 1977;59:416–418.
Draeger RW. Bynum DK Jr. Flexor tendon sheath in ections o the hand. J Am Acad Orthop Surg. 2012;20(6):373–382.
Fowler JR. Viral in ections. Hand Clin. 1989;5:613–627.
Freeland AE, Senter BS. Septic arthritis and osteomyelitis. Hand Clin. 1989;5:533–552.
Glickel SZ. Hand in ections in patients with acquired immunode ciency syndrome. J Hand Surg Am. 1988;13:770–775.
Goldstein EJ, Citron DM, Wield B, et al. Bacteriology o human and animal bite wounds. J Clin Microbiol. 1978;8:667–672.
Hausman MR, Lisser SP. Hand in ections. Orthop Clin North Am. 1992;23:171–185.
Hitchcock F, Amadio PC. Fungal in ections. Hand Clin. 1989;5:599–611.
Houshian S, Seyedipour S, Wedderkopp N. Epidemiology o bacterial hand in ections. Int J In ect Dis. 2006;10(4):315–319.
Hurst LC, Amadio PC, Badalamente MA, Ellstein JL, Dattwyler RJ. Mycobacterium marinum in ections o the hand. J Hand Surg Am.
1987;12:428–435.
Kanavel AB. In ections o the Hand. 7th ed. Philadelphia, PA: Lea & Febiger; 1939.
Mann RJ, Hof eld A, Farmer CB. Humanbites o the hand: twenty years o experience. J Hand Surg Am. 1977;2:97–104.
Neviaser RJ. In ections. In: Green DP, ed. Operative Hand Surgery. Vol 1. 3rd ed. New York, NY: Churchill Livingstone; 1993:
1021–1038.
Osterman M, Draeger R, Stern P. Acute hand in ections. J Hand Surg Am. 2014;39(8):1628–1635.
Ritting AW, O’Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012;37(5):1068–1070.
Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotizing asciitis o the upper extremity. J Hand Surg Am.
1982;7:15–20.
Siegel DB, Gelberman RH. In ections o the hand. Orthop Clin North Am. 1988;19:779–789.
Stern P, Staneck J, McDonough J, Neal H, yler G. Established hand in ections: a controlled, prospective study. J Hand Surg Am.
1983;8(5):553–559.
osti R, Ilyas A. Emperic antibiotics or acute in ections o the hand. J Hand Surg Am. 2010;35(1):125–128.

305
Pieter G.L. Koolen, MD,
John B. Hijjawi, MD, FACS, and
Samuel J. Lin, MD, MBA, FACS

What is the cause o Dupuytren disease?
It is usually amilial disease with multi actorial causes. T e tissue-level problem is a proli erative broplasias.

What are the diseases associated with Dupuytren disease?
1. Diabetes mellitus
2. Anti-convulsant therapy and epilepsy
3. Chronic alcoholism
4. HIV in ection
5. obacco consumption

Is the disease related to work or trauma?
T e disease has been noticed to increase in heavy manual workers or ollowing injury to the hand.

Who gets this disease?
ypically Scandinavian or Northern European men (10:1 prevalence over women).

Where do they get it?
T e most common ngers to get Dupuytren are the ring and small ngers.

What is Ledderhose disease?
Plantar bromatosis.

What is Peyronie disease?
Penile bromatosis.
Dupuytren Contracture
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Do these have anything to do with Dupuytren diathesis?
Yes. Dupuytren diathesis is the presence o a strong amily history o Dupuytren disease associated with knuckle
pads, Ledderhose or Peyronie disease. T e patient o ten develops aggressive disease at a young age with a high
likelihood o recurrence ollowing surgery.

What are the risk actors in developing Dupuytren disease?
1. Family history
2. Other type o bromatosis
3. Early and aggressive onset
4. Severe bilateral disease

What is Luck’s classi cation o the disease?
T ree phases:
1. proli erative phase
2. involutional phase
3. residual phase

What is the di erence between the collagen in normal ascia and that o the disease?
Normal ascia contains mostly type I collagen, whereas collagen in Dupuytren disease contains mostly type III
collagen.

What cell type is implicated in Dupuytren disease?
T e myo broblast.

What other molecules may play a role in the development o Dupuytren disease?
rans orming growth actors ( GF-B), platelet-derived growth actor, broblast growth actor.

Cytokines, which are hormone-like peptides, may be responsible or which process in humans that can lead
to Dupuytren disease?
Signaling the trans ormation o broblasts into myo broblasts.

Name the normal ascia and their pathological orms in Dupuytren disease.
• Pretendinous band becomes pretendinous cord.
• Lateral digital sheet becomes lateral cord.
• Natatory ligament becomes natatory cord.

What other cords contribute to the disease?
Central and spiral cords.

What orms the spiral cord?
It is ormed by the pretendinous band, spiral band, lateral digital sheet, and Grayson ligament.

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What other ligaments in the hand are not a ected by the disease?
• Super cial transverse ligament
• Deep transverse ligament
• Cleland ligament
• Landsmeer ligament

What causes metacarpophalangeal (MCP) joint f exion contracture in Dupuytren disease?
Pretendinous cord.

What causes proximal interphalangeal (PIP) joint f exion contracture in Dupuytren disease?
Spiral cord, lateral cord, and central cord.

What causes MCP adduction contracture in Dupuytren disease?
Natatory cords and the termination o the transverse bers o the palmar aponeurosis.

Does the distal interphalangeal (DIP) get involved in Dupuytren disease? I so, how?
Yes, essentially by the retrovascular cord and to some extent by the lateral cord.

What is the key thing to remember about natatory cords?
T ey prevent abduction o the ngers at the MCP joints.

What causes neurovascular displacement in the disease?
T e spiral cord.

What is the histological hallmark o the disease?
T e high cellularity. Notably, polyclonal in nature suggesting that the tissue is not truly neoplastic.

What could it be caused by?
Local ischemia and production o ree radicals.

What are the two orms o the diseased ascia?
Cord and nodule.

What is the histological eature o the nodule?
Dense collection o myo broblasts.

What are Garrod nodes?
An associated nding in Dupuytren disease: knuckle pads over the dorsum o the PIP joint.

How should Garrod nodes be treated?
Local steroid injection or oral nonsteroidal anti-in ammatory drugs.

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What are the histological eatures o the cord?
Contains no myo broblasts but highly organized collagen as seen in tendons.

What causes cord contracture?
Myo broblasts in the nodules account or active contraction.

Where are nodules usually located?
Usually just distal or just proximal to the distal palmar crease.

What can an area o skin dimpling alert the surgeon o in a patient with Dupuytren disease?
A spiral cord may exist, and the possibility that a digital nerve may be located in the immediate subcutaneous
position.

What is the di erential diagnosis or Dupuytren disease (including isolated nodules)?
1. Ganglion
2. Inclusion cyst
3. Epithelioid sarcoma
4. Camptodactyly
5. rigger nger
6. Boutonniere de ormity

How does one di erentiate a Boutonniere de ormity rom a severe PIP joint f exion contracture?
Hyperextension o the DIP joint may indicate that a Boutonniere de ormity is present. I there is resistance to
passive DIP joint when the PIP is passively extended, the oblique retinacular ligament is contracted and the lateral
bands are held palmar to the PIP joint axis.

I a patient has carpal tunnel syndrome and Dupuytren disease, can the two conditions be treated surgically
at the same time?
Controversy exists. Nissenbaum and Kleinert believe that the conditions should be treated at separate times, while
Michon, Gonzalez, and Watson advocated or simultaneous surgical treatment.

What are the nonsurgical treatments or the Dupuytren disease?
1. Steroid injections
2. Splinting and skeletal traction
3. Ultrasound therapy
4. Laser therapy
5. Collagenase and enzymatic asciotomy

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How success ul is the nonsurgical treatment?
Recent evidence has shown collagenase injections to be a promising alternative to surgery. In early trials, the
sa ety pro le is promising and the recurrence rates a ter injections appear to be low. At the time o this writing,
collagenase therapy is Food and Drug Administration approved or Dupuytren contractures o both the MP and
PIP joints.

What are the indications or surgery?
1. MCP contracture o 30 degrees or more
2. Any PIP contracture
3. Severe adduction contracture

What is the tabletop test?
Described by Hueston, it simply tests the patient’s ability to place the palm at on a tabletop. Once they cannot,
some surgeons recommend surgery.

What are some o the unctional tasks that a patient with Dupuytren contractures may complain o ?
Retrieving an object rom a pocket, wearing a glove.

What are the three aspects to be considered in the surgical treatment o Dupuytren disease?
1. Management o the skin.
2. Management o the ascia.
3. Management o the wound.

What does management o the skin involve?
It involves the skin incision either transverse or longitudinal (linear, zigzag, or lazy S).

What does management o the ascia involve?
Either can be used:
1. incision ( asciectomy)
2. local excision (regional asciectomy)
3. wide excision (extensive radical asciectomy)

What does management o the wound involve?
T e wound is sutured, le t open, or skin gra ted.

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Figure 33-1 A 90-degree MP joint exion contracture.
Figure 33-2 Percutaneous needle asciotomy.
Figure 33-3 Full extension ollowing percutaneous release.

What is percutaneous needle asciotomy (PNF)?
A technique rst described by Cooper, it involves per orming an aponeurotomy o the diseased ascia using a
needle. Several percutaneous stab incisions are made in the cord using the needle to “cut” or puncture the cord in
the palm and/or digit, while passive extension o the nger assists in releasing the contractures (Figs. 33-1 to 33-4).

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What are the results o PNF?
van Rijssen treated 88 rays by PNF and 78 rays by open-limited asciectomy. Follow-up was 6 weeks. T e total
passive extension de cit improved by 63% in the PNF group, and 79% in the limited asciectomy group. T e
results avored the limited asciectomy group with larger preoperative exion contractures. T e rates o major
complications were 5% in the limited asciectomy group, and 0% in the PNF group. T e authors concluded that
in cases o total passive extension de cit o 90 degrees or less, PNF is a very good treatment option.

What is dermato asciectomy?
Wide excision o the involved palmar and digital skin and ascia combined with skin gra ting.

What are possible indications or skin gra ting?
1. Patients with Dupuytren diathesis.
2. Patients with recurrent PIP joint contracture.
3. Patients with primary, severe PIP contracture resulting in skin de ciency at closure once the joint has been
restored to extension.

What is the di erence between extension and recurrence o the disease?
Extension re ers to the postoperative appearance o the disease in an area o the hand not involved in the surgery.
Recurrence re ers to postoperative appearance o the disease in the area o previous surgery.
Figure 33-4 Full exion ollowing percutaneous release.

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Mention some complications o the surgery.
1. Neurovascular bundle injury
2. Hematoma and skin necrosis
3. Joint sti ness
4. Re ex sympathetic dystrophy
5. Recurrent or uncorrected de ormity

What is the postoperative management?
1. Operated hand usually splinted in extension.
2. Wound care and requent dressing changes.
3. Active and passive range-o -motion exercises postoperatively.
4. Splinting varies depending on the surgical technique used.
5. PIP joint usually need 6 weeks o ull-time splinting and at least 3 months o night splinting.
REFERENCES
Benson LS, Williams CS, Kahle M. Dupuytren’s contracture. J Am Acad Orthop Surg. 1998;6(1):24–35.
Budalamente MA, Hurst LC. Ef cacy and sa ety o injectable mixed collagenase subtypes in the treatment o Dupuytren’s contracture.
J Hand Surg Am. 2007;32:767–774.
Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. 2003;28:427–431.
Gonzalez F, Watson HK. Simultaneous carpal tunnel release and Dupuytren’s asciectomy. J Hand Surg Br. 1991;16:175–178.
Hurst LN. Dupuytren’s contracture. In: Achauer BM, Ericksson E, Guyuron B, et al., eds. Plastic Surgery Indications, Operations and
Outcomes. Vol 4. St Louis, MO: Mosby; 2000:2057–2071.
Lubahn JD. Dupuytren’s disease. In: rumble E, ed. Hand Surgery Update 3 Hand, Elbow and Shoulder. Rosemont: American Society
or Surgery o the Hand; 2003:393–401.
Lubahn JD. Dupuytren’s disease. In: rumble E, Budo JE, Cornwall R, eds. Hand, Elbow and Shoulder: Core Knowledge in
Orthopaedics. Philadelphia, PA: Mosby; 2006:279–287.
Mac arlane RM, Ross DC. Dupuytren’s disease. In: Weinzweig J, ed. Plastic Surgery Secrets. Philadelphia, PA: Hanley and Bel us;
1999:554–559.
McGrouther DA. Dupuytren’s contracture. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. Vol 1. 4th
ed. New York, NY: Churchill Livingstone; 1999:563–591.
Michon J. Serious postoperative complications in Dupuytren’s disease. J Hand Surg. 1977;2:238.
Nissenbaum M, Kleinert HE. reatment considerations in carpal tunnel syndrome with coexistent Dupuytren’s disease. J Hand Surg
Am. 1980;5:544–547.
Short WH, Watson HK. Prediction o the spiral nerve in Dupuytren’s contracture. J Hand Surg Am. 1982;7:84–86.
van Rijssen AL, Gerbrandy FS, inden H , Klip H, Werker PM. A comparison o the direct outcomes o percutaneous needle asciotomy
and limited asciectomy or Dupuytren’s disease: a six-week ollow-up study. J Hand Surg Am. 2006;31:717–725.
Zachariae L. Dupuytren’s contracture. T e aetiological role o trauma. Scan J Plast Reconstr Surg. 1971;5:116–119.

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Trenton M. Morton, MD and
Jeffrey B. Friedrich, MD, FACS

How is nerve conduction in the carpal tunnel reported?
Nerve conduction is reported as “latency” in milliseconds (ms).

What is “latency”?
Latency is the time it takes or an electrical stimulus to travel along a nerve rom the site o stimulation to a
recording electrode in a target muscle.

What is the normal value or motor latency at the carpal tunnel?
Less than 4.0 ms.

How is nerve conduction at the elbow reported?
Nerve conduction is reported as velocity in meters per second (m/s).

What is a clinically signi cant decrease in velocity at the elbow?
A decrease in velocity o 10 m/s or more is considered clinically signi cant.

What is the di erence between compressive neuropathies and peripheral neuropathies?
In peripheral (systemic) neuropathies, the nerve conduction is decreased di usely both proximally and distally in
multiple nerves. In compressive neuropathies nerve conduction is decreased distal to the site o compression.

What are typical electromyography (EMG) ndings or long-standing nerve compression and axonal damage?
EMG will demonstrate wide biphasic brillation potentials in the presence o long-standing nerve compression
with axonal damage.

What is double crush syndrome?
T e double crush syndrome hypothesizes that a site o proximal nerve compression in series with a site o distal
compression o the same nerve results in clinical neuropathy; whereas independently, neither site o compression is
severe enough to result in clinical neuropathy.
Nerve Compression
Syndromes
CHAPTER 34

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What is the treatment o choice or an ulnar neuroma-in-continuity with intact motor unction?
T e current optimal therapy involves micro-dissection o the neuroma using electrostimulation to identi y and
preserve motor ascicles. En bloc resection o the neuroma is inappropriate, as this would sacri ce intact nerve ascicles.

What are some nonsurgical modalities that can be used to desensitize an amputation stump neuroma?
Vibration, massage, and transcutaneous nerve stimulation.

What is complex regional pain syndrome?
Complex regional pain syndrome (CRPS) is recognized as a constellation o symptoms including pain at rest,
vasomotor instability, and swelling that results in unctional impairment o the a ected hand or limb. It is usually
the result o previous limb trauma or surgery.

What diagnostic study can help establish the diagnosis o CRPS?
T ree-phase bone scintigraphy has been shown to be highly speci c or the diagnosis o CRPS in the upper limb.
ULNAR NERVE
THORACIC OUTLET SYNDROME

What nerve is a ected with thoracic outlet syndrome (TOS)?
Lower trunk o brachial plexus with symptoms mimicking cubital tunnel syndrome.

What are the contents o the “thoracic outlet”?
Subclavian vein, subclavian artery, and brachial plexus.

In what gender is TOS more prevalent?
Female (3.5:1).

Among the population o patients with cervical ribs, how many are bilateral?
50%.

When do patients with TOS typically get their symptoms (ulnar-sided numbness)?
Patient’s symptoms worsen when their hands are elevated above their head.

What is Adson maneuver?
Dampening o radial pulse with inhalation, neck extension, and head rotation to the a ected side in patients with
OS. T ere are varying descriptions o how to per orm this maneuver.

How accurate is an Adson maneuver?
False positives are very common and thus the Adson maneuver is valued in terms o historical interest only.

What is Wright maneuver?
T e Wright maneuver is reproduction o OS symptoms and/or dampening o radial pulse with arm
hyper-abducted with the patient’s head positioned in neutral or turned contralateral.

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How accurate is Wright maneuver?
T e Wright maneuver is positive in 7% o normal patients thus should be used only to support a diagnosis o
compression in patients with arterial symptoms.

What is Roos maneuver?
T e Roos maneuver involves placing both arms into 90 degrees o abduction and external rotation and the patient
is asked to open and close the hands or 3 minutes. Patients with OS have reproduction o their symptoms, while
those without OS generally experience orearm atigue.

How accurate is Roos maneuver?
O the three maneuvers described, the Roos is the most accurate. However, some patients with carpal tunnel
syndrome (C S) and no OS will develop symptoms limited to the median nerve distribution.

What are the electrodiagnostic testing results seen with TOS?
Negative EMG or ulnar nerve, positive somatosensory-evoked potentials with arm in o ending position.

What is the rst-line therapy or TOS?
Conservative treatment with exercises to strengthen the shoulder girdle, weight loss, and occasionally breast
reduction in women are rst line.

Name the two approaches to the thoracic outlet.
Supraclavicular and transaxillary.

What is similar and what is di erent about the presentation o TOS and cubital tunnel syndrome?
Both OS and cubital syndrome can present with ulnar distribution numbness, although OS also presents with
medial orearm numbness whereas cubital tunnel syndrome does not.
CUBITAL TUNNEL COMPRESSION

How do you tell the di erence between ulnar nerve compression at the cubital tunnel rom compression at
the wrist (Guyon canal)?
Diminished sensation on the dorsoulnar hand is present with cubital tunnel syndrome. T is is due to the act that
the dorsal sensory branch o the ulnar nerve exits the ulnar nerve approximately 7 cm proximal to the pisi orm, to
provide sensation to the dorsoulnar hand.

What is the distribution o motor weakness seen with cubital tunnel syndrome?
Motor weakness is seen in the f exor digitorum pro undus (FDP) o ring and small ngers, as well as the ulnar
intrinsic muscles.

Describe Froment sign.
With ulnar nerve palsy, patients compensate or lack o adductor pollicis (ulnar innervated) unction by f exing the
thumb interphalangeal (IP) joint (pinch power is then provided entirely by the median-innervated f exor pollicis
longus [FPL]).

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What are potential sites o ulnar nerve compression?
See Figure 34-1.
1. Arcade o Struthers—an upper arm ascial arcade through which the nerve passes. Present in 70% o patients.
2. Intermuscular septum between the brachialis and medial head o triceps. Can cause compression even in the
absence o arcade o Struthers so they are distinct.
3. Medial head o triceps—can cause compression by triceps hypertrophy (bodybuilders) or anterior subluxation
o the ulnar nerve over medial epicondyle.
4. Osborne ligament—Most common site o ulnar nerve compression. T is is a ascial arcade ormed between the
two heads o the f exor carpi ulnaris (FCU).
5. Flexor-pronator aponeurosis—a ascial band between the f exor digitorum super cialis (FDS) and the FDP.
6. Guyon canal—Second most common site o ulnar nerve compression. Located at the wrist (see Fig. 34-1).
Figure 34-1 Potential sites o ulnar compression.
Triceps (medial head)
Arcade of Struthers
Brachialis
Ulnar nerve
Intermuscular
septum
Osborne
ligament
Flexor carpi
ulnaris
Guyon canal

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Where is the arcade o Struthers?
Located 8 cm proximal to the medial epicondyle o the elbow.

What are the boundaries o the cubital tunnel?
Floor—medial collateral ligament o elbow (spans rom medial epicondyle to olecranon).
Roo —Osborne ligament.
Sides—medial epicondyle and olecranon (to which the above two structures attach).

Explain why the elbow hyperf exion test elicits symptoms o cubital tunnel syndrome?
Elbow f exion increases the distance the ulnar nerve has to travel to traverse the elbow.
ry it yoursel : Palpate your own olecranon and medial epicondyle with your elbow extended. Now f ex your
elbow and notice how the distance between them grows, tightening Osborne ligament and compressing the nerve.

How sensitive is electrodiagnostic testing at the elbow?
Electrodiagnostic testing has a 50% alse-negative rate or nerve compression at the elbow.

What is a Martin–Gruber anastomosis, and what is its signi cance in relation to cubital tunnel syndrome?
Naturally occurring anatomic variant involving an interconnection between the median and ulnar nerves at the
level o the orearm. T e presence o this anomalous interconnection can result in spared intrinsic muscle unction
with cubital tunnel syndrome (because the median nerve innervates the intrinsics in this situation).

What is a Riche–Cannieu anastomosis?
Naturally occurring anatomic variant involving an interconnection between the median and ulnar nerve in the
hand, typically the deep or motor branch o the ulnar nerve. Again, there may be con usion or the examiner as
muscles usually innervated by the ulnar nerve continue to unction.

What are the key steps involved in anterior submuscular ulnar nerve transposition?
Release o FCU origin, transposition o ulnar nerve anterior to medial epicondyle, resuturing o FCU to
epicondyle.

Must you do a submuscular transposition o the nerve when per orming a cubital tunnel release?
Maybe not. In 1957, Geo rey Osborne, a British orthopedic surgeon, reported 13 cases o cubital tunnel
syndrome in which he released the ligament or band that now bears his name noting that it was tight in elbow
f exion but lax in extension. T ese patients did no di erently than those patients having a ormal transposition.
Several studies since then have supported this nding.

What is the other common ulnar nerve transposition method?
T e ulnar nerve may be transposed subcutaneously.

What is a common postoperative complication o ulnar nerve surgery at the cubital tunnel that generally
results in a pain ul incision?
Injury to the medial antebrachial cutaneous nerve can result in pain ul neuroma ormation.

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What are the boundaries o the Guyon canal?
Roo : volar carpal ligament proximally and palmaris brevis distally.
Floor: transverse carpal ligament.
Ulnar wall: pisi orm.
Radial wall: less well established, although some consider the hamate hook the radial border despite the act that
in many specimens the ulnar neurovascular bundle lies palmar or even radial to the hamate hook.

What are the usual causes o ulnar tunnel syndrome?
Ganglions, trauma (hamate ractures), tumors, vascular anomalies, arthritis.

What is the distribution o numbness with ulnar tunnel syndrome?
Small and ring ngers, but not dorsum o hand (because dorsal sensory branch originates proximal to the Guyon canal).

How does the motor examination di er between ulnar nerve compression at the wrist and the elbow?
Ulnar nerve compression at the wrist a ects pinch strength but not grip strength; compression at the elbow a ects
both pinch and grip strength.

In general, what is the treatment or ulnar tunnel syndrome?
Exploration o the Guyon canal, decompression o nerve, removal o space-occupying lesion(s), and ulnar artery
reconstruction (i necessary). It is important to palpate or masses intraoperatively as they are responsible or 30%
to 45% o all cases o ulnar tunnel syndrome.

What ligaments must be released when surgically treating ulnar tunnel syndrome?
Release the pisohamate ligament and volar carpal ligament.

In what portion o the ulnar nerve cross-section is the motor ascicle at the level o the wrist?
Ulnar and dorsal.
MEDIAN NERVE

What are the syndromes associated with median nerve compression?
1. Pronator syndrome
2. Anterior interosseous syndrome
3. C S

What conditions are associated with an increased incidence o CTS?
Most cases o C S are idiopathic, but it can be associated with pregnancy, diabetes, alcoholism, arthritis,
amyloidosis, or thyroid disorders.

How o ten is CTS bilateral?
60% o cases o C S are bilateral.

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What are the borders o the carpal tunnel?
1. Roo —transverse carpal ligament
2. Floor—carpal bones and their ligaments
3. Radial wall—trapezium and scaphoid tubercle
4. Ulnar wall—hook o hamate

Describe the classic symptoms o CTS.
Classic symptoms o C S are numbness in the median nerve distribution (index, middle, radial side o ring
nger), weakness, nocturnal pain, and relie o symptoms while wearing a wrist brace.

What are the structures thought to cause e ort-associated CTS (i.e., symptoms seen with repetitive gripping)?
Lumbrical muscles. T ey originate rom the FDP tendons and reside within the carpal tunnel during gripping
activities which can exacerbate C S.

What is Phalen’s test?
Wrist is passively dropped into f exion. I symptoms are seen within 30 seconds, the test is positive.

What is the most sensitive physical examination maneuver or diagnosis o CTS?
Carpal compression test.

How are results o the carpal compression test reported?
Report the result o the carpal compression test in number o seconds rom initiation o thumb pressure over the
carpal tunnel (pressure should only be hard enough to make examiner’s thumb blanch).

What electrodiagnostic study results signi y median nerve conduction changes?
Median nerve latency increase o 10% or more above that o the ulnar nerve.

What electrodiagnostic study result signi es muscle denervation with CTS?
Fibrillation potentials in the abductor pollicis brevis signi y muscle denervation.

What is the earliest one might expect to see electromyographic changes a ter suspected nerve damage?
EMG studies will typically be altered around 2 to 3 weeks a ter the nerve injury.

What is the success rate o steroid injections or CTS?
Only approximately 20% to 22% o patients get long-term (> 18 months) relie .

Where is the median nerve located in the proximal orearm?
Between the super cial (humeral) and deep (ulnar) heads o the pronator teres muscle.

Where is the motor ascicle o the median nerve cross-section at the wrist?
Radial and volar. T is should be easy to remember since the recurrent motor branch o the median nerve comes
o o the main nerve radially and palmarly. In addition, remember that the median nerve motor ascicle (radial,
volar) is the direct opposite o the ulnar nerve motor ascicle (ulnar, dorsal).

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What is Kaplan’s line and how is it used to determine the position o the motor branch o the median nerve?
Kaplan’s line is a line drawn as an extension along the ulnar border o the abducted thumb. T e intersection o
Kaplan’s line and one drawn longitudinally rom the index–middle nger web space is the rough approximation o
the entrance o the recurrent motor branch o the median nerve into the thenar musculature.

What are the patterns o the route o the motor branch to the thenar musculature in relation to the
transverse carpal ligament?
Extraligamentous (approximately 50%), subligamentous (30%), and transligamentous (20–25%).

Which muscles are innervated by the motor branch o the median nerve in the hand?
1. Opponens pollicis
2. Flexor pollicis brevis
3. Abductor pollicis brevis
4. wo radial lumbrical muscles

What are the advantages o endoscopic carpal tunnel release when compared with the open technique?
Early postoperative di erences include decreased scar tenderness, and earlier restoration o grip and pinch
strength. A ter 3 months postoperatively, there are no di erences.

What has been demonstrated as the chie disadvantage o endoscopic carpal tunnel release when compared
to open?
Endoscopic carpal tunnel release carries a slightly higher incidence o reversible nerve injury like neuropraxia and
numbness.

Which outcomes between endoscopic and open carpal tunnel release have been ound to be equivocal?
Pain and return to work.

Is internal neurolysis indicated during routine carpal tunnel decompression?
No.

During secondary surgery or recurrent CTS, where should the incision be made?
A new incision should be made more ulnar to the previous scar because the median nerve is adherent to or within
the transverse carpal ligament.

What are sites o median nerve compression in the elbow/ orearm?
1. Ligament o Struthers—ligament located between humeral supracondylar process and medial epicondyle
2. Lacertus brosis—aka bicipital aponeurosis—a ascial band between the biceps tendon and the ascia o the
f exor pronator mass
3. wo heads o the pronator teres
4. FDS brous arch

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How can one speci cally test or median nerve compression at the ligament o Struthers?
T e symptoms are exacerbated when f exing the elbow against resistance.

How can one speci cally test or median nerve compression at the pronator teres?
Have the patient ully extend their elbow and pronate their orearm while the examiner introduces resistance to
patient pronation. With resisted pronation, symptoms are exacerbated. T e elbow must be ully extended to avoid
con usion with compression by the bicipital aponeurosis.

How can one speci cally test or median nerve compression at the FDS arch?
Long nger f exion test: with resisted f exion o the long nger, the FDS arch compresses the median nerve, and
symptoms are exacerbated.

What is a Gantzer muscle?
An accessory head o the FPL originating rom the medial humeral epicondyle and possibly the coronoid process o
the ulna. T is muscle is ound in up to 45% o specimens and can contribute to compression o the median nerve.

What is the chie di erence between the pronator syndrome and the anterior interosseous nerve (AIN)
syndrome?
De cits in pronator syndrome are sensory, whereas AIN syndrome demonstrates motor de cits.

What are the symptoms o the pronator syndrome?
Pain in orearm, numbness in median nerve sensory distribution (thumb, index, and middle ngers).

What muscles are innervated by the AIN?
1. FPL
2. Pronator quadratus
3. FDP to index nger
4. FDP to middle nger (this varies between the AIN and ulnar nerve depending on the patient)

What are the symptoms o AIN syndrome?
Loss o precision pinch (cannot f ex thumb IP or index DIP) and pain in the orearm relieved by rest are the classic
symptoms o AIN syndrome.

What can patients with AIN syndrome NOT do?
Make an “OK” sign. T ey cannot f ex their thumb IP or index DIP joints.

Is there a di erence in the surgical treatment o AIN syndrome and pronator syndrome?
No. In both cases the nerve is explored completely and released rom all compressing structures rom the elbow to
the distal orearm.