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What is the most common site o radial nerve compression?
Supinator muscle ascia (aka the arcade o Fröhse).

Where is the radial tunnel?
It runs rom the radial head to the distal edge o the supinator; the biceps tendon is the medial wall, and the
ECRL and ECRB origins orm the lateral wall.

How is the radial nerve approached in the dorsal orearm?
T e radial nerve can be approached between the ECRB and the extensor digitorum communis.

What are the symptoms o radial tunnel syndrome?
Lateral elbow pain, especially with repetitive elbow extension. Motor ndings are usually absent.

What physical examination nding di erentiates radial tunnel syndrome rom lateral epicondylitis?
enderness 4 cm distal to lateral epicondyle (between brachioradialis and ECRL) is seen with radial tunnel
syndrome.

Is there typically a sensory component to PIN syndrome?
No. T e PIN innervates the extensors, and there ore results in weakness and pain, but not sensory de cits.

What is the di erence between radial tunnel syndrome and PIN compression?
In radial tunnel syndrome symptoms involve pain over the dorsoradial orearm near the elbow. T ere is rarely
weakness.
In PIN compression symptoms include weakness o the thumb and nger extensors AS WELL AS pain.

Is it common to see electrodiagnostic changes with radial nerve compression?
O ten the EMG/NCS is normal, thus electrodiagnostic studies are o little use in evaluating radial nerve
compression. Diagnosis is o ten based solely on history and physical examination.

What is the role or surgery in PIN syndrome and radial tunnel syndrome?
Radial tunnel syndrome should be initially managed nonoperatively (muscle palsy is not seen with this syndrome);
PIN syndrome should be treated operatively to prevent permanent muscle palsy.

What is the vascular leash o Henry?
T e vascular leash o Henry is a network o radial recurrent vessels at the elbow that can compress the PIN, the
radial sensory nerve, or both.

What is Wartenberg syndrome?
Wartenberg syndrome is a compression neuropathy o the radial sensory nerve due to entrapment between the
brachioradialis and ECRL. Other names include super cial radial neuritis or “cheiralgia paresthetica.”

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What can cause Wartenberg syndrome?
It is generally caused by external compression (handcu s), tight watch, surgical scarring, or repetitive activities.

What is Wartenberg sign?
Wartenberg sign indicates ulnar neuropathy and is seen when the small nger is unable to adduct. T e patient is
unable to hold the small nger against the ring nger with the ngers in extension due to the unopposed action
o the radially innervated extensor digiti minimi. T e ulnarly innervated palmar interossei is weak and unable to
adduct the small nger.

How does one di erentiate radial sensory nerve compression rom de Quervain extensor tenosynovitis in the
presence o a positive Finkelstein sign?
Resisted thumb extension with the wrist held in neutral causes pain in tendinitis but not in nerve entrapment.

What is Volkmann’s contracture?
Volkmann’s contracture is the sequelae o orearm compartment syndrome generally ollowing a supracondylar
humerus racture that results in a severely contracted orearm and hand. Generally the orearm is xed in
pronated, the wrist is f exed, MCP joints are hyperextended and the IP joints are f exed orming a non unctional
claw hand.

How high must orearm compartment pressures be and or how long in order to develop Volkmann’s
contracture?
Compartment pressures > 30 mm Hg or at least 6 to 12 hours generally are necessary to result in sequelae o
Volkmann’s contracture.

What muscles are most at risk o ischemic sequelae with orearm compartment syndrome?
T e FDP muscle within the deep muscle compartment is most at risk o the sequelae o ischemia.

What is the treatment o Volkmann’s contracture?
Moderate Volkmann’s contractures are treated with operative exploration o the orearm with neurolysis o the
median and ulnar nerves as well as a muscle slide tendon-lengthening procedure.
REFERENCES
Botte MJ, Keenan MA, Gelberman RH. Volkmann’s ischemic contracture o the upper extremity. Hand Clin. 1998;14(3):483–497
Botte MJ. Nerve anatomy. In: Doyle JR, Botte MJ, eds. Surgical Anatomy of the Hand and Upper Extremity. 1st ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2003:185–236.
Durkan JA. A new diagnostic test or carpal tunnel syndrome. J Bone Joint Surg Am. 1991;73(4):535–538.
Fitzgerald B , Dao KD, Shin AY. Functional outcomes in young, active duty military personnel a ter submuscular ulnar nerve
transposition. J Hand Surg Am. 2004;29(4):619–624.
Heitho SJ. Cubital tunnel syndrome does not require transposition o the ulnar nerve. J Hand Surg Am. 1999;24(5):898–905.
Lowe JB III, Mackinnon SE. Management o secondary cubital tunnel syndrome. Plast Reconstr Surg. 2004;113(1):1e-16e.
Lowry WE Jr, Follender AB. Inter ascicular neurolysis in the severe carpal tunnel syndrome. A prospective, randomized, double-blind,
controlled study.Clin Orthop Relat Res. 1988;227:251–254.

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Nath RK, Mackinnon SE. Management o neuromas in the hand. Hand Clin. 1996;12(4):745–756.
Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. 1998;6(5):282–288.
Szabo RM. Entrapment and compression neuropathies. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand
Surgery. 4th ed. Philadelphia, PA: Churchill Livingstone; 1993:1404–1447.
T oma A, Veltri K, Haines , Duku E. A meta-analysis o randomized controlled trials comparing endoscopic and open carpal tunnel
decompression. Plast Recon Surg. 2004;114(5):1137–1146.
T oma A, Veltri K, Haines , Duku E. A systematic review o reviews comparing the e ectiveness o endoscopic and open carpal tunnel
decompression. Plast Reconstr Surg. 2004;113(4):1184–1191.
rumble E. Compressive neuropathies. In: rumble E, ed. Principles of Hand Surgery and T erapy. 1st ed. Philadelphia, PA: WB
Saunders; 2000:324–341.
Wüppenhorst N Maier C, Frettlöh J, Pennekamp W, Nicolas V. Sensitivity and speci city o 3-phase bone scintigraphy in the diagnosis
o complex regional pain syndrome o the upper extremity. Clin J Pain. 2010;26(3):182–189.
Żyluk A, Puchalski P. Complex regional pain syndrome o the upper limb: a review. Neurol I Neurochir Pol. 2014;48:200–205.

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327
Pieter G.L. Koolen, MD,
John B. Hijjawi, MD, FACS, and
Samuel J. Lin, MD, MBA, FACS

What three structures provide the greatest stability to the proximal interphalangeal (PIP) joint?
T e three-sided box con guration o the medial and lateral collateral ligaments and the volar plate.

What is the classi cation o Mallet ractures o the nger?
ype 1: closed tendon avulsion with or without racture
ype 2: laceration with extensor tendon disruption
ype 3: open injury with loss o skin and tendon substance
ype 4: physeal racture in children

What is the treatment o choice or a displaced racture o the dorsal base o the distal phalanx comprising
over 25% o the articular sur ace?
Operative intervention with closed or open reduction and internal xation.

What is the treatment o choice or a volar base racture o the distal phalanx with loss o the exor
digitorum pro undus insertion?
Open reduction and internal xation.

What is the acceptable angulation or metacarpal sha t ractures (index, middle, ring, and little)?
1. Index metacarpal: 10 to 15 degrees
2. Middle metacarpal: 10 to 15 degrees
3. Ring metacarpal: 30 to 35 degrees
4. Small metacarpal: 40 to 45 degrees

What is the most likely direction o angulation o an unstable transverse metacarpal sha t racture?
Apex dorsal angulation due to the volar directed pull o the interosseous muscles.
Hand Fractures/
Dislocations
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What are some indications or operative xation o phalangeal and metacarpal ractures?
• Malrotation
• Irreducible ractures
• Intra-articular ractures
• Open ractures
• Fractures with bone loss
• Fractures with associated tendon, vascular or nerve injury
• Polytrauma patients

How does one assess or malrotation in phalangeal and metacarpal ractures?
T e hand is assessed with the ngers in extension and exion. In extension the ngers should be parallel and
in exion they should all point toward the scaphoid tuberosity. Malrotation would present as subtle overlap or
scissoring o the ngers.

What is the number one complication o operatively treated phalangeal ractures?
Digital stif ness.

What is the most likely block to reduction in a complex dorsal dislocation o the metacarpophalangeal
(MCP) joint?
Volar plate.

What two structures act as a noose around the metacarpal head in an irreducible (complex) dorsal
dislocation o the index MCP joint?
T e exor tendons (ulnarly) and the lumbricals (radially) maintain a tight encirclement around the narrow neck o
the metacarpal preventing reduction.

In a Bennett racture, what is the de orming orce that causes proximal migration o the thumb metacarpal?
Abductor pollicis longus.

What is a Stener lesion?
A Stener lesion is ormed when the distally avulsed ulnar collateral ligament o the thumb MCP joint comes to lie
dorsal to the leading edge o the adductor aponeurosis.

What are the most reasonable treatment options or a racture/dislocation o the PIP joint with a severely
comminuted volar base racture o the middle phalanx involving 40% o the joint sur ace?
Volar plate arthroplasty or Suzuki-type dynamic external xation/traction.

In volar dislocation o the PIP joint, what commonly associated injury must be examined or?
Rupture or avulsion o the extensor tendon central slip.

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What is the treatment or a th metacarpal neck racture (Boxer racture) with 40 degrees o apex dorsal
angulation?
40 degrees is the maximal angulation acceptable; however, some would suggest attempted closed reduction to
improve angulation and ulnar gutter splinting.

What is the most common carpal bone ractured?
Scaphoid ractures account or 80% o all carpal bone ractures.

Describe the anatomy o the major blood supply to the scaphoid.
T e major blood supply is rom branches o the radial artery that enter the dorsal ridge o the scaphoid (distal to
the scaphoid waist). T is blood supply accounts or 70% to 80% o the total blood supply o the scaphoid and
100% o the blood supply to the proximal pole.

What is snuf box tenderness?
enderness on palpation o the anatomic snuf box (interval between the tendons o the rst and third dorsal
compartments distal to the radial styloid), which may indicate racture o the scaphoid.

What is a scaphoid humpback de ormity?
T e apex dorsal angulation seen with a scaphoid waist nonunion or malunion. T e distal scaphoid ragment
angulates volarly and the proximal scaphoid ragment extends with the lunate.

What type o carpal instability is seen most commonly with a malunited scaphoid (humpback de ormity)?
Dorsal intercalated segment instability is visualized on a lateral radiograph as the proximal scaphoid ragment
extends with the lunate.

What is the de nition o scaphoid racture displacement or instability?
• Presence o a racture gap o greater than 1 mm on any radiographic projection
• Scapholunate angle o greater than 60 degrees
• Radiolunate angle o greater than 15 degrees
• Intrascaphoid angle o greater than 30 degrees

What is the space o Poirier?
A palmar area o inherent capsular weakness between the capitate and lunate, which is torn in perilunate injuries
creating a capsular rent across the midcarpal joint.

What is May eld’s progressive sequence o perilunate disruption or dislocation?
Stage I: disruption o the scapholunate interosseous ligament complex
Stage II: disruption through the space o Poirier and the lunocapitate interval
Stage III: disruption o the lunotriquetral ligament complex and resultant separation o the entire carpus rom the
lunate
Stage IV: dislocation o the lunate rom its ossa in to the carpal tunnel

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What is a “lesser arc” injury?
T is type o injury re ers to a purely ligamentous disruption around the lunate.

What is a “greater arc” injury?
T is type o injury re ers to disruption around the lunate that involves ractures o some or all o the carpal bones.

What is the most common “greater arc” injury?
A trans-scaphoid perilunate racture—dislocation.

What is the normal intracarpal angle between the scaphoid and lunate (scapholunate angle)?
Between 30 and 60 degrees.

What is the most sensitive and speci c test or assessment o posttraumatic avascular necrosis o the
scaphoid?
Magnetic resonance imaging—MRI with gadolinium.

What is scaphocapitate syndrome?
Fracture o the neck o the capitate with rotation o the proximal ragment in association with a scaphoid waist
racture.

What is carpal instability dissociative?
Re ers to intrinsic ligament disruptions that occur between carpal bones o the same carpal row (i.e., scapholunate
dissociation caused by a scapholunate ligament tear).

What is carpal instability nondissociative?
Re ers to extrinsic ligament disruptions that occur between carpal rows (i.e., midcarpal instability).

What is Watson scaphoid shi t test?
T e test assesses or scapholunate ligament dissociation. T e examiner applies dorsally directed thumb pressure
over the patient’s distal scaphoid tubercle. I the SL ligament is torn, pain is elicited when the proximal pole o the
scaphoid subluxates dorsally out o the scaphoid ossa o the radius as the patient’s hand is passively moved rom
ulnar deviation to radial deviation.

What is a erry-T omas sign?
Increased gap between the scaphoid and lunate, greater than 3 mm, indicative o a scapholunate dissociation.

On a PA wrist radiograph, what are ndings o scapholunate dissociation?
• erry-T omas sign
• Cortical ring sign
• Reduced carpal height
• riangular shaped lunate
• Foreshortened scaphoid

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What are Gilula lines?
Gilula et al. described three smooth curved lines on a PA projection o the carpus. T e rst line represents the
proximal cortical sur aces o the proximal carpal row. T e second line represents the distal cortical sur aces o the
proximal carpal row and the third line represents the proximal cortical sur aces o the distal carpal row. A step-of
or disruption in any o these lines may indicate carpal malalignment or instability.

What radiographic projection would best visualize a hook o hamate racture?
Carpal tunnel pro le view.

What is the treatment o choice or a symptomatic hook o hamate nonunion?
Excision o the hamate hook.

What is the “sa e” position o immobilization or the hand?
T e “sa e” position or the intrinsic-plus position o James is 70 degrees o MCP joint exion and ull IP joint
extension.

What is the Salter–Harris classi cation o physeal injuries?
Salter–Harris classi cation:
ype I: transverse racture through the physis
ype II: racture through the physis with a metaphyseal ragment
ype III: racture through the physis and in to the epiphysis (intra-articular)
ype IV: racture through the physis, epiphysis, and metaphysis
ype V: crush injury o the physis

What radiographic projections would best visualize the position o a screw in the proximal pole o the
scaphoid?
o best visualize the proximal pole, an ulnar-deviated posteroanterior view and a true lateral radiograph.

What is the treatment o choice or a scaphoid racture that is 1.5 mm displaced?
Open reduction and internal xation with a compression screw.

What is an important actor to consider, other than the degree o intra-articular step, when deciding to
operate on a bony mallet nger?
Distal phalanx subluxation.

What is the most likely direction o a CMC dislocation o the thumb?
Dorsal.

What is the most likely direction o angulation o an unstable transverse proximal phalanx sha t racture?
Proximal phalangeal ractures, typically angulated apex volar.

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What is the structure at risk when treating a hook o hamate nonunion?
Motor branch o the ulnar nerve.

rans-trapezium, trans-hamate peri-pisi orm, and peri-hamate trans-triquetrum are all examples o which
carpal instability pattern?
Longitudinal or axial carpal instability.

What is the “Jahss maneuver”?
T e maneuver used or reduction o metacarpal neck ractures with MP and PIP joints exed to 90 degrees.
REFERENCES
Amadio PC, aleisnik J. Fractures o the carpal bones. In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill
Livingstone; 1999:809–864.
Garcia-Elias M. Carpal instabilities and dislocations. In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill
Livingstone; 1999:865–928.
Glickel SZ, Barron OA, Eaton RG. Dislocations and ligament injuries in the digits. In: Green DP, ed. Operative Hand Surgery. 4th ed.
New York, NY: Churchill Livingstone; 1999:772–808.
Henry M. Fractures and dislocations o the hand. In: Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults. 5th ed.
Philadelphia, PA: Lippincott Williams and Wilkins; 2001:655–748.
Seitz WH, Papandrea RF. Fractures and dislocations o the wrist. In: Bucholz RW, Heckman JD, ed. Rockwood and Green’s Fractures in
Adults. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001:749–814.
Stern PJ. Fracture o the metacarpals and phalanges. In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill
Livingstone; 1999:711–771.

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Steven L. Henry, MD, FACS
ANATOMY AND PHYSIOLOGY

From where do tendons receive their nourishment?
In the orearm, rom vessels in the paratenon.
In the hand, rom the vincular vessels (intrinsic system) and rom the synovial uid (extrinsic system) within the
tendon sheath.

Which source is more important to the tendons in the hand?
Synovial uid.

What are the vincula?
Folds o mesotendon containing blood vessels. Each tendon (Flexor digitorum super cialis [FDS] and Flexor
digitorum pro undus [FDP]) has two vincula, a short vinculum distally and a long vinculum proximally, that enter
the dorsal sur ace o the tendons.

What are the source vessels o the vincula?
T e transverse digital arteries, which enter the bro-osseous tunnel at the levels o the cruciate pulleys.

How is the short vinculum o the super cialis tendon related to the long vinculum o the pro undus tendon?
T ey cross each other at the distal P1 level.

How many pulleys are there in the ngers?
Eight ( ve annular and three cruciate).

What e ect do the pulleys have?
T ey prevent bowstringing o the exor tendons in exion, increasing the e ective excursion o the tendons and
thus the degree o nger exion. T eoretically, a nger with bowstringing exor tendons will actually ex with
greater strength because the orce vector is arther rom the joint axis, but will not be able to ex ully.
Tendon Injuries
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Which pulleys are the most important in the ngers, and where are they located?
• A2, at the proximal part o the proximal phalanx
• A4, at the middle part o the middle phalanx

T e interval between which annular ligaments has no cruciate ligament?
Between A1 and A2. T e rst cruciate ligament lies between A2 and A3.

How many pulleys are there in the thumb?
T ree:
• A1 at the MP level
• Oblique at the P1 level
• A2 at the IP level
T e oblique and A2 pulleys are the most important in the thumb.

What comprises the f oor o the bro-osseous tunnel?
T e periosteum o the phalanges and the volar plates o the MP and PIP joints.

What lies immediately volar to the volar plate o the PIP joint?
FDS tendon.

Describe the orientation o the FDS tendons within the carpal tunnel.
T e tendons o the index and small ngers are dorsal to the tendons o the long and ring ngers.
FLEXOR TENDONS

Describe the boundaries o the ve f exor zones o the ngers.
Zone I: Distal to the insertion o FDS on P2.
Zone II: Within the bro-osseous tunnel ( rom the A1 pulley to the FDS insertion).
Zone III: T e area o the palm between the carpal tunnel and the bro-osseous tunnel.
Zone IV: Within the carpal tunnel.
Zone V: Proximal to the carpal tunnel.

What are the two main de cits resulting rom zone I tendon laceration?
Loss o DIP exion and diminution o grip strength.

What provides the stronger repair in zone I injuries—suturing o tendon ends together or anchoring o
tendon end directly to bone?
Anchoring directly to bone.

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What is the arthest the FDP tendon should be advanced to achieve direct anchoring to bone?
1 cm.

What is a jersey nger?
Avulsion o the FDP tendon rom its insertion on P3 (an injury that might occur when a ootball player reaches
out to grab an opponent’s jersey).

What nger is most commonly a ected, and why?
T e ring nger, because:
1. It has the weakest FDP insertion.
2. It is the most protruding nger when the hand is in the grasping position.
3. T e juncturae tendinae prevent independent extension o the ring nger (much more so than the other
ngers).
4. T e common muscle belly o FDP prevents independent relaxation o the FDP tendon.

Describe the our types o FDP avulsion injuries.
ype I: endon retracts into palm.
ype II: endon retracts to level o PIP.
ype III: endon avulsed with large bony ragment, which catches at A4.
ype IV: Large bony ragment, with avulsion and retraction o tendon rom ragment.

Which type o FDP avulsion is most common? Which has the best prognosis? T e worst?
Most common: type II.
Best prognosis: type III.
Worst prognosis: type I and type IV.

What is the lumbrical plus de ormity?
I an injured FDP tendon retracts into the palm (type I avulsion), the lumbrical (which originates on the FDP
tendon) will be under tension, creating an extension orce on the IP joints. When one attempts to make a st,
the FDP tendon will place even greater tension on the lumbrical, paradoxically extending the nger. T is can also
happen i an FDP tendon in the nger is reconstructed with a tendon gra t that is too long.

Why must type I FDP avulsion be repaired without signi cant delay?
Because both the vincular and synovial nutritional supplies have been disrupted.

What holds the FDP tendon at the level o the PIP in a type II FDP avulsion?
T e vincula.

A heavy laborer sustained a type I FDP avulsion 1 month ago. What treatment should be considered?
DIP usion, i the joint is symptomatically unstable or pain ul. Attempt at repair would likely result in worse
sti ness.

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Where is a zone II f exor tendon laceration usually located with respect to the skin laceration?
Distal (the nger is usually exed at the time o injury).

I the vinculum is ruptured in a zone II injury, to where will the tendon usually retract?
o the palm, held in place by the lumbrical.

How can the tendon be retrieved rom the palm?
A rubber catheter or in ant eeding tube is guided down the tendon sheath rom the site o injury in retrograde
manner. An incision is made at the distal palmar crease, and the catheter is retrieved rom the proximal end o the
bro-osseous tunnel. T e tendon is attached to the catheter and pulled back into the tunnel.

What can happen i the FDP tendon is repaired but the FDS is not?
Higher risk o rupture o the FDP repair, loss o dexterity and grip strength, and hyperextension de ormity at the
PIP.

When should f exor tendon lacerations be repaired?
Flexor tendons should be repaired within a ew days, i reasonably possible. Success ul tendon healing may be
possible a ter a delay o several weeks i the vincular or synovial nutritional supplies are intact; however, scarring
within the tendon sheath and/or myostatic contracture o the muscle belly may preclude primary repair i surgery
is delayed beyond 10 to 14 days.

How many core suture strands are ideal?
Good question! It depends on the suture technique and the size/material o the suture. In general, more strands
are stronger, but many strands can increase the bulk at the repair site and can be dif cult to place in small tendons.
In the author’s opinion, a locking technique using 4-0 Fiberwire suture with 4 core strands is adequate to permit
early active motion.

How ar rom the cut edge o the tendon should the core suture purchase be?
Roughly 1 cm. Placing the suture closer to the edge weakens the repair, while placing it arther rom the edge
causes excessive bunching at the repair site.

What percentage o the total strength o a tendon repair is attributable to the epitendinous suture?
Approximately 20%.

Following repair, when does tendon rupture most commonly occur?
Around the 10th postoperative day.

How should the patient be splinted immediately ollowing f exor tendon repair?
T e wrist should be held in approximately 30 degrees o exion, the MPs in 50 to 70 degrees o exion, and the
IPs in ull extension.

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When should passive range-o -motion exercises be initiated ollowing f exor tendon repair? Active range o
motion?
Passive: as soon as possible.
Active: depends on the strength o the repair. I a strong repair is achieved (i.e., at least our core suture strands),
active motion can be started immediately. I not, about 4 weeks.

How is a splint constructed to permit active extension and passive f exion?
A rubber band is attached to the nail o the involved nger and to the splint in the region o the distal volar
orearm. T e wrist is held in neutral and the MP is blocked at 60 to 70 degrees o exion. T e rubber band
passively pulls the nger into exion, and provides resistance against active IP extension. (T e nger exors are
re exively inhibited when the nger extends against resistance.)

What are the most important prerequisites to f exor tendon gra ting?
Full passive range o motion and intact exor sheath.

What are the most common donor sites or f exor tendon gra ts?
Palmaris longus, plantaris, and the long toe extensors.

Where is plantaris with respect to the Achilles tendon?
Anterior and medial.

In reconstructing a zone II FDP injury with a gra t, how can the appropriate length o the gra t be
determined?
By matching the cascade o the injured digit with its uninjured neighbors. Additionally, per orming the surgery
under local anesthesia allows assessment o tendon balance with active exion.

What can happen i the gra t is too long?
Lumbrical plus de ormity, in which attempts to ex the nger cause paradoxical extension o the interphalangeal
joints.

What is quadriga syndrome?
I one FDP is tethered or shortened ollowing a repair, the others cannot shorten enough to achieve ull exion.
ry exing your ring nger DIP while holding your long nger in extension with the other hand. Named by
Verdan or the Roman charioteers who controlled teams o our horses with our sets o reins slung over their
backs.

What is the most common complication o tendon gra ting?
Adhesions (and thus, sti ness).

Following a zone II f exor tendon repair, a patient has limited active range o motion and has made little
progress in therapy. When is the earliest that f exor tenolysis should be considered?
At least 3 months o therapy should be attempted prior to per orming tenolysis.

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What is a Hunter rod?
A Hunter rod is a exible silicone implant that is placed within a scarred exor tendon bed. Formation o a
capsule around this implant will create a pseudosheath within which a tendon gra t can later be placed.
EXTENSOR TENDONS

At what level do the extensor tendons lie within a synovial sheath?
At the level o the extensor retinaculum. T e extensor tendons are surrounded only by paratenon at all other levels.

What tendons are present within each o the six extensor compartments?
First

APL, EPB
Second

ECRL, ECRB
Third

EPL
Fourth

EDC, EIP
Fifth

EDQ
Sixth

ECU

Which tendon inserts on the second MC? On the third? On the th?
• ECRL on the second
• ECRB on the third
• ECU on the th

What is the relationship o the proprius tendons (EIP and EDQ) to the communis tendons at the level o the
MPs?
T e proprius tendons lie ulnar to the communis tendons.

T e EDC tendon is o ten missing rom which nger?
T e small nger. In these instances, there are o ten two slips o EDC to the ring nger. T ere may also be two slips
o EDQ to the small nger.

What muscles extend the MP joints?
T e extrinsic extensors (EDC, EIP, and EDQ) are the only muscles that extend the MP joints.

What muscles f ex the MP joints?
Primarily the intrinsic (lumbricals and interossei). T e extrinsic exors (FDP and FDS) have a relatively weak
e ect at the MP joints.

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What muscles extend the IP joints?
When the MPs are exed, the extrinsics extend the IPs. When the MPs are extended, the intrinsics extend the
IPs. Remember that muscles can create little orce i they are not under stretch. When the MPs are extended, the
intrinsics are under stretch and can thus extend the IPs. When the MPs are exed, it is the extrinsics that are under
stretch.

What is the intrinsic minus de ormity?
Extension o the MPs and exion o the IPs, as in the claw de ormity seen with low ulnar nerve palsies. T is is a
good way to remember the unction o the intrinsics (i.e., to ex the MPs and extend the IPs).

A patient sustains a dorsal hand laceration at the mid-metacarpal level, completely transecting the EDC
tendon to the long nger. Yet he is still able to extend the MP joint o the long nger. How is this possible?
T e juncturae tendinae are interconnections between the extensor tendons at the level o the distal metacarpals.
T e juncturae extend in a distal-oblique direction rom the EDC tendon o the ring nger to those o the small
nger and long nger, and rom the EDC tendon o the long nger to that o the index nger. In this case, the
tendon was lacerated proximal to the junctura, which transmits extensile orce rom the ring nger tendon to the
long nger tendon.

Which extensor tendons do not have juncturae?
T e proprius tendons (EIP and EDQ).

What is a relative motion splint?
A yoke splint (think o brass knuckles, except made rom T ermoplast) that allows motion at all joints, but holds
the a ected nger’s MP in relative extension or exion, thereby unloading tension on the extensor or exor
tendon, respectively. T e most common use is or rehabilitation o an EDC repair at the dorsal hand, in which
case the a ected nger is held in relative extension. It works because the EDC tendons have a common muscle
belly, so tension is borne by the other ngers’ tendons rather than the nger held in relative extension.

What are the sagittal bands?
T e sagittal bands are transverse ligamentous structures that pass rom the extensor tendon to the volar plate o the
MP. T eir unction is to hold the extensor tendon in place over the MP. T ey also transmit orce rom the extensor
tendon to the proximal phalanx, thus extending the MP joint. T ey are somewhat analogous to the A1 pulley o
the exor system, except that the sagittal bands undergo proximal and distal excursion with extension and exion
o the MP, much like a bucket handle.

What holds the extensor mechanism in place over the PIP?
ransverse retinacular ligament.

Where is the extensor tri urcation?
Proximal to the PIP, the extensor tendon tri urcates into a central slip and two lateral bands. T e central slip
inserts on the dorsal base o P2, while the lateral bands bypass the PIP and insert on P3.

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Where is the triangular ligament? What does it do?
T e triangular ligament spans the dorsal sur ace o the middle phalanx, connecting the lateral bands to each other.
It helps to prevent the lateral bands rom migrating volarly.

What de ormity results rom laceration o the central slip with preservation and volar migration o the
lateral bands?
Boutonnière de ormity.

What is the oblique retinacular ligament o Landsmeer?
A ligament extending rom the volar aspect o the PIP to the dorsal aspect o the DIP. It unctions to coordinate
exion and extension o the IP joints—i the PIP exes, the ligament relaxes, permitting the DIP to ex; i the PIP
extends, the ligament tightens, helping the DIP to extend. In a long-standing boutonnière de ormity, this ligament
gradually contracts, potentially making the de ormity permanent. T us, resistance to passive exion o the DIP
(Boyes test) is a hallmark o a boutonnière.

How do you splint a patient with a Boutonnière de ormity?
Splint the PIP in extension (either with a static splint i the PIP is passively supple, or a static progressive [spring-
loaded] splint i the PIP has a exion contracture), keeping the DIP ree. T e patient should then actively ex
the DIP, which encourages dorsal migration o the lateral bands and stretching o the ligament o Landsmeer.
Alternatively, a relative motion splint can be used, keeping the a ected MP in relative exion compared to the
other ngers, also encouraging dorsal migration o the lateral bands.

A patient has sustained a complete laceration o the EPL tendon, yet can still extend the IP joint o the
thumb. How is this possible?
T e intrinsics o the thenar eminence insert on the extensor hood and can provide weak extension o the IP. In
addition, the EPB can have a super cial division that inserts on the extensor hood. However, only the EPL can
extend the entire rst ray. T us, i the patient places the palm at on a table, he or she will be unable to li t the
thumb o the table in the presence o a complete EPL laceration.

Describe the zones o injury o the extensor tendons o the ngers.
Odd zones are over joints.
Zones I, III, V, and VII overlie the DIP, PIP, MP, and carpal joints, respectively. Zones II, IV, VI, and VIII overlie
the P2, P1, MC, and distal orearm, respectively.

What can be done to prevent adhesions in the repair o a zone VII extensor tendon laceration?
Excision o the portion o the extensor retinaculum that overlies the repair site.

What is a mallet nger?
Flexion de ormity o the DIP resulting rom loss o continuity o the extensor mechanism.

CHAPTER 36 endon Injuries
341

Describe the classi cation o mallet nger injuries.
ype I: Closed, with or without a small chip racture.
ype II: Open laceration.
ype III: Deep abrasion o skin and tendon substance.
ype IV: P3 racture. T is type includes transepiphyseal racture in children (type IV-A), hyper exion injuries
(type IV-B), and hyperextension injuries (type IV-C). Note that these ractures involve signi cant portions o the
articular sur ace and are not to be con used with the largely irrelevant chip ractures seen in type I injuries.

How are various types o mallet injuries treated?
ype I: Splinting o the DIP in slight hyperextension (no more than 5 degrees) or 6–8 weeks, ollowed by night
splinting or 2 weeks.
ype II: Repair o skin and tendon with a single gure-o -eight suture, ollowed by splinting as above.
ype III: Skin coverage and tendon gra t.
ype IV-A: Closed reduction o the racture, ollowed by extension splinting or 3–4 weeks.
ype IV-B: Extension splinting, with ORIF reserved or cases in which the ragment is signi cantly displaced or
the distal phalanx has subluxated volarly.
ype IV-C: As above.

What can happen i a mallet injury is le t unrepaired?
Hyperextension at the PIP (i.e., swan neck de ormity). T is is because the orce o the extensor tendon is
concentrated only at the PIP, creating PIP hyperextension.
REFERENCES
Britton EN, Kleinert JM. Acute exor tendon injury: repair and rehabilitation. In: Peimer CA, ed. Surgery of the Hand and Upper
Extremity. New York, NY: McGraw-Hill; 1996:1113–1132.
Doyle JR. Extensor tendons–acute injuries. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone;
1988:2045–2072.
Henry SL, Katz MA, Green DP. ype IV FDP avulsion: lessons learned clinically and through review o the literature. Hand(N Y).
2009;4(4):357–361.
Lee SK, Goldstein RY, Zingman A, erranova C, Nasser P, Hausman MR. T e e ects o core suture purchase on the biomechanical
characteristics o a multistrand locking exor tendon repair: a cadaveric study. J Hand Surg Am. 2010;35(7):1165–1171.
Lee WAP, Gan BS, Harris SU. Flexor tendons. In: Russell RC, ed. Plastic Surgery: Indications, Operations, and Outcomes, Vol. IV: Hand
Surgery. St Louis, MO: Mosby; 2000:1961–1982.
Merritt WH. Relative motion splint: Active motion a ter extensor tendon injury and repair. J Hand Surg Am. 2014;39(6):1187–1194.
Pederson WC. Extensor tendons. In: Russell RC, ed. Plastic Surgery: Indications, Operations, and Outcomes, Vol. IV: Hand Surgery.
St Louis, MO: Mosby; 2000:1983–1994.
Schneider LH, Hunter JM. Flexor tendons-late reconstruction. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY:
Churchill Livingstone; 1988:1969–2044.

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343
Dipan Das, MD, FACS and
James R. Sanger, MD, FACS
ANATOMY

Name the labeled structures in Figure 37-1.
The Perionychium
CHAPTER 37
Figure 37-1 Anatomy o the perionychium.
4
5
6
7
8
1
2
3
1. Nail plate
2. Lunula
3. Eponychium
4. Nail old
5. Distal phalanx
6. Germinal matrix
7. Sterile matrix
8. Hyponychium

What is the perionychium?
T e nail bed (composed o the sterile and germinal matrix) and surrounding so t tissues (paronychium).

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What is the hyponychium?
T e junction o the nail bed (sterile matrix) and the ngertip skin, beneath the distal ree margin o the nail.
It consists o a keratinous plug that prevents debris rom getting under the nail plate. T e hyponychium also
contains large numbers o leukocytes and lymphocytes and is the rst barrier o de ense to prevent bacteria and
ungi rom invading the subungual area.

What is the eponychium?
T e distal portion o the nail old where it attaches to the sur ace o the nail.

What is the paronychium?
So t tissue around the nail and the nail olds comprises the paronychium.

What is the nail bed?
T e nail bed consists o (a) the germinal matrix on the proximal ventral oor o the nail old and (b) the sterile
matrix extending rom the lunula to the hyponychium.

What is the germinal matrix?
T e germinal matrix comprises the ventral oor o the nail old. Highly vascular and composed o germinal cells
near the periosteum, the germinal matrix produces 90% o the nail volume. As the germinal cells duplicate,
previously ormed cells are orced toward the nail and the pressure causes the cells to atten, elongate, and stream
distally into the nail.

What is the sterile matrix?
Part o the nail bed that extends rom the lunula to the hyponychium.

What is the nail old? Why is it important?
T e nail old houses the proximal nail plate and is composed o the germinal matrix on the ventral oor and the
portion o the nail bed that orms the cells which makes the nail shine on the dorsal roo . T e patency o the nail
old is crucial or normal nail growth; hence, either the nail plate or a temporary stent should be placed to keep
the nail old open.

What is the lunula?
T e curved white opacity representing the visible, distal portion o the germinal matrix.

What is the nerve supply to the perionychium?
Dorsal branches rom the volar digital nerves.

What is the arterial supply to the nail?
wo dorsal branches o the volar digital arteries.

What makes up the nail plate?
Flattened sheets o anuclear keratinized epithelium densely adherent to one another.

CHAPTER 37 T e Perionychium
345

What changes occur in the nail plate distal to the lunula?
T e cell nuclei degenerate distal to the lunula. T is is the junction o the sterile and germinal matrix.

What lies beneath the sterile matrix?
Periosteum o the distal phalanx; hence racture o the distal phalanx is associated with a high incidence o nail bed
injury.
PHYSIOLOGY

What produces the nail plate?
T e germinal matrix produces 90% o the nail plate volume.

What contributes to nail plate adherence?
T e sterile matrix produces keratin, which thickens the nail and allows adherence o the nail plate to the bed as it
migrates distally.

What contributes to the smooth shiny sur ace o the nail plate?
T e dorsal roo o the nail old.

How is the nail produced?
T e nail plate is a multilayered stacked sheet o corni ed cells derived rom anucleate onychocytes that arise
rom the germinal matrix epithelium o the nail bed.
T e epithelium o the germinal matrix, sterile matrix, and eponychial old contributes to the production o the
nail plate through three modes o keratinization.
T e germinal matrix epithelium undergoes onychokeratinization, orming the main substance o the hardened nail
plate, which is composed o strati ed layers o corni ed onychocytes.
T e sterile matrix epithelium produces a semirigid keratin through a process known as onycholemmal
keratinization. T is semirigid keratin increases the overall thickness o the nail and also acts as superglue adhesive
or the nail plate to maintain its adherence to the nail bed.
T e eponychial old (dorsal roo ) is responsible or the external sheen o the healthy nail plate by epidermoid
keratinization. T e cuticle, hyponychium, and lateral nail olds also contribute, in a minor degree, to the sur ace
epidermoid keratinization o the nail plate.

Name ve unctions o the ngernail.
1. Protection o the ngertip
2. Improved pulp tactile sensation through provision o counter orce to the pulp
3. Assistance in picking up objects
4. Sel -de ense (scratching)
5. Regulation o peripheral circulation

What area o the body has the highest concentration o lymphatics?
T e hyponychium.

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At what rate does the nail grow?
An average o 0.1 mm/day or 100 days or complete nail growth; however, a ter an injury, distal growth is halted
or 21 days as the proximal nail thickens.
MEDICAL PATHOLOGY

What is clubbing?
Exaggerated convex curvature o the nail plate.

What conditions are thought to cause clubbing?
• Familial clubbing (idiopathic)
• Pulmonary disease—pulmonary brosis, sarcoidosis, cystic brosis
• Cardiac disease—cyanotic congenital heart disease, bacterial endocarditis
• Gastrointestinal disease—ulcerative colitis, Crohn disease, liver cirrhosis
• Cancer—thyroid, thymus, disseminated chronic myelogenous leukemia
• Other—acromegaly, pregnancy

What is chromonychia?
Changes in nail color.

What causes this?
Chromonychia can be induced by renal ailure, subungual hemorrhage, or medications. Antineoplastic drugs
requently cause melanonychia. Drugs most commonly involved are adriamycin, cyclophosphamide, and
vincristine. Chromonychia is also associated with AIDS.
SURGICAL PATHOLOGY

What is onycholysis?
Premature separation o the nail bed and nail plate.

What causes this?
Abnormalities o the sterile matrix, o ten secondary to posttraumatic scarring.

What medications are strongly associated with onycholysis?
axane chemotherapeutics including paclitaxel and docetaxel.

What causes longitudinal splitting o the nail plate?
Abnormalities o the germinal matrix (ventral nail old), o ten secondary to posttraumatic scarring between the
nail roo and nail oor.

What causes longitudinal grooving in the nail plate?
Abnormalities o the nail old (tumor, bony change, or posttraumatic de ormities).

CHAPTER 37 T e Perionychium
347

What are nail spikes or remnants?
Small, o ten pain ul, volumes o nail plate that grow through the overlying skin. T ese usually occur a ter
incomplete removal o the nail matrix ollowing ngertip amputations.

How are these treated?
De nitive excision.

Which is the most commonly injured ngernail?
T e long nger ollowed in order o descending length, by the ring, index, small, and thumb.

What is the most common mechanism o injury?
Doors.

What is the signi cance o a subungual hematoma?
T ere is an underlying nail bed injury.

How are these treated?
rephination, i the hematoma covers less than 50% o the nail plate. Removal o the nail plate and direct repair o
the nail bed is required i the hematoma is more than 50% o the nail plate.

What is trephination?
Creation o a hole in the nail plate to allow drainage o the hematoma, done with a large bore needle. T e nail
plate should be surgically scrubbed prior to trephination to avoid in ection.

When should nail bed injuries be treated and why?
Acutely because secondary repair will rarely provide satis actory results.

Key steps in nail bed repair (to be carried out under loupe magni cation):
1. Adequate anesthesia to the nger in the orm o a digital block.
2. Use o digital tourniquet or optimal visualization.
3. Care ul removal o the nail plate using sharp scissors or a periosteal elevator to prevent urther iatrogenic injury
to nail bed.
4. Repair o laceration using ne absorbable suture such as 6-0 chromic.
5. Replacement o nail plate, or i absent, placement o a substitute material to protect the repair and maintain
the nail old.
6. Alignment and approximation o lacerated edges to avoid ridging.

Do you need an x-ray o the ngertip?
Yes, to evaluate the distal phalanx.

What percent o nail bed injuries are associated with a distal phalanx racture?
50%.

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How are nondisplaced ractures treated?
Repair the nail bed i necessary and replace the nail plate, to act as a splint.

How are unstable displaced ractures treated?
Fracture reduction, bony xation with crossed K-wires, repair o the nail bed, and replacement o the nail plate.

What is the treatment or an avulsed nail plate?
Find the nail plate, replace it with any attached portions o sterile matrix. I this is not available, splint the nail
old open with a piece o Adaptic, the back o a suture pack, or portion o a Penrose drain.

A ter nail plate removal, why is it important to replace the nail plate (or use a substitute replacement)?
o splint the repair and prevent scarring between the roo and oor o the nail old.

With severe crush injuries, what is done with the nail bed tissue attached to the nail plate a ter the nail plate
is removed?
Replaced onto the nail bed as ree gra ts.

What is a Seymour Fracture?
Displaced distal phalangeal racture that involves the physis with an associated nail bed laceration. echnically
these are open ractures and may have the nail bed incarcerated with the racture. T e nail bed needs to be
delivered rom the racture to get reduction.

When are split- ree nail bed gra ts used?
o replace large de ects in the nail bed.

Where is a split- ree nail bed gra t harvested rom?
Ideally rom an undamaged area on the injured nger or rom an amputated digit.

What is alternative source or split nail bed gra ts?
T e great toe.

What is a hook nail de ormity?
Nail that curves volar sharply at the ngertip.

What causes this?
Inadequate tip support, usually due to traumatic loss o bone.

What is pincer nail de ormity?
Re erred to as omega nail de ormity or trumpet nail de ormity, it is a relatively rare condition in which there is a
transverse overcurvature o the nail plate.

What is the etiology?
T e exact etiology is obscure, but a loss o the lateral integrity o the distal phalanx may occur, allowing a greater
curvature o the nail plate.

CHAPTER 37 T e Perionychium
349

What is the treatment?
Restoration o the normal contour and shape o the nail plate is achieved with the aid o dermal gra ts under the
lateral edges o the nail bed.

What causes nail ridges?
Scar beneath the nail bed or an irregularly healed distal phalanx racture.

What is the treatment?
Excision o the scar and/or smoothing out the irregularity.

What causes a split nail de ormity?
A ridge or longitudinal scar in the germinal matrix.

What is the treatment?
Resection o the scar and replacement with a FULL-thickness germinal matrix gra t (typically rom the second toe).

What causes nonadherence o the nail plate?
A transverse scar in the sterile matrix.

What is the treatment?
Scar resection and replacement with a split-thickness sterile matrix gra t.

What are nail cysts or nail spikes?
A spike o nail plate growing out rom an amputation stump.

What causes this?
Failure to remove all o the germinal matrix rom the nail old when per orming an amputation at the proximal
portion o the distal phalanx.

What is the treatment?
Complete resection o the nail cyst and its wall.
INFECTIOUS DISEASES

What is an acute paronychia?
In ection o the skin surrounding the nail plate.

What is the most common cause?
Staphylococcus aureus in ection.

What is the treatment?
Drainage with or without partial nail plate removal.

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What is chronic paronychia?
Chronic paronychia is characterized by persistent, indurated in ections o the eponychium, typically seen in people
whose hands are chronically exposed to water with detergents and alkali, such as cleaning workers, bartenders,
and kitchen sta . T e etiology is thought to be initial bacterial in ection, typically ollowed by superin ection and
colonization o the eponychium with a ungus such as Candida albicans.

How is it treated?
Systemic anti ungals or antibiotics with or without nail plate removal. Eponychial marsupialization has been
described and has been highly e ective at clearing persistent in ections.

What is onychomycosis?
Chronic ungal in ections o the nail.

How does it present?
Nail plate discoloration, thickening, and onycholysis.

How is this treated?
opical anti ungals alone are typically unsuccess ul. opical anti ungal with nail plate removal or systemic
anti ungal is recommended.

What is the most common cause o paronychial in ections?
Chronic ungal in ections.

What is the most common bacterial in ection o the nail?
S. aureus paronychium.

What is the treatment?
Drain any abscesses by li ting the paronychium with or without partial nail plate removal using a number 11 or
15 blade, ollowed by soapy water soaks 3 to 4 times a day.

What is herpetic whitlow?
Sel -limited viral in ection o the ngertips caused by the herpes simplex virus. It is transmitted by skin-to-skin
contact and is o ten seen in medical and dental personnel, as well as in children. Herpetic whitlow may also
present with swelling and erythema, though typically patients have disproportionately greater pain than in the case
o bacterial in ections. Vesicles are also seen, containing uid that may be clear or turbid, but is never purulent.

How do you diagnose herpetic whitlow?
T e diagnosis is usually made clinically, though it is possible to con rm it by use o a zanck preparation or viral
culture. It is important to distinguish herpetic whitlow rom bacterial in ections, as a surgical incision or the
ormer can lead to complications involving the entire digit or systemic spread, and is contraindicated.

CHAPTER 37 T e Perionychium
351

How do you treat herpetic whitlow?
Herpetic whitlow should generally be treated conservatively and typically runs a sel -limited course o
approximately 21 days. reatment most o ten is directed toward symptomatic relie .
In primary in ections, topical acyclovir 5% has been demonstrated to shorten the duration o symptoms and viral
shedding. Oral acyclovir may prevent recurrence. Doses o 800 mg twice daily initiated during the prodrome may
abort the recurrence. Antibiotic treatment should only be used in cases complicated by bacterial superin ection.
ense vesicles may be unroo ed to help ameliorate pain.
ONCOLOGY

Name three common benign periungual tumors.
Mucous cyst, glomus tumor, and pyogenic granuloma.

What is a mucous cyst?
A dorsal ganglion o the DIP, they are usually associated with an osteophyte.

How does it present?
Dorsal swelling o the DIP with or without longitudinal grooving o the nail plate.

How are they treated?
Excision o the ganglion and removal o the osteophyte.

What is the key to the treatment o a mucous cyst?
Removal o the osteophyte.

How do glomus tumors present?
T ese are 1 to 2 mm in size and have a classic triad o tenderness, pain, and cold sensitivity.

How can they be diagnosed?
MRI.

How are they treated?
Resection with an approach that includes removal o the nail plate.

What is a pyogenic granuloma?
Exuberant mass o granulation tissue that orms a ter a relatively minor trauma.

How are they treated?
Complete excision through curettage or ablation with silver nitrate sticks. Incomplete excision will lead to
recurrence.

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Dif erential diagnosis o a pigmented subungual lesion?
Posttraumatic hemorrhage (most common), benign nevus, subungual melanoma.

What is the dif erential diagnosis o pigment deposition within the nail plate?
Melanonychia striate longitudinalis (benign lesions common in black patients), a benign subungual nevus, and a
malignant melanoma.

What is Hutchinson sign?
Broad pigmented streaks o variegated color with cuticular pigmentation within the nail plate. It is associated with
a subungual melanoma.

How is a subungual hematoma dif erentiated rom a subungual melanoma?
Mark the nail plate and watch. I it is a hematoma, it will migrate distally. Ultimately, a nail bed biopsy is
recommended i even minor suspicion o melanoma exists.
REFERENCES
Abzug JM, Kozin SH. Seymour ractures. J Hand Surg Am. 2013;38:2267–2270.
Baden HP. Regeneration o the nail. Arch Dermatol. 1965;91:619–620.
Fleegler EJ, Ziewonwicc RJ. umors o the perionychium. Hand Clin. 1990;6:113–134.
Hijjawi JB, Dennison DG. Acute elon as a complication o systemic paclitaxel therapy: case report and review o the literature. Hand
(N Y). 2007;2:101–103.
Kleinert HE, Kutz JE, Fishman JH, McGraw LH. Etiology and treatment o the so-called mucous cyst o the nger. J Bone Joint Surg
Am. 1972;54:1455–1458.
Newmeyer WL, Kilgore ES Jr. Common injuries o the ngernail and nail bed. Am Fam Physician. 1977;16:93–95.
Quitkin HM, Rosenwasser MP, Strauch RJ. T e ef cacy o silver nitrate cauterization or pyogenic granuloma o the hand. J Hand Surg
Am. 2003;28:435–438.
Schiller C. Nail replacement in nger tip injuries. Plast Reconstr Surg. 1957;19:521–530.
Seaberg DC, Angelos WJ, Paris PM. reatment o subungual hematomas with nail trephination: a prospective study. Am J Emerg Med.
1991;9:209–210.
Sorene ED, Goodwin DR. Magnetic resonance imaging o a tiny glomus tumour o the ngertip: a case report. Scand J Plast Reconstr
Surg Hand Surg. 2001;35:429–431.
Wong CH, Chow L, Yen CH, Ho PC, Yip R, Hung LK. Uncommon hand tumours. Hand Surg. 2001;6:67–80.
Zook EG, Brown RE. T e perionychium. In: Green DP, ed. Green’s Operative Hand Surgery. Vol 2. 4th ed. New York, NY: Churchill
Livingstone; 1999:1353–1380.
Zook EG, Russell RC. Reconstruction o a unctional and esthetic nail. Hand Clin. 1990;6:59–68.
Zook EG, Van Beek AL, Russell RC, Beatty ME. Anatomy and physiology o the perionychium: a review o the literature and anatomic
study. J Hand Surg Am. 1980;5:528–536.

353
Emily Cushnie, MD, PhD and
César J. Bravo, MD

What are the three primary goals in treating the rheumatoid hand?
PRC:
1. Pain relie .
2. Restoration o unction.
3. Cosmetic improvement o the hand.

What are the three basic principles in rheumatoid hand surgery?
1. Synovectomy/so t-tissue reconstruction done early in disease.
2. Highly erosive disease (arthritis mutilans) treated early with usion be ore bone loss.
3. Correction o de ormity that causes loss o motion and may severely compromise hand unction.

What surgical sequence should be ollowed in a rheumatoid patient?
1. Lower extremity addressed rst.
2. Proximal joints be ore distal joints (e.g., elbow be ore wrist, wrist be ore metacarpophalangeal joint [MCPJ]
and proximal interphalangeal joint [PIPJ]).

What is an essential part o the preoperative evaluation in a rheumatoid patient?
Cervical spine evaluation. 25% to 50% o patients can have atlantoaxial instability (plain cervical radiographs
including exion and extension views are standard).

What is the pathogenesis in rheumatoid arthritis (RA) o the hand?
Autoimmune disorder resulting in erosive synovitis o the hand and wrist secondary to injury to synovial
microvascular endothelial cells triggering an in ammatory reaction causing in ux o polymorphonuclear
leukocytes (PMNs), monocytes, and macrophages.
Rheumatoid Hand
CHAPTER 38

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In ammatory cells/mediators produced by macrophages, monocytes, PMNs stimulate which cell type in the
rheumatoid hand?
Osteoclast. T ese are responsible or subchondral osteopenia.

What three classes o drugs are used to treat RA medically?
Nonsteroidal anti-in ammatory agents (NSAIDs), corticosteroids, and disease-modi ying anti-rheumatic drugs
(DMARDs).

Which o these medications can help to change the disease course?
Only DMARDs are ound to alter the course o RA and improve associated radiographic outcomes. T ey have
both anti-in ammatory ef ects as well as structural-modi ying properties.1,2

What are the two classes o biologic agents that exist to treat RA?
umor necrosis actor ( NF) inhibitors and interleukin-1 (IL-1) receptor antagonists. T ese agents act to
neutralize cytokines that mediate the in ammatory pathogenesis in RA.1

What are the extra-articular mani estations seen in RA? Which one is most common?
Vasculitis, pericarditis, pulmonary nodules, episcleritis, and subcutaneous nodules. Subcutaneous nodules (25% o
patients with RA).

Mani estation o accumulated in ammatory cells around capillaries o the synovium and tenosynovium is
known as:
Synovitis and tenosynovitis.

What cellular processes are responsible or cartilage damage in RA?
Cytokine-activated neutrophils release lysosomal enzymes and ree oxygen radicals, which destroy cartilage in the
af ected joint.3

Is pattern o joint involvement in RA di erent rom osteoarthritis (OA) o the hand?
Yes. In RA, MCPJ and PIPJ are commonly involved. In OA, distal interphalangeal joint and basilar joint o
thumb are involved.

What are Bouchard’s nodes?
Enlargement o PIPJ seen mainly in RA. **Heberden’s nodes are seen in OA and re er to DIP enlargement.

What is the most commonly a ected joint in RA?
T e wrist.4

What is the most requently a ected area about the wrist in RA patients?
Distal radioulnar joint (DRUJ).

CHAPTER 38 Rheumatoid Hand
355

Why is the DRUJ a ected early in the disease course?
T ere is a greater degree o vascularity at the prestyloid recess o the distal ulna, which allows or early synovial
in ltration.3

What are other commonly a ected areas o the wrist in RA?
Palmar side o distal radius, waist o scaphoid, triquetrum.3

What is the typical presentation o RA early in the disease?
Insidious onset o morning stif ness and polyarthropathy involving most commonly the hands and eet.

Decreased active digital exion in a patient with RA is usually caused by what?
Synovial nodules within exor tendons. T ese nodules within retinacular system reduce active exion o nger.

What is the natural course o rheumatoid disease with articular involvement at the MCPJ?
Progressive joint erosion and collapse with palmar displacement.

How do tendon ruptures o the hand and wrist occur in patient with RA?
By attrition (abrasion over bony prominences), in ltration (synovitis), and ischemia (external pressure by
compressive synovium).

What is the more common direction o sagittal band rupture in RA?
Radial sagittal band, results in ulnar displacement o the extensor tendons.

How is the wrist a ected in patients with RA?
Synovitis begins in ulnar aspect o the wrist with the DRUJ and radiocarpal joint rst af ected, usually sparing
the midcarpal joint. Erosive changes seen at the prestyloid recess o the ulnar styloid, sigmoid notch o radius,
insertion o radioscapholunate ligament, and the scaphoid waist. T e carpus subluxes ulnarly and volarly with
supination relative to radius. T is carpal alignment leads to radial deviation o the metacarpals.

What is the natural course o wrist de ormities with rheumatoid disease?
Supination, palmar dislocation, radial deviation, and volar–ulnar dislocation o the carpus on the radius (see Fig. 38-1).
Figure 38-1 Natural course o wrist de ormities with rheumatoid disease.
VOLAR
Lunate
DORSAL
Capitate
Ulna
Radius
MC

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Plastic & Reconstructive Surgery Board Review

What are the treatment options available or the rheumatoid DRUJ/wrist?
Treatm ent/ Procedure

Benef t
Synovectomy o radiocarpal joint and DRUJ

Pain relie , done a ter 6 months o medical treatment and
no radiographic changes
Partial arthrodesis (radiolunate and
scaphoradiolunate usions)
Prevents progression o collapse
Radiolunate preserves unction in patients with ulnocarpal
translocation.
Resection hemiarthroplasty o DRUJ

Preserves length o ulna and TFCC attachments. No DRUJ
contact on pronation/supination—pain relie
Darrach procedure (resection o distal ulna)

Easy. Can have radioulnar impingement/instability.
Sauvé–Kapandji ( usion o DRUJ, osteotomy o
ulna at radial metaphyseal are)
Less cosmetic de ect than Darrach. Can have radioulnar
impingement. Good or younger patients.
Total wrist arthrodesis

90–95% good to excellent results ( used in 10–20 degrees
extension and neutral deviation)
Wrist arthroplasty

Motion-preserving procedure (good bone stock, minimal
de ormity, intact extensors)
DRUJ, distal radioulnar joint; TFFC, triangular f brocartilage complex.

What is the total wrist arthroplasty experience in the United States?
1. 1967: Swanson. Silicone hinge.
2. 1972: Meuli. Ball and trunnion.
3. 1973: Volz. Dorsopalmar tracking.
4. 1977: Figgie and Ranawat. rispherical (hinge).
5. 1982: Beckenbaugh. Biaxial (ellipsoidal).
6. 1990: Mennon. Universal (anatomic).
7. 2002: Adams. Universal 2 (uncemented).

What are current accepted indications or total wrist arthroplasty?
1. Pain ul pancarpal (dif use) and advance arthritis.
2. Progressive de ormity with advanced arthritis.
3. Patients who do not use walking aids with af ected hand.
4. Other joints o same extremity have signi cant limitations.
5. Personal actors (low-demand activities that require wrist motion).
6. Contralateral wrist used.

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What are current accepted contraindications or total wrist arthroplasty?
1. Previous sepsis.
2. Rupture and not ully reconstructible wrist extensors.
3. Resorption o distal carpal row.
4. Previous wrist arthrodesis (auto usion not a contraindication).
5. Failed silicone wrist implant with ragmentation and particulate synovitis.
6. Progressive de ormity with advanced arthritis.

What is the recommended treatment or RA patients with bilateral wrists that require surgical intervention?
Arthroplasty o the dominant wrist and arthrodesis o the nondominant wrist with usion in neutral or 10 to
15 degrees o extension.4

In the rheumatoid hand, are women a ected more than men?
Yes. 2.5:1.

What is a painless dorsal wrist mass distal to the extensor retinaculum typically in RA patients?
ypical presentation o extensor tenosynovitis. enosynovectomy indicated a ter 4 to 6 months o medical
treatment to prevent rupture o extensor tendon.

What is the di erential diagnosis o a patient with a rheumatoid hand and with inability to extend his
f ngers?
1. Ulnar subluxation o extensor tendon over the MP joints due to ailure o the radial sagittal band.
2. Posterior interosseous nerve (PIN) palsy because o synovitis at the elbow.
3. MP joint subluxation/dislocation.
4. Extensor tendon attritional rupture.

When should PIN palsy at the elbow be a prime consideration in RA patients?
Inability to extend all our ngers and IP joint o thumb. Also, unable to deviate the wrist ulnarly secondary to
extensor carpi ulnaris (ECU) paralysis.

Does a patient with an extensor tendon rupture have the ability to maintain a digit extended i passively
placed in that position?
No. T ey also lose the tenodesis ef ect o the hand (e.g., nger extension with wrist exion and vice versa).

Why might a patient with a ruptured extensor digiti quinti (EDQ) minimi still be able to partially extend
the small f nger?
T e juncturae tendinum between the ring and the small nger is still intact.4

How might one clinically test the EDQ tendon in isolation?
Hold all other digits in exion and ask the patient to extend just the small nger.

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In decreasing incidence, which extensor tendons are a ected by RA?
Extensor digiti minimi (EDM), extensor digitorum communis (EDC) 5, EDC 4, EPL, EDC 3.

What anatomical landmark contributes to extensor pollicis longus rupture in patients with RA?
Lister’s tubercle. Contributes to attritional rupture while acting as a bone pulley.

What is Vaughn–Jackson syndrome?
Ischemic rupture o ulnar extensor tendons secondary to prominent irregular ulnar head. Most common cause o
tendon rupture in RA patients.

What is caput ulnae syndrome?
Failure o the ulnar aspect o the wrist and DRUJ secondary to RA resulting in:
1. dorsal dislocation o distal ulna
2. supination o carpus on the radius
3. volar subluxation o ECU

What is the “piano keyboard sign”? What does it signi y?
Elicited when the prominent ulnar head is volarly depressed and rebounds as pressure is released. DRUJ instability,
seen in a third o patients with RA.

What is the scallop sign in patients with RA?
Erosion o the radial sigmoid notch with ormation o a sclerotic border. It is an ominous sign o impending
extensor tendon ruptures.

When is extensor tendon surgery indicated in patients with RA?
1. Re ractory to medical treatment
2. Dorsal dislocation o the ulnar head
3. A positive scallop sign
4. Recurrent dorsal tenosynovitis

Is surgery needed a ter an extensor tendon rupture in RA patients to prevent damage to intact tendons?
Yes. Unchecked tenosynovitis damages outer sur aces o underlying tendons, leads to tendon adhesions and
eventual attritional rupture.

What is re erred to as a pseudotendon in patients with RA?
A thin strand o opaque tissue situated between healthy appearing tendinous material proximally and distally.

Attritional rupture o exor pollicis longus (FPL) is known as?
Manner elt–Norman syndrome. Most common exor tendon rupture in RA.

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Where is the most common location or rupture o FPL?
Scaphoid. Secondary to a spur at the level o S joint. *I spur is not excised, it will lead to tendon ruptures o
the FDP tendons in a radial to ulnar progression.*

What is the most common location o exor tenosynovitis?
T e palm. Seen as pain, triggering, and tendon rupture with passive nger exion that is greater than active
exion.

Should the A1 pulley be preserved in rheumatoid patients?
Yes. Avoid increasing the lever arm o the tendon and thus potentiating exion de ormity at the MP joints.

Triggering secondary to digital exor tenosynovitis usually locks the digit in exion. What is happening i
locked in extension?
Pro undus tendon nodule distally at the A2 pulley is the cause o locking.

What are the commonly used extensor tendon trans ers used a ter rupture?
Ruptured Tendon

Trans er Recom m ended
EPL

EIP to EPL or EPB to EPL at metacarpal level
EDM and EDC5, or EDM alone

EIP to EDC5 or EDM, side–to-side to EDC4
EDM, EDC5, EDC4

EDC4 side to side to EDC3, EIP to EDM or EDC5, tendon gra ts
EDC5/EDM, EDC4, EDC3

FDS (long) to EDC4 and EDC5, EDC3 side to side to EDC2/EIP
EDC5/EDM, EDC4, EDC3, EDC2

FDS (long) to EDC2 and EDC3, FDS (ring) to EDC4 and EDC5
EPL, extensor pollicis longus; EDM, extensor digiti minimi; EDC, extensor digitorum communis; FDS, exor digitorum
superf cialis.

How is tension adjusted in extensor tendon reconstruction/trans er in patients with RA?
enodesis o the wrist established. Wrist extension produces nger exion and wrist exion produces nger
extension.

What is associated with extension loss or all our f ngers with the absence o all digital extensor and
proprius tendon unction at surgery?
Palmar dislocation o the carpus on the radius rather than extensor tenosynovitis.

What is a contraindication in using the superf cialis exor tendon or extensor tendon trans er in RA?
Presence o swan neck de ormity and signi cant exor tenosynovitis.

What is the recommended treatment or loss o wrist extensors in RA?
Arthrodesis o the wrist.

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What is Clayton procedure in the rheumatoid hand? Prevents what?
rans er o the ECRL to ECU. Redistributes wrist orces, diminishing radial rotation and volar subluxation o
carpus at the wrist.

What are the eight steps leading to MCPJ ulnar dri t?
1. Synovitis leading to stretching o radial sagittal bands.
2. Extrinsic extensors subluxate into intermetacarpal sulcus, become ulnar deviators.
3. Lax MP collateral ligaments rom joint synovitis allow ulnar deviation.
4. Synovitis causing urther damage to cartilage and bone—destabilizes MCPJ.
5. Ulnar intrinsics contract and become ulnar and volar de orming orces.
6. Radial deviation o wrist alters vector pull on the extrinsic extensors toward ulnar direction.
7. Flexor sheath synovitis distends retinaculum allowing the exors to shi t in an ulnar direction.
8. Resultant orces during pinch are in volar and ulnar directions.

What is the Nalebu classif cation o MCPJ in a rheumatoid hand?
Stage I: only synovial proli eration.
Stage II: recurrent synovitis without de ormity.
Stage III: moderate articular degeneration, ulnar and palmar dri t o digits that is passively correctable.
Stage IV: severe joint destruction with xed de ormities.

What is the treatment recommendation based on the Nalebu classif cation o MCPJ?
Stage I: medical management and splinting.
Stage II: synovectomy (a ter 6 months o medical treatment).
Stage III: synovectomy plus extensor tendon relocation, intrinsic releases, crossed intrinsic trans ers, and radial
collateral ligament imbrication.
Stage IV: silicone spacer combined with relocation o extensors and radial collateral ligament imbrication.
**Surgical intervention reserved or patients with pain and unctional disability.

I you have MCPJ disease and tendon rupture, which do you treat f rst?
MCPJ. Multiple authors recommend treating both at same time.

What is the reported arc o motion usually achieved a ter silicone interposition arthroplasty or MCPJ in
patients with RA?
40 to 60 degrees. Regression o digits ulnarly commonly seen, typically < 10 degrees.

What is a swan neck de ormity? Causes?
PIP hyperextension and DIP exion. DIP mallet, synovitis attenuating volar plate, FDS rupture, and intrinsic
tightness rom MCPJ disease.

CHAPTER 38 Rheumatoid Hand
361

What is the recommended treatment and classif cation or rheumatoid swan neck de ormity?
**Classi cation based on severity o PIP de ormity, stif ness, and arthritis (radiographic ndings).
Type Description

Treatm ent
I

PIP exible in all MCPJ positions
Proximal Fowler tenotomy, exor PIP tenodesis, SORL
reconstruction
II

PIP joint exion position-dependent
on MCPJ
Intrinsic release and/or realignment or arthroplasty MCPJ
III

PIP exion limited in all MCPJ
positions
Open capsular release, dorsal skin releases, closed
manipulation with/without pinning, lateral band mobilization
IV

Radiographic joint destruction with
minimal PIP joint motion
Arthrodesis and arthroplasty
PIP, proximal interphalangeal; SORL, spiral oblique retinacular ligament; MCPJ, metacarpophalangeal joint.

What is a boutonnière de ormity? Causes?
Hyper exion o PIP joint and hyperextension DIP joint. Synovitis leading to attenuated central slip, volar
subluxation o lateral bands, tight transverse retinacular ligament, and volar plate contracture.

What is the recommended treatment and classif cation or rheumatoid boutonnière de ormity?
**Classi cation based on PIP motion and severity o arthritis.
Type Description

Treatm ent
I

Mild loss o PIP active extension, ull
passive PIP extension
Synovectomy, inject PIP and splints, lateral band, or distal
Fowler’s tenotomy
II

Moderate loss o PIP extension, ull
passive PIP extension
Synovectomy, central slip reconstruction, lateral band
reconstruction, or distal Fowler’s tenotomy
III

PIP not passively correctable, no
arthritic changes
PIP injection, serial extension casting, consider type II
treatment i motion restored
IV

Fixed PIP contracture, arthritic
changes
Objective is to reduce PIP, PIP usion or arthroplasty
PIP, proximal interphalangeal.

What is the most common rheumatoid thumb de ormity?
Boutonnière de ormity (MP joint exion and IP joint hyperextension).

What is the tendon most commonly responsible or the de ormity and in what direction is it displaced?
EPL. It subluxes ulnarly and volarly, producing exion at the MCP joint and weakening extension. T is de ormity
can also occur with MCP volar capsule laxity and/or FPL tendon rupture, with the de ormity occurring secondary
to IP hyperextension.5

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What is the Nalebu classif cation o rheumatoid thumb?
ype I: Boutonnière de ormity.
ype II: Boutonnière de ormity with CMC involvement
ype III: Swan neck de ormity (stage 1: CMC synovitis, stage 2: CMC joint synovitis, MP joint extension
de ormity correctable, stage 3: CMC joint destruction, MP joint extension de ormity xed)
ype IV: Gamekeeper de ormity
ype V: Swan neck de ormity with MP joint and CMC unaf ected
ype VI: Arthritis mutilans

What is the recommended treatment or the f rst our stages o the rheumatoid thumb?
Early Disease

Moderate Disease

Advanced Disease
Type I
MP synovectomy and EPL
rerouting
MP usion or arthroplasty IP usion and MP arthroplasty
Type II MP synovectomy and EPL
rerouting
MP joint usion and CMC
hemiarthroplasty
MP joint usion and CMC
hemiarthroplasty
Type III CMC partial trapezial/metacarpal
base resection CMC implant
arthroplasty
MP usion CMC partial
trapezial/metacarpal base
resection
MP usion CMC partial trapezial/
metacarpal base resection
CMC implant arthroplasty Release
f rst web space contracture
Type IV MP synovectomy, UCL
reconstruction
MP usion

MP usion Release f rst web space
contracture
MP, metacarpophalangeal; EPL, extensor pollicis longus; CMC, carpometacarpal; UCL, ulnar collateral ligament.

What is the recommended treatment or the stages V and VI o the rheumatoid thumb?
Stage V:
a. No articular degeneration o MCPJ—volar capsulodesis.
b. Articular degeneration—MCPJ usion.
Stage VI: Fusion and so t-tissue balancing when possible.

What are the three major types o juvenile rheumatoid arthritis (JRA)?
(**Based on presentation at onset o diagnosis and during rst 6 months o disease.)
1. Systemic onset (25%)
2. Polyarticular onset (30%)
3. Pauciarticular onset (45%)

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What are the characteristics o pauciarticular onset JRA?
1. Involvement o ewer than ve joints in an asymmetric pattern.
2. Involvement o large joints.
3. Male
Fem ale
Onset 10 years old
Onset < 6 years old
ANA and RF negative

ANA and RF positive
HLA–B27 association

Predominance o iridocyclitis
Lower-extremity involvement
Risk or sacroiliitis

Name f ve clinical di erences ound in JRA not ound in the rheumatoid hand?
1. Ulnar deviation o wrist and metacarpals.
2. Radial deviation o MCP J.
3. Abnormal ring and small nger metacarpals secondary to long bone epiphyseal accelerated maturation.
4. Shortened ulna.
5. Narrow small tubular bones o the hand (hand size is small).

What is Still disease?
It is the systemic onset o 20% JRA cases. Clinical ndings consist o :
1. intermittent high evers
2. transient arthritis with associated evers
3. hepatosplenomegaly, lymphadenitis, uveitis
4. leukocytosis and anemia
5. rheumatoid actor not present
6. severe, chronic arthritis in only 25% o patients
REFERENCES
1. Gibo sky A. Combination therapy or rheumatoid arthritis in the era o biologicals. HSS J. 2006;2:30–41.
2. Schett G, Stach C, Zwerina J, Voll R, Manger B. How antirheumatic drugs protect joints rom damage in rheumatoid arthritis.
Arthritis Rheum 2008;58:2936–2948.
3. Papp SR, Athwal GS, Pichora DR. T e Rheumatoid Wrist. J Am Acad Orthop Surg 2006;14:65–77.
4. Chung K, Pushman, A. Current Concepts in the Management o the Rheumatoid Hand. J Hand Surg. 2011;36:736–747.
5. Rozental D, Reconstruction o the Rheumatoid T umb. J Am Acad Orthop Surg. 2007;15:118–125.

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ADDITIONAL BIBLIOGRAPHY
Freiberg RA, Weinstein A. T e scallop sign and spontaneous rupture o nger extensor tendons in rheumatoid arthritics. Clin Orthop
Relat Res. 1972;83:128–130.
Herren DB, Simmen BR. Limited and complete usion o the rheumatoid wrist. J Hand Surg Am. 2002;2:21–32.
Lipsky PE. Rheumatoid arthritis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles
of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001:1928–1937.
Millender LH, Nalebuf EA, Holdsworth DE. Posterior interosseous nerve syndrome secondary to rheumatoid synovitis. J Bone Joint
Surg. 1973;55:753–757.
Millender LH, Nalebuf EA, Albin R, Ream JR, Gordon M. Dorsal tenosynovectomy and tendon trans er in the rheumatoid hand.
J Bone Joint Surg Am. 1974;56:601–609.
Moore JR, Weiland AJ, Valdata L. endon ruptures in the rheumatoid hand: analysis o treatment and unctional results in 60 patients.
J Hand Surg Am. 1987;12:9–14.
Nalebuf EA. Diagnosis, classi cation and management o rheumatoid thumb de ormities. Bull Hosp Joint Dis. 1968;29:119–137.
Nalebuf EA. Surgical treatment o tendon rupture in the rheumatoid hand. Surg Clin North Am. 1969;49:811–822.
Richards RA, Wilson RL. Management o extensor tendons and the distal radioulnar joint in rheumatoid arthritis. J Hand Surg Am.
2003;3:132–144.
Sauerbier M, Hahn ME, Fujita M, Neale PG, Berglund LJ, Berger RA. Analysis o dynamic distal radioulnar convergence a ter ulnar
head resection and endoprosthesis implantation. J Hand Surg Am. 2002;27:425–434.
Stuart PR, Berger RA, Linscheid RL, An KN. T e dorsopalmar stability o the distal radioulnar joint. J Hand Surg Am. 2000;25:
689–699.
errono AL. T e rheumatoid thumb. J Am Soc Surg Hand. 2001;1:81–90.
Wadstein . Spontaneous rupture o the long extensor tendon o the extensor pollicis longus. ransplantation o the extensor indicis
proprius. Acta Orthop Scand. 1946;16:194–202.
Wilson RL. Rheumatoid arthritis o the hand. Orthop Clin North Am. 1986;17:313–342.

365
Dennis S. Kao, MD and
Hani S. Matloub, MD

What is the cause o obstetric brachial plexus palsy?
raction injury to the brachial plexus during the birth process due to excessive lateral exion o the neck. When
the etus is delivered in cephalic presentation, shoulder dystocia can cause excessive lateral exion o the neck.
When the etus is delivered in breech presentation, di culty with delivery o the head a ter the body has emerged,
can cause the same problem.

What is the estimated incidence o obstetric brachial plexus palsy?
0.2% to 4% o live births globally, with higher incidence in underdeveloped countries with poor obstetrical care.

What maternal actors may be associated with obstetric brachial plexus palsy?
1. Diabetes
2. Preeclampsia
3. Long duration o labor
4. History o delivery problem or etus brachial plexus injury with prior pregnancy

What etal actors may be associated with obstetric brachial plexus palsy?
1. Large etus or gestational age
2. History o humeral racture or clavicle racture during birth

What actors during birth may be associated with obstetric brachial plexus palsy?
1. Di cult arm or head extraction in breech deliveries
2. Shoulder dystocia in vertex deliveries
3. Forceps or vacuum use during delivery
Obstetrical Brachial
Plexus Injuries
CHAPTER 39

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Does Cesarean section (C-section) protect against obstetric brachial plexus palsy?
C-section helps to lower, but not completely eliminate the risk o obstetric brachial plexus injury. T ere is a
reported ~1% rate o obstetric brachial plexus injury associated with C-section.

What are the common types and incidence o obstetric brachial plexus injuries?
1. Erb palsy (~60%), involving C5 and C6.
2. Extended Erb palsy (~20%), involving C5, C6, and C7.
3. otal brachial plexus palsy (~20%), involving C5, C6, C7, C8, and 1
4. Klumpke palsy (< 1%), involving C8 and 1.

What is the typical posture o Erb palsy (Figure 39-1)?
T e eatures o upper plexus palsy (“waiter’s tip” position) involving C5, C6, ± C7 are:
1. shoulder adduction and internal rotation
2. elbow extension
3. orearm pronation
4. wrist exion
5. f nger exion
Figure 39-1 ypical posture o Erb palsy (“waiter’s tip” position). Reproduced with permission rom Stead LG, Kau man MS, Waseem M.
First Aid for the Pediatrics Clerkship. 3rd ed. New York: McGraw-Hill, 2010. Fig. 2-5.

CHAPTER 39 Obstetrical Brachial Plexus Injuries
367

What is the signif cance o Horner’s syndrome in a patient with brachial plexus injury?
It indicates disruption o sympathetic f bers proximal to where the preganglionic f bers arise and suggests severe
brachial plexus avulsion injury (usually avulsion o 1 root, with disruption o communicating branch supplying
sympathetics to the stellate ganglion).

What is the signif cance o phrenic nerve palsy in a patient being evaluated or brachial plexus injury?
T e presence o phrenic nerve palsy suggests severe avulsion injury o the upper trunk. It also eliminates phrenic
nerve as a potential donor nerve or neurotization.

What studies can be ordered to evaluate obstetric brachial plexus injury?
1. CXR (look or elevated hemidiaphragm as an indication o ipsilateral phrenic nerve palsy)
2. MRI (evaluate or signs o nerve root avulsion)
3. EMG/NCS (assess the unction o each nerve and the muscles it innervates)

What is the most reliable method o assessing the level and severity o obstetric brachial plexus injury?
Physical examination to assess motor and sensory unction. EMG/NCS may be help ul but lacks accuracy.

What is the controversy regarding use o EMG/NCS in evaluation o obstetric brachial plexus palsy?
Denervation changes occur and disappear much aster in in ants than adults. T ere is also early massive collateral
sprouting o denervated muscles. T ere ore, EMG/NCS overestimates the clinical recovery, and may provide alse
hope to the parents and delay timely surgical intervention.

What is the modif ed Mallet classif cation system used or?
It is used to assess and document the recovery o upper trunk unction in obstetric brachial plexus palsy. However,
it cannot be used to assess orearm/wrist/hand unction.
Group Affected Nerve Roots Physical Findings
Spontaneous
Recovery Rate (%)
I

C5, C6

Lack o shoulder motion and elbow f exion,
(+ ) elbow extension and wrist/hand unction
~90
II

C5, C6, C7
Lack o shoulder and elbow motion, (+ ) wrist/
hand unction
~65
III

C5, C6, C7, C8, T1

Flail arm
< 50
IV

C5, C6, C7, C8, T1, with
Horner’s syndrome
Flail arm, with ipsilateral ptosis, meiosis, and
anhydrosis
~0

Which is the most use ul classif cation system or management and prognosis o obstetric brachial plexus?
T e classif cation system proposed by Gilbert/ assin (later ref ned by Narakas) provides a simple and reliable way
o assessing obstetric brachial plexus palsy.

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What is the most common indication or surgery in obstetric brachial plexus palsy patients?
Absence o elbow exion (biceps unction) by 3 to 6 months o age. Further delay results in poorer outcome,
especially in hand unction.

What are the common primary surgical treatments or obstetric brachial plexus palsy?
1. Neurolysis
2. Neurotization (with neuroma resection and nerve gra ting, vs. nerve trans er)

In avulsion injuries, innervation must be provided by alternative sources. T is can be accomplished rom
remaining roots (intraplexal neurotization) or donor nerve outside the plexus (extraplexal neurotization).
What are the options or extraplexal neurotization?
1. Spinal accessory nerve
2. Intercostal nerves
3. Contralateral C7 root

What secondary surgical procedures are used to correct internal rotation contracture o the shoulder due to
obstetric brachial plexus injury?
1. Early release o the subscapularis muscle/subscapularis tendon lengthening.
2. Anterior release o the pectoralis major tendon and trans er o the latissimus dorsi/teres major tendon
(conjoined tendon).
3. Humeral derotational osteotomy (i advanced glenohumeral joint de ormity).
REFERENCES
Abzug JM, Kozin SH. Evaluation and management o brachial plexus birth palsy. Orthop Clin North Am. 2014;45:225–232.
Al-Qattan M. Obstetric brachial plexus injuries. J Am Soc Surg Hand. 2003;3(1):41–53.]
Capek L, Clarke HM, Curtis CG. Neuroma-in-continuity resection: early outcome in obstetric brachial plexus palsy. Plast Reconstr Surg.
1998;102:1555–1562.
Chuang DC, Mardini S, Ma HS. Surgical strategy or in ant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial
Hospital. Plast Reconstr Surg. 2005;116:132–142.
Gilbert A, Brockman R, Carlioz H. Surgical treatment o brachial plexus birth palsy. Clin Orthop Relat Res. 1991;264:39–47.
Gilbert A. Long-term evaluation o brachial plexus surgery in obstetrical palsy. Hand Clin. 1995;11:583–594.
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Dunitz, 2001:42.

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

What is the most common mechanism or brachial plexus injuries?
Closed injury (traction, compression, or combination o the two).

What is the most common location o brachial plexus injuries?
Supraclavicular, root, and trunks.

What is the typical mechanism o a C8– 1/lower trunk traction injury?
Force ul abduction o the arm overhead.

What brachial plexus injury is typically produced by violent lateral bending o the head and neck?
raction injury o C5, C6/upper trunk.

What is a common site or brachial plexus compression injuries?
Between clavicle and rst rib, near the coracoid process.

What are the demographics o the majority o patients with brachial plexus injuries?
Male, aged 15 to 25.

What proportion o brachial plexus injuries occur in motor vehicle accidents?
70%.

What type o vehicle is most commonly implicated in brachial plexus injuries?
T e motorcycle (70% o motor vehicle accidents). Snow mobiles in colder climates.
Brachial Plexus
CHAPTER 40

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Plastic & Reconstructive Surgery Board Review

At what level do most root avulsions occur?
Lower roots (C7, C8, 1).
ANATOMY

How many nerve roots orm the brachial plexus?
Five (C5–8, 1).

What term describes a contribution o the C4 nerve root to the brachial plexus?
Pre xed plexus.

What phenomenon is described by the term “post xed” brachial plexus?
2 contribution to the plexus.

What are the ve separate sections o the brachial plexus?
Roots, trunks, divisions, cordserminal branches.
(Robert aylor Drinks Co ee Black)

What structure is ormed by coalescence o the ventral and dorsal rootlets?
T e nerve root.

What vascular structure is associated with the C7 root in the exposure o the cervical region o the brachial plexus?
ransverse cervical artery.

T e medial cord o the brachial plexus receives contributions rom which nerve roots?
C8 and 1.

Where does the nerve root leave the spinal canal?
T rough the neuro oramen.

What is contained in the dorsal root ganglion?
T e cell bodies o the sensory nerves.

Where do the motor nerves travel?
In the volar root ganglion. (V volar, Vroom!!)

What is described by the term preganglionic brachial plexus lesion?
1. Lesion proximal to the dorsal root ganglion
2. Intradural rupture o the rootlets
3. Avulsion rom spinal cord

CHAPTER 40 Brachial Plexus
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How are the upper, middle, and lower trunk typically ormed?
Upper trunk by C5 and C6.
Middle trunk by C7.
Lower trunk by C8 and 1.

What is Erb’s point?
Point where C5 and C6 merge to orm upper trunk.

What structures join to become the posterior cord?
All three posterior divisions.

What is ormed by the anterior divisions o the upper and middle trunk?
T e lateral cord.
(Imagine a ootball announcer, “Number 34 runs up [upper trunk] the middle [middle trunk] and throws a lateral
[lateral cord]!”)

What continues as the medial cord?
T e anterior division o the lower trunk.

T e cords are named a ter their location in relation to which structure?
T e axillary artery.

What part o the brachial plexus crosses underneath the clavicle?
T e divisions.

What muscles are innervated by the dorsal scapular nerve?
Rhomboid major/minor and levator scapulae.

What are the terminal branches o the posterior cord?
Proximal to distal:
1. upper subscapular n.
2. thoracodorsal n.
3. lower subscapular n.
4. axillary n.
5. radial n.

What branches originate at the C5 root level?
1. Phrenic n. contribution
2. Long thoracic n. contribution
3. Dorsal scapular n. (levator scapulae, rhomboids)