The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

SECTION VIII THE HAND AND UPPER EXTREMITY
1216
whether the joint is congruous or not congruous, not
what percentage of the joint is fractured. Only those
that are subluxated (not congruous) really need to be
manipulated with K-wires in a closed fashion.
I like the closed K-wire Ishiguru extension block
pinning operation for subluxated acute injuries.5 If the
two distal phalanx pieces are not subluxated (joint sur­
face is congruous), many patients do not need K-wire
reduction, and splinting alone will provide a good result.
The patient can be offered a choice. Many patients do
not develop the “bump” caused by the dorsally sublux­
ated fragment, and the bone fragments heal over time.
The cosmetic “bump” of widely separated congruous
fragments that occurs occasionally is not a major prob­
lem for most patients because they are pain free.
Thus the necessity for an operation is related to
whether the joint is subluxated, not the percentage of
joint involved. Video 62D.1 shows several examples of
this.
For a chronic painful subluxated DIP joint fracture, I
like to inject a local anesthetic and reduce the joint with
prolonged dorsally directed manual pressure on the sub­
luxated volar fragment over 5 to 10 minutes until the
collateral ligaments and volar plate stretch enough to
let the joint surface get congruous. I then pass a longi­
tudinal K-wire through the reduced volar distal phalanx
fragment to the middle phalanx for 8 weeks.
Boutonnière Deformity
I have not found open surgery for chronic boutonnière
deformity satisfactory, even with wide-awake surgery.
The forces are too great and the tendons are too thin to
respond well to reconstruction sutures. I have not met
a surgeon who can consistently get a good result with
any operation. This is why so many operations have
been described.
However, Merritt’s relative-motion flexion splint­
ing of the MCP joint6 has solved this problem for most
compliant patients for me, both in the acute and chronic
conditions. It rebalances the “noose” of the lateral slips
of the long extensor that anchor into the lateral bands.
Video 62D.2 demonstrates how the relative-mo­
tion flexion splint keeps the noose of the long extensor
and lateral bands tight so the PIP joint stops herniating
through it. It is the best solution for boutonnière defor­
mity to come along in the last 50 years.
When the MCP joint is held in flexion, the noose
tightens and the PIP joint is less able to herniate through
the noose. When the MCP joint is extended, and particu­
larly when the PIP joint is hyperextended, the balance
favors PIP flexion and the noose gets loose. MCP joint ex­
tension promotes herniation of the PIP joint through the
loose noose and perpetuates the boutonnière deformity.
Keeping the MP joint flexed with a relative-motion flex­
ion splint rebalances the MP into flexion and the PIP into
extension, keeping it from buttonholing into a bouton­
nière deformity. MCP flexion is good and MCP extension
is bad when treating a boutonnière deformity. MCP hy­
perextension is especially bad for perpetuating this bou­
tonnière deformity. The hyperextensibility of the little
finger MCP joint may be one of the reasons boutonnière
deformity of this digit is so hard to fix without relative-
motion flexion splinting.
In the acute boutonnière deformity with or with­
out a repaired laceration, a pencil is used to simulate
the relative-motion flexion splint. If the patient can ac­
tively extend the PIP when the MCP is held in flexion by
the pencil and by a relative-motion flexion splint, I go
directly to full-time relative-motion flexion splinting for
2 months. Patients can usually tell when they are ready
to stop splinting, because the finger no longer feels like
“it wants to go weird” if they leave the orthosis off for
a while.
In the chronic boutonnière deformity, I start with
serial casting to extend the PIP joint. I allow DIP flexion
if the finger is long enough. I serially cast until the PIP
joint has reached its best position of −20 degrees or less,
and until I see return of DIP flexion, which signifies that
the lateral bands are now dorsal to the PIP joint. As long
as there is no good flexion of the DIP joint with the PIP
extended, the lateral bands are still volar to the axis of
the PIP joint.
When I can, I add relative-motion flexion splinting
to serial casting or boutonnière cylinder splinting of the
PIP joint. This rebalances the extensor noose by tighten­
ing it with MCP flexion.
I use cylinder boutonnière splinting (which may
take as long as 2 to 3 months) until the finger keeps PIP
extension and DIP flexion when only in a relative-mo­
tion flexion splint. I then graduate to only a relative-mo­
tion flexion splint for 2 to 3 months, or until the patient
knows it is time to stop splinting under the supervision
of the hand therapists. All boutonnière deformity man­
agement happens under the direction of hand thera­
pists, who consult the hand surgeon as required.
Sagittal Band Injury
I have found that use of a relative-motion extension
splint for 4 to 8 weeks is the only treatment required
for most acute injuries.
In a chronic injury in which the long extensor sub­
luxates to the radial or ulnar gutter over the metacarpal
head, treatment is required only if the patient is both­
ered by it. Not all patients are bothered enough to have
surgery. If surgery is indicated, I open and repair them
with the patient wide awake. If the tissues are not robust
enough for repair, I use a distally based flap of extensor
tendon to bolster the repair. I have also used Dr. Merritt’s

1217
Chapter 62 Extensor Tendon Injuries
pulley creation6 in the metacarpal head with a tendon
graft to centralize the long extensor tendon, and I like
this technique. I have found that I need to place the pul­
ley as distally in the metacarpal head as possible.
I start relative-motion extension splinting 2 to 5
days after surgery for these patients. I splint for an
average of 4 to 6 weeks. Patients need to know what
movements to avoid by listening to their pain and by
discontinuing pain killers as soon after surgery as pos­
sible. They cannot judge their movement ability well if
analgesic use is allowed to mask the symptom of pain.
Long Extensor Repair (Zones IV to VII)
I have been using Merritt’s relative-motion extension
splint6 for 2 to 5 days after surgery for long exten­
sor repair to allow these patients to get back to early
functional use of the injured hand. These splints have
certainly improved the patient experience over the tra­
ditional 4 weeks of immobilization,7 and I feel that the
outcomes have been better as well. I still have not had
a rupture in almost 20 years of early mobilization with
the relative-motion extension splint.
I decide whether I want to add wrist extension
splinting to the relative-motion extension splint by
what I witness with comfortable patient active move­
ment during wide-awake extensor tendon repair. I sim­
ulate relative-motion splinting at surgery with a ster­
ile tongue depressor. I then watch the patient flex and
extend the fingers in both wrist flexion and extension.
I also assess the character of the patient to determine
whether he or she can be trusted to only have the rela­
tive-motion extension splint without the wrist support.
Video 62D.3 illustrates how relative-motion exten­
sion splinting protects an extensor tendon repair.
General Advice for All Hand Operations
For all hand operations, I educate my patients during
surgery, because they are wide awake. I have them
elevate and immobilize their hand for 2 to 5 days to
stop the internal bleeding. Immediate movement en­
courages bleeding in the wound. Blood clots need to be
resolved with vascular infiltration and scar formation.
Collagen formation does not start until day 3. I advise
patients to let the bleeding stop, the swelling to come
down, and the work and friction of movement to de­
crease. I encourage all patients to move only when they
are off all pain killers.
Conclusion
To prevent unfavorable results in extensor tendon re­
pair, hand surgeons and therapists should encourage
most patients to use relative-motion splinting in the
postoperative therapy regimen. These orthoses allow
the patient to continue to live and use their hand while
healing. They do not need to stop living to exercise.
Wide-awake surgery also decreases the unfavorable
result by allowing the surgeon to communicate with the
patient and fine-tune repairs tested by active movement
before skin closure.
References
1. Lalonde DH. Extensor tendon repair of the finger. In:
Lalonde DH, ed. Wide Awake Hand Surgery. Boca Raton,
FL: CRC Press; 2016
2. Hirth MJ, Howell JW, O’Brien L. Relative motion ortho­
ses in the management of various hand conditions:
A scoping review. J Hand Ther 2016;29(4):405–432
3. Merritt WH, Howell J, Tune R, Saunders S, Hardy M.
Achieving immediate active motion by using relative
motion splinting after long extensor repair and sagit­
tal band ruptures with tendon subluxation. Oper Tech
Plast Reconstr Surg 2000;7(1):31–37
4. Howell JW, Merritt WH, Robinson SJ. Immediate con­
trolled active motion following zone 4-7 extensor ten­
don repair. J Hand Ther 2005;18(2):182–190
5. Ishiguro T, Itoh Y, Yabe Y, Hashizume N. Extension block
with Kirschner wire for fracture dislocation of the dis­
tal interphalangeal joint. Tech Hand Up Extrem Surg
1997;1(2):95–102
6. Merritt WH. Relative motion splint: active motion af­
ter extensor tendon injury and repair. J Hand Surg Am
2014;39(6):1187–1194
7. Burns MC, Derby B, Neumeister MW. Wyndell merritt
immediate controlled active motion (ICAM) protocol
following extensor tendon repairs in zone IV-VII: re­
view of literature, orthosis design, and case study—a
multimedia article. Hand (NY) 2013;8(1):17–22

1218
CHAPTER
63
Bone and joint injuries in the hand, wrist, or radius are very
common and require exacting care to achieve a good ­result.
Complications may occur even when things are ­correctly
performed. When things are performed faultily, even an
average result is rare. Hand surgeons see an enormous
number of complications after fractures and realize that
the ability, as surgeons, to cause further harm is immense.
Some of the complications stem from overt malpractice,
whereas others originate from traps that can be deceptive
even for relatively expert surgeons. This chapter only ad­
dresses the most common errors and the less common but
more detrimental ones. The chapter also offers some solu­
tions for those untoward results. Some of the alternatives I
propose here are unproved and require an open mind. How­
ever, experience has shown some complications cannot be
solved by following the current “standard of care.” Areas of
general knowledge are not covered here.
I have adopted several principles in managing fractures
through the years:
Principles in Fracture
Management
1. Incorrect or marginal treatment will result in either
poor or very poor outcomes.
Surgeons must study all published data regarding fracture
management to be able to make well-informed decisions.
2. Overly aggressive surgery will trigger major
complications.
Surgery in itself causes additional damage and interferes
negatively in the outcome. Hence, only what truly needs to
be operated should be operated, and with the least possible
invasiveness. In other words, the damage the surgeon is
­going to inflict has to be worthwhile. Unnecessarily aggres­
sive surgery will mostly yield poor results.
I have a low threshold to operate in search of the ana­
tomical exactness on radiographs. However, some patients
can tolerate some deformity and still have a good functional
result. Nevertheless, there are two reasons for searching for
perfect radiographs in my practice. The first, and most log­
ical, is that restoring the anatomy is a surgeon’s goal and
avoids preventable problems. The second, less obvious, rea­
son is that even if an abnormal radiographic result will yield
a functional result for most patients, this may not be true for
a worker’s compensation case. Another surgeon may argue
that the cause of the patient’s complaint is a “faulty” reduc­
tion that is evident on the radiograph. This may be the first
step of a claim, and my practice is very much biased toward
work-related injuries.
3. The policy of “sensible radicalism” yields the best
results.
This essentially means that the surgeon should not com­
plicate a case that may benefit from a simple treatment.
However, the surgeon also should not accept a poor re­
sult to keep the surgery simple to avoid complications.
Complex, unsolved problems require newer approaches
and sometimes aggressive surgeries to achieve a good
result.
The application of this principle requires surgeons to be
good technicians. This means not just being a good plastic
surgeon (understanding soft tissue management and being
efficient in microsurgery) but also being a good orthopaedic
surgeon (competent at arthroscopy, knowledgeable in fixa­
tion, understanding bone healing).
4. Complex surgery is for skilled surgeons.
A skillful technician will achieve reproducible results in
complicated surgery. On the other hand, complicated sur­
gery performed by a poor technician yields catastrophic re­
sults. As a corollary, easy surgery is more popular but not
necessarily the best for the patient’s problem.
Bone and Joint Injuries:
Hand, Wrist, and Distal Radius
Francisco del Piñal

1219
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
is needed, the surgeon should determine the least invasive
method that provides stable fixation to allow immediate
range of motion. The surgical options are wide-ranging.
­Table 63.2 provides a summary of methods that meet most
of my needs. Needless to say, the surgeon should be pre­
pared to change plans according to the personality of the
fracture and the intraoperative findings. I have achieved very
satisfying results by using intramedullary headless cannu­
lated screws for fractures of metacarpals and phalanges.4 A
1-mm K-wire is introduced through a nick in the skin, ret­
rogradely (distal to proximal), and through the head of the
metacarpal–proximal phalanx. This K-wire is used to reduce
and align the fracture. Next, the K-wire is used as a guide
for a double-threaded headless cannulated screw (as a rule,
2.5-mm diameter for phalanges and 3 mm for metacarpals)4
(Fig. 63.2). The procedure is particularly indicated in trans­
verse and short oblique fractures. Fixation can be performed
in a matter of minutes, allowing immediate range of mo­
tion, with minimal trauma. The operation is not indicated
when there is bone loss but can be used successfully in very
­complex scenarios (Fig. 63.3).
Phalangeal fractures, more so than metacarpal fractures,
are prone to complications and bad results: lack of full range
motion; loss of normal alignment; lack of union; and the
catastrophic infection are among the most prevalent.
Ideally, a finger should recover an excellent result af­
ter any fracture, defined as more than 240 degrees of total
Fractures of the Phalanges and
Metacarpals
A hand surgeon commonly sees digital fractures. Most
cases respond well to the following:
•• Reduction under local anesthesia
•• Immobilization or protected range of motion for 3 to
4 weeks
•• Self-directed exercises
When the reduction does not meet the criteria of accept­
ability1 (Table 63.1), surgery is recommended. Because
articular fractures need an exacting reduction, most re­
quire surgery too. Finally, open fractures require emer­
gent débridement and fixation. Patients with special needs
(professional sportsmen, surgeons, etc.) may need surgery
despite meeting the criteria referred to in Table 63.1 to
shorten the recovery period. The presence of multiple frac­
tures is in itself not an indication for surgery. However, it
is quite common that one of them fails to meet the criteria
of ­acceptability, making surgery necessary for all of them1
(Fig. 63.1).
Open reduction and internal fixation, although at­
tractive to surgeons, has a deleterious effect on the func­
tional outcome of any digital fracture.1–3 Hence if surgery
Table 63.1 Criteria of acceptability
for phalangeal fractures depending
on the location of the fracture
Diaphysis
Metaphysis
10° of sagittal
angulation
20° of sagittal angulation
10° of coronal
angulation
10° of coronal angulation
0° of rotational
deformity
0° of rotational deformity
Source: From Chow SP, Pun WK, So YC, et al. A prospective study of 245
open digital fractures of the hand. J Hand Surg Br 1991;16(2):137–140.
Table 63.2 Surgical options for
fracture
Fracture type
Options
Stable fractures
Early protected range of
motion
Unstable fractures
• Transverse or short
oblique
Intramedullary screws
• Long oblique
Lag screws
• Comminuted
Blocked plates (with or
without bone graft)
• Bone loss
• Blocked plates with bone
graft
• Axial K-wires with bone
graft (for P2 or thumb P1)
• Vascularized bone graft

SECTION VIII THE HAND AND UPPER EXTREMITY
1220
Fig. 63.1 Multiple fractures can be dealt with by immobilization alone provided the criteria of acceptability are met after the reduction.
(a,b) Significantly displaced fractures of the proximal phalanges of the fingers and base of the first metacarpal. All were reduced under local
anesthesia in the office. Range of motion was started after 3 weeks. (c,d) Result at 6 weeks. (Copyright Dr. Piñal, 2015.)
a
b
c
d
Fig. 63.2 Intramedullary headless cannulated screw fixation technique (see text for details). (Copyright Dr. Piñal; reproduced from del
Piñal F, Moraleda E, Rúas JS, et al. Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated
headless compression screws. J Hand Surg Am 2015;40[4]:692–700.)
cooperative patient; combined injuries; and, very often, late
initiation of active range of motion.
An uncooperative patient will spoil any complex recon­
struction. However, most cases of insufficient range of mo­
tion I see are related to faulty fixation, overinvasive fixation,
active motion (TAM; active flexion of the metacarpophalan­
geal, proximal interphalangeal, and distal interphalangeal
joints minus the extension deficits in these joints). However,
loss of the normal arc motion is common. Incomplete range
of motion can be related to poorly executed surgery; a non­

1221
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
this to be the case. Extensor tenolysis rarely yields a nor­
mal result (260 degrees of total active motion), particularly
if multiple fingers are involved.5 By the same token, when
flexor tendons are involved, an excellent result is rarely pos­
sible, and there is an unknown (but real) risk of flexor ten­
don rupture during or after the operation, a catastrophic
situation. Again, the surgeon must resist the temptation to
place a plate dorsally in a proximal phalanx. Although eas­
ier, technically speaking, the plates destroy the gliding layer
and create massive adhesions that are nearly impossible to
or a dorsally placed plate. The latter is especially relevant,
because it is axiomatic that any plate placed on the dorsal
surface of the proximal phalanx will yield a poor functional
result (Fig. 63.4).
Incomplete range of motion is much more common in
phalangeal than metacarpal fractures, because the former
is surrounded by tendons and has a minimal gliding layer.
Restrictive adhesions are common and require tenolysis. Te­
nolysis is sometimes offered as a simple solution for dealing
with the adhesions, but my experience has often not shown
Fig. 63.3 Multiple fracture, multifixation method in a patient who sustained a crush. (a,b) In addition to the obvious soft tissue defect and
extensor tendon laceration of the ring and little finger and open fractures in all cases. Note the severe comminution of the head of the ring
finger metacarpal. (c,d) Radiographs at 4 months. The injury was managed by a standard 3-mm HCS for the index finger, a 3-mm antegrade
for the comminuted middle finger, a Y strut for the ring finger (and primary bone grafting of the defect), and a 4-mm HCS for the small
finger. A free flap was used for coverage. (e,f) Clinical result at 2 years. (Copyright Dr. Piñal, 2015.)
e
f
a
b
c
d
Fig. 63.4 “Frozen finger.” This patient had a lack of active extension and lack of active flexion at presentation and the telltale sign in the
lateral radiograph: a dorsally placed plate (arrows). (Copyright Dr. Piñal, 2015.)

SECTION VIII THE HAND AND UPPER EXTREMITY
1222
ance for deformity in phalangeal fractures (see Table 63.1)
will reward the surgeon with mostly good results. By the
same token, corrections that appear to fall within the ac­
ceptable limits on radiographs after reduction may develop
into a major deformity and the need for corrective oste­
otomy if left unaddressed. It is important to highlight that
malunions are often associated with delayed healing, and
this in turn creates an adhesion issue, thus compounding
the problem exponentially. The need for secondary surgery
and a poor functional result will be nearly guaranteed if the
surgeon is not prepared to perform a complex surgical recon­
struction (discussed later). It is therefore of utmost impor­
tance to achieve healing of the digit in the customary 3 or 4
weeks. The surgeon must do everything possible to procure
stability to permit full range of motion as soon as possible.
Metacarpal fractures, as opposed to phalangeal frac­
tures, are much more tolerant of deformity, particularly in
less-demanding individuals. However, they can be a source
of problems as well. A 50-degree flexion deformity in the neck
of the fifth metacarpal may be considered as highly success­
ful to the surgeon but can be unbearable for a patient if the
injury occurred at work. For this reason, I am very reluc­
tant to leave radiological deformities unaddressed. Further­
more, the fact that a generous soft tissue layer protects them
makes the metacarpals less prone to extensor and flexor ad­
hesions after localized trauma. However, after major trauma,
the bed becomes heavily scarred and devascularized—the fat
disappears. In this setting, adhesions are impossible to solve
unless a gliding layer is restored again6 (Fig. 63.5).
resolve. Tenolysis in an uncooperative patient is highly dis­
couraged, because the possibility of complications is high
and the likelihood of improvement nil. These factors have
led me to become increasingly concerned regarding patients
with adhesions after digital fractures, and I recommend all
readers not to approach tenolysis lightly. Lack of full range
of motion after a tenolysis is poorly accepted and is a major
cause of patient dissatisfaction. All this underscores the im­
portance of doing things right from the beginning.
Delay in starting active range of motion in a phalangeal
fracture for more than 3 or 4 weeks will unavoidably yield
a poor result because of adhesions. Early range of motion
should be encouraged in stable fractures using functional
braces.1 Others require immobilization, because they are not
as stable, but they will still heal in 3 weeks. However, if the
fracture characteristics arouse concerns of not healing by
3 to 4 weeks (basically because of poor contact or comminu­
tion), surgery is recommended. Delayed healing will cause
hypertrophic callus and more inflammation, entrapping the
flexor and extensor tendons over large surfaces. By the same
token, if the surgeon decides to operate on a fracture, sur­
gery must be followed by immediate range of motion. As a
rule, open reduction and internal fixation followed by im­
mobilization is nonsensical.
Malunions
Malunions should not occur if the basic tenets of fracture
management are applied. As stated earlier, low or no toler­
Fig. 63.5 (a) In exhausted beds tenoarthrolysis is doomed to fail, because the scarred tissue will not permit tendon gliding. The surgeon
should wrap the scarred tendons with adipofascial flaps. Plain radiographs (b) and computed tomography (c) show that volar angula­
tion of the malunited or nonunited third through fifth metacarpals has compounded the problem of the hyperextension of the MPJs.
(d) Preoperatively the lack of flexion of the MPJs is evident. In a single-stage procedure the metacarpals were aligned with plates, arthroly­
sis of all MPJs was performed, and the extensor was freed from scarred tissue. A lateral arm adipofascial flap was used to wrap the tendons.
(e) Result at 1 year. (Copyright Dr. Piñal, 2015.)
d
e
b
c
a

1223
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
a
b
c
d
f
g
e
Fig. 63.6 (a,b) This patient sustained a crush injury that resulted in comminuted phalangeal fractures and an open palmar wound
with devascularization of the fourth and fifth finger. The common digital arteries were found to be avulsed and consequently repaired.
(c,d) Because of the amount of comminution (arrows) and the extent of cortical shattering, the fractures were primarily bone grafted.
(e) Plates placed laterally allowed immediate range of motion. (f,g) Result at 4 months. (Copyright Dr. Piñal, 2015.)
Nonunions
When a large amount of bone is devascularized, such as in
severe cortical comminuted fractures, or when the fracture
is combined with a soft tissue injury, the surgeon should
consider nonunion as a possibility—a functional catastro­
phe at best. Even the most benign of these scenarios will
have a poor result requiring secondary surgery.
The surgeon should do everything possible to achieve
healing in the customary 3 to 4 weeks. In my practice this
includes providing rigid fixation with the minimal possible
devascularization, liberal use of cancellous bone graft, and
provision of good soft tissue cover and vascularized bone
graft for the worst cases. I use this armamentarium with
the sensible radicalism mentioned previously—that is, if I
have any doubt that the patient may experience a delayed
healing, I opt for a more aggressive treatment. For example,
a fracture may heal with a plate, but if there is cortical com­
minution, the healing is going to be slow and interfere with
the result. Thus I would add cancellous bone graft (Fig. 63.6).
It is important to understand that surgery may convert
a somewhat misaligned yet potentially healing fracture into
a nonunion because of the negative effect that exposure has
on the blood supply. Salvage of any nonunion may require
“exceptional” surgery if a good result is to be obtained. I
typically combine new fixation and vascularized bone graft
to speed healing (Fig. 63.7).
Infection and Osteomyelitis
After any fixation, the appearance of infection is a ma­
jor disaster. Fortunately, the infection rate in phalangeal
fractures is very low. In fact, it has been calculated to be
2% in open fractures and less if closed.6 Although some
of them can be treated by removal of the hardware and
antibiotic therapy, amputation is also quite prevalent.2,6,7
Established infection in the tubular bones of the hand re­
sulted in an amputation rate approaching 50% in a study
by Reilly et al.7
The management of infection depends on whether there
is bony stability and whether there is associated combined
soft tissue loss (Table 63.3). In the “ideal” case of infection
with bone continuity, hardware removal and oral antibiot­
ics will cure the problem. The issue becomes increasingly
complicated if the soft tissue cover is insufficient or the fixa­
tion is tenuous.
In my experience, most severe infections occur as a
combination of open fracture and poor coverage, as after

SECTION VIII THE HAND AND UPPER EXTREMITY
1224
Table 63.3 Management of infected
digital fractures
Soft tissue cover
Bone stability
Treatment
Ok
+
1 + 2
+/−
+
1 + 2 + 3 + 4
(local flap)
++
+
1 + 2 + 3 + 4
(distant flap)
+
+/−
1 + 2 + 3 + 4 + 5
Any
−
1 + 2 + 3 + 6
Notes: 1, Hardware removal; 2, antibiotics; 3, débridement; 4, local flap
(minor soft tissue defect) or free flap (major defect); 5, cancellous bone
graft; 6, vascularized bone flap.
g
Fig. 63.7 (a) This patient sustained an open crush and was managed by plating. According to the re­
port the intrinsic muscles were devitalized and had to be debrided. All these unfavorable factors lead
to an atrophic nonunion and hardware failure. (b) To overcome an exhausted bed (with no healing
potential) apart from a new fixation, vascularized tissue with osteogenic potential was planned (the
cannulated screws in the medullary canal). (c) A wedge-shaped flap from the medial femoral condyle
was harvested and fixed in position with lag screws (d). In the same surgery tenolysis and capsuloto­
mies (second through fourth fingers) were added to treat the stiff hand. (e,f) Immediate range of
motion was begun and a full functional result was achieved at 3 weeks. (g) Radiograph at 4 months,
showing the amount of new bone formed by the corticoperiosteal flap. (Copyright Dr. Piñal, 2015.)
a
b
c
e
f
Flap
Pedicle
(arrow)
d
a crush. It is axiomatic that if the soft tissues are left unat­
tended (i.e., they are not radically débrided and good cover
is not provided at the time of initial treatment), infection is
unavoidable. Infection in the setting of poor coverage does
not clear until the bone is radically débrided and a good
soft tissue provided (which is what the surgeon should have
done in the first place). Even if, after a heroic surgical opera­
tion, amputation is avoided, infection will rarely clear with­
out a high price: a major loss of motion and/or arthrodesis
of a neighboring joint (Fig. 63.8).
I have had positive experience using vascularized bone
graft taken from the toe metatarsal for long defects and the
phalanx for medium and small defects.8 As in most cases of
infection in the fingers there is a need of soft tissue cover;
there is no role for the medial femoral condyle corticoperi­
osteal flap.

1225
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
Condylar malunions are managed by a dorsal approach
and after creating a distally based extensor flap that contains
most of the central band and part of the lateral bands. The
joint is flexed and the malunion comes easily into view. Af­
ter stable fixation, active flexion exercises are encouraged,
whereas the extensor repair is strong enough to allow ac­
tive assisted exercises (Fig. 63.9). What is key at the time
of mobilization and fixation of the displaced fragment is to
understand that aggressive maneuvers may lead to fragment
devascularization and, in turn, necrosis. Radiographs of
a previously perfect result may reveal a collapsed joint—a
disaster that only can be solved in young individuals by a
joint transfer or an arthrodesis.
Malunion after impacted fracture dislocation of the
base of the middle phalanx is more common. Unless prop­
erly performed radiographs are taken, the diagnosis will
be missed. Unfortunately, this is common, but most cases
are amenable to reconstruction. I favor a shotgun approach
to fully see the deformity. Then, by using ultrathin bone
Articular Fractures
Articular fractures need exacting reduction if pain and early
degeneration are to be avoided. Although any joint can be
injured and be a source of problems, because of its preva­
lence, the young age of the group involved, and the high im­
pact it has on hand global function, this discussion focuses
solely on the so-called PIP joint “sprain,” which may have an
extremely poor outcome.
PIP joint dislocations are extremely common. Most are
reduced on the side of a sports field by a well-intentioned
coach, and many do well. Some, however, are actually im­
pacted fracture dislocations and difficult to diagnose even
if proper radiographs are taken. These subtle differences,
which are not appreciated initially, can evolve and become
evident later.
At the PIP joint level the following difficult problems oc­
cur: condylar malunions, impacted fracture–dislocation, and
irreversible damage or partial joint loss.
g
Fig. 63.8 (a) This patient had a replantation elsewhere of the index and middle finger. He presented
for a second opinion because he was scheduled for a secondary amputation. Multiple draining sinuses
were present in the middle finger and in the radial aspect of the index finger (white arrows). (b) Radio­
graphs of the index finger revealed a radial abscess and a partially healed fracture ulnarly. A massive
abscess was present in the middle finger with the distal proximal phalanx acting as a sequestrum.
(c) After débridement, the middle finger had a through-and-through soft tissue defect and a bone
defect that involved most of the middle phalanx and the distal interphalangeal joint. (d) A vascular­
ized second toe proximal phalanx spanned the bony ends. Minimal fixation was used to stabilize this
vascularized bone graft. The index hardware was left in place because it was away from the infection.
However, the bone was débrided, cancellous bone was applied, and a local flap (a hatchet flap) was
used for coverage. No other surgery had been performed. (e,f) Functional range of motion of the
proximal interphalangeal joint was achieved. (g) Plain radiographs showed complete bone healing at
1 year. Infection has not recurred after 6 years. (Copyright Dr. Piñal, 2015.)
a
Sequestrum
Bone
abscess
Partial
bone
healing
Bone
abscess
b
c
Artery
Vein
d
Flap
e
f

SECTION VIII THE HAND AND UPPER EXTREMITY
1226
Fig. 63.9 (a) The Chamay approach for treatment of the malunion of the head of the proximal phalanx permits a pristine view of the problem
(arrow indicates extension slip). (b) The malunited condyle has been reduced and fixed rigidly. (c) The extensor tendon slip is repaired with
a continuous 5–0 nylon suture. This enables immediate active flexion and active assisted extension exercises. (Copyright Dr. Piñal, 2015.)
a
b
c
Fig. 63.10 (a) This 32-year-old physiotherapist was seen 7 weeks after sustaining a basketball injury to her middle finger. She had been
immobilized for 3 weeks but presented because of a minimal range of motion and deformity. (b,c) In the original radiographs in the pos­
teroanterior view, some clinodactyly is already evident. In the lateral view the apparently aligned middle phalanx is revealed to actually be
dorsal to the dorsal axis of the proximal phalanx and the impacted fragment can be imagined in the base of the middle phalanx (arrows).
Notice also the widening of the base of the middle phalanx. All these radiological signs are pointers to a major joint disruption. (d,e) In­
traoperative view of the impacted fragments and after mobilization and reduction. Bone graft was packed under the fragments and the
fracture fixed with a cerclage wire. (f,g) Result at 3 years. (Copyright Dr. Piñal, 2015.)
f
g
b
a
c
d
e
instruments (dental picks and 1.0-mm rongeurs) the frac­
ture is re-created and fixation with 1.3-mm screws or cer­
clage wire is carried out.9 I have had very good results in
previously nonoperated patients with this approach (Fig.
63.10). Conversely, I have had mostly disappointing results
when patients have been “aggressively” operated previously
(i.e., screws, plates, or combined approaches). In this situa­
tion there is an enormous amount of scarring, and the risk
of devascularization of the fragments is very high. I believe
most of these cases will end up requiring a salvage opera­
tion, which I would recommend from the outset in some
individuals.

1227
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
Some patients are seen for unsalvageable joint trauma
or previously failed surgery that are already beyond re­
construction. For those patients the only alternative is an
­arthrodesis, a prosthesis, or a vascularized joint transfer.10
I do not believe a prosthesis has a role in the PIP joint for
active patients. I have a fair experience (nearly 50 cases) in
transferring PIP joints from the second toe to the PIP joint
of fingers and in MCP joint reconstruction (both metatar­
sophalangeal and PIP joints). My results can be summa­
rized as follows: When the injury is isolated to the joint
and there is minimal scarring, a very good result can be ex­
pected. However, when there is multitissue damage (flexor
tendon, ­previous flaps, or late reconstructions) a moder­
ate (30–50 degrees of active range of motion) result can be
­anticipated. In most published series the cases are mixed,
and it is ­difficult for the reader to determine the real benefit
of the joint transfer in young individuals (Fig. 63.11).
Carpus Fractures
The scaphoid is the most commonly fractured bone in the
carpus and the most difficult to handle. Furthermore, being
a bone mostly covered by cartilage, the blood supply has
limited entryways, and mismanaged fractures have a high
rate of nonunions and delayed union. The introduction by
Fig. 63.12 This patient was seen 8 months after a prior percuta­
neous screw fixation of a middle third displaced scaphoid frac­
ture. Nonhealing and radius surface destruction is evident. An
arthroscopic radioscapholunate arthrodesis was performed to
salvage this catastrophic scenario. (Copyright Dr. Piñal, 2015.)
b
c
a
Fig. 63.11 This 28-year-old man was seen for irreversible degeneration of the PIP joint after sustaining a “sprain,” which was operated sec­
ondarily elsewhere with resulting pain and stiffness. (a,b) A PIP joint was transferred, and the result is shown at 5 years. The dots outline
the skin monitor. (The screw in the middle phalanx is unrelated to the joint transfer [c]). (Copyright Dr. Piñal, 2015.)
Herbert and Fisher11 of the double-threaded screw marked
a benchmark in the treatment of scaphoid fractures. A high
success rate was reported for fractures and nonunions
alike.11 Some factors that are known to carry a poor prog­
nosis for healing have been found to be a clear indication
for surgery:
•• Proximal pole fractures
•• Displaced fractures (more than a 1 mm)
•• Delayed presentation (more than 4 weeks)
As for other fractures, to shorten the recovery period, pa­
tients in certain types of professions benefit from surgery
despite it not being, technically speaking, medically indi­
cated.
Unfortunately, what was not underlined when the pro­
cedure was presented was that the technique is exacting and
without room for error. The risk of causing devastating dam­
age to the joint is even higher if inexperience is combined
with the now in vogue percutaneous approach. Understand­
ing the complex scaphoid anatomy is key to avoiding com­
plications.12 The industry has a major role in pushing the
product, which may have overwhelmingly negative effects
for the joint (Fig. 63.12).

SECTION VIII THE HAND AND UPPER EXTREMITY
1228
a vascularized transfer. This may be considered overkill, but
if one minimizes dissection at the time of flap harvesting,
the donor site sequelae are negligible, and the benefit of the
blood supply undeniable (Fig. 63.14).
When degeneration of the wrist occurs as a result of
scaphoid nonunion, it follows a predictable pattern. Initially
this involves the radial styloid (SNAC I), then the area of the
capitate neighbor to the nonunion (SNAC II), and finally, the
capitate–lunate joint (SNAC III). As a rule, I deal with SNAC
I as in nondegenerated cases, but with the addition of a sty­
loidectomy. Again arthroscopy allows, without , scaphoid
healing in early cases of degeneration (arthroscopic styloid­
ectomy plus scaphoid grafting).14 In more advanced cases,
arthroscopy can also be used in salvaging operations, such as
partial wrist arthrodesis.17 Although this may be considered
yet another arthroscopic filigree, the operation is sound and
allows in a competitive time, at worst, similar results with­
out scarring or proprioception damage.
When the scaphoid has failed to unite by a certain time
after the fracture (6–12 weeks), the possibility of healing
without intervention is nil. The nonunited scaphoid requires
treatment in symptomatic patients, and it is probable that
asymptomatic “patients” should also undergo reconstruction
to avoid development of the scaphoid nonunion advanced
collapse (SNAC) wrist. However, surgery is controversial in
truly asymptomatic patients, because a clear progression to
degeneration is not certain, whereas patients may become
symptomatic if the surgery is unsuccessful. Scaphoid non­
union on its own is the topic of several books, so summa­
rizing it is a difficult endeavor. There are myriad techniques,
but the basic modifiers are the blood supply of the proxi­
mal pole, the location of the fracture, the loss of length of
the scaphoid, and the degree of degeneration of the joint.
Table 63.4 summarizes my current management protocol
of scaphoid nonunion.
The presence of blood supply in the proximal fragment
is a sine qua non condition to proceed to reconstruction. I
have found that if the proximal fragment is avascular, there
is no way to achieve healing of the cartilage cover (though
the bone may heal). An exceptional reconstructive opera­
tion may be indicated apart from a salvage operation.13 The
problem is that the definition of vascularity is subjective.
Part of the confusion relates to the fact that authors (surely
unconsciously) stretch the term to their benefit to glorify
the virtues of a proposed technique. However, I have tried
nearly every technique, and I have reached the conclusion
that when the scaphoid is necrotic (i.e., fragmented, “tooth­
paste” aspect with yellowish deposits), healing is impossible.
However, a hypovascular scaphoid (the bone may not have
bleeding points but has normal bony structure at surgery)
deserves an attempt at reconstruction, independently of the
imaging result. Any hypovascular fracture benefits from vas­
cularized bone transplant, and the scaphoid is no exception.
Finally, if the scaphoid has good blood supply, then nonvas­
cularized bone graft is enough.
The location of the fracture is important for the ap­
proach and the method of fixation. Ideally all reconstruc­
tions should be fixed with screws, but a small fragment
may not have enough volume to harbor the screw without
further fragmentation. K-wires may be the only feasible
method in this scenario. Another major breakthrough in the
management of the scaphoid has been the introduction by
Ho of the arthroscopy in scaphoid nonunion.14 This method
is particularly useful in hypovascular proximal poles, be­
cause the surgeon does not disturb the remaining blood sup­
ply and bone can be added into the nonunion (Fig. 63.13).
If the scaphoid is deformed and flexed, the so-called
humpback deformity, the surgeon must restore the length.
Otherwise, the wrist joint mechanics will be distorted and
degeneration will ensue. Again there are several methods:
a nonvascularized wedge graft, a pedicled volar graft,15 and
a distant medial femoral condyle flap are among the most
popular.16 I do not hesitate, if the defect is long and any of
the unfavorable modifiers are present, to proceed directly to
Table 63.4 Management of scaphoid
nonunion
Type/location
DISI
Vascularity
Treatment
Proximal
pole
No
+
Arthroscopic
grafting and
K-wires
Middle third
No
+
Arthroscopic
grafting and HBS
Any
+
+
Anterior carpal
artery flap15
Any
−
Hypo
Anterior carpal
artery flap15 or
medial femoral
condyle flap16
Any
++
Hypo
Medial femoral
condyle
Necrotic/
fragmented
Any
NA
MTF13/salvage
(A-PRC/A-4CF)
With joint changes
SNAC I
NA
NA
As above plus
(arthroscopic)
stylodectomy
SNAC II
NA
NA
A-PRC/A-4CF
SNAC III
NA
NA
A-4CF
Abbreviations: A-4CF, Arthroscopic four corner fusion; A-PRC, ar­
throscopic proximal row carpectomy; HBS, headless bone screw; MTF,
medial trocheal graft; SNAC, scaphoid nonunion advanced collapse.

1229
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
Fig. 63.14 (a) A corticoperiosteal flap from the medial femoral condyle
is recommended to be harvested with a small pedicle. (b) The vessels
are small but large enough for end-to-end anastomosis to local vessels
in the wrist. This minimizes the approach needed in the wrist and in the
knee (c). (d) Typical indication of the flap: a young patient with a failed
surgery and a massive volar defect corrected in one stage. (e) Graft
incorporated at 3 months. (Copyright Dr. Piñal, 2015.)
d
e
Wedge
graft
Pedicle
a
b
c
Fig. 63.13 (a) Arthroscopy allowed us to not only have a pristine qual­
ity view of this nonunion of the proximal pole, but also to débride the
cavity and to add bone graft. (b) The wrist at 2 weeks, highlighting the
portals used and the incision needed to insert the screw (arrowhead).
(c,d) Radiographs at 3 months. (Copyright Dr. Piñal, 2015.)
c
d
UMC
RMC
b
a

SECTION VIII THE HAND AND UPPER EXTREMITY
1230
tion of classic (wet, or with water) arthroscopy and any open
surgery is awkward at best. However, many of the associated
limitations are overcome when the arthroscopy is carried
out “dry.” Dry arthroscopy is extremely useful when dealing
with distal radial fractures. Apart from not using water, the
operation is greatly simplified if, instead of trying to reduce
all the fragments under arthroscopy, the arthroscope is used
at the end of the operation only to fine-tune the reduction.
Briefly, in the technique I recommend,18 a volar lock­
ing plate is placed in the radius between the flexor carpi
radialis and the radial artery. The plate is stabilized to the
shaft of the radius by screws, and after reduction the ar­
ticular fragments are stabilized with K-wires introduced
through the auxiliary holes of the plate. Once the surgeon
has achieved what is considered the best fluoroscopic reduc­
tion, before any permanent fixation is placed in the articu­
lar fragments, an arthroscopic checkup is carried out. If the
reduction achieved has been anatomical, the arthroscopic
part of the operation is terminated after two or three lock­
ing screws are inserted to stabilize the epiphysis. If a frag­
ment is found to be still unreduced, then the corresponding
K-wire is backed out to release it from the plate. A shoulder
arthroscopic probe is then used to pull from the depressed
fragment and reduce under arthroscopic guidance the dis­
placed fragment. Then, directly viewing the position of the
reduced fragments, the locking screws or pegs are inserted
(Fig. 63.15). Clinically, I have often seen step-offs that cannot
be detected by fluoroscopy, even in fractures with minimal
comminution (Fig. 63.16). Once the fixation is finished the
wounds are closed and the patient discharged, because the
operation is carried out on an outpatient basis. As stated
previously, the construct is stable enough to allow immedi­
ate range of motion. Most patients do not need formal physi­
cal therapy but should perform self-directed exercises.
Although predictable and consistently good results can
be achieved in nearly all distal radius fractures if the sur­
geon carefully follows the principles presented here, I often
see complications related to faulty technique at the time of
fixation. Indeed, the widespread use of plates for the distal
radius has shifted complications in a different direction from
Distal Radial Fractures
Acute Fractures
When dealing with distal radial fractures, the best way to
avoid complications is, in my experience, by achieving ana­
tomical reduction and rigid fixation with one of the available
so-called volar locking plates (VLPs). The fixation allowed by
these plates is sufficient to permit immediate range of mo­
tion, allowing the patient to return to usual duties in a mat­
ter of weeks. This does not mean that all fractures should be
operated. After reduction, stable fractures need a cast and
appropriate follow-up (weekly radiographs). However, dis­
placed fractures after reduction and most articular fractures
benefit from exacting surgery. By the same token, lower­
ing the tolerance to deformity on the grounds of patient’s
age (older than 65 years) is not justifiable. Individuals older
than 65 years are often extremely active in sports or have a
major role in family life, running the house or looking after
grandchildren. Just like any active worker, these people need
a fully functional wrist as soon as possible.
In articular fractures I have found the most consistent
way to achieve predictably good results, even in the most
complex distal radius fractures, is by combining a volar im­
plant with (dry) arthroscopic-guided reduction.18 The use
of the arthroscope is essential to have a clear view of the
joint surface. Surprisingly, there is a high reluctance by the
hand surgery community to use the arthroscope in distal
radial fracture fixation. This is not logical. Articular step-
offs have been directly correlated with the development of
early joint degeneration, and they are difficult to detect by
fluoroscopy. On the other hand, the arthroscope permits the
joint surface to be seen, fully magnified, and with minimal
additional damage. However, many hand surgeons insist that
arthroscopy consumes excessive operating time for a mar­
ginal benefit. Nonetheless, there are several well-executed
studies that prove better results when using the scope.19,20
Furthermore, we have demonstrated that arthroscopy can
be performed in less than 5 minutes.18 The underlying cause
for surgeons to reject this technology is that the combina­
Fig. 63.15 Author’s technique to reduce depressed fragments. (Copyright Dr. Piñal, 2011.)

1231
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
a dorsally implanted plate. Dorsal plates always cause ir­
ritation and only after their removal (requiring a second
operation months after the trauma) will the patient regain
happiness with the result. Thus I find no reason for placing
plates dorsally no matter how thin they might be, or how
highly the industry speaks about their benefits.
There are also preventable problems when using volar
plates. One of the most common is radial-side pain related to
positioning the plate too radially. This responds well to plate
removal, but again this entails another operation. Similarly,
what was typical 5 years ago. Although extra-articular mal­
unions have been reduced drastically, the number of plate-
related complications and intra-articular malunions have
increased.
Most problems related to plates are secondary to mis­
placement and can cause tendon irritation or local pain. Ex­
tensor tendon complications are common when using dorsal
plates. Despite confusing literature supporting its use, in­
dustrial pressure may be the main reason for its advocacy.
As a matter of fact, I have never seen a satisfied patient with
Fig. 63.17 (a) This patient achieved a satisfactory result after an arthroscopy-assisted distal radius fracture fixed with a volar plate. At the
6-month follow-up visit he is shown pointing to an area of recently appearing soreness. The edge of a functioning extensor pollicis longus
(EPL) can also be seen in the anatomical snuffbox. (b) An overshooting screw is evident in the lateral radiograph. (c) An emergent decom­
pression of the third extensor compartment aborted an impeding EPL rupture. (d) The EPL was left subcutaneously and the extensor reti­
naculum was closed with a stitch to prevent the tendon from falling back into the danger zone. The plate was not removed and full recovery
was achieved. (Copyright Dr. Piñal, 2015.)
a
b
6R
3-4
Proximal
c
EPL
d
Fig. 63.16 (a) This patient sustained a sagittal fracture in the lunate fossa. (b) Although the fluoroscopic view seems to be perfect, the joint
was actually incongruent, because the ulnar part of the lunate fossa had rotated. (c) This was confirmed in the corresponding arthroscopic
view. (d) The step-off was corrected under arthroscopic guidance. (Copyright Dr. Piñal, 2015.)
d
c
0° radial inclination
a
b

SECTION VIII THE HAND AND UPPER EXTREMITY
1232
d
e
a
b
c
f
g
Fig. 63.18 (a) This patient who sustained a minimally displaced fracture treated in a cast 8 weeks prior noticed sudden loss of thumb exten­
sion. (b) Through a minimal incision over the MPJ the distal extensor pollicis longus (EPL) stump was retrieved. Primary suture is impossible in
these circumstances because the tendon has been ragged in the vicinity of Lister’s tubercle and the defect is always significant. (c) A (double)
interposition palmaris longus graft was sutured to the distal stump. (d,e) With a tendon passer the tendon grafts were retrieved proximally
and sutured to the proximal stump of the EPL. (f,g) Normal thumb function was achieved with minimal scarring. (Copyright Dr. Piñal, 2015.)
irritation on the extensor surface of the wrist and exten­
sor tendon tendinitis were common, related to overshooting
screws. Now most surgeons are aware of this complication,
and it is common practice to err on the side of screws that
are too short when using volar plates. Presently, the recom­
mendation is to use screws that are 2 mm shorter than the
measured length. In any case, if a patient is seen with nor­
mal function on the extensor pollicis longus (EPL) but pain in
the vicinity of Lister’s tubercle, emergent release of the EPL
should be carried out or an EPL rupture is likely (Fig. 63.17).
The EPL is also the most commonly ruptured tendon in pa­
tients whose fracture has been treated nonoperatively. Inter­
estingly, this occurs more often in patients with minimally
displaced fractures treated in a cast. The patient notices the
sudden loss of extension around the sixth to eighth week
after the fracture and in most cases when already out of the
cast. If recognized early (3 to 4 weeks) I prefer to restore the
function with a double-loop palmaris longus graft, which
avoids the use of the extensor indicis proprius. If there is no
palmaris or the patient is seen later than this time frame, I
opt for an EIP transfer (Fig. 63.18).
Plate irritation on the radial side of the wrist and even
extensor tendon ruptures, as just discussed, are minor prob­
lems compared with the possibility of flexor tendon rupture
(Fig. 63.19). Although this complication is much more com­
mon when the plate is placed too distally or too proximally,
there is a risk of irritation of the flexor pollicis longus and
flexor digitorum profundus even when the plate is correctly
placed.21 The reconstruction of a flexor tendon in the midst
of a scarred bed has a dreadful prognosis. Hence, if a patient
complains of grating when flexing the thumb or the index
finger and/or refers to any pain when doing so, the plate
should be removed as soon as possible. I foresee an increase
in the numbers of flexor tendon ruptures resulting from the
widespread use of volar locking plates by surgeons who are
not fully trained in the use of plates.
Finally, it is not uncommon to encounter intra-articu­
lar screws. This has devastating consequences for the car­
tilage of the carpals. This complication is inherent to the
fact that the screws have a preset position in volar lock­
ing plates. Hence if the fracture is not reduced properly,
the screws will invade the joint. By the same token, if the

1233
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
(extra-articular malunion), the joint itself (intra-articular
malunion), or both. Any of these may cause pain, restricted
range of motion, and arthrosis.
When the radius loses its normal orientation in any of
the planes, the load-bearing area, the amount of load trans­
mitted, and the biomechanics of the radiocarpal, midcarpal,
and/or distal radioulnar joint may experience major altera­
tions. In a typical Colles’ type extra-articular malunion, the
distal fragment will be dorsally angulated and shortened,
often supinated, and will lose some of the physiological ra­
dial inclination.
Loss of inclination on the sagittal plane (the ­so-called
physiological volar tilt) has been demonstrated to
plate is positioned too distally, apart from an increase in
the incidence of flexor tendon irritation just discussed, the
screws will also ­penetrate the joint. These two scenarios are
complications common to inexperienced surgeons and are
­perfectly preventable with minimal knowledge. It is more
difficult to detect intra-articular penetration in comminuted
articular fractures. Again, this does not occur when arthros­
copy is used systematically (Fig. 63.20).
Malunions
Malunions are the most common complication after distal
radius fractures. The malunion can affect the metaphysis
Correct
Extra-articular
unreduced
Reduced plate
too distal
Intra-articular
unreduced
Fig. 63.20 The preset angulation of the distal screws in most volar locking plates will lead to screw penetration when the distal fragment is
unreduced, the plate is too distal, or intra-articular fragments are unreduced. (Copyright Dr. Piñal, 2015.)
Fig. 63.21 The different patterns of carpal response to dorsal tilt. Both
patients are young and had a similar degree of deformity. (a) The
carpus has subluxed as a whole dorsally. (b) A zigzag collapse has oc­
curred. (Copyright Dr. Piñal, 2011.)
a
b
Fig. 63.19 Plates located anteriorly to the anterior rim of the radius
have been associated with a higher incidence of flexor tendon ruptures.
This patient was seen with limited extension of the thumb when the
wrist was brought to extension. The plate, which was suspiciously too
radial and separated from the radius surface itself, was found to have
ripped 80% of the flexor pollicis longus (FPL). The plate was removed
and the FPL was repaired, yielding an acceptable function. (Copyright
Dr. Piñal, 2015.)
a
B
A
b

SECTION VIII THE HAND AND UPPER EXTREMITY
1234
dorsally; for a volar closing wedge, further shortening of the
radius requires the surgeon to conduct a concomitant ul­
nar procedure to level off the shortened radius. It is very
pertinent at this point to underline that although by defini­
tion all fractures in this group have the distal radius surface
tilted dorsally, not all Colles’ malunions have concomitant
radius shortening, as has been believed for many years. True
shortening will occur only when there has been volar me­
taphyseal comminution or when the continuity of the vo­
lar cortex has been lost, related to dorsal translation of the
distal fragment. In many of the dorsally tilted malunions,
however, the volar cortex acts as a hinge point at the frac­
ture line, and the distal fragment rotates on it, but does not
translate. This occurs if there is only dorsal comminution: if
the distal fragment, unsupported dorsally, pivots on the vo­
lar cortex, slowly rotating in the cast, or if the reduction was
insufficient from the beginning. This represents a “sagittal
rotational malunion,”23 and there is no shortening despite
the appearance on a posteroanterior radiographic view21
(Fig. 63.22).
Such a sagittal rotational malunion can be recognized
on the lateral radiograph, by the “preservation” of the vo­
lar cortex and by having the anterior rim of the radius lon­
ger (more distal) than the head of the ulna, confirming the
absence of shortening (Fig. 63.23). The distinction is not
a trivial dialectical theory; it is key for managing the mal­
union. A pure sagittal malrotation will respond to a much
simpler derotational osteotomy, but shortening requires a
more complex tridimensional reconstruction or a Wada pro­
cedure (Fig. 63.24).
In cases of true concomitant radial shortening (and an­
gulation) the technique I recommend is Wada’s operation
(see Fig. 63.24). Despite the necessity of, and risks inherent,
a concomitant ulnar shortening, Wada et al24 have shown
superior outcomes in the closed wedge osteotomy group
significantly affect the carpal mechanics in different ways
in each patient. In one group of patients, the carpus may
glide as a whole dorsally, whereas in others the lunate may
stay in position, and it is the midcarpal joint where sublux­
ation occurs during ulnar deviation (Fig. 63.21).
Loss of the volar tilt of the radius has also dramatic con­
sequences on the ulnocarpal and distal radioulnar joint me­
chanics and load distribution. The load borne by the head
of the ulna will increase by 50% with a dorsal tilt of only 10
degrees.22 Furthermore, the congruency and contact areas
at the sigmoid fossa will be changed, thus creating a prear­
throtic state and diminishing the forearm rotation.
The ulnar symptoms and joint biomechanics alterations
will further worsen as a consequence of shortening of the
radius that frequently accompanies radius malunion. The
TFC will be locked as a result of shortening, and the load
transmitted through the head of the ulna will be increased
exponentially. It has been demonstrated that only 2.5 mm
of ulnar lengthening (radius shortening) increases the load
borne by the head of the ulna from the normal 21% to 42%
as the load through the radius decreases and concentrates
dorsally.22
The widespread use of VLP for displaced distal radius
fractures has decreased the number of extra-articular mal­
unions in my practice, whereas the opposite has occurred for
intra-articular malunions. This section thus focuses on the
most common forms of extra-articular malunions that I see:
sagittal rotational malunions and major extra-articular defor­
mities in older individuals who were not considered as candi­
dates for surgery, but who ended up with major limitations.
In both these types of extra-articular malunions, the
radius has lost its physiological volar tilt and requires cor­
rection. Simply, there are two ways of repositioning a dor­
sally tilted radius: a dorsal opening wedge or a volar closing
wedge. For a dorsal opening wedge, a bone graft is needed
Fig. 63.22 (a) A malunited distal radius fracture with true dorsal tilting and apparent shortening of the radius. (b) The sclerotic rim appears
to show a positive ulnar variance and a dorsal tilt of the distal radius. (c) The contour of the distal radius has been highlighted by dots; it
is evident that the volar rim of the radius (V) is actually distal to the head of the ulna, but the dorsal rim (D) is proximal. (d) On the same
view as in a, the volar lip (dotted line) is clearly distal to the head of the ulna, confirming the inaccuracy of the variance measured in a. A fine
gray line has been drawn tangentially to the ulnar dome across all the radiographs. A fine black line marks the volar rim of the radius. (From
Limthongthang R, Bachoura A, Jacoby SM, et al. Distal radius volar locking plate design and associated vulnerability of the flexor pollicis
longus. J Hand Surg Am 2014;39[5]:852–860.)
a
b
c
d

1235
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
the step-off (interfacet step-offs are much better tolerated
than intrafacet ones), height of the step-off, and, above all,
time and overzealous use of the hand during physical ther­
apy. Time elapsed since the fracture further complicates the
surgery (particularly open osteotomy) by making the frac­
ture lines at the metaphysis barely identifiable.
Selecting a procedure to deal with any malunion is not
simple. To complicate it further, the decision often has to
be made intraoperatively. Indeed, although a radiological
workup (radiographs and computed tomography) is invalu­
able, often a difficult diagnostic arthroscopy—in the setting
of a scarred joint—is needed before choosing a surgical op­
tion. My approach to malunion is summarized in Fig. 63.25
and depends on the stage of the cartilage. When the car­
tilage is intact in the radius and in the carpals, I prefer an
(arthroscopy-aided) intra-articular osteotomy.26 Corrective
compared with the open wedge group, and the remarkable
advantage of not requiring bone graft.
Intra-articular malunions have a much worse prognosis
because of the rapid development of osteoarthrosis. Baratz
et al25 have demonstrated that step-offs at the radiocarpal
joint cause abnormal concentration at the edges of the step-
offs (up to eight times the basal value) and abnormal motion
of the corresponding carpal bone. Loss of cartilage will occur
early in this setting, and osteoarthritis will be the end result.
Because pain and other unfavorable results have been
found in patients with an intra-articular step-off of more
than 1 mm, I have defined any step-off larger than this as
intra-articular malunion and thus requiring surgery. Intra-
articular malunion should be considered a surgical emergency
to prevent irreversible damage to the cartilage surfaces. Bad
prognostic factors for cartilage preservation are location of
Fig. 63.23 Pure sagittal malrotation: diagnostic pointers, planning, and execution (this is the same patient as in Fig. 63.1). (a) A clear hinge
point corresponding to the original fracture line can be seen (arrow), attesting to preservation of the volar cortex length. The distal volar
rim can be seen distal to the head of the ulna, confirming the ulna minus variance (stippled in black). (b) The hinge point will be used as the
rotation point of the distal fragment. (c) Pure rotation on the fulcrum will correct dorsal tilting preserving the radial length. (d) The result
on this patient. A fine gray line has been drawn tangentially to the ulnar dome across all the radiograms. A fine black line marks the volar
rim of the radius. (Reproduced from Limthongthang R, Bachoura A, Jacoby SM, Osterman AL. Distal radius volar locking plate design and
associated vulnerability of the flexor pollicis longus. J Hand Surg Am 2014;39[5]:852–860, with permission.)
a
b
c
d
Fig. 63.24 Wada’s osteotomy. (a) The correction angle is drawn at the planned osteotomy site in the lateral radiograph. (b) The resulting
value (x) corresponds to the amount of volar cortex that has to be removed during the operation. (c) Correction of the dorsal tilt in the same
patient after the osteotomy. (d,e) Preoperative and postoperative posteroanterior radiographs of the same patient. Notice the ulna has been
shortened by the preoperatively measured ulnar variance (y mm) plus the amount of volar cortex removed (x). (Copyright Dr. Piñal, 2011.)
X mm
a
X mm
b
c
d
e

SECTION VIII THE HAND AND UPPER EXTREMITY
1236
fully functional recovery. Most of my patients have much
more complex problems: old malunions; previously oper­
ated on fractures; and intra- and extra-articular pathology
(Fig. 63.26).
All in all, this is a complex group of patients: The defor­
mities are technically demanding, the surgeon cannot offer a
single alternative preoperatively, and the postoperative care
varies depending on the choices made intraoperatively. Of­
ten these patients have received an incorrect diagnosis of
reflex sympathetic dystrophy (see Complex Regional Pain
Syndrome Type 1), and it is difficult to convince them that
they need a complex operation, which even in the best case
will not restore function to normal. Furthermore ulnar con­
ditions can coexist with the main problem. All doubts and
osteotomy is not indicated when the radial articular surface
is shattered or the cartilage is gone. If this damage is local­
ized to the radial joint surface only, I consider the use of a
vascularized osteochondral graft.27 Finally, if there is local­
ized damage to the cartilage of the radius and the carpals
(mirror-image lesions) I opt for arthroscopic resection ar­
throplasty,28 whereas an arthroscopic radioscapholunate ar­
throdesis is my preference when the damage is generalized.
The ideal candidate for correction is a young patient
with a malunion of a single recent (less than 3 months)
nonoperated fracture. Single fragments such as radial sty­
loid, anteroulnar, or dorsoulnar fragments are the most
amenable to correction. This group of patients responds
extremely well to arthroscopy-guided osteotomy, with near
Radius step-off
Localized
Widespread
Simple
fragments
Irregular
fragments
Vascularized
osteochondral
graft
Open
osteotomy
Arthroscopy-
guided
osteotomy
Eroded
Intact
Radius cartilage
With
static carpal malalignment
or
carpal cartilage damage
Arthroscopic resection
arthroplasty
or
partial wrist arthrodesis
Fig. 63.25 Decision-making process for approaching malunion.
Fig. 63.26 (a) Correction of a 4-mm step-off on the lunate fossa (right wrist scope in 6R). (b) The osteotome (entering the joint through a
dorsal portal) is separating the malunited fragments. (c) Corresponding view after reduction. (Copyright Dr. Piñal, 2010.)
a
b
c

1237
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
Symptoms caused by joint incongruity typically are
decreased range of motion and pain on pronosupination.
Because of its intimate relationship with the lunate fossa
fragments, osteotomy and reposition of the lunate fossa
spontaneously restores the sigmoid notch anatomy. The
articular fragments can be repositioned with good results
independently of the lunate fossa fragments. Irreversible
damage to a part of the sigmoid notch and lunate facet
can be reconstructed in one stage by the base of the third
­metatarsal.27 Pain related to degeneration of the ulnar head
typically increases when the patient is asked to perform
­active pronation and supination while the surgeon squeezes
the wrist to increase the compression forces at the DRUJ. In
most cases the problem can be solved only by a “salvage”
operation: Darrach, Bowers, Sauvé-Kapandji, or ulnar head
prostheses are possible options. They all give equal results
(though never close to a normal DRUJ function), and the use
may be more a matter of surgeon preference rather than
the results of a scientifically tested study. All these proce­
dures share risks of instability of the ulnar stump, impinge­
ment, and painful motion, and some are also associated with
uncertainties should be explained openly to the patient. In
my experience, once they understand their situation, pa­
tients with these intra-articular malunited cases benefit
enormously from surgery, because they are extremely co­
operative and eager for an improved prognosis.
As mentioned previously, ulnar-sided pathology ­always
accompanies the more obvious radius deformity and is a
major cause of persistent pain and secondary surgery.
­Impaction, incongruity, instability, and stiffness can all be
present together or separately and can be responsible, in
differing degrees, for the patient’s symptoms. By the same
token, radius correction may by itself “spontaneously” deal
with some of the ulnar conditions, because the anatomical
­relationship between the radius and ulna will be restored
after the osteotomy. Specifically, symptoms related to impac­
tion may not need to be addressed. Furthermore, symptoms
related to instability may vanish once the sigmoid facet is
repositioned and the ligaments are retensioned, after the
radius osteotomy. It is therefore paramount that the sur­
geon carries out a reexploration and an arthroscopy after the
­osteotomy to clarify the potential sources of persistent pain.
Fig. 63.27 (a,b) This 33-year-old woman has had, over a 6-year period, eight operations to address ulnar pain, which appeared after sus­
taining a distal radius fracture. All of her previous surgeons had overlooked the effect of the malaligned radius on the ulnar side of the wrist.
At the time of her visit the patient was crippled with painful pronation–supination, instability of the ulnar stump, and limited flexion of the
wrist. (c) Salvage required correction of the dorsal malunited radius fracture and a Scheker-type ulnar head prosthesis. The feasibility of
combining both operations was studied preoperatively and the operation carried out in a single-stage. (d–g) Full recovery of range of mo­
tion and disappearance of pain ensued. (Copyright Dr. Piñal, 2015.)
a
b
c
d
e
f
g

SECTION VIII THE HAND AND UPPER EXTREMITY
1238
can be performed arthroscopically. It is also my experi­
ence that the more information the surgeon has (through
magnetic resonance imaging, nerve conduction studies, ar­
throscopy, etc.) the fewer cases that are labeled as CRPS. In
other words, if surgeons keep investigating these patients
and have better diagnostic tools, there will be a time when
the condition will be eliminated entirely, just as vaccine did
for smallpox. Resorting to this diagnosis is not helpful for
the patient or for the progress of science.29
Conclusion
The problems discussed in this chapter are much easier to
avoid than to solve. In my view, to reduce the incidence of
complications, surgeons should seriously consider that hand
fractures cannot be approached carelessly. Perhaps the most
important message for finger fractures is the need to do every­
thing possible to achieve healing in less than 3 to 4 weeks to
preserve active range of motion. If surgery is needed, it should
be exacting. Our role as surgeons is to master the techniques
that give better results, not the ones that are easier.
nonunion, loosening, breakage, or other complications. The
technical intricacies and advantages of each are beyond the
scope of this chapter (Fig. 63.27).
Complex Regional Pain
Syndrome Type 1
The issue of chronic pain after any type of hand trauma
deserves a closing remark regarding my (as yet unproven)
thoughts. I believe diagnosing reflex sympathetic dystro­
phy or complex regional pain syndrome type 1 (CRPS1) af­
ter any trauma to the hand is a “trump card” that we use to
label what we do not understand or (often) what we have
done wrong. There is no need to look for a supernatural
explanation for our patients in pain. In my experience,
100% of patients who present after trauma with swell­
ing, redness, and disproportionate pain (the landmarks of
CRPS1) do have either a clear underlying cause or a subtle
nerve compression. Addressing the underlying cause cures
most patients. However, some patients still have pain after
surgery. Nevertheless, most of them benefit from motion-
sparing arthrodesis or a total arthrodesis—some of which
References
1. Pun WK, Chow SP, So YC, et al. A prospective study on 284
digital fractures of the hand. J Hand Surg Am 1989;14(3):
474–481
2. Duncan RW, Freeland AE, Jabaley ME, Meydrech EF. Open
hand fractures: an analysis of the recovery of active mo­
tion and of complications. J Hand Surg Am 1993;18(3):
387–394
3. Page SM, Stern PJ. Complications and range of motion fol­
lowing plate fixation of metacarpal and phalangeal frac­
tures. J Hand Surg Am 1998;23(5):827–832
4. del Piñal F, Moraleda E, Rúas JS, de Piero GH, Cerezal L.
Minimally invasive fixation of fractures of the phalanges
and metacarpals with intramedullary cannulated head­
less compression screws. J Hand Surg Am 2015;40(4):
692–700
5. del Piñal F, Moraleda E, de Piero GH, Ruas JS. Outcomes of
free adipofascial flaps combined with tenolysis in scarred
beds. J Hand Surg Am 2014;39(2):269–279
6. Chow SP, Pun WK, So YC, et al. A prospective study of
245 open digital fractures of the hand. J Hand Surg [Br]
1991;16(2):137–140
7. Reilly KE, Linz JC, Stern PJ, Giza E, Wyrick JD. Osteomy­
elitis of the tubular bones of the hand. J Hand Surg Am
1997;22(4):644–649
8. del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Re­
galado J, Cagigal L. Vascularized bone blocks from the toe
phalanx to solve complex intercalated defects in the fin­
gers. J Hand Surg Am 2006;31(7):1075–1082
9. Del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Re­
galado J. Results of osteotomy, open reduction, and inter­
nal fixation for late-presenting malunited intra-articular
fractures of the base of the middle phalanx. J Hand Surg
Am 2005;30(5):1039.e1–1039.e14
10. Dautel G, Gouzou S, Vialaneix J, Faivre S. PIP reconstruc­
tion with vascularized PIP joint from the second toe:
minimizing the morbidity with the “dorsal approach
and short-pedicle technique”. Tech Hand Up Extrem Surg
2004;8(3):173–180
11. Herbert TJ, Fisher WE. Management of the fractured scaph­
oid using a new bone screw. J Bone Joint Surg Br 1984;
66(1):114–123
12. Compson JP, Waterman JK, Heatley FW. The radiological
anatomy of the scaphoid. Part 2: Radiology. J Hand Surg
[Br] 1997;22(1):8–15
13. Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized
medial femoral trochlea osteocartilaginous flap recon­
struction of proximal pole scaphoid nonunions. J Hand
Surg Am 2013;38(4):690–700
14. Wong WY, Ho PC. Minimal invasive management of scaph­
oid fractures: from fresh to nonunion. Hand Clin 2011;
27(3):291–307
15. Mathoulin C, Haerle M. Vascularized bone graft from the
palmar carpal artery for treatment of scaphoid nonunion.
J Hand Surg [Br] 1998;23(3):318–323
16. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized
bone graft for nonunion of the scaphoid. J Hand Surg Am
2000;25(3):507–519
17. del Piñal F, Klausmeyer M, Thams C, Moraleda E, Galindo
C. Early experience with (dry) arthroscopic 4-corner ar­
throdesis: from a 4-hour operation to a tourniquet time.
J Hand Surg Am 2012;37(11):2389–2399
18. Del Piñal F. Technical tips for (dry) arthroscopic reduc­
tion and internal fixation of distal radius fractures. J Hand
Surg Am 2011;36(10):1694–1705
19. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-
articular fractures of the distal aspect of the radius: ar­

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opening and closing-wedge techniques. J Bone Joint Surg
Am 2011;93(17):1619–1626
25. Baratz ME, Des Jardins JD, Anderson DD, Imbriglia JE. Dis­
placed intra-articular fractures of the distal radius: the
effect of fracture displacement on contact stresses in a
cadaver model. J Hand Surg Am 1996;21(2):183–188
26. del Piñal F, Cagigal L, García-Bernal FJ, Studer A, Regalado
J, Thams C. Arthroscopically guided osteotomy for man­
agement of intra-articular distal radius malunions. J Hand
Surg Am 2010;35(3):392–397
27. del Piñal F, Klausmeyer M, Moraleda E, et al. Vascularized
graft from the metatarsal base for reconstructing major
osteochondral distal radius defects. J Hand Surg Am 2013;
38(10):1883–1895
28. del Piñal F, Klausmeyer M, Thams C, Moraleda E, Galindo C.
Arthroscopic resection arthroplasty for malunited intra-
articular distal radius fractures. J Hand Surg Am 2012;
37(12):2447–2455
29. Del Piñal F. Editorial. I have a dream . . . reflex sympathetic
dystrophy (RSD or Complex Regional Pain Syndrome—
CRPS I) does not exist. J Hand Surg Eur Vol 2013;38(6):
595–597
throscopically assisted reduction compared with open re­
duction and internal fixation. J Bone Joint Surg Am 1999;
81(8):1093–1110
20. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME,
Bargiotas K, Malizos K. Treatment of intra-articular frac­
tures of the distal radius: fluoroscopic or arthroscopic re­
duction? J Bone Joint Surg Br 2008;90(6):778–785
21. Limthongthang R, Bachoura A, Jacoby SM, Osterman AL.
Distal radius volar locking plate design and associated
vulnerability of the flexor pollicis longus. J Hand Surg Am
2014;39(5):852–860
22. Werner FW, Palmer AK, Fortino MD, Short WH. Force
transmission through the distal ulna: effect of ulnar vari­
ance, lunate fossa angulation, and radial and palmar tilt of
the distal radius. J Hand Surg Am 1992;17(3):423–428
23. Del Piñal F, García-Bernal FJ, Studer A, Regalado J, Ayala
H, Cagigal L. Sagittal rotational malunions of the distal ra­
dius: the role of pure derotational osteotomy. J Hand Surg
Eur Vol 2009;34(2):160–165
24. Wada T, Tatebe M, Ozasa Y, et al. Clinical outcomes of cor­
rective osteotomy for distal radial malunion: a review of
Discussion by Steven L. Moran
Some techniques, such as advanced arthroscopy and
microsurgery, may be beyond the scope of some plas­
tic surgeons. Key points for avoiding a suboptimal out­
come include the following:
•• Secure skeletal fixation
•• Beginning hand rehabilitation early
•• Knowing when to refer
We would add one additional pearl to help in ­avoiding
unfavorable outcomes: Make the complete diagnosis.
Often fractures have associated ligamentous inju­
ries that, if missed, can result in suboptimal results,
continued pain, and potential arthritis. This discussion
expands on these themes in addition to providing addi­
tional perspective on fixation techniques and fracture
management.
Fractures of the Phalanges and
Metacarpals
Phalangeal Fractures and Proximal
Interphalangeal Fracture Dislocations
The management of phalangeal fractures can be chal­
lenging even in the best of hands. Shortening of the
proximal phalanx even by 2 mm can result in post­
operative extension deficits. Rotational deformities of
only 10 degrees can produce symptomatic scissoring of
the digits.1 Further complicating matters is that open
reduction of the finger can result in postoperative ten­
don adhesions. The chapter presents the use of com­
pression screws placed through the articular surface
to minimize soft tissue dissection. This is an attractive
option because it avoids exposing the phalangeal shaft,
uses buried hardware, and obtains rigid fixation; how­
ever, questions still remain regarding the long-term
implications of the trailing screw head on the articular
cartilage and subchondral bone. In addition, this ap­
proach cannot be used in a skeletally immature patient
with an open physis.
Most phalangeal fractures can be managed with K-
wire fixation. This technique does not require special
equipment, is easily removable once union is achieved,
and produces minimal disruption of the soft tissue and
articular surface; however, it lacks the stability achieved
with compression screws or plates.2 Nonetheless, it still
provides as much postoperative motion as the stability
of the fracture and its fixation allows. Even gentle post­
operative passive distal interphalangeal motion may be
helpful if, for example, a proximal phalangeal fracture
has been pinned. Only 2 to 8 mm of extensor tendon
motion is required over the dorsum of the finger. Plate
fixation of phalangeal fractures is known to produce
problems. In Page and Stern’s study,2 of 82 patients with
105 metacarpal and phalangeal fractures stabilized with
plates, major complications were encountered in 36% of
fractures, especially phalangeal fractures. Complications
included stiffness, nonunion, plate prominence, infec­
tion, and tendon rupture. Only 4 of 37 (11%) phalangeal
fractures achieved greater than 220 total degrees of ac­
tive motion after surgery.2,3 Patients should appreciate

SECTION VIII THE HAND AND UPPER EXTREMITY
1240
the sequelae of such injuries and have realistic expecta­
tions during the rehabilitation process.
Intra-articular proximal interphalangeal (PIP) frac­
tures remain a difficult problem. Case figures in the
chapter show the beautiful results that are possible with
open reduction and fine manipulation of the bone frag­
ments of the PIP articular surface; however, other means
may be more appropriate for those with less experience
with intra-articular fixation or free joint transfer, par­
ticularly when there is concomitant joint instability. We
have found dynamic distraction pinning a reliable means
of managing an unstable PIP fracture dislocation.
PIP fracture dislocations lie within the spectrum
of PIP dislocation. Dorsal dislocations and fracture dis­
locations are the most common but are also the most
commonly undertreated. Unrecognized joint instability
can lead to pain, arthritis, and stiffness4 (Fig. 63D.1). A
general treatment algorithm for all forms of PIP disloca­
tion is to initially perform a joint reduction. The surgeon
then needs to verify the congruency of the joint surfaces
throughout a normal range arc of motion; thus it is es­
sential that the surgeon assess the joint under fluoros­
copy or other means to ensure the joint remains reduced
throughout the arc of flexion. Subluxation or dislocation
with motion necessitates splinting the joint in a position
of stability (which is usually in some amount of flex­
ion at the PIP joint) to allow for ligament healing before
mobilization. If the joint is unstable throughout the arc
of motion or requires an excessive amount of flexion to
remain reduced, surgery is necessary.
PIP fracture dislocations may be either stable or un­
stable based on the size and comminution of the frac­
ture fragment. Stable fractures usually involve less than
30 to 40% of the volar articular surface of the middle
phalanx. In these cases a portion of the proper collat­
eral ligament remains attached to the middle phalanx,
Fig. 63D.1 Proximal interphalangeal (PIP) fracture dislocations represent the most severe of PIP dorsal dislocations. PIP dorsal dis­
locations are divided into three types as described by Eaton. (a) In a type I hyperextension injury there is an injury to the volar plate,
but the proper and accessory collateral ligaments remain intact. The joint surface remains congruent after the injury and there
is no need for surgery. (b) In a type II dorsal dislocation injury there is a complete disruption of the volar plate and a complete tear
between the accessory and proper collateral ligament. The middle phalanx lies on the dorsum of the proximal phalanx in a bayo­
net fashion. These injuries can often be closed reduced. (c) A type III hyperextension injury is a fracture dislocation. The volar plate,
accessory collateral ligament, and proper collateral ligament are damaged. The volar margin of the middle phalanx fractures, at
the site of proper collateral ligament insertion, remains with the proximal phalanx, whereas the middle phalanx moves dorsal and
proximal. These fractures often require surgery if they remain unstable after reduction.
a
b
c

1241
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
Box 63D.1
•• Dynamic skeletal traction: Longitudinal
digital traction tightens the soft tissue
envelope holding the bone fragments reduced
(ligamentotaxis). Motion can be initiated
immediately6 (Fig. 65D.2).
•• Open reduction internal fixation (as described
in the chapter) using a lag screw or cerclage
wire can be performed through a volar
approach.
•• Extension block pinning: The proximal inter­
phalangeal (PIP) joint dislocation is reduced
with axial traction and joint flexion. After closed
reduction, a K-wire is placed retrograde into the
distal dorsal aspect of the proximal phalanx. The
wire is placed approximately 10 to 20 degrees
from the coronal plane through or next to the
central slip to block terminal extension of the
PIP joint. The K-wire is removed after 3 weeks
and the finger is mobilized.7
•• Extension block splinting: Unstable PIP fracture
dislocations tend to become more stable with
an increasing degree of flexion. A dorsal splint
can be used to block extension at the point
of instability but allow for ongoing active
flexion. The splint can be modified weekly to
progressively decrease the degree of extension
blocking.8
•• Immediate hemihamate osteochondral
arthroplasty: For severe comminution of the
middle phalanx, reconstruction of the volar
portion of the middle phalanx is possible with
the use of an osteochondral graft from the
hamate. This procedure can be useful when
there is more than 50% articular bone loss
with instability. The dorsal central ridge of the
hamate lies between the ring and small finger
metacarpals, and its shape mimics the base of
the middle phalanx. The graft is centered on
this ridge and harvested slightly larger than the
measured defect to allow for final contouring
before inset. A volar approach to the PIP joint
is used and the graft is secured with two or
three bicortical screws. Early motion is begun
at 1  week.9
•• Volar plate arthroplasty: Although originally
described for chronic problems, this can
be used for acute fracture dislocations by
advancing the volar plate up into the joint.
Treatment Options for an Unstable Fracture Dislocation
providing stability once the fracture is reduced. Unsta­
ble fractures usually involve more than 40% of the volar
articular surface of the middle phalanx. In these cases
most of the proper collateral ligament remains with the
fracture fragment; thus the middle phalanx has no re­
maining ligamentous support. Closed congruent articu­
lar reduction is unlikely in these cases, and some form of
surgical fixation is required.5 The goals of surgery are to
restore joint congruency and allow early motion. There
are several treatment options for unstable fracture dis­
locations, and the surgeon should be familiar with these
options because each fracture is different (Box 63D.1).
Metacarpal Fractures
Metacarpal fractures can be more forgiving than
­phalangeal fractures because there is more soft tis­
sue surrounding the bone to provide blood supply and
stability. Additionally, the extensor mechanism is not
­directly adherent to the bone, allowing for placement of
small plates and screws. Plates and screws are the stan­
dard treatment for comminuted unstable fractures, as
opposed to intramedullary compression screw fixation.
Most isolated fractures can be treated with K-wires;
however, lag screws or plate and lag screw constructs
provide stronger biomechanical fixation, potentially al­
lowing earlier rehabilitation.
Concomitant ligamentous injuries after metacar­
pal fractures are rare but should not be missed. Spe­
cific fracture patterns can alert the surgeon to associated
ligamentous injuries. Fractures at the metacarpal bases,
including the thumb, should be examined carefully for
potential ligamentous or carpal injury. Axial carpal dis­
locations can be associated with fractures through the
proximal metacarpal bases over the ulnar and radial as­
pect of the hand. Metacarpal fractures of the thumb and
small finger must be assessed for Bennet or baby reverse
Bennet fractures. Such injuries can be very subtle but re­
sult in long-term instability and poor outcomes. Grossly
displaced fractures may draw the surgeon’s attention
away from radiographic evidence of concomitant liga­
mentous injuries10,11 (Fig. 63D.3).
Wrist Fractures
The scaphoid is the most commonly fractured bone in
the wrist. Scaphoid fractures can proceed to nonunion
if they are initially missed by the treating physician or if

SECTION VIII THE HAND AND UPPER EXTREMITY
1242
Fig. 63D.2 (a) Lateral radiograph of an impacted fracture dislocation of the small finger in the right hand of a 32-year-old man.
(b) The fracture is treated with dynamic traction, which allows for congruent joint reduction by ligamentotaxis, as seen in the
anteroposterior radiograph (c). (d,e) Dynamic traction allows for immediate motion, allowing the patient to regain near full mo­
tion by the 2-year follow-up.
a
b
c
d
e
Fig. 63D.3 A 36-year-old woman was involved in a motor vehicle accident. (a) The initial reading of the anteroposterior radiograph
noted the distal radius fracture and thumb metacarpal fracture, but missed the comminuted fracture at the base of the index finger
and associated scapholunate ligament injury (suggested by the widened scapholunate interval). (b) Fluoroscopy of the wrist under
traction in the operating room alerts the surgeon to the concomitant injuries at the scapholunate joint and second metacarpal
base. Fractures at the bases of the index, long, and ring fingers can suggest more significant carpal ligamentous injury related to
injury proximity and energy of the initial injury.
a
b

1243
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
initial treatment is delayed. Early surgery or casting has
been shown to produce the best outcomes, particularly
for complex proximal pole fractures.12 Thus early diag­
nosis is paramount to successful outcomes; however,
the “occult” scaphoid fracture, a fracture not initially
visualized on plain radiographs, is not an uncommon
occurrence, seen in up to 25% of cases13 (Fig. 63D.4).
In occult fractures initial radiographs are read as nor­
mal and symptoms may be minimal, with only pain be­
ing elicited with palpation of the anatomical snuffbox.
If initial radiographs are negative but there is clinical
suspicion for a fracture, traditional teaching has recom­
mended immobilizing the wrist in a splint and repeat­
ing radiographs in 1 to 3 weeks.13 This elapse in time
allows for resorption around the fracture line so the
fracture can be better visualized in future radiographs.
The disadvantage of this protocol is that it delays di­
agnosis, inconveniences the patient, and adds cost in
terms of repeat evaluation, time away from work, and
additional radiographs. In such cases we prefer to move
immediately to computed tomography or magnetic res­
onance imaging.
Recent literature by Gäbler and others14 has found
MRI to have up to 100% sensitivity and specificity for
identifying acute scaphoid fractures. MRI can also iden­
tify occult fractures of the capitate or trapezium, which
can also present with similar clinical symptoms.15 Fi­
nally, MRI of suspected scaphoid fractures has been
shown to provide a cost benefit compared with splint­
ing and repeat radiographs. Our algorithm for the
identification of occult scaphoid fractures is listed in
Box 63D.2.
Distal Radial Fractures
Distal radial fractures are one of the most common up­
per extremity fractures. There are many ligamentous
injuries that can occur in conjunction with this injury,
and perilunate dislocations are one such injury pat­
tern. Perilunate injuries are severe carpal disruptions
usually resulting from high-velocity trauma, such as a
motor vehicle accident or a fall from a height. These in­
juries can include pure carpal dislocations and fracture
dislocations. The term perilunate refers to the fact that
all fractures or ligamentous disruptions occur around
or through the bones and ligaments immediately
Fig. 63D.4 (a) Anteroposterior radiograph of the wrist in a 15-year-old soccer player. The initial radiograph was read as normal, but
because of persistent pain within the anatomical snuffbox, magnetic resonance imaging (MRI) was obtained. (b) The MRI showed
a fracture of the distal pole of the scaphoid.
a
b
Box 63D.2
1. Obtain neutral posteroanterior, oblique,
and lateral radiographs, with addition of a
radial and ulnar deviation and clenched fist
view if necessary.
2. Obtain magnetic resonance imaging (MRI)
for clinically suspected cases with normal
radiographs.
3. If MRI is negative, assume no fracture.
4. If MRI is positive for bony contusion or
bone edema, but the fracture location is
not clear on radiographs, obtain computed
tomography.
Algorithm for Evaluation
of Suspected Scaphoid
Fracture

SECTION VIII THE HAND AND UPPER EXTREMITY
1244
surrounding the lunate. Recognition of these injury pat­
terns may be difficult for the untrained eye, which may
result in treatment delays; however early diagnosis is
important because progression of carpal instability and
traumatic arthritis will result if treatment is ­delayed.
Herzberg et al16 reported that 25% of perilunate injuries
go undiagnosed at initial presentation. Clinical findings
are dependent on the acuity and the pattern of injury,
and these injuries may be misdiagnosed as distal radius
fractures.16
Plain radiographic evaluation remains the corner­
stone of diagnosis, and the surgeon should obtain a
true lateral, a neutral anteroposterior (AP) or postero­
anterior (PA), and an oblique view. The PA or AP radio­
graph demonstrating discontinuity of the smooth carpal
arcs defined by Gilula17 suggest abnormal intercarpal
alignment. Overlapping of carpal bones, loss of parallel
alignment, and widened intercarpal distances, such as a
scapholunate interval exceeding 3 mm, imply ligamen­
tous disruption (Fig. 63D.5). Abnormal carpal shape and
configuration, such as a palmarly flexed scaphoid with
a “ring sign,” may also indicate perilunate instability.
The lunate itself may rotate and lose its normal trap­
ezoidal shape and appear triangular or wedge-shaped.18
On the lateral radiograph, the normal collinear align­
ment ­between the radius, lunate, and capitate is lost in
perilunate dislocations. The capitate usually is displaced
dorsally relative to the lunate. In a lunate dislocation the
lunate primarily displaces in a palmar direction from the
radius and rotates into a palmarly flexed position sec­
ondary to its attached palmar ligaments, producing the
“spilled teacup” sign (see Fig. 63D.5).
Perilunate injuries are also considered within a
spectrum of severity, which includes scapholunate in­
trinsic ligament (SLIL) injuries as the first stage of sever­
ity. The injury pattern travels around the lunate (hence
the term perilunate) with sequential ligament disruption
leading to increased instability throughout the carpus.
Fig. 63.5 The many forms of perilunate injury. (a) Three-dimensional computed tomography reconstruction of a perilunate frac­
ture dislocation showing widening of the scapholunate (SL) interval and minimally displaced triquetral fracture. Disruption of the
SL ligament is suggested by the widened SL interval and small bone fragment associated with the lunate, which usually represents
the avulsed portion of the SL ligament attachment to the scaphoid. (b) Lateral radiograph showing dislocation of the capitate
dorsally. (c) AP radiograph of the wrist in a 38-year-old man. (d) The AP radiograph shows minimal signs of major injury, whereas
the lateral radiograph on the same patient shows the dislocation of the lunate palmarly.
a
b
c
d

1245
Chapter 63 Bone and Joint Injuries: Hand, Wrist, and Distal Radius
This injury pattern was originally described by Mayfield
(Mayfield classification)19 and describes the stages of
perilunate instability (Box 63D.3, Fig. 63D.6).
Median neuropathy is common, particularly with
stage IV injuries, and urgent carpal tunnel release may
be required. Perilunate injuries may also occur with as­
sociated fractures of the radial styloid, scaphoid, capi­
tate, triquetrum, or ulnar styloid. When fractures are
present with a perilunate dislocation, the injury is called
a perilunate fracture dislocation. The most commonly
fractured bone in these injuries is the scaphoid. Perilu­
nate ligamentous injuries are called lesser arc injuries,
but when associated with fractures such as the scaph­
oid or capitate or triquetrum, they are termed greater
arc injuries.
All perilunate injuries should be treated with opera­
tive repair of all injured structures. If there is any delay
in getting the patient to the operating room, an attempt
at closed reduction should be made in the emergency
room to restore the carpal geometry, control pain, and
alleviate median nerve compression. Perilunate fracture
dislocations are also managed operatively by initially re­
ducing the fracture fragments to provide a stable plat­
form upon which the surgeon can perform carpal bone
reduction followed by ligament repair. Early treatment
and anatomic reduction is the mainstay of treatment
and has been shown to produce better outcomes than
delayed treatment or casting alone.18
Box 63D.3
Stage I: Involves disruption of the scapholu­
nate ligament, resulting in scapholunate disso­
ciation. This may be present in up to 15 to 25% of
distal radius fractures (see Fig. 63D.5a)
Stage II: Involves a stage I injury in addition to
a disruption of the lunocapitate ligaments as
the force transmits through the space of Poirier.
Stage III: Involves a stage I and II injury in addi­
tion to a disruption of the lunotriquetral inter-
osseous ligament (LTIL). The lunate is attached
only to the radius. The capitate and attached
carpus often will sublux or completely dislo­
cate dorsally, resulting in a dorsal perilunate
dislocation (see Figs. 63.5b and 63D.6).
Stage IV: Involves a dislocation of the lunate, in
either in a volar or dorsal direction. Most com­
monly the lunate dislocates volarly into the
carpal tunnel and is attached only to the short
radiolunate ligament, but it may be disrupted
from all ligamentous attachments (see Figs.
63D.5c,d and 63D.6).
Mayfield’s Classification:
Stages of Perilunate
Instability
Fig. 63D.6 The progression of a perilunate injury was originally described
by Mayfield et al.19 Illustrated are the stages of progressive perilunar in­
stability of the wrist. Stage I represents an injury to the scapholunate liga­
ment, stage II represents an injury to the lunocapitate ligament, stage III
represents an injury to the lunotriquetral ligament. Stage IV injuries result
in capitate dislocation from the lunate fossa and lunate dislocation either
palmarly or dorsally. (Reproduced from the Mayo Clinic, with permission of
the Mayo Foundation.)

SECTION VIII THE HAND AND UPPER EXTREMITY
1246
Conclusion
Hand and wrist fractures are common, and radio­
graphic findings can often be predictive of underlying
ligamentous injuries. The surgeon should not be misled
by obvious bony injuries and miss underlying ligamen­
tous injuries, because these may result in instability,
pain, and poor results.
References
1. Moran SL, Berger RA. Biomechanics and hand trau­
ma: what you need. Hand Clin 2003;19(1):17–31
2. Page SM, Stern PJ. Complications and range of motion
following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am 1998;23(5):827–832
3. Faruqui S, Stern PJ, Kiefhaber TR. Percutaneous pin­
ning of fractures in the proximal third of the proximal
phalanx: complications and outcomes. J Hand Surg
Am 2012;37(7):1342–1348
4. Eaton RG, Littler JW. Joint injuries and their sequelae.
Clin Plast Surg 1976;3(1):85–98
5. Bakri B, Carlsen BT, Moran SL. Ligament injuries of
the hand and wrist. In: Thorne CH, Chung KC, Gosain
AK, et al, eds. Grabb and Smith’s Plastic Surgery. Phil­
adelphia: Wolters Lippincott Williams Wilkins; 2013:
817–832
6. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of
dynamic distraction external fixation for unstable
fracture-dislocations of the proximal interphalangeal
joint. J Hand Surg Am 2008;33(1):19–25
7. Waris E, Mattila S, Sillat T, Karjalainen T. Extension
Block Pinning for Unstable Proximal Interphalangeal
Joint Dorsal Fracture Dislocations. J Hand Surg Am
2016;41(2):196–202
8. Dobyns JH, McElfresh EC. Extension block splinting.
Hand Clin 1994;10(2):229–237
9. Capo JT, Hastings H II, Choung E, Kinchelow T, Rossy
W, Steinberg B. Hemicondylar hamate replacement
arthroplasty for proximal interphalangeal joint frac­
ture dislocations: an assessment of graft suitability.
J Hand Surg Am 2008;33(5):733–739
10. Reinsmith LE, Garcia-Elias M, Gilula LA. Traumatic ax­
ial dislocation injuries of the wrist. Radiology 2013;
267(3):680–689
11. Garcia-Elias M, Dobyns JH, Cooney WP III, Linscheid
RL. Traumatic axial dislocations of the carpus. J Hand
Surg Am 1989;14(3):446–457
12. Rettig ME, Raskin KB. Retrograde compression screw
fixation of acute proximal pole scaphoid fractures.
J Hand Surg Am 1999;24(6):1206–1210
13. Amadio PC, Moran SL. Fractures of the carpal bones.
In: Green DP, et al, eds. Green’s Operative Hand Sur­
gery. 5th ed. Philadelphia: Elsevier Churchill Living­
stone; 2005:711–768
14. Gäbler C, Kukla C, Breitenseher MJ, Trattnig S, Vécsei
V. Diagnosis of occult scaphoid fractures and other
wrist injuries. Are repeated clinical examinations and
plain radiographs still state of the art? Langenbecks
Arch Surg 2001;386(2):150–154
15. Breitenseher MJ, Metz VM, Gilula LA, et al.
­Radiographically occult scaphoid fractures: value of
MR imaging in detection. Radiology 1997;203(1):
245–250
16. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney
WP, Stalder J. Perilunate dislocations and fracture-
dislocations: a multicenter study. J Hand Surg Am 1993;
18(5):768–779
17. Gilula LA. Carpal injuries: analytic approach and case
exercises. AJR Am J Roentgenol 1979;133(3):503–517
18. Moran SL, Lin L. Dislocations and perilunate injuries
of the carpus. In: Guyuron B, Eriksson E, Pershing JA,
et al, eds. Plastic Surgery: Indications and Practice.
Philadelphia: Saunders Elsevier; 2009:1057–1077
19. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal disloca­
tions: pathomechanics and progressive perilunar in­
stability. J Hand Surg Am 1980;5(3):226–241

1247
Mutilating upper extremity injuries generally cause sub­
stantial damage to more than one of the five basic tissues
of the hand: integument, skeletal, vessels, nerves, and
tendons.1 Injury to the hand and the subsequent healing
process jeopardizes hand function, which depends on the
intricate anatomical arrangements of these structures.
Understanding the physiology of wound healing and the
scarring process is crucial to restoring optimal functional
outcome.
Wound healing is the body’s response to injury. This
complex process is divided into three distinct but overlap­
ping phases: inflammation, proliferation, and remodeling.2
Immediately after injury, vasoconstriction and recruitment
of platelets promote hemostasis. Platelets are activated to re­
lease neutrophils and macrophages, which both function in
phagocytosis of microbes and debris. In the presence of for­
eign material or necrotic tissue, inflammatory mediators will
persist, resulting in a prolonged inflammatory phase and
delayed healing (Fig. 64.1). Early and meticulous débride­
ment of nonviable, contaminated tissue is therefore essential
to shorten the inflammatory phase and reduce edema. The
proliferative phase overlaps with the ending of the inflam­
matory phase and consists of granulation tissue formation,
neovascularization, reepithelialization, and extracellular ma­
trix production. Fibroblasts migrate to the wound around
day 3 and are primarily responsible for production of the
structural proteins and collagen. The remodeling phase in­
volves rearrangement of the collagen fibers to increase ten­
sile strength of the wound. As the phases of wound healing
progress, granulation tissue and collagen fibers form what
will ultimately evolve into a scar.
Reepithelialization and wound contraction have a cru­
cial impact on scar formation. Epithelial cells from wound
margins and residual dermal appendages within the wound
bed migrate inward to fill the defect.2 Small wounds that
are approximated early after injury heal rapidly without the
need for significant wound volume reduction. This is healing
by primary intention. Large wounds with significant tissue
loss heal by secondary intention. There is gradual filling of
the defect with granulation tissue, wound contraction, and
reepithelialization at the wound edges. If an open wound
overlying joints and tendons is allowed to heal by second­
ary intention, joint stiffness and deforming joint contracture
may result. Early soft tissue coverage, when feasible, is a pri­
mary objective to avoid pathologic contractures.
The cellular response to injury results in edema forma­
tion. The body sends fluids containing inflammatory cells,
plasma proteins, and antibodies to the wound site after in­
jury. In the injured hand, edema accumulates on the dor­
sum where there is dependent space, drawing the wrist into
flexion, the metacarpophalangeal (MCP) joints hydraulically
into extension, the proximal interphalangeal (IP) joints into
flexion, and the thumb into adduction3 (Fig. 64.2). Therefore
the traumatized hand must be immobilized in the intrinsic
plus position with the MCP joints in flexion and the IP joints
in extension. Early mobilization is emphasized, however, be­
cause it is necessary to reduce edema and preserve the glid­
ing function of tissues.
Peacock and Van Winkle4 described the concept of “one
wound–one scar,” in which scar forms from the skin down
through bone and binds together all surrounding tissues.
Fundamental hand function, such as prehension, is re­
stricted by the inability of the tissues to glide against each
other. This concept forms the biologic basis for remodeling
of the scar tissue. Secondary procedures after reconstruction
of the injured hand such as tenolysis, joint contracture re­
leases, or web space deepening may be necessary to improve
mobility and function5 (Fig. 64.3).
Soft Tissue Coverage and
Mutilating Extremity Injuries
David T. Netscher
CHAPTER
64

SECTION VIII THE HAND AND UPPER EXTREMITY
1248
NORMAL WOUND HEALING
INFECTED WOUND/DELAYED WOUND HEALING
Inflammatory
Proliferation
Remodeling
Inflammatory
Proliferation
Remodeling
Days to weeks
Weeks to months
Months to years
a
b
Fig. 64.1 (a) Normal timing of wound healing. The inflammatory phase occurs immediately after the injury and lasts approximately 4 to 6
days. The proliferative phase occurs at the termination of the inflammatory phase and lasts about 3 weeks. The remodeling phase begins
at the fourth week and can last months to even years. (b) Delayed wound healing. In the presence of a contaminated wound, the inflam­
matory phase can persist for days to weeks if not adequately débrided. This in turn will postpone the start of the proliferative phase and
delay wound healing.
a
b
Fig. 64.2 (a) Injured hand position. Edema accumulates in the dorsum of the injured hand, which draws the wrist into flexion, the metacar­
pophalangeal (MCP) joints into hyperextension, the proximal interphalangeal joints into flexion, and the thumb into adduction. Addition­
ally, the MCP joints are at their most voluminous in extension. The fluid-filled MCP joints hydraulically drive these joints into extension. (b)
Intrinsic plus position. The traumatized hand must be appropriately immobilized with the MCP joints in flexion, the IP joints in extension,
and the thumb in abduction to minimize joint stiffness.

1249
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Having the concept of wound healing and scar formation
in mind throughout the reconstructive and repair process
will help the surgeon to avoid common complications that
result from mutilating hand injuries. This chapter describes
the management of complex hand injuries and how to avoid
unfavorable results at each stage. It explains how to address
these complications and provides case illustrations.
Avoiding Unfavorable Results
and Complications in the
Treatment Of Mutilating Injuries
Missed Diagnosis and Delayed
Treatment
Missing Life-Threatening Injuries
Because mutilating hand injuries often occur from high-
impact mechanisms, patients may have sustained injuries
to other organ systems that may be life-threatening. The
standard advanced trauma life support protocol should be
initiated to stabilize the patient before eliciting a thorough
history and evaluation of the injured extremity. Partington
et al6 studied the incidence of unrecognized injuries in pa­
tients referred for emergency microsurgery over a 7-year
period. They found that 9 out of 1,100 patients (0.8%) trans­
ferred had unrecognized coexisting injuries that put the
patient at high risk for morbidity and altered the original
plan of care. Although the hand mutilation may be severe,
it is rarely life-threatening; hence the mantra of “life before
limb” should be abided before considering any reconstruc­
tion.
Underestimating the Severity of Injury
A detailed history of the mechanism, timing, and location
of injury will avoid underestimating the severity of injury
and guide further management. The mechanism of injury
Summary Box
Common Complications, Causes,
and Treatment
Common Complications
•• Wound infection and dehiscence
•• Wound contraction and pathologic contractures
•• Tendon adhesion and joint contracture
•• Donor site morbidity and unaesthetic
reconstruction
•• Dysesthetic and anesthetic hand
•• Nonunion and malunion
Causes of Complications
•• Missed diagnosis and delayed treatment
•• Inadequate débridement
•• Poor planning
•• Poor skeletal fixation
•• Inadequate soft tissue coverage
•• Excessively delayed soft tissue coverage
•• Improper splinting and edema management
•• Improper timing of nerve and tendon repair
Treatment of Complications
•• “Re-creating” the original wound for soft
tissue coverage when the initial procedure was
inadequate
•• Bone grafting and osteotomies for bone malunion
and nonunion
•• Joint releases
•• Tenolysis
•• Neurolysis and neuroma excision
Fig. 64.3 (a) A 20-year-old man experienced a table saw injury to his nondominant hand that traversed through the metacarpophalangeal
joints of the index to little fingers. Joint, tendon, and microvascular repairs were performed, but he had limited range of motion postop­
eratively. (b) The patient has flexion of all his fingers after dorsal MCP joint capsulotomies. (c) The patient has achieved extension of all his
fingers after intrinsic muscle releases.
a
b
c

SECTION VIII THE HAND AND UPPER EXTREMITY
1250
system, because the presence of compartment syndrome
or hand ischemia requires emergent intervention.7 Early
recognition and treatment of compartment syndrome is
essential to prevent irreversible muscle and nerve damage.
Patients may not be sufficiently lucid to express the cardi­
nal signs of extremity pain exaggerated by passive stretch­
ing, because the extremity may already be too painful and
injured to elicit these signs. Diagnosis is best confirmed by
measurements of compartment pressures, with a pressure
of more than 30 mm Hg commonly considered an indica­
tion for fasciotomy.8 If a commercial monitor is unavailable,
a modified needle manometer technique can be performed
with a straight 18-gauge needle, arterial line transducer,
and central venous pressure monitor9 (Fig. 64.5).
The injured hand should also be assessed for active
bleeding and potential critical ischemia. Active bleeding is
likely related to laceration of a major vessel. It is usually con­
trolled with direct pressure and compressive dressing and, if
necessary, short-term tourniquet application. Bleeding ar­
eas should not be blindly clamped, because this could dam­
age neighboring neurovascular structures. Perfusion to the
injured extremity is difficult to assess clinically because of
extensive structural damage. A modified Allen test using a
handheld Doppler probe is often necessary to assess patency
of the major vessels, because patients with mutilating hand
injuries may not be able to make a fist. Presence of vascular
insufficiency will prompt immediate exploration and repair.
Discarding Spare Parts
When examining the skin, the degree of soft tissue loss,
laceration, and contamination are noted to determine the
amount of débridement and soft tissue coverage needed.
Amputated parts should not be discarded, because they can
serve as tissue donors for repair of other parts.10 Skin from
an unsalvageable digit can be harvested with a neurovascu­
lar pedicle to provide sensate coverage to the adjacent de­
fect. Bones can be used as grafts to add length to amputated
digits. Tendon remnants can be used as grafts to bridge seg­
mental defects or to reconstruct pulleys or ligaments.
can reveal the force and zone of injury. In the case of motor
vehicle accidents, a high-speed rollover accident in which
the patient was ejected from the vehicle will have a broader
zone of injury requiring repair of multiple tissue layers.
The time of injury and the time elapsed between injury
and presentation is critically important, especially with a
devascularizing injury. Warm ischemia for longer than 6
hours may affect successful digit replantation or revascu­
larization. Delays longer than 6 to 12 hours may preclude
primary closure because of a greater risk of infection. The
environment of the injury is pertinent because the expo­
sure to caustic industrial chemicals or highly contaminated
farming fields will likely require more extensive and serial
débridement (Fig. 64.4).
Incomplete Patient History
Other important aspects of the history that should not be
missed include the patient’s overall functional status, co­
morbidities, and occupational goals, because this infor­
mation will help to formulate a treatment plan. Elderly
patients with cardiovascular or pulmonary disease have
increased perioperative morbidity and may benefit from
shorter, simplified reconstruction. Smoking and use of va­
soactive drugs have a deleterious effect on microcirculation
and are often a contraindication to complex microvascular
reconstruction.1 The patient’s occupation, preinjury func­
tional status, and willingness to adhere to a rehabilitation
program are also relevant factors. For instance, a self-em­
ployed construction worker will likely be interested in a
procedure that offers expeditious return to work, whereas
a dentist may be more willing to undergo complex recon­
struction and prolonged hand therapy to achieve optimal
five-digit function.
Missing Limb-Threatening Injuries
The preliminary evaluation is often limited because of sig­
nificant pain and contamination. Nevertheless, it is impera­
tive to assess all tissue systems, beginning with the vascular
Fig. 64.4 (a) A 28-year-old woman sustained a blast injury to her left forearm in an industrial accident. There was gross contamination,
extensive soft tissue loss, and a crush avulsion injury of the extensor tendons. (b) A posteroanterior view of the forearm demonstrated ex­
tensive debris surrounding a complex comminuted ulna fracture.
a
b

1251
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
poor abduction of fingers suggests ulnar nerve weakness,
and difficulty in opposing the thumb and index fingers
reflects median nerve impairment. The sensory system is
examined done by checking light touch in the sensory dis­
tribution of the three nerves. In the setting of open hand
injuries, early surgical exploration is required to evaluate
the continuity of the nerves. Blunt injury is associated with
entrapment of the nerve from swelling and would benefit
from surgical decompression, especially in the presence of
evolving nerve deficits or very dense initial sensory defi­
cits. Carpal tunnel syndrome is a common condition after
a distal radial fracture; the surgeon should be cognizant of
Missing Fractures and Dislocations
Evaluation of the skeletal system generally requires plain
radiographs to confirm a clinical suspicion of skeletal in­
juries, to see any foreign bodies, and to note any previous
healed fractures. Multiple views that include a joint above
and below the level of injury should be obtained.1 Identifi­
cation of unstable fractures and joint dislocations require
immediate fixation and reduction. Delay in diagnosis can
result in nonunion and joint instability.
Missing Tendon Injuries
Underlying muscle–tendon unit injury can be appreciated
by noting any deviation in the resting posture of the hand,
which is maintained by normal flexor—extensor tendon
balance.1 Lacerations of both digital flexor tendons results
in the finger lying in extension while other fingers are in
their normal flexion cascade. Laceration of the extensor
tendons will result in wrist drop and lack of full extension
of the involved finger.
Missing Nerve Injuries
Nerve injury should be evaluated by testing motor and
sensory function of the median, radial, and ulnar nerves. A
useful method to rapidly assess motor function of all three
nerves is by asking the patient to extend the wrist, abduct
the middle and little finger, and make a ring sign with
thumb and index finger touching each other11,12 (Fig. 64.6).
Inability to extend the wrist indicates radial nerve injury,
a
b
c
Fig. 64.5 (a) This 3-year-old boy presented with severe pain and a swollen
hand 4 hours after an automobile ran over his hand. (b) A posteroanterior
view of the hand revealed significant soft tissue swelling and fractures through
the finger metacarpal bases. (c) A Stryker monitor was inserted into the first
dorsal compartment and connected to a continuous central venous pressure
monitor. (d) Intracompartmental pressure measurements were elevated up
to 97 mm Hg.
d
Fig. 64.6 Testing motor function of the hand. Assess motor func­
tion of all three nerves by asking the patient to make an “OK” sign.

SECTION VIII THE HAND AND UPPER EXTREMITY
1252
Managing Unfavorable Results
and Complications in the
Treatment of Mutilating Injuries
Complications of Inadequate
Débridement
Wound Infection and Delayed Wound
Healing
Foreign material and necrotic tissue stimulate release of
proteases, collagenases, and elastases that impede wound
healing.16 In addition, bacteria produce wound-inhibiting
enzymes and consume surrounding oxygen and nutrients.
This environment inhibits macrophages’ ability to direct
the formation of granulation tissue and neovascularization.
Inadequate débridement will consequently result in wound
infection and delayed wound healing.
Adequate débridement begins with extensive irriga­
tion and is followed by excision of the wound. The wound
is initially cleaned using a surgical scrub brush and sterile
soap followed by pulse lavage irrigation with sterile saline.17
Unless prolonged ischemia has already occurred, excisional
wound débridement is best performed under tourniquet
control with loupe magnification. Major neurovascular
structures should be identified and tagged first. Wound ex­
cision is then performed layer by layer from the skin to the
deeper tissues. Dead skin and fascia should be excised back
to bleeding edges. Muscle viability should be assessed by
color, contractility, and bleeding and excised if nonviable.
Damaged ends of tendon should be débrided. Clinical judg­
ment will then dictate immediate or delayed tendon repair
or even reconstruction through grafts or tendon transfers.
The ends of major nerves should be tagged for primary re­
pair or delayed nerve grafting. Avascular bone fragments de­
void of soft tissue attachment should be removed and bone
ends débrided back to bleeding bone. The tourniquet should
be released for reassessment of tissue viability, and further
débridement is performed as needed.
Delayed Wound Closure
Although it may be necessary to perform serial débride­
ment of contaminated wounds, progressive edema and
granulation tissue will accumulate; therefore there should
not be an undue delay in wound coverage. Early aggressive
débridement is strongly advocated over traditional serial
débridement whenever feasible.18 Wound vacuum-assisted
closure (VAC) can provide temporary wound coverage
while the wound is undergoing serial débridement or until
a stable wound bed is achieved.19 It decreases buildup of
edema and exudates to promote formation of granulation
tissue. The surgeon should be mindful that a wound VAC
this fact and perform urgent release and fracture fixation
when indicated.13
Prioritization of Repair
In general, the order of repair should be based on level of
urgency, which is usually7:
1. Débridement
2. Skeletal fixation
3. Revascularization
4. Soft tissue coverage
5. Delayed nerve and tendon repair
Adequate débridement is the cornerstone before any repair.
Inadequate débridement results in infection, further tissue
loss, and potential systemic complications. The next step is
to stabilize fractures, because skeletal fixation provides the
foundation for reconstruction. Restoration of bone align­
ment and length provides a solid base for anastomosing
and grafting injured vessels and nerves. The bone is also
the deepest structure and will be difficult to access if other
superficial structures are repaired first. Joint stabilization
helps provide smooth articulation and promote early reha­
bilitation, thereby minimizing joint stiffness. In the event of
prolonged upper extremity ischemia in the proximal fore­
arm or upper arm, revascularization should be done be­
fore operative débridement and bony fixation to decrease
ischemia time and the attendant potential risks of myoglo­
binemia and muscle death with fibrosis. This is achieved
using a temporary vascular conduit, and definitive revascu­
larization is performed after skeletal reconstruction.14 Ad­
equate, durable soft tissue coverage is as important as the
reconstruction of the skeletal framework of the hand. Soft
tissue replacement is performed as early as possible, be­
cause this minimizes the inflammatory reaction, scar for­
mation, and wound contraction. Primary closure or delayed
primary closure is preferred when feasible. The choice for
soft tissue coverage is guided by the reconstructive elevator
and is adjusted to fit the individual case. The decision is not
always the simplest soft tissue reconstruction, but rather
the technique that will ultimately achieve optimum form
and function.15 Nerve and tendon repair should be delayed
until stable soft tissue coverage is available. This minimizes
the risk of tendon or nerve graft loss related to wound in­
fection.
The goals of reconstruction should be pliable soft tissue
coverage, stable fracture fixation, supple joints and tendons,
and good muscle function and distal digital sensibility.7 The
surgeon should formulate a treatment plan that achieves
both short- and long-term objectives. There should be real­
istic goals for anatomical and functional outcome. The basic
plan, need for multiple surgeries, rehabilitation, and possible
complications should be explained to the patient.

1253
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Failure to Proceed with Primary
Amputation
Among the most difficult challenges in the management
of mutilating hand injuries is the decision between am­
putation and limb salvage. Amputation is undoubtedly
an unpleasant and devastating event; on the other hand,
salvage of a stiff, painful, and insensate limb can be more
detrimental. McCormack22 found that irreparable damage
to three or more of the five tissues in the hand may be a
strong indication for early digit amputation. The best time
to perform primary amputation is at the initial operation.
Delayed amputation is associated with adverse psychologi­
cal effects and an inferior functional result.23
Understanding the biomechanics of the hand is crucial
in determining what anatomic components are needed for
hand function. The minimal elements for the hand include
the thumb and two digits for three-point stability24 (Fig.
64.7). This allows for prehension, which requires opposi­
tion between the thumb and fingers to coordinate pinch.
The American Medical Association Guidelines of Permanent
Impairment25 estimates that loss of the thumb is equivalent
to a 40% loss of hand function, which makes it the most im­
portant digit to preserve and reconstruct. For the most part,
loss of the distal phalanx and interphalangeal joint produce
minimal functional deficit of the thumb, whereas injuries at
or proximal to the MCP joint may require toe transfer or dis­
traction lengthening to maintain oppositional function. The
index finger has a major role in precision pinch and direc­
tional grip but has little function if amputation exists proxi­
does not result in optimal functional coverage and must
have a definitive plan for soft tissue reconstruction.
Complications of Skeletal and Joint
Repairs
Malunion and Nonunion
Complex fractures often occur with mutilating hand in­
juries and can result in malunion and nonunion if appro­
priate methods of bony fixation are not used. The optimal
time for reduction and fixation is at the initial operation
or within the first week to permit early mobility.7 K-wires
provide rapid stabilization of digital fractures with the least
amount of additional soft tissue damage. However, they do
not provide rigid fixation for early mobility, and collapse
may occur at the fracture site, resulting in misalignment.20
Miniplates or interosseous wires offer stable fixation but
are more technically challenging and require additional
soft tissue dissection. In the setting of extensive contami­
nation or bone loss, external fixation may be the method
of choice for temporary skeletal stabilization. The fixators
should be positioned so that they will not interfere with
future soft tissue reconstruction.
Metacarpal and phalangeal fracture malunions can be
repaired by corrective osteotomy at the prior fracture site
and may accompany simultaneous tenolysis and capsulot­
omy.21 Nonunions can be treated with cancellous bone graft
from the radius or iliac crest and maintained in place with
a compression plate.
a
b
c
Fig. 64.7 (a) Uninjured hand. (b) Amputation of the index and little finger through the metacarpal joints. (c) Good prehension demon­
strated with the thumb and two digits.

SECTION VIII THE HAND AND UPPER EXTREMITY
1254
Osteomyelitis
Osteomyelitis of the hand is a potential complication that
can result in significant morbidity and functional loss. It
can occur after inadequate débridement, because of ex­
posed hardware, or when overlying soft tissue coverage is
lost or inadequate (Fig. 64.9). It is clinically manifested by
erythema, edema, and pain of the extremity. There is often
no associated fever or leukocytosis.28 Definitive diagnosis
is made by cultures obtained from bone biopsy. Treatment
involves operative débridement and intravenous antibiot­
ics for up to 6 weeks.21 If the hardware is unstable, it should
be removed and stabilized with an external fixator. Packing
or use of antibiotic beads can also help to minimize dead
space after bone débridement; however, some form of de­
finitive bone reconstruction will then be required. Options
mal to the PIP level and when there is minimal MCP motion
remaining. Under these circumstances, ray amputation can
often improve function by opening the first web space, and
its function is then taken over by the middle finger.7 The
middle and ring fingers provide grip and grasp functions.
After amputation of the middle finger, grip is weakened be­
cause of loss of the three-point chuck pinch. Small objects
can also fall from grasp through the space left by the miss­
ing digit. Transposition of the index finger to the amputated
middle finger can be performed to widen the first web space
and close the gap and to achieve better prehension and aes­
thetic appearance26 (Fig. 64.8). Despite the least strength in
flexion, the little finger defines hand width for grip func­
tions and has been reported to have the greatest functional
value after the thumb. In general, single-digit amputation
other than the thumb does not result in substantial loss of
hand function.
Complications of Replantation
The advancement of microvascular surgery has allowed for
replantation and/or revascularization of digits. Early failure
of replantation is usually related to inadequate perfusion,
which is influenced by the mechanism of injury and case
selection. Unfavorable conditions for replantation include
severe crush or avulsion injuries, amputations at multiple
levels, and prolonged warm ischemia time.27 Replantation
is usually not recommended for a warm ischemia time of
more than 6 hours for an amputation proximal to the wrist.
Because digits lack muscle, warm ischemia is tolerated for
up to 8 hours and extended to 24 hours with adequate
cooling. The most common complication after successful
replantation is stiffness related to tendon adhesions.
a
b
Fig. 64.8 (a) A gunshot wound to the hand can result in an amputated middle finger through the proximal phalanx and a large defect in
the palm. (b) Transposition of the index finger to the amputated middle finger widens the first web space. The soft tissue defect is covered
by a local fillet flap from the middle finger stump.
Fig. 64.9 This 45-year-old woman had prior distal forearm open frac­
tures. At the time of the original injury, soft tissue repair, which used
skin grafting and a groin pedicle flap, was inadequate. She presented
a year later with a purulent draining wound over exposed bone and
osteomyelitis. This complication may not have occurred if the soft
tissue wound had initially been treated with more durable vascular­
ized tissue such as a free flap.

1255
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Complications of Soft Tissue Coverage
Delayed Soft Tissue Coverage
Early soft tissue coverage has become widely accepted
after studies demonstrated successful long-term results.
Godina31 showed that early microsurgical reconstruction
during the first 72 hours had significantly lowered postop­
erative morbidity compared with delayed reconstruction.
Lister and Scheker32 had successful results using emer­
gency flap coverage within 24 hours after injury. Early
well-vascularized soft tissue coverage is associated with
fewer flap failures, lower postoperative infection rate, and a
shorter overall period of disability. It brings oxygen and im­
munologic mediators to the zone of injury, which combats
infection and promotes the healing process. Delay in soft
tissue coverage results in desiccation of vital structures and
persistent edema and wound contraction leading to stiff­
ness and pathologic contracture.1
Improper Coverage or Flap Selection
Although there is no uniform consensus on the best tis­
sue for wound coverage, the concept of the reconstructive
ladder has been modified and popularized (Fig. 64.11).
Procedures are arranged in ascending order starting from
primary closure, skin graft, local and regional flaps, distant
flaps, and ultimately microsurgical free flap. The advance­
ment in the understanding of flaps and microsurgery has
shifted the emphasis to selecting the technique that will
achieve greater function, even if it involves complex recon­
struction (the reconstructive elevator).1
Mutilating hand injuries often involve full-thickness
soft tissue loss with surrounding tissue damage, making
it difficult to use local flaps to replace “like with like.”15 A
systematic approach to flap selection for wound coverage is
based on the location of injury, size of defect, involvement
of deeper tissues, and sensory restoration. Goals of soft tis­
include bone graft (vascularized or nonvascularized), bone
transposition and Ilizarov distraction, or Masquelet cancel­
lous grafting after removal of an antibiotic cement spacer.29
Complications of Revascularization
Ischemia–Reperfusion Injury
Because of the small amount of muscle mass in the distal
forearm and wrist, the systemic consequences of ischemia–
reperfusion injury do not usually manifest. However, more
proximal forearm amputations have the potential for dam­
aged muscle to release large amounts of myoglobin once
the limb is reperfused.17 The combination of intravascular
volume depletion and myoglobinuria can lead to renal dys­
function. Early aggressive fluid resuscitation and forced al­
kaline diuresis remains the best preventative measure.
Volkmann Ischemic Contracture
Prolonged upper extremity ischemia can cause areas of
muscle infarction that are replaced by fibrosis and may re­
sult in ischemic contractures. The most commonly affected
areas are the flexor forearm and interosseous compart­
ments in the hand30 (Fig. 64.10). A classification system of
Volkmann ischemic contracture and treatment recommen­
dations follows:
•• Type 1 involves proximal artery injury resulting in
ischemia distally.
•• Type 2 involves localized ischemia caused by external
pressure in the form of tight bandages or crushing
injury.
Depending on the severity and available residual functional
muscle, contractures are corrected by excision of a muscle
infarct with flexor muscle slide, excision with combined
tendon transfer, or excision with combined free vascular­
ized muscle transfer.30
Fig. 64.10 (a) A 52-year-old man with posttraumatic Volkmann contracture showing contracted digits and wrist. (b) The Volkmann angle,
which is the angle of wrist flexion required to achieve full digital extension.
a
b

SECTION VIII THE HAND AND UPPER EXTREMITY
1256
portance of performing an Allen test with a Doppler probe
preoperatively.15 When using a radial forearm pedicle flap, a
much better aesthetic appearance results when a fascial flap
is used and skin grafting is performed to the recipient site.
This obviates the unaesthetic forearm donor site with skin
grafting when a fasciocutaneous flap is used.34 The poste­
rior interosseous artery (PIA) flap offers similar benefits as
the radial forearm flap without the sacrifice of a major limb
vessel; however, it is reported to be less reliable.
For more extensive upper extremity defects, common
workhorse flaps for reconstruction include lateral arm,
groin, anterolateral thigh, latissimus dorsi, and scapular
and parascapular flaps. Variation of these flaps with differ­
ent tissue components to include bone, muscle, fascia, and
sensory nerve are available to cover tissues with composite
loss.33 The lateral arm flap has the advantage of being away
from the zone of injury and having a relatively inconspicu­
ous donor site scar. Its main drawback is that it has a short
pedicle length and obligatory sensory loss on the forearm.
The groin flap is now primarily used to cover amputated
thumb wounds because it has the advantage of preserving
the recipient vessel and providing sufficient bulk for later
toe transfer. It does require that the hand be attached to the
groin for at least 3 weeks, which prevents early mobiliza­
tion.15 Larger wounds can be covered with a free flap using
muscle such as the latissimus dorsi or rectus abdominis flap,
or fascia for an improved gliding surface such as the antero­
lateral thigh flap.
sue reconstruction are to provide durable coverage to vital
structures and hardware, restore vascularity for healing, and
reestablish three-dimensional volume to the defect.33 Recon­
struction can be tailored to meet the recipient site require­
ments. For instance, a flap can be harvested to incorporate
adjacent tendon, muscle, nerve, or bone if tendon restora­
tion, motor function, protective sensation, or primary bone
grafting is needed, respectively.
Finger, Hand, and Wrist
Donor site selection for coverage of the hand should take
into account the anatomical differences between the dor­
sal and volar surfaces. Dorsal skin is thinner and looser to
enable tendon gliding, whereas volar skin is thicker and
tougher for grasping and tactile sensation.33
For small defects in the fingers, there are several suitable
local flaps such as the V-Y advancement flap, cross-finger
flap, and homodigital or heterodigital island flaps. However,
mutilating hand injuries often involve multiple crushed dig­
its and larger soft tissue defects that require regional or free
flaps.15
Local reconstructive options include the reversed radial
forearm flap and the posterior interosseous artery flap. The
advantages of the radial forearm flap are that it is a thin, pli­
able flap that can cover moderate-sized hand defects with
well-matched skin color and contour. However, its use is pre­
cluded if the injury involves the radial artery—hence the im­
Fig. 64.11 (a) Reconstructive ladder. Methods of reconstruction are ranked
by complexity starting with direct closure, local flaps, and distant flaps.
(b) Reconstructive elevator. This modification to the reconstructive ladder
emphasizes selecting the reconstructive method that will result in optimal
functional outcome as opposed to selecting the least complex technique.
a
b

1257
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Complications of Tendon Repair
Premature Tendon Repair
With crushing injuries, primary tendon repair may be con­
sidered to prevent tendon retraction with the expectation
that future tenolysis may be required. Primary tendon re­
pair through grafting when there is segmental tendon loss
is not recommended unless there is stable fracture fixation
and soft tissue coverage. Loss of soft tissue coverage related
to wound dehiscence or infection in the presence of a ten­
don graft will result in loss of the graft as well.7 Usually
tendon reconstruction through grafting is delayed until
scar maturation and maximum tissue pliability and pas­
sive joint motion have been restored. At the initial surgery,
the proximal ends of tendons should be sutured to deep
tissue so muscle does not lose contractility. For delayed
or staged reconstruction, a silicone tendon spacer can be
placed so passive joint motion can be maintained until it
is later replaced with tendon graft.5 Tendon grafts can be
obtained from the palmaris longus, plantaris, or toe exten­
sor tendons.
The Stiff Hand
A stiff, immobile hand is caused by scar tissues that form
around different components of the hand, resulting in ten­
don adhesions, joint stiffness, and skin contractures. The
systemic inflammatory response that is elicited after a mu­
tilating hand injury results in increased collagen synthesis
and scar formation.5 Early soft tissue coverage and mobili­
zation are therefore emphasized to minimize this process
(Fig. 64.12).
Forearm, Elbow, and Shoulder
Coverage of forearm soft tissue defects with local and re­
gional flaps is usually limited because of their proximity
to the zone of injury. The anterolateral thigh flap is a good
option because it has a long pedicle, provides large fascia
coverage for gliding tissues, and has a donor site that can
be closed primarily.18 If bone is required for forearm re­
construction, the fibula is a good match for the radius and
ulna. The scapular flap can be harvested to incorporate the
lateral part of the scapula for an osteocutaneous flap.17 The
parascapular flap has similar characteristics.
The paraumbilical perforator (PUP) flap is a very ver­
satile tube pedicle flap that can comfortably be used for
wounds between the elbow and hand.35 It provides tissue
of a large surface area and, in nonobese patients, the flap
is not too bulky. It is quick and easy to raise. It can be very
useful with crushing injuries that may not have suitable re­
cipient vessels for a free flap (Video 64.1).
Defects around the elbow or shoulder often require
durable coverage best provided by a pedicled muscle flap.
The brachioradialis muscle flap is a good choice for defects
around the antecubital area that may have exposed neuro­
vascular structures.1 Other pedicle flaps include the radial
forearm flap and even a proximally based random-pattern
transposition flap. Latissimus muscle can be used as a flap
for restoration of biceps or triceps function.33 It is one of the
most versatile flaps for reconstruction because of its large
size and reliable long vascular pedicle. Other options include
a gracilis or rectus abdominis flap as a free muscle flap. Dis­
advantages to muscle flaps include donor morbidity from
potential functional motor deficit and less optimal gliding
compared with fascial flaps.
Inflammation
Edema
Immobility
Fig. 64.12 Clinical triad leading to a stiff hand. The presence of persistent
inflammation, edema, and immobility will form a cycle that can lead to
joint stiffness.

SECTION VIII THE HAND AND UPPER EXTREMITY
1258
does not provide sufficient length to manage gaps, nerve
autograft or allograft is recommended.38 Autograft is the
gold standard because it is nonimmunogenic. The sural
nerve is the workhorse autograft, but other options include
lateral and medial antebrachial cutaneous nerves, the pos­
terior interosseous nerve, and the superficial radial nerve.
Allografts have the drawback of requiring temporary im­
munosuppression to allow for adequate host Schwann cell
migration into the nerve allograft. Allografts treated with
cold preservation, irradiation, and lyophilization have been
demonstrated to reduce nerve allograft antigenicity.38 The
immunosuppressive agent FK-506 (tacrolimus) has been
shown to augment neuroregeneration and, when com­
bined with cold preservations of allografts, has produced
good functional outcome. Nerve conduits have limited use
for nerve digital gaps greater than 2 cm or for major pe­
ripheral nerve injury, although allografts may yet prove to
have a role for these nerve defects. Nerve transfers have the
advantage of overcoming a long segment of injured nerve,
bringing nerve closer to the motor target to minimize mo­
tor atrophy, and reinnervating multiple muscle groups.37
Neuroma
Neuroma is abnormal nerve regeneration after a periph­
eral nerve injury, allowing regenerating axons to escape
and advance in a disorganized fashion into the surrounding
tissues. Patients often present with localized pain and hy­
persensitivity. Initial treatment involves local percussion,
massage, and electrical stimulation to desensitize neuro­
mas.5 Local steroid injections around the neuroma have
short-term success. Surgical neuroma excision and nerve
end transposition are recommended when pain becomes
debilitating (Fig. 64.13).
Complex Regional Pain Syndrome
Complex regional pain syndrome (CRPS) is characterized
by pain, limited range of motion, and autonomic mani­
festations such as swelling, vasomotor changes, and skin
Secondary procedures such as tenolysis, joint contrac­
ture release, or scar release are often necessary to regain
hand mobility and function. These are usually performed 3
to 6 months after the initial injury, the minimum time re­
quired for scar tissue to soften.5 During flexor tenolysis, care
is taken to preserve the A2 and A4 pulleys in zone II to pre­
vent bowstringing. Adequacy of tendon release is evaluated
by applying traction to each flexor tendon at the proximal
wrist incision.5 Joint capsulotomy may be required at the
time of tenolysis or as a staged procedure if joint stiffness
has resulted in contracture. A “wide-awake” local anesthesia
technique also enables patient involvement during surgery,
and the surgeon can assess the completeness of tenolysis.36
First web space adduction contracture results in inabil­
ity of the thumb to oppose to other digits, thus affecting
pinch and grasp function. It is typically caused by immobili­
zation of the thumb in a poor position with resultant fibrosis
of the adductor pollicis and first dorsal interosseous. First
web space contracture can be released and replaced with
four-flap z-plasties, full-thickness skin graft, or flap, depen­
dent on whether this is a skin contracture only or a deeper
contracture involving muscle and a three-dimensional space
between the first and second metacarpals.5
Complications of Nerve Repair
Inappropriate Closure of Nerve Gaps
In the setting of open blast or crushing injuries, primary
nerve repair should be delayed because of the inflamma­
tory nature of the tissue and until soft tissue coverage is
obtained. The nerve ends should be reapproximated and
sutured to a local structure, such as tendon or fascia, to
prevent retraction and facilitate repair at a later time.37 At
the time of repair, nerve ends should be transected sharply
back to healthy nerve fascicles and the ends mobilized to
allow tension-free repair by direct coaptation or with graft.
Tension at the repair site may result in gapping, connective
tissue proliferation, scar formation, and ischemia. When
transposition and proximal or distal dissection of the nerve
Fig. 64.13 (a) This 38-year-old woman had a traumatic upper arm amputation. She developed painful neuroma (asterisk) that were treated
by (b) nerve exploration and neuroma excision and transposition.
a
b

1259
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Failure to Address Psychosocial Issues
A mutilating hand injury and the subsequent psychologi­
cal implications should not be overlooked. The hand has an
immense and integral role in an individual’s daily life. The
functional loss after a devastating injury can result in mal­
adaptive behavior that can affect rehabilitation. Adopting a
biopsychosocial perspective toward treatment of complex
hand injuries will help to address psychosocial issues ear­
lier and improve functional outcome.40
Outcomes
Inadequate Soft Tissue Coverage
Resulting in Contractures
A 22-year-old patient presented several years after a dev­
astating hand injury from a wood sawmill (Fig. 64.14). The
thumb and two adjacent digits had been amputated and a
chest tube pedicle flap had been constructed for soft tis­
sue coverage. The patient developed dysfunctional flexion
changes.28 It is common in mutilating hand injuries associ­
ated with crush injuries. Type I CRPS is usually related to
soft tissue injury and not associated with a nerve injury.
Type II CRPS occurs when there is a nerve injury. Typically,
sympathetic and stellate ganglion blocks are used to treat
nerve pain associated with CRPS. Surgical neurolysis is un­
likely to relieve pain and may risk further loss of function.
Physical therapy is encouraged to build strength, promote
bone healing, and prevent dysfunctional patterns of disuse.
Complications of Rehabilitation
Failure to Complete Rehabilitation
The patient commitment to rehabilitation is the most im­
portant factor to functional outcome. Recovery from hand
surgery takes months and often requires additional sec­
ondary procedures. A hand therapist may help to assess ap­
propriate wound care, teach therapeutic exercises, provide
sensory reeducation, and adjust orthoses throughout the
recovery period.39
Fig. 64.14 (a) This 22-year-old patient suffered a wood sawmill injury to his right hand several months previously. Underestimation of the
initial soft tissue deficit resulted in dysfunctional flexion contracture of the ring finger and first web space adduction contracture. (b) The
original wound was opened and the first web space and ring finger contractures were released. (c) A template was made of the soft tissue
defect to design for the ipsilateral groin flap. (d) A large groin flap permitted abundant soft tissue coverage. (e) The well-healed flap after
the pedicle was divided. (f) A secondary toe-to-hand transfer was performed. (g) The final result with improved flexion contracture of the
ring finger and widened first web space.
a
b
f
g
c
e
d

SECTION VIII THE HAND AND UPPER EXTREMITY
1260
sue coverage while preserving recipient vessels for future
microvascular toe transfer. If an initial soft tissue free flap
had been performed, finding recipient vessels for the toe
transfer would have been more difficult. The radial forearm
flap would have been a poor choice because it would have
provided inadequate soft tissue coverage, left an unsightly
forearm donor scar, and still have been problematic for
subsequent recipient vessels for microvascular toe transfer.
Minimal Number of Digits Needed
for Prehension
A 32-year-old female patient had a groin flap as an excel­
lent initial soft tissue coverage choice (Fig. 64.16). She had
all four fingers amputated through a crushing injury, and
contracture of the ring finger and significant first web space
adduction contracture. Analysis of the problem revealed
that the initial soft tissue deficit had been underestimated.
The scar was opened and the first web space and ring fin­
ger contractures released to “re-create” the original wound.
A template was made of the soft tissue defect and a large
groin flap was used for coverage. At a second stage, micro­
vascular toe transfer was performed.
Preserving Recipient Vessels to Avoid
Burning Vascular Bridges
A 30-year-old man had an avulsion injury to his dominant
right thumb that was not suitable for replantation (Fig.
64.15). A tube pedicle groin flap provided robust soft tis­
Fig. 64.15 (a) This 30-year old man sustained an avulsion injury to his right thumb. (b) The avulsed thumb was not suitable for replanta­
tion. (c) A tube pedicle groin flap provided robust soft tissue coverage. (d) Excellent coverage of the defect after flap division. (e) The pa­
tient achieved thumb flexion after a secondary microvascular toe transfer was performed. (f) The patient is able to fully extend the thumb.
d
f
e
a
c
b
Fig. 64.16 (a) This 32-year-old patient previously had all four fingers amputated in a crushing injury. Soft tissue coverage was initially pro­
vided by a groin flap. (b) Two adjacent toes were later transferred to the hand in a single stage. They were preferentially positioned at the
middle and ring finger site to maintain an adequate first web space and enable prehensile reach to the thumb. (c) The patient achieved
thumb opposition to the two toes.
a
c
b

1261
Chapter 64 Soft Tissue Coverage and Mutilating Extremity Injuries
Early Wound Débridement, Skeletal
Fixation, and Soft Tissue Coverage for
Optimal Functional Outcome
A 40-year-old patient had a punch press injury to the base
of the thumb. Initial wound débridement and exploration
revealed that the thumb extensor tendons were intact but
the base of the thumb metacarpal and trapezium were
destroyed (Fig. 64.18). The skeletal wrist injury and other
metacarpal fractures were stabilized through external fixa­
tion. Within 5 days, the freshly débrided wound was then
reconstructed in a single stage before tendons would be­
come encased in adherent granulating tissue. Bone graft­
ing preserved the length of the thumb metacarpal, and a
split FCR anchovy basilar thumb joint was reconstructed.
A rectus abdominis muscle flap with a skin graft provided
soft tissue coverage, with the injured radial artery being
the natural choice for recipient microvascular anastomosis.
The muscle provided initial bulk to fill the soft tissue dead
space and, with time, it atrophied to provide an excellent
contour without need for further revision and debulking
surgery. A fasciocutaneous flap would have theoretically
provided a better gliding surface for tendons; however, this
patient had all important tendons intact and had no need
for future tendon transfers. A fascia-only flap may have
been too thin for this large three-dimensional wound and
less durable.
initial soft tissue coverage came from a groin flap. Two ad­
jacent toes were subsequently transferred to the hand in
a single stage and were preferentially positioned at the
middle and ring finger site. With a fully functional thumb,
at least two additional opposing digits are necessary to pro­
vide pinch. Priority positions for revascularized fingers go
first to the middle and ring finger sites to maintain an ad­
equate first web space and enable prehensile reach to the
thumb.
Proper Flap Selection to Set the Stage
for Secondary Procedures
A 28-year-old patient sustained a first web space explosive
injury (Fig. 64.17). A simple dorsal hand transposition flap
provided sufficient soft tissue coverage after skeletal fixa­
tion of the thumb base. Bone injuries were treated by first
metacarpal splinting and nonvascularized interpositional
bone grafting. Split flexor carpus radialis (FCR) tendon in­
terposition and trapezium reconstruction provided stabil­
ity of the thumb basilar joint. Skin grafting of the initial
dorsoulnar donor site was performed. A radial forearm re­
verse flow flap was not feasible in the setting of the radial
artery injury at the base of the thumb. The patient retained
a supple and substantial first web space for future tendon
transfer. An extensor indicis proprius opponensplasty was
performed under the previous transposition flap.
Fig. 64.17 (a) This 28-year-old patient sustained a first web space blast injury. (b) A transposition flap provided adequate soft tissue cover­
age for critical underlying skeletal reconstruction at the thumb basilar joint. (c) The dorsoulnar donor site in a less critical area was covered
by a split-thickness skin graft. (d) An extensor indicis proprius opponensplasty was subsequently performed under the previous transposi­
tion flap. (e) The patient has full thumb opposition to the index finger.
a
b
c
e
d

SECTION VIII THE HAND AND UPPER EXTREMITY
1262
urgency, and the goal is to provide maximal restoration of
function. The key elements to minimizing complications
involve shortening the inflammatory phase with adequate
débridement and early soft tissue coverage and promot­
ing early mobility with stable fracture fixation. The patient
should be counseled that multiple surgeries and extensive
rehabilitation are often necessary. The patient’s under­
standing of the complexity of the condition will allow him
or her to anticipate the arduous recovery and prepare for
rehabilitation, which will ultimately result in optimal func­
tional outcome.
Conclusion
Mutilating hand injuries affect tissues at all levels, and as
the hand heals, a scar forms that binds together all sur­
rounding tissues. This is detrimental to the hand because
its function depends on mobility of joints and gliding ten­
dons. The treating surgeon should have a fundamental
knowledge of wound healing and scar formation and ap­
ply it to each stage of the treatment process. Treatment
begins at the first encounter with a thorough history and
physical examination to avoid missing injuries and delay­
ing treatment. Repair is prioritized based on the level of
Fig. 64.18 (a) This 40-year-old patient had a punch press injury to the base of the thumb. Initial wound exploration revealed intact thumb
extensor tendons but a crushed first metacarpal and thumb basilar joint. Skeletal stabilization of the wrist and metacarpal fractures were
obtained with external fixation. (b) Bone grafting preserved the length of the thumb metacarpal and a split FCR anchovy basilar thumb
joint added stability. (c) A rectus abdominis muscle flap with a skin graft provided durable soft tissue coverage for the underlying recon­
struction. Several months postoperatively, the patient demonstrated (d) extension of fingers, (e) full flexion of fingers, and (f) thumb op­
position to the index finger.
d
f
e
a
c
b
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Discussion by David W. Person
What makes mutilating extremity injuries difficult is
that several separate injuries present in combination
in one limb. The interrelated problems posed by these
individual injuries is greater than their sum when con­
sidered in the context of the entire injury.
In general, mutilating extremity injuries affect skin,
bone, tendon, nerves, and vasculature. The approach to
these multidisciplinary problems is the essence of hand
surgery best treated by the plastic surgeon. Prompt rec­
ognition of the extent of injury and affected subunits al­
lows the plastic surgeon to formulate a plan. Only with
training, knowledge, and experience can the surgeon
organize the pieces of the puzzle to begin assembling
them in a cogent fashion that allows maximal functional
recovery. Avoiding burning bridges and being cognizant
of the necessary subsequent steps to plan ahead opti­
mize the final outcome.
Missed Diagnosis
Missed diagnosis in trauma is unfortunately common,
around 15% in many series. Unfortunately, the plas­
tic surgeon is often called directly to take a patient
in transfer in mutilating extremity injuries. Although

SECTION VIII THE HAND AND UPPER EXTREMITY
1264
most plastic surgeons are trained in general surgery, it
is not appropriate for these specialists to evaluate the
trauma patient beyond the specific mutilated extrem­
ity. As such, patients should be evaluated and followed,
for their own safety, by a general and/or trauma sur­
geon. Time is typically of the essence in these injuries,
but surgical treatment of other injuries can take many
hours when replantation or early free flap coverage is
needed or appropriate. If serious injuries are missed
before a lengthy operation, catastrophic complications
can ensue.
Wound Care
In general, wound coverage should be achieved shortly
after débridement. Dr. Marco Godina1 elucidated the
importance of early soft tissue coverage in the avoid­
ance of osteomyelitis in Gustilo type IIIB tibia frac­
tures. This data is extrapolated to the upper extremi­
ties. Although I use negative-pressure wound therapy
between rounds of débridement, complacency easily
sets in and it can be a crutch or a bridge in a very busy
elective practice to avoid prompt coverage. As soon as a
wound is ready for soft tissue coverage (which may be
on presentation), it is in the surgeon’s and the patient’s
best interest to do so.2
Skeletal Repair
The most expeditious skeletal fixation is with K-wires
in most upper extremity fractures, particularly in cases
of contamination, revascularization, or replantation.
If there is a delay between the index surgery and soft
tissue coverage, consideration should be given to con­
version of K-wire fixation to rigid fixation using the AO
principles of fracture management. Such care allows
for early motion protocols within days after soft tissue
coverage. The focus should be on preventing known
and anticipated complications, specifically malunion,
nonunion, and joint stiffness. Finally, with these mu­
tilating injuries it is critical to pin the thumb in radial
and palmar abduction to avoid first web space con­
tracture. This simple preventive maneuver potentially
prevents a devastating, anticipated complication that is
not easily corrected.
Amputations
Amputations are a particularly difficult area and re­
quire significant experience and tact. I usually revert to
a more paternalistic discussion with patients (and their
families) regarding amputation. There is no greater fail­
ure than an inappropriate but successful replantation
that results in a stiff, painful digit. A vicious cycle en­
sues that may lead to a worse overall result. My regret­
table experiences with poor outcomes from replanta­
tion of parts that would be better suited for amputation
have tempered my judgment, yet furthered me as a
surgeon. Sound judgment in the decision to save digits
must be practiced for the patient’s benefit.
Flap Complications
The options for soft tissue reconstruction are many,
and the flap should fit the wound. In other words, the
plastic surgeon should choose the appropriate recon­
struction from the myriad available flaps to appropri­
ately fill the defect from the standpoint of size, depth,
irregularity, exposed tissues, and function. Microvas­
cular anastomoses must be out of the zone of injury
(healthy vessels with good inflow and outflow) to pre­
vent potential flap loss. The skills of the surgeon will
also dictate the options, choices, and outcomes. A fail­
ing flap is only one of many potential complications in
the treatment of a mangled extremity.
Tendon Repair
Tendon repair, transfers, and reconstruction (one or
two stage) provide a backdrop for many complications.
The choice of repair, the zone of tendon injury, the tim­
ing of the repair, and the subsequent rehabilitation of
the tendon repair are all complicated and varied issues.
The importance of a skilled Certified Hand Therapist
(CHT) is paramount in the treatment of any tendon is­
sue. My preference is for the CHT to initiate early active
motion protocols when appropriate. Often such com­
plex patients remain in the hospital and do not have
access to a CHT until discharge. Lost time in tendon re­
habilitation usually leads to further difficulties and the
need for secondary procedures.
Nerve Injuries
Nerve injuries add an additional layer of complexity
to mutilating extremity injuries. I prefer to immobi­
lize nerve injuries that are repaired primarily for a few
weeks. Unfortunately, immobilization is precisely what
must be avoided in the postinjury period for almost all
other problems. When nerves are grafted, typically a
little slack is built in to mitigate the complications in
early movement with nerve repairs. Autogenous graft­
ing remains the gold standard. The density of fascicles
is an important consideration in nerve grafting and is
the primary reason most surgeons use the sural nerve
as a first choice.3 Though rare, nerves can be harvested
from amputated parts judiciously. Finally, in a delayed
fashion, nerve transfer is a valuable tool as well.