Hand and Upper Extremity Reconstruction
44
injury, it may be diffi cult to fi nd the proximal lacerated
tendons. A good landmark is to identify the lumbrical
muscles, which are attached to the radial borders of the
FDP tendons. Pulling on the lumbrical muscles will always
retrieve the profundus tendons. By placing traction on the
profundus tendons, the FDS will be visible as well because
of the shared synovial layer between the two tendon systems.
In this zone the FDS tendon has much more substance and
the typical four-strand repair can be performed. It is not
necessary to perform an epitendinous Prolene suture repair
because the two tendon systems are not within a restrictive
tendon sheath, and tendon gliding between the systems is
usually not too prohibitive.
ZONE 4
Tendon lacerations in this zone are quite unusual unless
the laceration is longitudinal in orientation. A transverse
laceration in the carpal tunnel region will often be blocked
by the trapezium and the hamate. However, one should
understand the topography of the fl exor tendons and the
median nerve in the carpal tunnel, and systematic repair of
the tendons can be achieved by matching the shape of the
laceration proximally and distally, as well as the size of the
tendons.
ZONE 5
Injury in zone 5 is quite common. The wrist and forearm
are not protected by bony structures and lacerations can
cause multiple structural injuries to nerves, vessels, and
tendons (Fig. 3.39). Understanding the topography of the
structures in the cross-sectional arrangement is important
to effectively identify injured structures (see Fig. 3.3). The
fl exor tendons in the wrist are arranged in three layers. The
most superfi cial layer are the wrist fl exors, which consist
of the FCU, the PL, and the FCR. Immediately dorsal and
radial to the PL is the median nerve. If the patient has a
fi nger fl exor tendon laceration in zone 5, it is highly likely
that the median nerve will be lacerated because of its loca-
tion superfi cial to the fi nger fl exors. The second layer con-
sists of the superfi cialis tendons, which are arranged with
the middle and ring fi ngers more superfi cial to the index
and little fi nger tendons. The third layer consists of the
profundus tendon with the index, middle, ring, and little
fi ngers; the FPL tendon lies radially between the second and
third layers. The index FDP tendon usually has an inde-
pendent muscle belly, but the middle, ring, and little fi ngers
share a common muscle belly.
Exposure of the structures in the wrist is not too diffi -
cult. The laceration can be extended by incisions proxi-
mally and distally. The forearm fascia is sharply incised
with no. 15 blades, and blade dissection is used to rapidly
dissect the individual structures by separating the synovial
tissues from each tendon. When the laceration occurs with
the wrist fl exed, the distal tendons may be found in the
carpal tunnel. Therefore, a carpal tunnel incision is made
to expose the distal contents. When one understands the
cross-sectional relationship of the tendon structures, one
should be able to match respective tendons for repair, start-
ing from level 3 and proceeding to the superfi cial structures.
It is critical that the tendons are appropriately sutured to
their counterparts, because it is quite disturbing at the end
of the case when there is an extra tendon in the wound
without an accompanying proximal or distal tendon.
The author typically uses two horizontal mattress sutures
to repair the tendons (Fig. 3.40). There is so much space
within the wrist that tendon adhesions are usually not prob-
lematic. If both the radial and ulnar arteries are injured, they
are repaired fi rst to establish blood fl ow. I will repair a lacer-
ated artery at the wrist because technically it is not diffi cult
and it ensures good blood supply to the hand. The median
nerve is repaired last. When a median nerve injury is sus-
pected, one should not wait for a few days to repair the nerve
(Fig. 3.41). Retraction of the nerve several days after injury
makes it extremely diffi cult to bring the nerves together
FIGURE 3.39 Lacerated zone 5 showing multiple lacerations to
tendons, nerves, and vessels.
FIGURE 3.40 Repaired median nerve and tendons.
Surgical Techniques for Flexor Tendon Repair
45
without fl exing the wrist excessively. If the nerve can be
repaired within 24 hours it is technically quite easy to bring
the nerves together tension free. The nerve is examined
under the microscope and the ends are cut using a fresh no.
11 blade distally and proximally to achieve healthy nerve
ends for repair. Vascular landmarks on the proximal and
distal nerves will allow appropriate alignment of the epineu-
rium using 8/0 or 7/0 nylon sutures (see Fig. 3.40). There
are staining methods to identify motor and sensory fascicles,
but these techniques are still quite diffi cult to perform. Fas-
cicular suturing of the median nerve without ensuring proper
matching can create a mismatch of fascicles that will be
deleterious to nerve regeneration. For the median nerve at
the wrist, I prefer epineural repair and engage the nerve
specifi city properties for appropriate matching of fascicles.
The ulnar nerve at the wrist has two predictable sensory and
one predictable motor fascicle; I will perform fascicular
repair for the ulnar nerve at the wrist. It is important to
match the motor fascicle and the sensory fascicles using
interfascicular repair to ensure good recovery of important
intrinsic muscle function (Fig. 3.42).
Therapy
The wrist is splinted with a dorsal blocking splint in
approximately 60º of fl exion. The patient can start gentle
passive motion exercises within a few days of surgery. Out-
comes of fl exor tendon repair at the wrist are predictably
good if the patient is compliant with therapy and the thera-
pist understands the therapy protocol for this region. Similar
to zone 2 fl exor tendon injuries, patients are progressed
through a sequence of passive motion exercises, active
motion exercises, and strengthening exercises at the end of
the eighth week after surgery. Nerve recovery for median
and ulnar nerve laceration at the wrist is always incom-
plete. This is complicated by neuropathic pain, which is
diffi cult to treat and will be most bothersome to the
patient.
Complications
Complications of zone 5 injuries relate primarily to median
nerve dysfunction due to the mismatch of sensory and
motor fi bers, as well as incomplete recovery of sensation
and thenar muscle function. Patients typically complain of
prolonged periods of neuropathic pain that is very diffi cult
to control and can be quite devastating, particularly for
manual workers. Scarring of tendons in zone 5 is quite
uncommon. With judicious therapy and strengthening
exercises, most of the minor adhesions can be broken up
and will soften over time. Tenolysis in this region is gener-
ally not necessary.
CONCLUSION
Understanding the anatomy and physiology of fl exor tendon
is crucial to treat and repair these injuries. Handling of
Sensory
fascicles
Motor
fascicles
Blood
vessel
FIGURE 3.41 Median nerve laceration.
FIGURE 3.42 Ulnar nerve anatomy showing motor and sensory
fascicles.
Hand and Upper Extremity Reconstruction
46
tendon ends must be meticulous to prevent scarring that
could hamper healing.
Flexor tendon injuries and related lacerated structures
should be exposed meticulously but effi ciently using sharp
dissection with a knife. Aggressive spreading of scissors
through tissue plane induces too much trauma to the deli-
cate tissue. The author prefers sharp dissection with a knife
to separate the tissue layers. The surgeon must work closely
with the therapist to ensure that the patient receives the
most optimal and attentive therapy protocol in order to
optimize outcomes. Despite great advances in tendon repair
techniques and therapy protocols, inadequate outcomes are
not uncommon. Tremendous research effort is under way
to enhance the healing capability of tendons in order to
achieve earlier recovery of function and stronger repairs
to withstand more aggressive active protocols in an effort
to decrease tendon adhesions and to return useful
function.
REFERENCES
1. Abrahamsson SO, Lohmander S. Tendon healing in vivo. An
experimental tendon. Scand J Plastic Surg Hand Surg 1989; 23:
199–205.
2. Verdan CE. Primary repair of fl exor tendons. J Bone Joint Surg
1960; 42A: 647–657.
3. Bunnell S. Repair of tendons in the fi ngers. Surg Gynecol Obstet
1922; 35: 88–97.
4. Boyes JH, Stark HH. Flexor tendon grafts in the fi ngers and
thumb. A study of factors infl uencing results in 1000 cases. J
Hand Surg 1971; 53A: 1332–1342.
5. Boyes JH. Evaluation of results of digital fl exor tendon grafts. Am J
Surg 1955; 89: 1116–1119.
6. Kleinert HE, Kutz JE, Cohen MD. Primary repair of zone II fl exor
tendon lacerations. In: AAOS Symposium on Tendon Surgery in
the Hand. St Louis: CV Mosby, 1975; 91–104.
7. Leddy JR, Packer JW. Avulsion of the profundus tendon insertion
in athletes. J Hand Surg 1977; 2: 66–69.
47
C H A P T E R
4
The Management of Extensor
Tendon Injuries
Brent Bickel, David B. Shapiro, Michael W. Keith, and Harry A. Hoyen
ANATOMY
The extensor apparatus is a fi nely tuned system that relies
on the complex interplay between the intrinsic muscles
(originating and inserting on the hand) and the extrinsic
muscles (originating proximal to the wrist and inserting
distally on the hand). Any logical repair algorithm must
have as its basis a fi rm understanding of the anatomy of
the extensor system.
The tendons of the extrinsic musculature are aligned at
the wrist into the six dorsal wrist compartments (Fig. 4.1).
The fi bro-osseous extensor retinaculum creates the con-
fi nes of their respective compartments.
The retinaculum acts as a pulley to prevent ‘bowstring-
ing’ of the tendons during combined fi nger and wrist exten-
sion. The fi rst dorsal compartment contains the abductor
pollicis longus (APL) and extensor pollicis brevis (EPB),
which insert on the bases of the thumb metacarpal and
proximal phalanx, respectively. The APL has multiple
tendon slips in up to 40% of cases.1
The extensor carpi radialis longus (ECRL) and brevis
(ECRB) are contained within the second dorsal compart-
ment and attach to the bases of the index and long meta-
carpals, respectively. The third compartment contains only
the extensor pollicis longus (EPL) tendon, which courses
around Lister’s tubercle obliquely and inserts onto the distal
phalanx of the thumb. The EPL not only provides interpha-
langeal joint extension, but also adds an adduction moment
to the thumb. The fourth compartment contains the exten-
sor indicis proprius (EIP) and extensor digitorum commu-
nis (EDC) tendons that form the bulk of the extensor
apparatus; they attach primarily to the base of the middle
phalanx via the central slip. The EIP and extensor digiti
minimi (EDM) can be differentiated from their EDC coun-
terparts at the level of the metacarpophalangeal joint by
their more ulnar position (Fig. 4.2).
The EDM lies in the fi fth dorsal compartment over the
distal radioulnar joint and is responsible for small fi nger
extension independent of the EDC. The extensor carpi
ulnaris (ECU) is contained in the sixth and most ulnar
dorsal compartment. Its insertion on the base of the small
fi nger metacarpal allows for wrist extension and ulnar
deviation.
The intrinsic muscles of the hand contribute to the
extensor mechanism and include the interosseous and
lumbrical muscles. These muscles (except for the two radial
lumbricals, which are innervated by the median nerve) are
innervated by the deep branch of the ulnar nerve. There are
four dorsal bipennate and three volar unipennate interossei.
The dorsal interossei abduct the fi ngers away from the
centrally located long fi nger. They accomplish this by origi-
nating on adjacent borders of the metacarpals and inserting
onto the radial side of the proximal phalanx when the
muscles are over the radial side of the long fi nger, and onto
the ulnar side of the proximal phalanx when the muscles
are over the ulnar side of the long fi nger. Their combined
action serves to abduct the fi ngers from the midline.
The three unipennate palmar interossei adduct the
fi ngers towards the midline. When located ulnar to the
central long ray, they originate on the radial border of
the metacarpal and insert on the radial aspect of the proxi-
mal phalanx to pull the ulnarly located fi nger towards the
midline. This is a mirror image on the index metacarpal to
pull the radially located index fi nger toward the long ray.
All of the interossei also contribute to the extensor appara-
tus via their contributions to the lateral bands. Their com-
bined pull results in fl exion at the MP joint and extension
at the PIP and DIP joints.
The lumbricals originate on the radial border of the
fl exor digitorum profundus tendon just distal to or occa-
sionally within the carpal tunnel. Their initial path is volar
to the intermetacarpal ligament and their tendons work
similarly to the lateral bands to provide MP joint fl exion
and PIP and DIP joint extension. However, the lumbrical
muscle is unique because it is the only muscle that bridges
Hand and Upper Extremity Reconstruction
48
the extensor and fl exor system by providing synchronous
motion during fi nger extension and fl exion.
On the dorsum on the hand, between the retinaculum
proximally and the MP joint distally, the EDC tendons are
connected by the juncturae tendinae (Fig. 4.3). Their inter-
connections can make tendon lacerations proximal to the
MP joint diffi cult to diagnose because the distal tendon
connection can maintain extension of the fi nger with the
lacerated extensor tendon.
The extensor mechanism distal to the juncturae can
become more complex because of the inherent connection
between the extrinsic and intrinsic systems. The EDC
tendons pass over the MP joint and are held in a centrally
located position by the sagittal bands (Fig. 4.4).
The sagittal band fi bers maintain the extensor in a
central location by fi bers that attach into the volar plate of
the proximal phalanx. The EDC contributes to MP joint
extension through these fi brous insertions.
Distal to the MP joint the extensor system divides into
three distinct portions (Fig. 4.5), the central slip and the
two lateral bands.
FIGURE 4.1 Dorsal wrist compartments; hand is at the left side of the
fi gure.
FIGURE 4.2 EIP ulnar to EDC in zone 5.
FIGURE 4.3 Juncturae tendinae interconnections (arrows).
FIGURE 4.4 Radial sagittal band of the index fi nger.
FIGURE 4.5 Lateral bands (large arrows) and central slip (small arrow)
at the level of the proximal phalanx.
The Management of Extensor Tendon Injuries
49
The central slip continues distally to insert onto the
base of the middle phalanx. The intrinsic contribution to
the lateral bands passes volar to the MP axis, thereby aiding
MP fl exion, whereas the terminal tendons contribute to PIP
and DIP extension through their relatively dorsal location.
This relationship permits smooth conjugated fi nger fl exion
and extension.2
The lateral band position is maintained at the level of
the PIP joint by the transverse retinacular ligament (TRL)
(Fig. 4.6). The clinical signifi cance of the TRL after PIP and
central slip trauma is in preventing dorsal subluxation of
the lateral bands at the level of the PIP, which can cause a
hyperextended posture and ‘swan-neck’ deformity at the
PIP joint.
The lateral bands join at the level of the middle portion
of the middle phalanx dorsally. They are held dorsally by
the triangular ligament (Fig. 4.7). Rupture or attrition of
this ligament can result in volar lateral band subluxation
and a fl exed posture of the PIP. This deformity presents as
a ‘boutonnière’ deformity. If the PIP joint is not maintained
in an extended position after central slip trauma, the lateral
bands migrate volarly, causing a fl exed PIP posture.
Distally the lateral bands form a conjoined tendon that
inserts onto the base of the distal phalanx to provide ter-
minal extension of the DIP joint. The spiral oblique reti-
nacular ligament originates on the fl exor sheath volarly at
the PIP joint and courses distally and dorsally to contribute
to the dorsal extensor mechanism and stabilize the PIP
joint.
INNERVATION SEQUENCE
The origin of the forearm extensor musculature is the
lateral humeral epicondyle and the interosseous membrane.
Each of the muscles has a relatively fl at muscle belly prior
to forming a fl at, broad tendon. The myotendinous junc-
tion for the wrist extensors is in the mid-forearm, whereas
that of the fi nger extensors is in the distal forearm.
Innervation comes from the radial nerve. Based on
research work with functional electrical stimulation, the
motor point for each nerve is located fairly consistently just
proximal to the myotendinous junction. There is usually
one larger motor branch from the radial nerve or posterior
interosseous nerve to each muscle.
The sequence of innervation is an important distinction
for this muscle group. In contrast to some nerves that
branch in a tree-like fashion, the radial nerve innervates the
extensor musculature in an orderly pattern from proximal
to distal. The main radial nerve supplies the brachioradia-
lis, ECRL, and occasionally the ECBR. The posterior inter-
osseous nerve innervates the ECRB, EDC, ECU, EIP, and
EPL sequentially. The order of innervation is important in
differentiating a radial nerve injury from a mechanical myo-
tendinous or muscle disruption after forearm lacerations.
Understanding the innervation is likewise helpful when
observing clinical recovery after radial nerve injury or
repair.
INJURY AND PRESENTATION
The description of extensor injuries is based on eight zones
for the hand and fi ve for the thumb, as described by Verdan.3
The odd-numbered zones lie over joints, whereas the
even-numbered ones lie over bones. The Verdan zones are
depicted in Figure 4.8.
This classifi cation is important because the pathogene-
sis, mechanisms of injury, repair strategies, and rehabilita-
tive programs are based on the level of injury. The clinical
presentation is likewise important because certain injuries
require acute intervention to restore the extensor biome-
chanics adequately, whereas others can be treated more
conservatively.
INITIAL ASSESSMENT
Careful assessment and evaluation of the skin overlying the
extensor injury is of paramount importance. Traumatic
FIGURE 4.6 The transverse retinacular ligament shown by the arrow
at the level of the PIP laterally viewed.
FIGURE 4.7 Triangular ligament holding the lateral band in a dorsal
position.
Hand and Upper Extremity Reconstruction
50
lacerations will often need to be extended to gain adequate
exposure for tendon repair, and skin fl ap viability should
be assessed. Local anesthesia at the time of the initial
emergency evaluation will help determine the extent of the
injury and confi rm intra-articular involvement for injuries
to zones I, III, or V.
Lacerations over the MP joint can result in tendon and
sagittal band injury. PIP extension is possible through the
intrinsic contributions. In zone V injuries, the individual
fi nger tested should have the PIP in full extension and the
wrist in neutral position to remove the contribution of the
intrinsic musculature to MP extension.
Special attention should be paid to zone VI injuries,
where an intact juncturae tendinum may mask a complete
EDC injury by allowing the MP joint to extend, but will
seldom allow full extension that is symmetric to the con-
tralateral side. In order to test individual EDC tendons, one
should have all fi ngers fl exed except the fi nger in question,
so as to prevent the patient extending through the intact
juncturae. The contralateral hand should be examined for
comparison.
For injuries proximal to zone V, MP extension may be
altered. Extensor strength and individual MP, PIP and DIP
range of motion should be graded from 0 to 5 and compared
to the uninvolved side. Individual muscles should be iso-
lated to assess strength. Table 4.1 describes the individual
examinations for these individual muscle groups.
Adequate irrigation will remove contaminated material
and debris from the wound. Bone loss, soft tissue defects,
or joint instability should be fundamental in the decision-
making process because skin coverage and osseous stability
are just as important as tendon integrity.
Radiographic examination will help determine whether
bony injury, bone avulsion, or joint incongruity have
occurred. Foreign bodies will often be seen on plain radio-
graphs. A thorough examination of the neurologic and
fl exor functions of the hand should be performed. These
concomitant injuries may alter the treatment plan and the
outcome of extensor tendon injuries.
NON-OPERATIVE TREATMENT
Partial extensor tendon injuries that are <50% of the tendon
width are usually managed non-operatively (Fig. 4.9). In the
clinical setting, the percentage of tendon laceration can be
diffi cult to determine, especially when the laceration has
already been repaired in the emergency department. In
these situations the aforementioned physical examination
techniques can be used, and if no extensor lag is present,
conservative treatment can be instituted. Non-operative
treatment of individual Verdan zones I–VIII will be dis-
cussed in the following paragraphs.
SUTURE TECHNIQUE
The type of suture and technique will vary according to the
Verdan zone. Smaller tendons are usually repaired with 4/0
non-absorbable braided suture and larger tendons with 3/0
or 2/0 sutures. Use of a 5/0 or 6/0 monofi lament epitendi-
nous suture is usually not possible until the tendon injury
is proximal to zone V. In general, extensor tendons are
fl atter and have less excursion than their fl exor counter-
parts. An extensor lag can occur with even a minimal gap
at the repair site.
Many suture techniques have been described to repair
extensor tendons. They include the Silfverskiöld, the
FIGURE 4.8 Verdan’s zones of extensor tendon injury.
FIGURE 4.9 Extensor tendon with <50% involvement.
The Management of Extensor Tendon Injuries
51
TABLE 4.1 Description of individual examination, technique, grading, and signifi cance for individual muscle groups
Examination
Technique
Illustration
Grading
Signifi cance
Evaluate the
skin for any
signs of
infection,
open
wounds, or
lacerations
Observation and documentation
By noting a skin injury
close to a joint, one
can anticipate the
possibility of intra-
articular infection,
injury, or foreign body.
Plan incision technique
to incorporate the
lacerations
Active and
passive
range of
motion and
strength
Patients with extensor tendon
lacerations often have no pain
with passive extension, but
cannot perform active extension
or may do so with considerable
pain
Assess for
strength and
pain with
resistance
The loss of active
motion helps identify
tendon defi cits. Keep
in mind, a patient with
near full motion may
have a tendon injury
proximal to the
juncturae tedinum. The
lost of passive motion
can be related to pain,
arthritis, or other
non-related injuries.
Extensor
pollicis
longus (EPL)
Patients with extensor tendon
lacerations typically have a loss
of active extension (or pain with
testing), but full passive
extension with little discomfort
As above
IP extension without
retropulsion can be
performed by the
thenar intrinsics
Extensor
indicis
proprius (EIP)
Isolated extension of index
fi nger
As above
Hand and Upper Extremity Reconstruction
52
Extensor
digitorum
communis
(EDC)
Extension of all fi ngers together
As above
Lacerated EDC to index
or small fi nger with
intact proprius tendon
can mask the EDC
defi cit
Abductor
pollicis
longus (APL)
Palpate the fi rst dorsal
compartment while the thumb
is abducted in the plane of the
hand
The APL may have
multiple slips, making
an injury to one of
these slips diffi cult
Extensor
carpi radialis
brevis and
longus
Make a fi st to take out the
contribution of EDC, then
extend the wrist while palpating
the second dorsal compartment
Extensor
carpi ulnaris
Extend and ulnarly deviate the
wrist while palpating the sixth
dorsal compartment
Extensor
tendon
subluxation
at the MP
joint
First observe the EDC tendon
while placing the MP joint in
fl exion, then incorporate passive
fl exion at the PIP to magnify a
more subtle injury. Tenderness is
usually exhibited at the
ruptured side of the sagittal
band (usually radially). Always
test the patient’s ability to
extend the fi nger from a fl exed
position, because even patients
with marked instability can hold
a fi nger in extension
The EDC
tendon is
subluxing
ulnarly as the
MP joint is
fl exed
Longitudinal
lacerations around the
MP joint may require
repair if tendon
subluxation is present
or suspected
TABLE 4.1 Continued
Examination
Technique
Illustration
Grading
Signifi cance
The Management of Extensor Tendon Injuries
53
modifi ed Bunnell, and the modifi ed Kessler techniques (Fig.
4.10). The technique should have the ability to provide
minimal gapping and hence less loss of motion. For fl at
tendon confi guration, a horizontal mattress suture pattern
is also quite acceptable.
TREATMENT
Zone I
The disruption of the terminal tendon results in an exten-
sor lag at the DIP joint. Positioning of the DIP in persistent
fl exion is commonly referred to as mallet fi nger. Mallet
fi nger or disruption of the terminal extensor tendon at the
DIP is usually caused by an external fl exion force against
an otherwise extended DIP joint (Fig. 4.11). The result is
either a tendinous rupture or avulsion of the bony insertion
of the terminal tendon (bony mallet). The injury can also
result from a laceration over the DIP joint (Fig. 4.12). The
hallmark fi nding is a fl exed DIP posture with lack of active
extension. This injury is seen in sports (baseball and bas-
ketball) or industrial injuries. It may also occur spontane-
ously in individuals with collagen vascular disease or
rheumatoid arthritis. Radiographic fi ndings are variable,
Extensor
tendon
tenodesis
test
Test for normal full fi nger fl exion
(at MP, PIP and DIP) with passive
wrist extension, and full fi nger
extension upon passive wrist
fl exion
Useful in children and
in unresponsive
patients to assess
tendon function, and
in patients whose
radial or posterior
interosseous nerve
injury may
masquerade as an
extensor tendon injury
Central slip
test (Elson’s
test)
Flex patient’s fi nger at PIP then
have patient extend to evaluate
isolated extensor tendon
strength without the infl uence
of the lateral bands
If uncertain, may do
digital block and then
test strength
TABLE 4.1 Continued
Examination
Technique
Illustration
Grading
Signifi cance
Hand and Upper Extremity Reconstruction
54
G
F
E
D
C
B
A
FIGURE 4.10 Some suture techniques for extensor tendon repair. The strongest repairs are the Silfverskiöld cross-stitch for fl at tendons, and
the four-strand cruciate suture for tendons able to accept a core suture. A Running suture. B Horizontal mattress suture. C Silfverskiöld cross-
stitch (which can also be used as a circumferential epitendinous tidying suture over a core suture). D Modifi ed Kessler suture. E Modifi ed
Bunnell suture. F Krakow suture. G Four-strand cruciate suture.
FIGURE 4.11 Flexion moment on the DIP.
FIGURE 4.12 Full-thickness laceration in zone 1 resulting in a mallet
deformity.
but attention should be paid to dorsal avulsion fragments
and joint subluxation on a true lateral view. Doyle4 has
described four types of mallet fi nger. This classifi cation
scheme can guide treatment.
● Type I: Closed injury as a result of hyperfl exion, with
or without a small bony avulsion (treatment is 6–8
weeks of immobilization).
● Type II: Open laceration injury that divides the terminal
tendon at or just proximal to the DIP, with loss of exten-
sor tendon continuity.
● Type III: Deep abrasion to the tendon involving bone
and soft tissue.
● Type IV: Subdivided into three groups:
● Transepiphyseal fracture (usually a Salter–Harris
type II) in children ‘Seymour’s fracture’.
● A fracture of 20–50% of the joint surface on the
lateral view.
● A fracture with >50% of the joint involved with joint
subluxation on the lateral radiograph.
Surgical treatment is indicated for open injuries to
mallet fi ngers. A relative indication is in closed injuries
when patients cannot tolerate splinting. Age, skin condi-
tion, medical comorbidities, associated injuries, the pres-
ence of arthritis, and the age of the injury must all be
considered in the surgical decision-making process. Type I
closed injuries with or without a small bony fragment
The Management of Extensor Tendon Injuries
55
receive 6–8 weeks of continuous static splinting, followed
by 6 weeks of intermittent and night-time splinting. Patients
should be made aware that any fl exion of the DIP during
this treatment period will result in an additional 6 weeks
of splinting. Full active PIP motion should be maintained
during this treatment. A residual extensor lag of <10º is
generally seen as a ‘good’ result and is attainable in 80% of
patients.5
Various splint types have been suggested. It is important
for the fabricated splint to be comfortable and well molded
to the patient. Skin integrity and compliance are directly
related to the fi t of the splint. Dorsal extension splinting
has the advantage of allowing the use of the digit for activi-
ties of daily living.
Type II open laceration injuries should be treated opera-
tively. A fi gure-of-eight or running cross-stitch can be used
with 5/0 non-absorbable sutures. ‘Tenodermodesis’ may
also be performed, in which a 5/0 or 4/0 nylon suture is
used to capture both the overlying skin and the underlying
tendon in one pass6 (Fig. 4.13). This repair may require
transarticular stabilization with a K-wire for 6 weeks.
Type III injuries are diffi cult to manage and often require
primary grafting or late reconstruction, with soft tissue
coverage or arthrodesis.
Type IVa injuries represent an open Salter–Harris frac-
ture in children. A concomitant nail-bed injury may also
be present. These open injuries require debridement and
reduction. Depending on the fracture type and joint stabil-
ity, a splint or transarticular K-wire may be used. Subtype
4b injuries usually heal well with extension splinting. Frac-
tures with palmar subluxation (type 4c) should be treated
surgically. Options include open reduction and internal
fi xation with the use of K-wires, pullout sutures, or wires.
Operative intervention can lead to a higher rate of compli-
cations. Stern and Kastrup7 reported on 123 mallet fi ngers
and found a 53% complication rate in surgically treated
mallet fi ngers and a 45% complication rate using splints.
Chronic mallet deformities, if still supple and reducible,
may be treated by splinting up to 3 months after injury.
Garberman et al.8 showed that splinting of a mallet fi nger
for an average of 53 days from injury resulted in a successful
outcome with or without the presence of a small (<30% of
articular surface) fracture.
In chronic mallet deformities, the chronically fl exed
posture of the DIP may result in central tendon retraction
with TRL attrition and dorsal lateral band subluxation
at the PIP. This leads to a ‘swan-neck’ deformity. Many
surgical options exist, including superfi cialis tenodesis,
transarticular wire stabilization for 6 weeks,9 a central slip
tenotomy,10 or a spiral oblique retinacular ligament (SORL)
reconstruction.11 The choice of procedure relies largely on
the surgeon’s preference. In a chronically stiff and painful
mallet deformity, arthrodesis may be the best option.
Zone II
These injuries are usually due to sharp or penetrating lac-
erations and may have the clinical appearance of a zone I
injury. Damage to underlying bone and periosteum often
can lead to stiffness and tendon adherence. As with most
extensor tendon injuries, if <50% of the tendon is involved,
early active range of motion is initiated. If >50% of the
tendon is damaged, it should be repaired with one of the
various suture techniques and rehabilitated similarly to a
zone I injury.
Zone III
A laceration in the PIP region results in PIP fl exion and
DIP hyperextension owing to the pull of the lateral bands.
Early recognition is very important, as loss of the interac-
tion between the intrinsic and extrinsic mechanisms results
in early permanent capsular and tendon effects.
Zone III injuries are usually classifi ed as acute (open/
closed), or chronic (supple/contracted). They can also be
associated with a traumatic arthrotomy, volar PIP disloca-
tion, crush injury, and attritional ruptures due to infl am-
matory arthritis. Similarly to a zone I injury, the central
slip may displace proximally with an avulsion fragment of
the middle phalanx. The main concern with this zone of
injury is progression to a boutonnière deformity. In the
weeks following injury the lateral bands migrate volarly,
with attrition of the triangular ligament. The lateral bands
then impart a fl exion moment on the PIP and, by shorten-
ing, have an extension moment to the DIP.
Acute closed injuries are usually treated in PIP exten-
sion splints for 4–6 weeks. DIP fl exion is permitted. Because
of the interconnections in the extensor system, there is
minimal proximal retraction of the lacerated tendon. There-
fore, splinting can approximate the tendons’ ends. For
fl exor tendons, the lacerated tendons will retract substan-
tially and surgical repair is the only option. Active PIP joint
fl exion exercises are begun, with continued protection in
extension for an additional 2 weeks. Acute central slip avul-
sions may present with swelling and pain that may mask
the diagnosis. As the swelling and pain subside, weak or
absent PIP extension will persist and alert one to the diag-
nosis of a central slip injury.
FIGURE 4.13 ‘Tenodermodesis’ technique.
Hand and Upper Extremity Reconstruction
56
Acute open injuries can be treated similar to closed
injuries after appropriate wound management or with
extensor tendon repair. The repair is usually performed
with 4/0 suture because of the tendon’s width and thick-
ness. If tendon loss is encountered, a V-Y advancement, or
turn-down fl ap of the central slip proximal to the laceration
may be performed.5 Dorsal rim fragments should be stabi-
lized with a K-wire or small cortical screw (1.3–1.5 mm). It
is important to maintain the tendon attachment to the
fragment during the dorsal exposure. If the osseous or soft
tissue repair is tenuous, transarticular K-wire stabilization
is recommended for 3–4 weeks. Operative intervention is
also necessary with PIP volar instability, displaced articular
fractures, and failed splinting.
Chronic zone III injuries may be fl exible or fi xed. Fixed
boutonnière deformities should have aggressive occupa-
tional therapy with splinting or serial casting to improve
the PIP fl exion contracture prior to surgical intervention. If
PIP extension cannot be achieved by non-surgical means,
surgical release of the tight volar structures may be required
prior to central slip reconstruction. As PIP extension is
achieved, active DIP fl exion should be emphasized to stretch
the tight lateral bands. Once the PIP/DIP relationship is
restored, a central slip advancement procedure may be
considered. The PIP joint is maintained in extension
with a transarticular K-wire, and MP and DIP motion is
permitted.
Salvage options include tendon grafting and tendon relo-
cation procedures, as described by Littler,12 and tenotomy
of the extensor mechanism over the middle phalanx as
described by Fowler.13
Zone IV
Disruption in this region is most commonly caused by lac-
erations. The presentation is variable, as there is a confl u-
ence of the intrinsic and extrinsic components. With partial
laceration of the central slip, full extension of the PIP and
DIP joints is often possible. With the PIP in fl exion, weak
extension indicates incomplete laceration of the central
slip.
The central tendon in zone IV has a broad fl at surface,
therefore lacerations at this level seldom lead to complete
extensor tendon laceration. Without an extensor lag, immo-
bilization in extension for 3–4 weeks is recommended.
Lacerations with extension loss are repaired and splinted
for 3–4 weeks to avoid central slip lengthening and bou-
tonnière deformity. As in zone III, a 4/0 core suture is
suffi cient.
Zone V
Zone V injuries are commonly associated with sharp pen-
etrating injuries to the MP joint from a ‘fi ght bite’ type
mechanism. All suspected intra-articular injuries should be
explored because contamination is likely. Damage to
tendon, joint surface, and cartilage can approach 75% in
this type of injury.14 The MP joint may be approached
proximally or through the ulnar sagittal band (Fig. 4.14).
In a clean wound the tendon may be repaired acutely.
With a subacute presentation, or if an infection occurs, the
tendon can be repaired at 7–14 days once the soft tissue
bed has improved. The tendon injury is often proximal to
the laceration owing to the fl exed position of the fi nger at
the time of injury, thus the initial traumatic laceration
should be extended proximally. The tendon in zone V is
much more substantial than in zone IV, allowing for a
larger core suture (3/0 or 4/0) with an epitendinous repair.
Large capsular injuries can be repaired with an absorbable
suture.
Closed blunt injuries in zone V (boxer’s knuckle) may
lead to rupture of the radial sagittal band. This injury may
present with limited terminal extension because the EDC
subluxes ulnarly at the MP joint (Figs 4.15–4.19).
The patient may be unable to actively extend the MP
joint because of pain; however, when the MP is passively
FIGURE 4.14 MP joint entered proximally to avoid damage to
sagittal bands.
FIGURE 4.15 Radial sagittal band of the index at the MP joint level.
The Management of Extensor Tendon Injuries
57
extended they will be able to hold the extended posture.
Acute closed treatment consists of extension splinting for
6 weeks. Acute surgical repair may be indicated in some
subacute cases or with continued subluxation. Primary
repair, or secondary reconstruction with an ulnar slip of the
EDC, is performed when attenuated tissue is encountered.
Ishizuki16 reported no cases of recurrent subluxation after
primary repair in 13 patients.
Zone VI
Extensor tendon anatomy in zone VI is more robust and
therefore repair with a core suture and epitendinous repair
is straightforward. Injuries in this area may be masked by
the pull of the juncturae and only adequately diagnosed by
exploration. The extensor retinaculum usually requires
division during the dorsal exposure.
The juncturae also play a role in the rehabilitation pro-
tocols. If the EDC is injured distal to the juncturae inser-
tion then the entire EDC and wrist should be protected
because of the combined and uneven pull of the juncturae.
An alternative to static splinting in the compliant patient
is dynamic splinting.17 The MP joints can be supported
with an outrigger-type splint that permits passive extension
and active fl exion after the wound has sealed.
Zone VII
Treatment at this level is complicated by the presence of
the extensor retinaculum (Fig. 4.20). The retinaculum can
be partially excised to facilitate extensor repair and excur-
sion, but a portion must be preserved to prevent bowstring-
ing. The retinaculum is typically repaired with 3/0 or 4/0
non-absorbable sutures.
Adhesions are common at this level and can be pre-
vented by a strong repair and early motion. Injury to dorsal
cutaneous nerves is a common occurrence. Repair is recom-
mended to prevent painful neuroma formation.
FIGURE 4.16 Rupture of the radial sagittal band.
FIGURE 4.17 Ulnar subluxation of the EDC over the MP joint in MP
fl exion.
FIGURE 4.18 Repair of the sagittal band.
FIGURE 4.19 Repair results in centered EDC at MP with fl exion.
Hand and Upper Extremity Reconstruction
58
FIGURE 4.20 Tendon repair in zone VI is complicated by the
retinaculum. Adhesions are common at this level and can be
prevented with a strong repair and early motion. Injury to dorsal
cutaneous nerves is a common occurrence. Repair is recommended
to prevent painful neuroma formation.
Zone VIII
Injuries in this zone are usually due to penetrating trauma.
Complete neurovascular examination is necessary, as con-
comitant nerve injury can occur. Diagnosis is confi rmed
with the tenodesis affect testing. The fi brous septa of indi-
vidual muscle bellies are reapproximated with a grasping
suture. The fascia should be likewise approximated with a
2/0 suture. Laceration to the PIN or its branches should be
repaired because of early reinnervation owing to the prox-
imity of the lacerated nerve ends to their respective end
organs. It is a priority to restore wrist and thumb extension.
The wrist is immobilized in slight extension with the MP
joints in slight fl exion. If the repaired tendons have their
origin proximal to the elbow, the elbow is fl exed to reduce
strain on the repair. Protected range of motion is initiated
at 4 weeks.
Thumb (TI–V)
Mallet injuries (zones I and II) of the thumb are treated
similarly to mallet injuries of the fi ngers. Any joint sublux-
ation or joint involvement >50% should be treated surgi-
cally. Lacerations at or distal to the MP level are usually
not associated with retraction of the EPL. Lacerations pro-
ximal to the MP often do retract to the level of the wrist
retinaculum. EPL lacerations proximal to the MP may be
diffi cult to repair primarily and may require grafting or EIP
transfer as little as 2 weeks after injury. Attritional rupture
of the EPL is a well known complication after non-displaced
distal radius fractures.
Repair of EPL, EPB, or APL injuries in zone TV requires
release of the fi rst and second compartments to prevent
postoperative adhesions. Postoperatively the thumb should
be placed in adduction and extension for 4–6 weeks. Lacera-
tions to the EPB in zone TIII are associated with radial
collateral ligament and dorsal MP capsular avulsions. This
injury can be managed acutely in a thumb spica splint.
Continued laxity after a period of immobilization may
require surgical repair.
REHABILITATION
Static splinting of extensor tendon injuries following repair
has been the mainstay of treatment, with predictable
results.17,20 Crosby and Wehbe proposed early protected
motion using dynamic splinting to promote tendon mobi-
lization. This protocol resulted in 93% retention of extensor
strength at 9–12 weeks. They attributed their excellent
results to this early mobilization program.18
Tendon excursion of 3–5 mm is thought by Duran and
Houser19 to be critical for the prevention of adhesions, and
this amount of excursion can be achieved with 30º of MP
motion postoperatively.20 Controlled motion has also been
shown to improve tendon glide and tensile strength in
fl exor tendons.
In dynamic splinting, the splint is applied 3–5 days
postoperatively with the wrist in 30º of extension and the
MP joint in 10–20º of fl exion. The IP joints are usually held
in full extension. Improved functional outcomes of the
dynamic protocol over the standard static splinting proto-
cols have been proven.21
COMPLICATIONS
Complications of extensor tendon injury include infection,
rupture following repair, joint stiffness (either from immo-
bilization or as a result of tendon adherence to surrounding
tissues), and extensor lag. If aggressive therapy does not
improve passive joint range of motion by 4–6 months after
repair, extensor tendon tenolysis may be considered.
REFERENCES
1. Jackson WT, Viegas SF, Coon TM, et al. Anatomical variations in
the fi rst extensor compartment of the wrist. A clinical and
anatomical study. J Bone Joint Surg 1986; 68A: 923–926.
2. Kaplan EB, Hunter JM. Extrinsic muscles of the fi ngers. In:
Spinner M (ed) Kaplan’s functional and surgical anatomy of the
hand, 3rd edn. Philadelphia: JB Lippincott, 1984; 93–112.
3. Kleinert HE, Verdan C. Report of the Committee on Tendon
Injuries (International Federation of Societies for Surgery of the
Hand). J Hand Surg [Am] 1983; 8: 794–798.
4. Doyle JR. Extensor tendons: Acute injuries. In: Green DP (ed)
Operative hand surgery, 4th edn. New York: Churchill
Livingstone, 1999; 1950–1987.
5. Abouna JM, Brown H. The treatment of mallet fi nger: The results
in a series of 148 consecutive cases and a review of the literature.
Br J Surg 1968; 55: 653–667.
6. Iselin F, Levame J, Godoy J. A simplifi ed technique for treating
mallet fi ngers: tenodermodesis. J Hand Surg [Am] 1977; 2:
118–121.
7. Stern PJ, Kastrup JJ. Complications and prognosis of treatment of
mallet fi nger. J Hand Surg [Am] 1988; 13: 329–334.
8. Garberman SF, Diao E, Peimer CA. Mallet fi nger: Results of early
vs. delayed closed treatment. J Hand Surg [Am] 1994; 19:
850–852.
9. Burton RI, Melchior JA. Extensor tendons – late reconstruction.
In: Green DP (ed) Operative hand surgery, 4th edn. New York:
Churchill Livingstone, 1999; 1988–2021.
10. Grundberg AB, Reagan DS. Central slip tenotomy for chronic
mallet fi nger deformity. J Hand Surg [Am] 1987; 12: 545–547.
The Management of Extensor Tendon Injuries
59
11. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular
ligament, SORL. J Hand Surg [Am] 1978; 3: 482–487.
12. Littler JW. The digital extensor–fl exor system. In: Converse JM
(ed) Reconstructive plastic surgery. Vol 6. Philadelphia: WB
Saunders, 1977; 3166–3183.
13. Fowler SB. The management of tendon injuries. J Bone Joint Surg
[Am] 1959; 41: 579–580.
14. Patzakis MJ, Wilkins J, Bassett R. Surgical fi ndings in clenched fi st
injuries. Clin Orthop Relat Res 1987; 220: 237–240.
15. Snow JW. A method for reconstruction of the central slip of the
extensor tendon of a fi nger. Plast Reconstr Surg 1976; 57:
455–459.
16. Ishizuki M. Traumatic and spontaneous dislocation of extensor
tendon of the long fi nger. J Hand Surg [Am] 1990; 15:
967–972.
17. Chow JA, Dovelle S, Thomes LJ, et al. A comparison of results of
extensor tendon repair followed by early controlled mobilisation
versus static immobilisation. J Hand Surg [Br] 1989; 14: 18–20.
18. Crosby CA, Wehbe MA. Early protected motion after extensor
tendon repair. J Hand Surg [Am] 1999; 24: 1061–1070.
19. Duran RJ, Houser RG, Stover MG. Management of fl exor tendon
lacerations in Zone 2 using controlled passive motion
postoperatively. In: Hunter JM, Schneider LH, Mackin EJ, Bell JA,
eds. Rehabilitation of the hand. St Louis: CV Mosby, 1978;
217–224.
20. Evans RB, Burkhalter WE. A study of the dynamic anatomy of
extensor tendons and implications for treatment. J Hand Surg
[Am] 1986; 11: 774–779.
21. Browne EZ Jr, Ribik CA. Early dynamic splinting for extensor
tendon injuries. J Hand Surg [Am] 1989; 14: 72–76.
61
C H A P T E R
5
Metacarpal and Phalangeal Fractures
David P. Moss and Keith A. Segalman
INTRODUCTION
Fractures of the phalanges and metacarpals are the most
common fractures of the upper extremity.1 Many of these
fractures are treated non-operatively, but instability and
displacement may necessitate operative intervention.
Fractures of the hand that meet operative criteria can
be among the most diffi cult injuries to treat because the
surgeon is faced with the dilemma of achieving stable
fi xation, angular correction, freely mobile joints, and soft
tissue balance while still allowing an active range of
movement.
More extensive dissections that permit the placement
of rigid fi xation can result in excellent correction of defor-
mity, but may also create adhesions that limit motion and
hinder overall patient outcome. On the contrary, lack of
appropriate fi xation may maintain adequate joint motion
but fail to correct deformity. It is this fi ne balance bet-
ween bony stability and motion that affects the surgeon’s
decision-making process when treating fractures of the
hand.2,3
METACARPAL FRACTURES
Operative approach
Operative treatment of metacarpal fractures is performed
with the patient in the supine position and the hand on
a hand table. Either regional or general anesthesia is
appropriate. Percutaneous pinning is often performed under
monitored anesthesia and a wrist block.
Fractures of the metacarpals that require internal fi xa-
tion are approached through a dorsal longitudinal incision.
For fractures involving a single metacarpal, the incision
may be placed dorsolateral to the injured bone to limit
scarring between the skin and the extensor tendon. When
adjacent metacarpals are injured, it is prudent to make a
longitudinal incision centered between the affected bones,
as each fracture will be easily accessible through the mobile
skin on the dorsum of the hand.
After incision of the skin, one must protect the underly-
ing sensory branches of the radial and ulnar nerves. The
extensor tendons should be retracted to expose the proxi-
mal and midshaft fractures. The periosteum should be
incised in a plane different from an extensor tendon
incision to limit tendon adhesions. More distal injuries
involving the metacarpal neck or head may require midline
longitudinal incision of the tendon in order to expose the
underlying fracture site adequately. Intra-articular fracture,
whether proximal or distal, requires a midline dorsal
arthrotomy to visualize the fracture.
Indications for surgery
● Unstable fracture
● Rotational deformity
● Open fracture
● Concomitant neurovascular injury
● Concomitant compartment syndrome
● Polytrauma
● Multiple hand fractures
● Articular step-off >1 mm
METACARPAL SHAFT FRACTURES
Fractures of the metacarpal shaft may result from axial
load, torsional forces, or from three-point bending. In the
case of crush injuries involving multiple metacarpal frac-
tures, the surgeon should recognize signs of compartment
syndrome, such as excessive swelling, pain, and change in
neurovascular status. Clinical suspicion of compartment
syndrome warrants emergency operative release of the
compartments.
The majority of fractures of the metacarpal shaft are
treated conservatively. Reduction and fi xation are essential
Hand and Upper Extremity Reconstruction
62
if there is any rotational malalignment. Angulation
>10º for the index metacarpal shaft, 20º for the middle, 30º
for the ring, and 40º for the small metacarpal shaft is gener-
ally recognized as unacceptable and requires surgical
fi xation.
Indications for surgery
● Rotational deformity
● Index: >10º of dorsal angulation
● Middle: >20º dorsal angulation
● Ring: >30º of dorsal angulation
● Small: >40º of dorsal angulation
● Shortening >10 mm
Operative treatment
An attempted closed reduction is performed under fl uoro-
scopic guidance. Reduction can usually be obtained by lon-
gitudinal traction and manual manipulation at the fracture
site. Once reduced, fracture fi xation depends upon the
specifi c fracture pattern. If an acceptable closed reduction
cannot be achieved, then it is necessary to expose the frac-
ture site to remove any anatomic structures that may be
blocking reduction. Alternatively, the surgeon may choose
to proceed with open reduction and internal fi xation (ORIF)
in order to allow an earlier return to activities.
Collateral recess K-wires and transverse K-wires
Collateral recess pinning can be used for displaced frac-
tures of the midshaft or base of the metacarpal, for
carpometacarpal
(CMC)
dislocations,
or
for
CMC
fracture–dislocations.
The metacarpophalangeal (MCP) joint should be placed
in 90º of fl exion, and a 0.045 inch K-wire placed by hand
at the deepest portion of the collateral recess. Appropriate
positioning is confi rmed using fl uoroscopic imaging, and
the pin is power-driven retrogradely into the metacarpal
shaft, almost co-linear with its long axis (Fig. 5.1).
Once the tip of the wire is within the medullary canal,
the wire is driven past the fracture site and into subchon-
dral bone at the base of the metacarpal, or into the hamate
if the CMC joint is involved. We leave the K-wires outside
the skin in the web spaces for easy removal in the offi ce.
This procedure is repeated using a second 0.045 K-wire
in the opposite collateral recess, thereby obtaining stable
fi xation.
For transverse pinning, a K-wire is passed through the
fractured metacarpal into the adjacent, uninjured meta-
carpal. This technique essentially acts as internal traction,
keeping the fractured metacarpal out to length.
The fi rst step of this technique is to reduce the fracture
as described previously. The fracture is then stabilized by
passing two parallel 0.045 K-wires through the affected
metacarpal distal to the fracture site and perpendicular to the
long axis of the bone. Next, the K-wire is driven into the
adjacent, uninjured metacarpal shaft. A third parallel trans-
verse K-wire is passed through the two metacarpals proximal
to the fracture site for stable two-point fi xation (Fig. 5.2).
Although this technique is best suited for treating the
index and small metacarpals, as these ‘border’ metacarpals
are most easily accessible to transverse percutaneous
pinning, it is still reasonable to use this for middle or ring
metacarpals.
FIGURE 5.1 Diagram of collateral recess pinning.
FIGURE 5.2 Diagram of transverse pinning of a metacarpal fracture.
Metacarpal and Phalangeal Fractures
63
In the operating room, a sterile dressing is applied,
and an ulnar gutter splint is placed with the affected MCP
joints in 70º of fl exion. At the follow-up visit, the operative
dressing is removed and a custom splint is fabricated by the
hand therapist, mimicking the operative splint. At 3–4
weeks the pins are removed in the offi ce and the splint is
discontinued.
Operative reduction and internal
fi xation (ORIF)
Transverse or short oblique fractures of the metacarpal
midshaft are well treated with plating (Fig. 5.3). This mode
of fi xation is particularly attractive when there are multiple
metacarpal fractures, as rigid stability can be obtained to
permit early rehabilitation.
Using the dorsal approach as previously described, the
surgeon retracts the tendon and strips the periosteum just
enough to expose the fracture site (Fig. 5.4). A properly
sized plate, usually 2.0 or 2.4 mm, is then selected. The
screw diameter should not exceed one-third the diameter
of the bone. The appropriate number of screws on either
side of the fracture is yet to be determined, but we prefer
at least two screws proximally and two distally.
The plate is placed dorsally and reduced to the bone. In
short oblique fractures it is preferable to lag the fracture
through the plate. The remaining screws are then placed in
neutral mode.
For transverse fractures, the plate is fi xed to one fracture
fragment using two screws placed in neutral mode, and
then the fracture is compressed by placing screws in com-
pressive mode in the opposite fragment. The remaining
screws are then placed in neutral mode. It is essential to
place the screws perpendicular to the plate to prevent rota-
tion when tightening the screws.
Lag screws
Long oblique and spiral fractures of the metacarpal midshaft
may be fi xed using lag screws placed perpendicular to the
fracture line. Lag screws are most appropriate for fractures
with a length exceeding twice the diameter of the bone. At
least two lag screws should be used if the fracture is twice as
long as the diameter of the bone. Three lag screws should be
A
B
FIGURE 5.3 A Comminuted fracture of the middle metacarpal midshaft and ring metacarpal proximal shaft. B ORIF was performed using
dorsally placed T-plates.
Hand and Upper Extremity Reconstruction
64
used if the fracture is three times the diameter of the bone.
Three lag screws have 50% more strength than two. As with
compression plating, the screw diameter should not exceed
one-third the diameter of the bone.
With this technique the fracture is exposed as described,
and then reduced and clamped in place. Great care is taken
when over-drilling the gliding hole to prevent iatrogenic
fracture. A safe distance from the fracture edge – at least
one diameter of the drill bit – should be maintained when
drilling. For screws placed in an oblique orientation to the
cortex, countersinking will enhance surface contact of the
screw head while minimizing prominence of the head. This
latter point may be important to limit irritation of the
overlying extensor tendons and soft tissue.
Intramedullary nail
The use of locked intramedullary (IM) nails has been
described for open comminuted midshaft fractures of the
metacarpals.4 This implant requires placement of the nail
through the fracture site in antegrade and retrograde fashion,
and then locking of the nail proximally and distally using
a locking jig.
Locked IM nails are more practical for wounds that are
grossly open at the fracture site with bone loss, such as
gunshot wounds to the midshaft of the metacarpal. For
closed injuries, locked IM nails are impractical because of
the amount of soft tissue stripping necessary to obtain
exposure. In addition, the use of an outrigger to lock the
nails makes this implant more appropriate for use in the
index and small metacarpals, rather than the middle and
ring metacarpals.
Alternatively, pre-bent 0.045 K-wires may be inserted
through a drill hole in the proximal metacarpal and
passed antegrade across the reduced fracture. Two to
three such wires will provide stable fi xation with minimal
dissection.5,6
Postoperative care
A splint is worn for 4 weeks, and protected range of motion
exercises are initiated 3–5 days after surgery. K-wires should
be removed 3–4 weeks after surgery.
Extensor
tendon
Periosteum
Fracture
site
FIGURE 5.4 Exposure of metacarpal shaft fracture.
Clinical Pearls and Pitfalls
●
No rotational malalignment can be tolerated in the
metacarpals.
●
When using screws, the diameter of the screw should not
exceed one-third the diameter of the bone.
●
Two lag screws are appropriate for spiral fractures twice as
long as the diameter of the bone.
●
Three lag screws are appropriate for spiral fractures three
times as long as the diameter of the bone.
●
Three lag screws enhance fi xation strength by 50%.
●
Countersinking the screw head enhances its contact with
bone while diminishing the prominence of the hardware.
●
Multiple 0.045 K-wires may be passed antegrade through a
proximal drill hole.
METACARPAL BASE FRACTURES
Metacarpal base fractures are commonly the result of
loading along the long axis of the bone and may present in
combination with CMC dislocation. Usually the small
metacarpal and the adjacent ring metacarpal are involved.
Dislocations may be diffi cult to assess on plain X-rays
owing to overlapping of the metacarpals, particularly on the
lateral projection. If this is the case, the oblique view may
help delineate fracture patterns and provide more of a true
lateral view of the ulnar two metacarpals. A true anteropos-
terior (AP) view of the ring and small metacarpal may be
obtained by taking the image with the hand pronated 30º
from the fully supinated position. If the X-ray technician is
not familiar with this view, simply order a ‘supination
oblique’ radiograph. If the radiographic picture remains
Metacarpal and Phalangeal Fractures
65
obscured, a CT scan will help clarify the distorted anatomy
at the CMC joint. The hamate should be inspected care-
fully to ensure that there is not a shear fracture of the distal
portion involving the CMC joint.
Isolated extra-articular fractures at the base of the meta-
carpal that are minimally displaced are usually treated suc-
cessfully by non-operative means in a well-molded short
arm cast or custom splint. The MCP joint should be in
70–90º of fl exion, and the remaining joints of the fi nger
may be left free.
Operative treatment
Exposure of the CMC joint is through a dorsal longitudinal
incision directly over the fracture site, as described for shaft
fractures of the metacarpals. It is usually necessary to incise
the CMC joint capsule in line with the skin incision to fully
expose the fracture, particularly if the fracture is intra-
articular. After exposure, the fracture site should be
inspected and cleansed of debris (Fig. 5.5) This is also a
good time to examine the articular portion of the hamate.
Displaced articular fractures of the hamate should be
reduced and fi xed with lag screws, if possible.
Many of the techniques described for treatment of meta-
carpal shaft fractures also apply to fractures of the metacar-
pal base.
Lag screws
Long oblique fractures of the base of the metacarpal may
be fi xed using two, or preferably three, lag screws placed
from the dorsum. Care should be taken to place the screws
perpendicular to the fracture and to ensure that they remain
extra-articular. Some authors advocate plating for border
metacarpals, but the authors do not feel that this is essen-
tial if stable fi xation is obtained.
Postoperatively, the patient is placed in an ulnar gutter
splint in the safe position, and early protected range of
motion is initiated. The splint is discontinued at 3–4
weeks.
Transverse K-wire pinning
In the presence of a small fi nger CMC dislocation, percu-
taneous oblique K-wires can be placed without violating the
MCP joint capsule. One pin is placed from the ulnar border
of the hand across the small fi nger metacarpal base into the
hamate, and a second K-wire is placed from the small into
the ring fi nger metacarpal. The technique is also possible
with a ring fi nger CMC dislocation, but is technically more
diffi cult (Fig. 5.6).
After confi rming fracture reduction fl uoroscopically, the
pins are cut below the skin in anticipation for removal in
the offi ce. A protective splint is applied in the intrinsic-plus
position and discontinued when the pins are removed four
weeks after surgery.
Extensor
carpi ulnaris
Hamate
Extensor digitorum
Joint capsule
FIGURE 5.5 Exposure of metacarpal base fractures.
FIGURE 5.6 A fracture at the base of the small metacarpal treated
with two K-wires into the adjacent metacarpal, and two K-wires into
the hamate.
Hand and Upper Extremity Reconstruction
66
Collateral recess pinning
Many of the principles that apply to fi xing metacarpal shaft
fractures also apply to fi xing fractures of the base.
When treating the small fi nger, collateral recess K-wires
driven from the ulnar collateral recess of the MCP joint
may be driven across the CMC joint into the hamate, if
necessary. However, because of the anatomy of the small
CMC joint, collateral recess pins originating from the radial
collateral recess are likely to miss the hamate. Thus, for
extra-articular fractures of the small metacarpal, it is best
to drive the K-wire originating from the radial collateral
recess no further than subchondral bone at the base of the
metacarpal (Fig. 5.7).
CMC fractures or fracture–dislocations of the small
fi nger may be treated with a single collateral recess K-wire
originating in the ulnar collateral recess, or with an addi-
tional transverse K-wire from the small metacarpal to the
ring metacarpal.
In the operating room a sterile dressing is applied, and
an ulnar gutter splint is placed with the affected MCP joints
in 70º of fl exion. At the follow-up visit the operative dress-
ing is removed, and a custom splint is fabricated by the
hand therapist, mimicking the operative splint. At 3–4
weeks the pins are removed in the offi ce and the splint is
discontinued.
A
B
FIGURE 5.7 A CMC fracture–dislocations of the ring and small
fi ngers. B The injury is reduced anatomically with collateral recess
pinning.
Clinical Pearls and Pitfalls
●
An adequate reduction must be confi rmed before
attempting fi xation. For CMC dislocations of the ring or
small fi nger, a ‘supination oblique’ x-ray view is essential.
●
Transverse K-wires using two pins distal to the fracture site
and one pin proximal to the fracture site, extending from
the injured fi nger into the uninjured metacarpal, are
appropriate for extra-articular fractures. For dislocations of
the CMC joint, pinning from the small fi nger into the
hamate and small to ring fi ngers is appropriate.
●
Collateral recess K-wires originating from the radial
collateral gutter of the MCP joint in the small fi nger may be
diffi cult to drive into the body of the hamate, and should
be used cautiously with CMC fractures of the small fi nger.
METACARPAL NECK FRACTURES
Like other fractures in the hand, most metacarpal neck
fractures are treated non-operatively. Any rotational defor-
mity is unacceptable and requires correction of the defor-
mity by closed or open reduction. Fractures of the index
and middle metacarpal necks are generally treated with
splinting or casting if the dorsal fracture angulation does
not exceed 15º. Similarly, conservative management is sug-
gested for ring metacarpal neck fractures where dorsal-apex
angulation is <30–40º. Small metacarpal fractures may be
treated closed if the dorsal–apex angulation is <50–60º.
The Jahss maneuver is used to reduce excessively dor-
sally angulated fractures. (Jahss’ treatment is hinged upon
the notion that MCP fl exion to 90º relaxed the deforming
intrinsic muscles and simultaneously tightened the collat-
eral ligaments, allowing for control of the distal metacarpal
fragment. The Jahss maneuver involves fl exion of the distal
interphalangeal, proximal interphalangeal, and metacarpo-
phalangeal joints, followed by dorsally directed pressure
over the fl exed PIP while applying a volar directed force
over the apex of the fracture. This maneuver delivers the
three-point fi xation needed for fracture immobilization and
ensures reduction with angulatory and rotary correction.)
Under adequate anesthesia, the MCP joint is fl exed 90º,
thereby relaxing the intrinsic tendons while tightening the
Metacarpal and Phalangeal Fractures
67
collateral ligaments. A dorsally directed force is then applied
to the proximal phalanx to reduce the fracture. In Jahss’
description, the hand was splinted with the MCP and PIP
joint maximally fl exed in order to maintain reduction.
Today, if acceptable reduction cannot be maintained after
performing the Jahss maneuver, then operative fi xation is
indicated to avoid prolonged immobilization of the MCP
and PIP joints in extreme fl exion.
One special consideration in treating metacarpal neck
fractures is that of the open injury. Because many of these
fractures are sustained in altercations, it is important to
thoroughly examine concomitant lacerations over the meta-
carpal head. ‘Fight bites’ should be thoroughly debrided in
the operating room and the patient should be treated with
appropriate antibiotic coverage. Extensor tendon compe-
tency should be documented to evaluate the likelihood of
joint penetration by the teeth.
Operative indications
● Rotational deformity
● Index and middle metacarpal: >15º of apex dorsal
angulation
● Ring metacarpal: >30–40º of apex dorsal angulation
● Small metacarpal: >50–60º of apex dorsal angulation
Operative treatment
The operative approach to the metacarpal neck is usually
through a dorsal approach, as previously described. The use
of the Jahss maneuver renders open treatment unnecessary
in most metacarpal neck fractures, with the exception of
subacute or chronic fractures that have substantial callus
formation.
Transverse K-wire fi xation
A similar technique previously described is used. Be wary
of translation of the fractured metacarpal head when driving
the K-wires. One outcome study showed acceptable out-
comes of transverse K-wire fi xation of small metacarpal
neck fractures7 (Fig. 5.8).
Crossed K-wire fi xation
After fracture reduction, a K-wire may be placed on either
side of the head of the fractured metacarpal. Use imaging
to ensure that the pins are placed on the lateral non-
articular facets of the bone rather than in articular cartilage.
The K-wires are then advanced proximally in an oblique
fashion across the fracture and into the cortex of the meta-
carpal. To increase torsional stability, do not cross the K-
wires at the fracture site.
Bouquet pinning
Bouquet pinning encompasses the use of multiple K-wires
passed antegradely through a cortical window in the meta-
carpal base. These wires are driven across the reduced frac-
ture into the metaphyseal bone in the distal metacarpal,
thereby stabilizing the fracture.8 This technique is most
amenable to the index and small metacarpals.
The skin is incised on the ulnar border of the small
metacarpal. Take care to protect branches of the dorsal
ulnar sensory cutaneous nerve. The extensor carpi ulnaris
insertion may be incised longitudinally, and the cortex is
perforated using a power drill oriented nearly in line with
the long axis of the metacarpal.
Prior to intramedullary insertion, the K-wires must be
prepared by cutting off the sharp tip: a 30º bend in the wire
is made about 5 mm proximal to its distal tip. Removal of
the sharp tip and the 30º bend will help prevent perforation
of the radial metacarpal cortex.
The pins are then inserted through the proximal cortical
hole, advanced antegradely across the reduced fracture, and
passed into the cancellous bone of the distal metaphysis
(Fig. 5.9). The pins are then cut short, and the skin is
closed. This technique is technically more challenging than
other forms of pinning described.
Open reduction with internal fi xation
The small size of the distal fragment makes it diffi cult to
place more than one fi xation screw. If adequate purchase
can be obtained in the distal fragment, a dorsal plate will
provide stable fi xation and permit early rehabilitation.
Concern about extensor tendon adhesions is always present,
but early movement should reduce the incidence.
FIGURE 5.8 Metacarpal neck fracture treated with transverse K-wires.
Hand and Upper Extremity Reconstruction
68
A lateral plate must be positioned over the collateral
ligaments, which will limit motion at the MCP joint. For
these reasons, we discourage the use of lateral plates for
metacarpal neck fractures. The authors prefer to use a uni-
condylar plate in the rare instances when plate fi xation is
required.
Postoperative care
Postoperatively the patient is placed in a splint with the
MCP joints in 70º of fl exion. The splint is worn for 3–4
weeks with daily range of motion exercises of the hand to
limit stiffness. K-wires should be removed 3–4 weeks after
the surgery.
FRACTURES OF THE METACARPAL HEAD
Metacarpal head fractures are usually the result of clenched-
fi st trauma. As with metacarpal neck fractures, open inju-
ries sustained in an altercation necessitate examination of
the extensor mechanism and a thorough irrigation and
debridement of the joint.
Radiographic assessment includes the standard AP,
lateral, and oblique views. Additionally, a Brewerton view
(dorsal metacarpals fl at on X-ray plate, MCP joint fl exed
65º, X-ray beam angled 15º radially) can help to delineate
fracture patterns.
Operative management
Management of fractures should be tailored to the individ-
ual patient, but displaced fractures are indicated for surgical
fi xation. Varus and valgus competency should be assessed
in fracture lines that extend proximally because the frag-
ment may include the collateral ligament origin.
As with other metacarpal fractures the surgical approach
consists of a dorsal incision, and then midline division of the
extensor tendon to gain access to the MCP joint. The synovium
and capsule should be dissected off of the bony fragments just
enough to provide adequate visualization without compromis-
ing vascularity to the fracture fragments.
Our preference for fi xation is headless bone screws.
Countersunk conventional mini-screws can also be used.9
We do not perform percutaneous K-wire fi xation through
the articular cartilage.
Operative indications
● Open fractures – ‘fi ght bites’
● Joint incongruity
● Collateral ligament avulsion fractures displaced more
than 2 mm
Headless bone screws
Headless bone screws are ideal for intra-articular fractures
because stable fi xation can be achieved while minimizing
damage to the articular surfaces. Several brands are avail-
able. A headless screw with variable pitch will create com-
pression at the fracture site and increase stability.
If a headless compression screw is not available, a con-
ventional mini-screw can be used. Countersinking the
screw head well beneath the articular surface will protect
the cartilage. The head of the screw should be placed in a
non-articular area.
Early range of motion exercises are initiated, and the
splint is discontinued 3–4 weeks after surgery.
Extensor
carpi ulnaris
Extensor
digitorum
K wire
Curved
blunt tip
FIGURE 5.9 Bouquet pinning diagram.
Clinical Pearls and Pitfalls
●
Make sure that K-wires cross each other proximal to the
fracture.
●
When using transverse K-wire fi xation, beware of lateral
translation of the fractured metacarpal head when placing
the pins.
●
Unicondylar plates are preferred in the rare instances
where plate fi xation is required.
Clinical Pearls and Pitfalls
●
The Brewerton X-ray view may help delineate fracture
patterns.
●
Take care to avoid devitalizing articular fracture fragments.
●
Headless compression screws are ideal for fi xation.
Metacarpal and Phalangeal Fractures
69
PHALANGEAL FRACTURES
Numerous fracture patterns of the phalanges have been
described. For the sake of brevity, we have chosen only to
discuss the treatment of common injuries, or of unique,
complex injuries. Many of the fi xation principles described
for the treatment of metacarpal fractures also apply for the
phalanges, and the section on metacarpal fractures will be
referenced when appropriate.
Operative approach
Operative treatment of phalangeal fractures is performed
with the patient in the supine position using a hand table.
Local, regional, or general anesthesia is appropriate.
The incisions and approaches may be placed straight
dorsal, dorsolateral, or mid-axial, depending on the fracture
location and characteristics.
Operative indications
● Open fracture
● Concomitant neurovascular injury requiring repair
● Malrotation
● Intra-articular displaced fracture
● Unstable fracture
● >10º of angulation
● <50% bony apposition
● Multiple fi nger or hand fractures
PHALANGEAL SHAFT FRACTURE
Minimally displaced fractures of the phalangeal shaft may
be treated conservatively with splinting in the safe position
for 1–3 weeks, and then with buddy taping until clinically
healed. Careful lateral X-rays are required, as proximal pha-
langeal fractures may be missed owing to inadequate radio-
graphic visualization.
Because of the pull of extrinsic tendons, many phalan-
geal fractures have a tendency to displace apex volar. Dis-
placed proximal phalangeal fractures are more functionally
limiting owing to the inherent loss of PIP motion. Dis-
placed middle phalangeal fractures cause more cosmetic
deformity because most are distal to the superfi cialis inser-
tion, so that PIP motion is preserved.
Fractures in the proximal third to quarter of the middle
phalanx will usually have apex dorsal angulation because
of proximal force by the central slip on the dorsal proximal
fragment. Fractures of the distal third of the middle phalanx
will result in apex volar angulation as a result of proxi-
mal pull of the volarly inserting FDS (fl exor digitorum
superfi cialis).
Operative approach
Either a dorsolateral or a mid-axial skin incision can be
used to expose the proximal phalanx (Figs 5.10, 5.11). The
authors prefer a mid-axial incision when possible because
it minimizes disturbance of the extensor mechanism, and
we feel it provides a better postoperative range of movement
(Fig. 5.12). A lateral incision is diffi cult to use for intra-
articular fractures of the PIP joint, or fracture of the base
of the proximal phalanx extending into the metacarpopha-
langeal joint. After incision, the neurovascular bundles are
identifi ed and protected. Care should be taken to protect
the dorsal branch of the digital nerve. The transverse reti-
nacular fi bers are divided, exposing the lateral aspect of the
phalanx.
With a dorsolateral incision, a curvilinear incision on
the dorsolateral border of the digit is used to minimize
scarring across the extension creases over joints. The inci-
sion begins just proximal to the MCP joint and extends just
distally to the PIP joint. The skin fl ap is then retracted,
allowing access to the phalanx by a dorsal or lateral approach.
The extensor tendon is incised along its midline, exposing
the underlying fracture.
If the lateral approach is used, the confl uence of the
sagittal fi bers with the central extensor tendon is identifi ed
and sharply divided, exposing the underlying phalanx. This
approach allows access to both the dorsal and the lateral
aspects of the bone. The sagittal fi bers can be excised with
impunity, and this step may limit scarring over laterally
placed hardware. If the fracture extends to the neck of the
phalanx, the plane between the central extensor tendon and
the lateral bands should be developed to provide access to
the phalangeal head and neck.
K-wire fi xation
K-wires can be used in a variety of ways to fi x phalangeal
fractures. For long oblique fractures, several K-wires can be
placed perpendicular to the fracture line, similar to lag
screws.
Short oblique and transverse fractures are treated with
crossed K-wires, ensuring that the wires do not cross at the
fracture line (Fig. 5.13). Crossed K-wires provide the most
resistance to torsion and distraction.10 If crossed K-wires
are used in conjunction with an open approach, then the
wires may be passed antegradely, starting at the fracture
site. The fracture is then reduced, and the pins are driven
retrogradely across the fracture into the proximal bone
fragment.
Alternatively, fractures of the proximal phalanx can be
treated by fl exing the MCP joint, and then driving K-wires
antegradely through the metacarpal head and MCP joint
into the shaft of the proximal phalanx.11 It is essential that
the protruding pins are away from the PIP joint.
Open reduction with internal fi xation
Open reduction with internal fi xation (ORIF) is indicated
if appropriate reduction cannot be obtained by K-wire fi xa-
tion or in the case of multiple fractures in the hand. Reports
of the use of ORIF have indicated excellent results.12
Because of the small size of phalangeal fracture frag-
ments, a fi xed-angle device may be advantageous to increase
purchase and overall construct stability. This is especially
useful for very distal or proximal fractures where it is diffi -
cult to place two screws on either side of the fracture. The
mini-condylar blade plate is applied by drilling a hole in the
cortex of the smaller fracture fragment and then inserting
the fi xed-angle spike of the plate. The plate is then fi xed to
bone using conventional screws (Fig. 5.14).
Hand and Upper Extremity Reconstruction
70
A
B
C
FIGURE 5.10 A Curvilinear line depicting incision used for
approaching the proximal phalanx. B The skin incised, underlying
extensor mechanism exposed. C Straight dorsal incision through the
central slip, exposing the phalanx.
A
B
FIGURE 5.11 A Dorsolateral approach to the proximal phalanx, exposing the sagittal bands. B The sagittal bands are outlined by the blue line.
Metacarpal and Phalangeal Fractures
71
Extensor tendon
incised along midline
A
B
Dorsal extensor tendon
Lateral band
Transverse retinacular fibers divided
FIGURE 5.12 Lateral and dorsal exposure of proximal phalangeal
fractures.
FIGURE 5.13 Crossed K-wires fi xing a short oblique fracture of the
midshaft of the middle phalanx. Note that the K-wires cross each
other distal to the fracture.
A
B
FIGURE 5.14 A Comminuted fractures of the index and ring proximal phalanges. B The alignment has been corrected with unicondylar blade
plates.
Hand and Upper Extremity Reconstruction
72
If the size of the fracture fragments permits, a mini T-
plate or a simple straight plate may be used. Compression
can be used for transverse and short oblique fractures if
desired, but is usually not necessary.
Lag screws
Long oblique fractures of the phalanges can be fi xed with
two or three lag screws (Fig. 5.15). The same principles are
applied as described for fi xing long oblique metacarpal
fractures.
Postoperative care
Postoperatively the patient is placed in a splint in the
intrinsic-plus position. The splint is worn for 3–4 weeks,
with daily range of motion exercises of the hand to limit
stiffness. K-wires should be removed 3–4 weeks after the
surgery.
there is a longitudinal directed force. Any fracture that is
displaced >1 mm is indicated for open reduction and inter-
nal fi xation. The patient will present with swelling, pain,
and limited motion in the PIP joint. It is imperative that
true AP and lateral X-rays are obtained to confi rm the
diagnosis.
Operative exposure
A dorsal curvilinear incision is made over the joint. The
interval between the central slip and the lateral band is
made (Fig. 5.16) and the capsule incised and the hematoma
removed. The collateral ligament attachment to the condyle
must be preserved to prevent avascular changes to the
condyle. If only one condyle is fractured, the fracture is
reduced to the intact portion and held in place with a K-
wire. Fixation is obtained with preferably two lag screws
across the fracture site (Fig. 5.17). The screws are usually
1.5 mm, and one of these must be put through the collat-
eral ligament attachment. Occasionally there is insuffi cient
room for two screws, and one screw and a K-wire are placed.
If both condyles are fractured, then a unicondylar plate
should be placed laterally after temporary fi xation. Dorsal
T-plates will be insuffi ciently stable to begin active move-
ment and can lead to more stiffness.
PIP fracture–dislocation
Fracture–dislocation at the PIP joint is one of the most dif-
fi cult treatment entities in hand surgery. This injury usually
occurs with the PIP joint in some degree of hyperextension,
followed by axial loading, such as in ball-handling sports.
Longitudinally directed forces contribute to the volar lip
shear–fracture component that is frequently seen.
A
B
FIGURE 5.15 A A long oblique fracture of the proximal phalanx. The fracture length is approximately twice the diameter of the bone. B Two lag
screws were placed perpendicular to the fracture.
Clinical Pearls and Pitfalls
●
Blade plates are preferred over simple compression plates
to enhance bony purchase, particularly with small
fragments.
●
Lag screws are optimal for spiral fractures.
●
Avoid placing the pins in the vicinity of the PIP joint.
INTRA-ARTICULAR PROXIMAL PHALANGEAL
HEAD FRACTURES
Fractures of the intra-articular portion of the proximal
phalanx typically involve one or both condyles. Typically
Metacarpal and Phalangeal Fractures
73
PIP fracture–dislocations are classifi ed as stable or
unstable. The major distinguishing feature between these
two types of injury pattern is the presence or absence of
intact collateral ligaments.
In stable fracture–dislocations, the collateral ligament
insertions remain intact. The fracture pattern through the
volar lip of the base of the middle phalanx does not disrupt
the insertion of the collateral ligaments. In addition, the
fracture does not exceed 40% of the volar articular
surface.
Unstable fracture dislocations involve fractures through
more than 40% of the volar articular arc, or when there
is disruption of the collateral ligaments. The collateral
ligament insertion remains attached to the volar fracture
fragment of the middle phalanx, and the remainder of the
phalanx dislocates dorsally. Successful closed reduction of
this injury pattern is unlikely. It is often diffi cult to see
subtle subluxation of the joint after these injuries. ‘True’
lateral radiographs are mandatory! The ‘V sign’ is seen with
subluxation of the joint. Do not be fooled into thinking that
just because the fracture of the base of the middle phalanx
involves less than 40% of the articular surface, the joint is
stable (Fig. 5.18).
Dorsal blocking splint
Stable PIP fracture–dislocations can be treated with closed
reduction followed by the application of a dorsal blocking
splint. The PIP joint is inherently more stable in fl exion,
Central slip
B
A
D
C
Lateral band
eriw
-
K
tn
e
m
a
gil laretallo
C
FIGURE 5.16 Dorsal exposure of the PIP joint between the lateral band and central slip.
Hand and Upper Extremity Reconstruction
74
and the joint should be splinted in the degree of fl exion that
prevents subluxation.
After 3 weeks, we recommend discontinuation of the
splint, with initiation of range of motion exercises to prevent
stiffness.
External fi xation
An unstable injury with a comminuted volar lip can be
treated using external fi xation (Fig. 5.19). This method
employs ligamentotaxis to apply traction to the soft tissue
envelope, thereby indirectly reducing the fragments. Gener-
ally the authors prefer indirect means of reduction through
external fi xation, rather than proceeding with open reduc-
tion and internal fi xation.
Several dynamic external fi xators have been described.
Variations include outrigger splints,13 intraoperatively fab-
ricated devices using K-wires and rubber bands, and com-
mercially available constructs. The key to dynamic external
fi xation is that the center of rotation is at the isometric
FIGURE 5.17 Three screws across a unicondylar fracture of the
proximal phalanx.
FIGURE 5.18 A PIP fracture–dislocation, demonstrating the dorsal ‘V’
sign.
FIGURE 5.19 A commercially available external fi xator.
Metacarpal and Phalangeal Fractures
75
point on the head of the proximal phalanx and the joint is
reduced anatomically. Agee14 has described a force coupling
device most useful for fracture dislocations in which at
least 50% of the dorsal portion of the middle phalanx is
intact. It is beyond the scope of this chapter to review the
technique.
Dynamic longitudinal traction is most useful to treat
comminuted fractures of the base of the middle phalanx.
Schenck13 described this useful technique. Finally, there are
commercially available external fi xators that can stabilize
the joint in a reduced position and/or provide longitudinal
traction. External fi xation allows immediate range of motion
at the PIP joint. These frames require signifi cant expertise
to apply, but can be quite useful.
External fi xators are generally left in place for 4–6 weeks,
during which time active range of movement exercise is
allowed. Usually, the patient requires the services of a certi-
fi ed hand therapist to aid in ranging motion.
Open reduction with internal fi xation
Unstable fractures with a single, large fracture fragment
may be amenable to ORIF.15 A volar approach using a
Bruner incision is made over the PIP joint, and the joint is
then exposed through the interval between A2 and A4
pulleys in the fl exor sheath. The profundus tendon is
retracted laterally while the superfi cialis is split longitudi-
nally, and the volar plate is usually still attached to the
volar fragment from the base of the middle phalanx. An
indirect reduction of the joint is performed (Fig. 5.20).
The accessory collateral ligaments are incised sharply
and the joint is ‘shotgunned’ open. The fracture is reduced
and temporarily fi xed in its proper position using K-wires.
The wires are then exchanged for screws, taking care to
ensure that the screws do not interfere with either fl exor or
extensor tendon excursion.
If fracture reduction is not feasible, then volar plate
arthroplasty or hemihamate reconstruction remain viable
alternatives with this approach.
Volar plate arthroplasty
The same approach as described for ORIF is used for volar
plate arthroplasty (VPA). In the ‘shotgunned’ position
the fracture fragments and non-viable bone are removed
from the volar lip of the proximal phalanx to create a defect
that can accommodate the thickness of the volar plate
(Fig. 5.21).16
A running suture is then placed in the volar plate, start-
ing at the distal lateral margin. The stitch is advanced
proximally along the lateral edge of the volar plate, crossed
over the proximal edge of the volar plate to the contralateral
edge, and then advanced distally. Many authors prefer an
absorbable suture to prevent diffi culty with the suture
postoperatively.
Drill holes are then made starting in the dorsal edge of
fracture line on the base of the middle phalanx and directed
dorsally. The two ends of the suture, from either side of the
volar plate, are passed through the drill holes and tied dor-
sally over a padded button with the PIP joint in extension.
Alternatively, mini bone anchors can be used to sew the
volar plate into place. The volar plate should now cover the
articular surface of the proximal phalanx. Some authors
advocate bone grafting ‘behind’ volar to the volar plate, but
the authors feel this is not necessary. Finally, a 0.045 K-
wire is used to transfi x the joint in about 20º of fl exion for
2 weeks, at which time range of motion exercises can be
initiated. The pullout suture and button are removed 4
weeks postoperatively.
Hemihamate arthroplasty
When there is insuffi cient bone stock to support VPA, a
hemihamate arthroplasty is an alternative salvage proce-
dure.17 The same ‘shotgun’ approach is used for ORIF and
VPA. A trough at the volar base of the middle phalanx is
prepared to receive the hemihamate autograft (Fig. 5.22).
This is obtained through a dorsal incision on the affected
hand centered over the fourth and fi fth CMC joints. The
graft incorporates the dorsal 50% of the hamate, and extends
radially and ulnarly such that it includes 50% of the articu-
lar width of the fourth and fi fth CMC joints, respectively.
The graft is then trimmed so that it fi ts into the phalangeal
defect, replicating the native articular surface, and secured
in place using two or three mini-screws. The volar plate is
repaired to its distal insertion.
The fi nger is splinted for 3–5 days, and then early active
motion is initiated.
A
B
FIGURE 5.20 ORIF of volar plate avulsion fracture. A Shotgunned
open with fracture exposed. B Fixation of fracture with two screws.
FIGURE 5.21 ‘Shotgun exposure’ for volar plate arthroplasty. A The
joint is shotgunned open. B Volar plate is interposed into fracture.
C Lateral radiograph with joint reduced.
Hand and Upper Extremity Reconstruction
76
FIGURE 5.22 A PIP fracture of the volar lip. B The joint is
‘shotgunned’ open and the hamate graft fi xed to the volar lip of the
middle phalanx with two lag screws. Note that the middle phalanx is
toward the bottom of the picture. C Lateral radiograph of
hemihamate autograft in place.
A
B
C
Metacarpal and Phalangeal Fractures
77
COMPLICATIONS
Scar formation is a potential complication with injuries to the
hand. Extensive scarring can occur in the skin, the tendons,
or the joint capsule. The goal of early range of movement
protocols is to limit the degree of scarring and preserve
motion. Aggressive therapy, such as tendon gliding, scar
mobilization and joint mobilization are essential to preserve
motion. Scars that are unresponsive to therapy may be indi-
cated for surgical release of the skin, tendon, or joint.
Malunion is most common with fractures treated non-
operatively. Shortening, angulation, and malrotation are
possible. The presence of scissoring as the patient makes a
fi st is consistent with malrotation. One cadaveric study
found that metacarpal shortening is related to loss of power,
with 10 mm of shortening corresponding to 45% loss of
power.18 Symptomatic malunions should be corrected by
osteotomy.19
Non-unions of the hand are rare, with a reported inci-
dence of <1%.20 Patients with a non-union usually have
open injuries with extensive soft tissue stripping and are
smokers. Hypertrophic non-unions should be treated with
rigid fi xation. Atrophic non-unions require curettage of
fi brous material at the fracture, followed by bone graft and
rigid fi xation (Fig. 5.23).
CONCLUSION
The majority of fractures in the hand can be managed
conservatively. Fractures that require surgery can be treated
successfully using a variety of techniques. It is essential that
the surgeon be adept with multiple operative techniques for
a particular injury in order to tailor treatment to the
patient’s specifi c needs.
REFERENCES
1. Feehan LM, Sheps SB. Incidence and demographics of hand
fractures in British Columbia, Canada: a population-based study.
J Hand Surg [Am] 2006; 31: 1068–1074.
2. Kawamura K, Chung KC. Fixation choices for closed simple
unstable oblique phalangeal and metacarpal fractures. Hand Clin
2006; 22: 287–295.
3. Kurzen P, Fusetti C, et al. Complications after plate fi xation of
phalangeal fractures. J Trauma 2006; 60: 841–843.
4. Downing ND, David TR. Locked intramedullary nailing of
metacarpal fractures secondary to gunshot wounds. J Hand Surg
[Am] 2006; 31: 1083–1087.
5. Gonzalez MH, Hall RF Jr. Intramedullary fi xation of metacarpal
and proximal phalangeal fractures of the hand. Clin Orthop 1996;
327: 47–54.
6. Orbay J. Intramedullary nailing of metacarpal shaft fractures. Tech
Hand Up Extrem Surg 2005; 9: 69–73.
7. Wong TC, Ip FK, Yeung SH. Comparison between percutaneous
transverse fi xation and intrameduallary K-wires in treating closed
fractures of the metacarpal neck of the little fi nger. J Hand Surg
[Br] 2006; 31: 61–65.
8. Foucher G. Bouquet osteosynthesis in metacarpal neck fractures:
a series of 66 patients. J Hand Surg [Am] 1995; 20: S86–S90.
9. Weiss AC, Hastings H. Distal unicondylar fractures of the
proximal phalanx. J Hand Surg [Am] 1993; 18: 594–599.
10. Viegas SF, Ferren EL, Self J, Tencer AF. Comparative mechanical
properties of various Kirschner wire confi gurations in transverse
FIGURE 5.23 Non-union of a middle phalanx that had been fi xed
using interosseous wires.
Clinical Pearls and Pitfalls
●
PIP fracture–dislocations are classifi ed as stable or unstable,
depending on the amount of collateral ligament attached
to the fracture.
●
It is crucial that a true lateral radiograph be obtained to
confi rm a concentric reduction of the joint.
●
Stable injuries can be treated closed with a dorsal blocking
splint.
●
Unstable injuries are indicated for operative fi xation.
●
External fi xation is usually the fi rst choice of treatment.
●
Single, large fracture fragments are amenable to ORIF.
●
Irreparable fractures of the volar lip of the middle phalanx
are well treated with VPA or hemihamate arthroplasty.
and oblique phalangeal fractures. J Hand Surg [Am] 1988; 13:
246–253.
11. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal
fi xation of proximal phalangeal fractures. J Hand Surg [Am] 1984;
9: 725–729.
12. Dabezies EJ, Schutte JP. Fixation of metacarpal and phalangeal
fractures with miniature plates and screws. J Hand Surg [Am]
1986; 11: 283–288.
13. Schenck RR. Dynamic traction and early passive movement for
fractures of the proximal interphalangeal joint. J Hand Surg [Am]
1986; 11: 850–858.
14. Agee JM. Unstable fracture dislocations of the proximal
interphalangeal joint. Treatment with the force couple splint.
Clin Orthop Relat Res 1987; 214: 101–112.
15. Hamilton SC, Stern PJ, et al. Mini-screw fi xation for the treatment
of proximal interphalangeal joint dorsal fracture–dislocations.
J Hand Surg 2006; 3: 1349–1354.
16. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal
interphalangeal joint: a review of ten years’ experience. J Hand
Surg [Am] 1980; 15: 260–268.
17. Williams RM, Kiefhaber TR, et al. Treatment of unstable dorsal
proximal interphalangeal frature/dislocations using a hemi-hamate
autograft. J Hand Surg [Am] 2003; 28: 856–865.
18. Meunier MJ, Hentzen E, et al. Predicted effects of metacarpal
shortening on interosseous muscle function. J Hand Surg [Am]
2004; 29: 689–693.
19. Gross MS, Gelberman RH. Metacarpal rotational osteotomy.
J Hand Surg [Am] 1985; 10: 105–108.
20. Jupiter JB, Koniuch MP, Smith RJ. The management of delayed
union and nonunion of the metacarpals and phalanges. J Hand
Surg [Am] 1985; 10: 457–466.
Hand and Upper Extremity Reconstruction
78
79
C H A P T E R
C6
Thumb Ulnar Collateral Ligament
Repair Techniques
Robert M. Greenleaf and Thomas B. Hughes
INTRODUCTION
Ligamentous injuries are some of the most common inju-
ries to the hand, ranging from simple sprains to complete
rupture. The purpose of this chapter is to describe the treat-
ment algorithms and surgical techniques for such injuries.
The treatment of these conditions is frequently more com-
plicated because they are associated with high-stress activ-
ities and a greater probability of developing arthritis.
Surgery
is
frequently
unnecessary
for
ligament
injuries. Although collateral ligament injuries to the proxi-
mal interphalangeal (PIP) joints and distal interphalangeal
(DIP) joints are frequent, the overwhelming majority can
be managed non-operatively. This chapter will focus on
ligament repair techniques that are commonly encountered
in the routine treatment of hand pathology, specifi cally
ulnar collateral ligament (UCL) injuries of the thumb (acute
and chronic), volar oblique ligament attrition of the thumb
carpometacarpal (CMC) joint, and collateral ligament
entrapment at the metacarpophalangeal (MCP) joints.
This chapter is not an exhaustive review of all hand
ligament injuries; instead, a comprehensive diagnostic and
evaluation scheme will be presented, as well as detailed
descriptions of the surgical treatment options available for
the more common conditions encountered.
ULNAR COLLATERAL LIGAMENT:
ACUTE INJURY
Ulnar collateral ligament injury to the thumb represents
one of the most common surgically treated ligament inju-
ries encountered by hand surgeons. In 1955 Campbell1
described the ‘gamekeeper’s thumb’, referring to chronic
laxity of the UCL seen in Scottish gamekeepers who con-
stantly stress the UCL by snapping the neck of small game.
This pathologic process must be differentiated from acute
injuries. Gerber et al.2 popularized the term ‘skier’s thumb’
to refer to acute thumb UCL injuries seen in skiing acci-
dents in which a radially directed force (abduction) is placed
on the thumb MCP joint, causing acute rupture of the
UCL.1 In one series, thumb UCL injuries represented 7%
of all skiing injuries and 33% of upper extremity skiing
injuries.3
The MCP joint of the thumb has little intrinsic bony
stability and therefore relies on capsular, ligamentous, and
musculotendinous structures for support. Static restraints
of the MCP joint include the proper collateral ligament, the
accessory collateral ligament, the volar plate, and the dorsal
capsule (Fig. 6.1). The proper ligament originates on the
lateral condyle of the metacarpal and travels obliquely to
insert on the volar third of the proximal phalanx. The
proper collateral ligament is taut in fl exion and provides
stability against both radial and volar subluxation of the
proximal phalanx. The dorsal capsule is also taut but adds
little stability. The relatively weaker accessory collateral
ligament, which travels from a more volar site on the lateral
metacarpal head and inserts on the volar plate and sesa-
moids, is tight in extension and in this position provides
stability against valgus stress.
The dynamic stabilizers of the thumb include the thumb
extrinsic muscles (extensor pollicis longus, extensor pollicis
brevis, and fl exor pollicis longus) and intrinsic muscles
(abductor pollicis brevis, fl exor pollicis brevis, and adductor
pollicis.) The adductor aponeurosis, which inserts into the
extensor expansion superfi cial to the joint capsule and col-
lateral ligaments, is particularly important to MCP joint
stability. Injury to any of these structures, particularly the
adductor aponeurosis and dorsal capsule, may accompany
UCL injuries. These should be identifi ed and repaired
during UCL reconstructive surgeries. The proper and acces-
sory ligaments, along with these secondary static and
dynamic stabilizers, confer MCP joint stability during pinch
between the thumb and index fi nger. Injury leads to a weak,
painful, and unstable pinch and grasp. Arthritic changes
eventually develop.
Hand and Upper Extremity Reconstruction
80
In 1963, Stener4 described what would come to be
known as the ‘Stener lesion’ (Fig. 6.2). He found that 25
of 39 cases of complete UCL rupture involved both the
proper and accessory ligaments, where the adductor
aponeurosis had become interposed between the distal end
of the avulsed ligament and its insertion into the proximal
phalanx (see Fig. 6.4C). He accurately concluded that
healing after any length of immobilization or rehabilitation
would result in chronic laxity. The presence of a Stener
lesion almost defi nitely indicates a need for surgical treat-
ment, whereas its absence suggests good healing with
immobilization.
Proper ulnar
collateral ligament
Accessory ulnar
collateral ligament
3 mm
3 mm
3 mm
8 mm
8 mm
7 mm
FIGURE 6.1 Anatomy of the ulnar collateral ligament of the thumb
metacarpophalangeal joint. There are two ligaments stabilizing the
ulnar side of the metacarpophalangeal (MCP) joint: the proper ulnar
collateral ligament (UCL) and the accessory UCL. They originate from
the lateral condyle of the metacarpal head. The proper UCL inserts on
the volar third of the proximal phalanx and provides maximum
stability against a valgus stress in 30º of fl exion. The accessory UCL is
weaker, inserts on the volar plate, and provides stability to the MCP
joint during full extension. In surgical repairs, the insertion of the
proper UCL is reproduced by placing a drill hole for the suture anchor
or pullout suture approximately 3 mm distal and 3 mm dorsal to the
volar lip of the base of the proximal phalanx.
A
B
C
D
E
FIGURE 6.2 Stener lesion. The Stener lesion results from a severe
valgus force applied to the thumb metacarpophalangeal joint (MCP).
A The normal relationship of the adductor aponeurosis to the UCL.
B A moderate valgus force may cause the UCL to be partially torn,
but it will not displace proximal to the adductor aponeurosis and will
heal without surgical intervention. C A greater valgus stress will cause
the UCL to be displaced proximal to the aponeurotic edge, but
remain attached to the metacarpal head. D The UCL will remain
displaced after the valgus stress is relieved. E Clinically, the Stener
lesion appears as a hemorrhagic tendon edge (white circle) proximal
to the adductor aponeurosis (white lines). Note the branch of the
radial sensory nerve dorsal to the incision (blue arrow).
BOX 6.1 Indications and contraindications for acute
ulnar collateral ligament repair
Indications
●
Stener lesion
●
Valgus laxity 15º > contralateral thumb in full extension and
30º of fl exion
●
Valgus laxity of 30º in full extension and 30º of fl exion
●
Instability after 4–6 weeks of casting
●
Persistent pain after 4–6 weeks of casting
●
Open injuries
●
Combined injuries (fl exor tendons, more involved fractures,
etc.)
Contraindications
●
Attritional instability/chronic laxity
●
Late presentation of acute injuries (requires reconstruction)
●
Signifi cant arthritic changes to MCP joint
Thumb Ulnar Collateral Ligament Repair Techniques
81
INDICATIONS AND CONTRAINDICATIONS
The presence of a Stener lesion is an absolute indication
for surgery. Interposition of the adductor aponeurosis
between the ruptured collateral ligaments precludes suc-
cessful healing of the ligament to restore stability. The
accurate identifi cation of a Stener lesion is diffi cult preop-
eratively, but it occurs with such frequency after rupture of
both the proper and accessory collateral ligaments (approxi-
mately 80% of cases5) that this fi nding alone is an indica-
tion for surgery. Conversely, if one of the ulnar collateral
ligaments is intact, the adductor aponeurosis cannot inter-
pose between the ruptured ligaments and the injured liga-
ment will be in anatomic proximity to its insertion. This
is an incomplete rupture and good outcomes can be achieved
without surgery.6 Other indications for surgical treatment
include open avulsion injuries, lacerations, combined inju-
ries with fl exor or extensor tendon lacerations, and patients
who have failed immobilization with persistent pain or
instability.
Contraindications to surgical repair of the UCL include
chronic attritional instability, signifi cantly late presenta-
tion of acute tears, extensive MCP joint arthritis, and
patients with signifi cant medical comorbidities. In patients
with delayed presentation consideration should be given to,
and consent obtained for, a ligamentous reconstruction
with tendon graft in case the UCL is insuffi cient for primary
repair.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
The key to treating patients with acute UCL injuries is
accurately determining when a Stener lesion is present.
Most agree that the history and physical examination (Fig.
6.3) provide enough information to make this determina-
tion. Patients can often recall direct trauma to the thumb;
however, this may not be the case in more complex acci-
dents, such as skiing or motor vehicle accidents. It is impor-
tant to question the patient about previous injuries or
pre-injury symptoms, as acute-on-chronic injuries should
be managed as an acute injury.
The initial examination is diffi cult in most patients who
present within days of the injury because of pain and swell-
ing. Evaluation may be facilitated with a local anesthetic
block or joint injection to allow a more thorough examina-
tion. However, this is not practical in many situations. The
use of anesthetic agents can increase swelling, making
evaluation diffi cult. It may be better to immobilize the
patient for 7–10 days in a thumb spica splint and re-examine
them after some of the pain and swelling has resolved. At
this time the laxity is easier to appreciate as the patient
guards less and allows a more complete examination. A
palpable mass may be present along the metacarpal that
suggests a Stener lesion.
Laxity of the MCP joint with radially directed stress is
the hallmark diagnostic feature of complete UCL tears. The
metacarpal head should be stabilized with one hand while
stress is applied to the distal aspect of the proximal phalanx.
The proper ligament should be tested with the MCP joint
in 30º of fl exion. Conversely, the accessory ligament is
isolated with the MCP joint in full extension. Many differ-
ent parameters have been suggested to represent a positive
fi nding. Smith and Peimer6 used 45º of laxity in both fl exion
and extension. Osterman et al.8 suggest 40º of extension
and 20º of fl exion, and Glickel et al.9 used 30º of both
fl exion and extension.
We believe that at least 30º of laxity in both fl exion and
extension is necessary, along with at least 15º of laxity
more than the contralateral normal thumb in both fl exion
and extension. Comparison with the contralateral thumb
is critical for an accurate diagnosis. The variability in joint
laxity can be quite wide, and the quality of the laxity should
also be evaluated. A fi rm endpoint may indicate partial
rupture or sprain, whereas a soft endpoint is more typical
of complete ruptures.
Imaging may also play a role in the management of acute
UCL injuries but should only serve as an adjunct to physical
examination. Classically, radiographs are obtained before
stressing the joint to avoid displacing a non-displaced frac-
ture. However, if ligament displacement did not occur during
the violent, uncontrolled initial injury, it will not occur
during gentle controlled stressing during examination.6 Pos-
teroanterior, lateral, and oblique plain radiographs may
reveal avulsion fractures, most commonly of the ulnar base
of the proximal phalanx. Avulsion fractures of any size may
occur concomitantly with either incomplete or complete
UCL ruptures. In most cases the injuries are ligamentous
only, and radiographs may be normal. In grossly unstable
joints with complete ligament ruptures radial subluxation
may be seen on the posteroanterior view, whereas volar
subluxation may be seen on the lateral view. Comparison
views of the contralateral thumb are useful, as subtle incon-
gruity of the thumb MCP joint may be a normal variant.
Other imaging modalities such as arthrography,10 ultra-
sound,12 and MRI13 have been used but are typically unnec-
essary. If additional imaging beyond plain radiographs is
desired, MR arthrography is more sensitive than either
conventional arthrography or standard MRI.14
FIGURE 6.3 Physical examination.
Hand and Upper Extremity Reconstruction
82
For partial UCL injuries, immobilization in a thumb
spica cast for 4–6 weeks is recommended. More reliable
patients may be placed in a removable thumb spica splint,
but non-compliant patients may require full-time casting.
At 4 weeks these patients should follow the same protocol
as outlined below for surgical patients.
OPERATIVE APPROACH
Surgical repair may be performed with use of a regional
anesthetic (axillary or Bier blocks) with or without sedation
or under general endotracheal anesthesia. A curved longi-
tudinal or lazy S-shaped incision is made over the dorsoul-
nar border of the thumb, centered at the level of the joint
(Fig. 6.4A). The central curve of the incision should run
parallel to the joint and extend volarly and distally along
the ulnar midaxial line.
The terminal branches of the superfi cial radial nerve,
which innervate the dorsoulnar aspect of the distal thumb,
A
FIGURE 6.4 Surgical approach for UCL repair and reconstruction.
A An S-shaped incision is planned with the distal portion more volar
to gain better access to the volar proximal phalanx and the anatomic
insertion of the UCL. B Beneath the fi rst layer of adipose tissue the
branches of the radial sensory nerve are identifi ed and retracted.
C The adductor aponeurosis covers the ulnar aspect of the joint, but
with a Stener lesion the proximal stump of the UCL can be seen
proximal to the proximal edge of the aponeurosis. D The adductor
aponeurosis is incised slightly volar to the extensor pollicis longus
tendon for lateral repair. A stay suture helps to identify this thin tissue
layer and assists in retraction. The ulnar collateral ligament can be
visualized beneath the aponeurosis and is repaired to its anatomic
insertion site (marked).
should be adequately dissected and gently retracted to
prevent traction injury (Fig. 6.4B). Patients should be made
aware preoperatively of the possibility of numbness or dys-
esthesias after simple retraction of this sensitive nerve. The
terminal branches pass distally and longitudinally on each
side of the dorsolateral aspect of the MCP joint, deep to the
subcutaneous fat. After deeper dissection through the sub-
cutaneous fat, the adductor aponeurosis will be visible
attaching to the extensor expansion superfi cial to the joint
(Fig. 6.4C). If a Stener lesion is present, its round, hemor-
rhagic distal end seen in cross-section will be fl ipped up
into the subcutaneous fat proximal to the edge of the apo-
neurosis. Incise the adductor aponeurosis longitudinally
about 3 mm volar and parallel to the ulnar border of the
EPL tendon, leaving a cuff to facilitate later repair (Fig.
6.4D). A suture can be placed through the volar fl ap of the
aponeurosis to facilitate later repair at the conclusion of the
case. Refl ect the aponeurosis ulnar volarly to allow visual-
ization of the ulnar aspect of the joint. Examine the condi-
Terminal branches of
radial sensory nerve
Extensor aponeurosis
UCL stump
Proper ulnar
collateral ligament
Suture anchor
B
C
D
Thumb Ulnar Collateral Ligament Repair Techniques
83
tion of the joint capsule and the joint itself: small loose
articular fragments in the joint should be removed. Signs
of arthritic changes should also be inspected for now, as
outcomes will be predictably worse when there is pre-
existing arthritis. The ligament can be reduced back into
its anatomic position. Tears in the middle two-thirds of the
ligament, albeit rare, may be repaired primarily using a
non-absorbable synthetic suture with horizontal mattress
or interrupted fi gure-of-eight sutures. More often, the distal
end of the ligament is avulsed from the proximal phalanx
and requires repair to its normal insertion site.
Bone anchor technique
Repair of the UCL with a bone anchor is an accepted tech-
nique that yields good clinical results.15 Following the
approach detailed above, the ligament is approximated to
the base of the proximal phalanx at its normal anatomic
insertion site. This site is marked for bone anchor place-
ment. Any soft tissues or remnant of UCL present in this
region is debrided with a rongeur or elevator. A bony bed is
preferred for tendon healing, although cortical bone should
not be removed as it may weaken the bone anchor holding
strength.
The bone anchor hole is drilled in the ulnar base of the
proximal phalanx volar to the axis of the joint, roughly 3 mm
distal and dorsal to the volar aspect of the proximal phalanx.
This is near the anatomic insertion of the UCL proper (see
Fig. 6.1) The bone anchor is carefully advanced into the
predrilled hole. Harley et al.16 showed in vitro that anchor
pullout occurs at signifi cantly weaker loads to failure than
suture or tendon repairs. In other words, the anchor is typi-
cally the ‘weakest link.’ An 0 or 2/0 braided suture
pre-threaded though the bone anchor is used to repair
the UCL. One limb of the suture is placed through the
tendon in a locked loop, and the other limb is placed through
in an unlocked fashion. This allows the tendon to be slid
down on the unlocked limb to appose the ligament closely to
the bone. It is important that the ligament has good bony
contact.
Alternatively, a pullout suture technique may be used
to fasten the ligament to its anatomic insertion site. If a
fragment of bone is avulsed with the ligament from the
proximal phalanx, its treatment depends on the size of the
fragment. If small (no more than 10% of the articular
surface) the fragment and the ligament should be secured
into the defect with either a bone anchor or a pullout
suture. Larger fragments should be reduced and fi xed ana-
tomically with a pullout suture, K-wire, or mini-fragment
screw.
After UCL repair with a suture anchor or a pullout
suture, any capsular tear that can be repaired is approxi-
mated with a 2/0 braided non-absorbable suture (Fig. 6.5).
However, there is not always suffi cient tissue for this. Care
should be taken to ensure that the extensor tendon or apo-
neurosis is not incorporated into this repair, as it will limit
tendon motion postoperatively. Another suture should be
secured between the volar aspect of the ligament and the
volar plate to recreate this complex.
Following the ligament and capsule repair, the joint
should be gently checked for stability. This should be done
under fl uoroscopy to better assess subluxation. If there is
still substantial laxity, or if the repair is tenuous, a 0.045
in K-wire should be placed across the MCP joint with the
proximal phalanx in slight ulnar deviation. A tenuous repair
can occur because of poor tissue quality of the UCL remnant
or poor quality of bone holding the bone anchor.
The adductor aponeurosis is repaired with an absorbable
suture. This is done with a buried fi gure-of-eight confi gura-
tion, as the knots can be prominent and bothersome. The
skin is closed with interrupted non-absorbable sutures. A
plaster thumb spica splint with the IP joint free is placed,
FIGURE 6.5 Repair of acute UCL injury with a pullout suture.
A A Keith needle is drilled through the base of the proximal phalanx
at the attachment site of the torn proper UCL. In hard bone, the path
is predrilled with a Kirschner wire. B A monofi lament suture is placed
through the distal stump of the UCL. These sutures are pulled
through the base of the proximal phalanx and out through the radial
skin. The sutures are placed through a padded button and tied. The
ulnar side is visualized as the sutures are tied to be certain that
excellent contact is achieved between the ligament stump and the
bone.
B
A
Hand and Upper Extremity Reconstruction
84
with care taken not to mold the cast with a radial or abduc-
tion stress on the MCP joint. At 10–14 days the splint is
removed and cast immobilization is continued for 2–3 more
weeks. The cast is then removed and replaced with a remov-
able splint. This amounts to about 4 weeks of strict immo-
bilization postoperatively.
Pullout suture technique
A pullout suture may be used to fi x the avulsed ligament.
A synthetic non-absorbable monofi lament suture such as
3/0 nylon or a stainless steel wire is secured into the stump
of the UCL via a modifi ed Kessler technique. Care is taken
not to lock the suture, as this would prevent pullout when
the ligament has healed. A curette or small rongeur is used
to remove a little of the bone at the reattachment site in
the same anatomic location as described previously for bone
anchor placement. Next, two Keith needles are drilled
transversely through the decorticated site ulnoradially to
exit percutaneously on the radial side of the thumb. While
holding the thumb in slight fl exion and in a slightly ulnarly
deviated, overcorrected position, tension is applied until the
ligament is pulled into the shallow trough created in the
ulnar base of the proximal phalanx. The sutures are secured
to the pullout Keith needles and are tied over a rubber
catheter or padded button on the radial side skin surface.
Preferably, the skin between the ends of the Keith needles
is incised to expose the opposite cortical bone and the
sutures are tied on the bone to reduce the discomfort of
having the rubber catheter impinging on the skin.
As with any instability surgery, the most worrying com-
plication is persistent or recurrent instability. Stiffness,
however, is probably more common. Reinserting the UCL
too far dorsally may lead to instability, particularly in
fl exion. An excessively distal insertion leads to over-tight-
ening. Prolonged immobilization can also lead to stiffness,
although this is usually preferred to recurrent instability, as
functional defi cits are minimal with MCP joint stiffness.
POSTOPERATIVE CARE
After 10–14 days the splint and non-absorbable sutures are
removed. A thumb spica cast is placed, again leaving the IP
joint free, and motion at the joint is encouraged. The patient
returns in 3–4 weeks for removal of the cast. A forearm-
based removable splint is applied and is removed for range
of motion exercises. Active fl exion and extension of the IP
and MCP joints and full range of motion of the CMC joint
are encouraged under the guidance of a hand therapist.
At 7–8 weeks the splint is changed to a hand-based
thumb spica splint. Increased splint removal at home to
perform simple activities such as zipper manipulation and
buttoning is allowed. The therapist initiates fl exion of the
IP joint and thumb adduction against light resistance. Wrist
and forearm strengthening exercises are also begun. By
week 10, near complete active range of motion should be
achieved, with specifi c therapy directed towards correcting
these defi cits. Pinch should be 60–70% of contralateral
strength, with restrictions still placed on activities that
place radial force on the tip of the thumb. The splint may
be discontinued except in higher-risk locations (work, out-
doors, etc.).
Full activity is allowed at 3 months, with the exception
of contact sports, which are prohibited for another month.
Taping or semi-rigid splinting of the MCP joint should be
applied when play resumes.
CONCLUSIONS
Acute injuries to the ulnar collateral ligament of the thumb
MCP joint result from a violent valgus stress. Pain on the
ulnar side of the MCP joint, swelling, and instability to
valgus stress suggest injury to the UCL. If the joint is
unstable to valgus stress with the MCP joint in both exten-
sion and fl exion, a Stener lesion is probably present, neces-
sitating surgical repair of the UCL. During operative repair,
the ruptured UCL is fi xed in its anatomic location by secur-
ing the distal end to either a bone anchor or a pullout
suture. Four weeks of postoperative immobilization is fol-
lowed by progressive range of motion and resistance exer-
cises under the supervision of the surgeon and therapist.
By 3 months the results are typically good to excellent, with
strength and motion close to those of the uninjured hand.
CHRONIC UCL INJURY REPAIR
Gamekeeper’s thumb is the classic term coined by Camp-
bell1 in 1955 to describe chronic attritional laxity of the
thumb ulnar collateral ligament. Most cases of chronic
Optimizing outcomes
●
Dissect out and protect terminal branches of the superfi cial
radial nerve.
●
Place bone anchor or pullout suture hole at anatomic
insertion site over the base of proximal phalanx.
●
Stress repair under fl uoroscopy to ensure stability of repair
and joint congruity.
●
Repair capsule and ligament/volar plate complex.
●
Be prepared for ligament reconstruction with tendon graft in
late presentations, as ligament tissue may be insuffi cient.
●
Immobilize in splint or cast in neutral position without radial
or abduction stress, with IP joint free.
●
Encourage motion at the IP joint to prevent extensor tendon
adhesions and stiff ness.
●
Begin range of motion exercises by 4 weeks.
COMPLICATIONS AND SIDE EFFECTS
The most commonly encountered complications of UCL
repair are postoperative radial sensory nerve defi cits. These
are usually transient, frequently resolving before the sutures
are removed. The symptoms can be painful, however, and
patients should be made aware of the potential problem
with simple traction alone. True nerve injuries and symp-
tomatic neuromas should be rare, as the anatomy in this
region is very predictable.
Thumb Ulnar Collateral Ligament Repair Techniques
85
UCL defi ciency encountered by hand surgeons today are the
result of untreated or unsuccessfully treated acute injuries,
rather than subacute repetitive stress such as that endured
by the Scottish gamekeepers. Lesions are typically consid-
ered chronic at 6 weeks after acute injury. Helm et al.17
showed that the older a lesion is, the less likely it is that
stability can be achieved by anatomic repair as described for
acute rupture.17 When a patient presents 3 weeks or more
after an acute injury, ligament reconstruction should be
considered and discussed.
INDICATIONS AND CONTRAINDICATIONS
Ligament reconstruction is required in all cases of chronic
instability, whether it be attritional rupture, late presenta-
tion of acute injuries, or unhealed treated acute injuries.
Whereas it is easy to make the decision in patients who
present 3 months after injury, it is harder when they present
between 3 and 8 weeks after acute injury. Although suc-
cessful primary repairs have been reported, the results are
poorer as time elapses.9
The greatest contraindication to UCL reconstruction is
MCP arthritis. Radiographic evidence of arthritis is a con-
traindication to the repair or reconstruction of UCL-
defi cient joints. In these patients, MCP joint fusion is the
preferred treatment. In patients with early radiographic
changes or very chronic injuries, preoperative discussions
should focus on possible joint fusion, as intraoperative joint
inspection may show more advanced degeneration. In these
patients, reconstruction will lead to a stiff painful joint that
will probably progress to fusion at a later date.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
Patients with chronic defi ciency of the UCL typically
present with thumb weakness, pain, and swelling. Weak-
ness and instability are the most common complaints,
exacerbated when trying to grasp large objects or during
torsional movements such as unscrewing a jar.9 The patient
can usually recall a specifi c acute injury event.
The examination of chronic UCL injuries is similar to
that for acute injuries, with a few key differences. Gross
volar subluxation, diffuse MCP swelling, or radial deviation
on inspection are observations characteristic of chronic
defi ciency of the UCL. There is gross instability without a
defi ned endpoint. Crepitus with active motion is the most
specifi c examination sign of arthritis.
Radiographic evaluation with posteroanterior, lateral,
and oblique views is imperative to rule out degenerative
changes. The joint can again be evaluated for radial devia-
tion and volar subluxation, which is made easier by com-
parison with the other hand.
OPERATIVE APPROACH
The anesthesia, positioning, incision and surgical approach
for UCL reconstruction are the same as for acute repair (see
above).
Suture anchor technique
The authors prefer a method of repair similar to that
described by Mitsionis et al.18 The remnants of the proxi-
mal and distal ligaments are isolated and preserved, with
roughening of the bone at the insertion sites. There is fre-
quently little ligament tissue remaining distally, but the
proximal stump can supplement the proximal attachment
of the graft. A hole is drilled at the roughened anatomic
insertion sites and a bone suture anchor with a 2/0 suture
attached is placed. We prefer bioabsorbable anchors. The
sutures are pulled upon to set the anchor and test its stabil-
ity. In cases with osteoporotic bone we have had success
using larger anchors with larger sutures when the smaller
anchors have pulled out. Alternatively, a larger anchor can
be used, but the larger suture (usually a number 2) can be
exchanged for smaller suture material more appropriate for
the UCL ligament.
A suffi cient length of palmaris longus tendon is har-
vested using two 5 mm transverse incisions, one at the
volar wrist fl exion crease and one near the musculotendi-
nous junction. A tendon stripper of the appropriate size, if
available, can be used through a single distal incision. In
the absence of the palmaris longus, a strip of the fl exor carpi
radialis or the abductor pollicis longus may be used, although
a more extensile approach is required to safely harvest these
tendon grafts. The suture of the proximal bone anchor is
passed through a free end of the graft via a mattress suture.
One limb of the suture is locked through the tendon and
the other is allowed to slide to permit good tendon–bone
apposition. If an intact proximal remnant of the UCL is
present, the graft is reinforced through a slit made in the
remnant and then secured to the distal bone anchor, as
shown in Figure 6.6.
Bone tunnel technique
Two holes 3 mm in diameter are made at roughly the 1
and 5 o’clock positions on the ulnar side of the proximal
phalanx. The holes are progressively deepened with a small
curette, aiming obliquely towards each other to meet in the
medullary canal. Care must be taken to keep the holes suf-
fi ciently far apart – at least 5 mm – to maintain a stable
bone bridge (Fig. 6.7).
BOX 6.2 Indications and contraindications for
chronic ulnar collateral reconstruction
Indications
●
Attritional UCL insuffi ciency (repetitive stress)
●
Injuries over 6 weeks old
●
Failed acute repairs
●
Open injuries with defi cient ligament tissue
Contraindications
●
MCP arthritis
●
Open injuries with contamination
Hand and Upper Extremity Reconstruction
86
Another gouge is placed at the ulnar concavity of the
metacarpal head corresponding to the origin of the UCL.19
This hole should be slightly larger – roughly 4 mm – as
both ends of the graft will be passed through this tunnel.
It should be directed dorsoradially to exit the radial cortex
and emerge subcutaneously on the radial side of the thumb.
A small incision is made at this location. A 28-gauge steel
wire is passed radioulnarly through this incision and bone
tunnel to emerge through the ulnar cortex of the metacarpal
head. Next, another wire is passed through one of the holes
in the proximal phalanx and out the other. A tendon graft
is harvested as described for the previous method. The nar-
rowest end of the graft is secured to the wire passed through
the proximal phalanx tunnel and passed through this tunnel
by traction on the wire. Next, the wire passed through the
metacarpal tunnel is secured to the other free end of
the graft, and both ends are passed ulnoradially through the
metacarpal head and out the radial side of the thumb.
Tension on the repair is adjusted by traction on the wires.
The ends are secured over a felt-backed button or a section
of rubber catheter. Alternatively, a suture anchor can be
placed on the radial side of the metacarpal head to set the
tension on the ends of the graft.
To help reinforce either type of repair, the graft is sutured
to any local periosteum and capsule using a slowly absorb-
UCL remnant
Tendon graft
UCL remnant sewn
over tendon graft
A
B
FIGURE 6.6 Chronic UCL reconstruction with suture anchors.
A A suture anchor is placed at the origin of the UCL under the
remnant of the torn ligament. A second anchor is placed at the site of
the normal insertion of the proper UCL. A tendon graft (TG) is
harvested for reconstruction. B The proximal attachment is sewn in
fi rst and is placed through a slit in the base of the UCL remnant to
reinforce the repair. The distal end of the tendon graft is sewn second
in order to set the tension.
3 mm
3 mm
3 mm
8 mm
7 mm
3 mm
4 mm
5 mm
5 mm
FIGURE 6.7 Bone tunnel placement. Two holes are placed in the
base of the proximal phalanx. The tunnels are angled towards each
other and connected below the cortex. Care is taken to preserve at
least 5 mm of cortical bridge between the two holes. Another hole is
placed in the site of the origin of the UCL that traverses the
metacarpal head and exits on the radial side.
ing suture such as 4/0 Vicryl. Another suture should be
secured between the volar aspect of the ligament and the
volar plate to recreate this complex. Further, any defect in
the dorsal capsule of the joint should be repaired to prevent
future joint subluxation.
Lastly, the stability of the repair should be evaluated, as
for acute repairs. A radially directed stress should be gently
applied to the joint under fl uoroscopy to ensure stability. If
there is any instability, the authors use K-wire fi xation
more liberally in chronic reconstruction than in acute
repairs. A retrograde 0.045 wire is passed, with anatomic
joint reduction assured by fl uoroscopy. The adductor apo-
neurosis is repaired with an absorbable suture and the skin
closed with interrupted non-absorbable sutures. A plaster
thumb spica splint is placed with the IP joint free, with care
taken not to mold the cast with a radial or abduction stress
on the MCP joint. At 10–14 days the splint and sutures are
removed, and cast immobilization is continued for 4–5
more weeks. At this time it is replaced with a removable
splint. Strict postoperative immobilization totals about 6
weeks, 2 weeks longer than for acute repairs. Subsequently,
postoperative care and rehabilitation are the same as for
acute repairs (Fig. 6.8).
Optimizing outcomes
●
Dissect out and protect terminal branches of the superfi cial
radial nerve.
●
Preserve at least a 5 mm bone bridge between holes in the
proximal phalanx.
●
Stress repair under fl uoroscopy to ensure stability of repair
and joint.
●
Place 0.045 K-wire through joint to secure anatomic
reduction.
●
Repair adductor aponeurosis with slowly absorbing suture.
●
Immobilize in splint or cast in neutral position without radial
or abduction stress, and with IP joint free.
●
Encourage motion at the IP joint to prevent extensor tendon
adhesions and stiff ness.
●
Maintain immobilization 2 weeks longer than for acute
repairs.
Thumb Ulnar Collateral Ligament Repair Techniques
87
COMPLICATIONS AND SIDE EFFECTS
As in acute repairs, the most commonly encountered com-
plications of UCL repair are radial sensory nerve defi cits
postoperatively. Other similarities include continued laxity
or instability, stiffness, infection, and continued pain. Pro-
gressive arthritis is possible as a result of any of these
complications. Most are treated with MCP joint fusion.
POSTOPERATIVE CARE
Postoperative care is similar to that for acute repairs. The
notable difference is the length of immobilization, 6 weeks
of full-time immobilization being required. At this point
the pullout suture is removed. Splint wear is recommended
for another 6 weeks. Early IP motion is encouraged in the
cast, and formal hand therapy is initiated with splint wear.
Rehabilitation protocols from this point on are similar to
those used in acute repairs.
CONCLUSION
Chronic UCL lesions are usually the result of an unrecog-
nized, untreated, or unsuccessfully treated acute injury.
The chronic lesion is at least 6 weeks old and typically
results in instability and pain. The evaluation for a sus-
pected chronic UCL injury is the same as that for acute
injuries. When considering operative treatment, one must
entertain the option of arthrodesis for patients in need of
stability and longevity in return for a reduced range of
motion. Operative reconstruction carried out using a free
tendon graft can restore stability and function in the unsta-
ble thumb.
REFERENCES
1. Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br 1955;
37B: 148–149.
2. Gerber C, Senn E, Matter P. Skier’s thumb. Surgical treatment of
recent injuries to the ulnar collateral ligament of the thumb’s
metacarpophalangeal joint. Am J Sports Med. 1981; 9: 171–177.
3. Warme WJ, Feagin JA Jr, King P, et al. Ski injury statistics, 1982
to 1993, Jackson Hole Ski Resort. Am J Sports Med 1995; 23:
597–600.
4. Stener B. Skeletal injuries associated with rupture of the ulnar
collateral ligament of the metacarpophalangeal joint of the thumb.
A clinical and anatomical study. Acta Chir Scand 1963; 125:
583–586.
5. Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the
ulnar collateral ligament of the thumb metacarpophalangeal joint.
Biomechanical and prospective clinical studies on the usefulness of
valgus stress testing. Clin Orthop Relat Res 1993; 292: 165–171.
6. Heyman P. Injuries to the ulnar collateral ligament of the thumb
metacarpophalangeal joint. J Am Acad Orthop Surg 1997; 5:
224–229.
7. Smith RJ, Peimer CA. Injuries to the metacarpal bones and joints.
Adv Surg 1977; 11: 341–374.
8. Osterman AL, Hayken GD, Bora FW Jr. A quantitative evaluation
of thumb function after ulnar collateral repair and reconstruction.
J Trauma 19981; 21: 854–861.
9. Glickel SZ, Malerich M, Pearce SM, Littler JW. Ligament
replacement for chronic instability of the ulnar collateral ligament
of the metacarpophalangeal joint of the thumb. J Hand Surg [Am]
1993; 18: 930–941.
10. Bowers WH, Hurst LC. Gamekeeper’s thumb. Evaluation by
arthrography and stress roentgenography. J Bone Joint Surg Am
1977; 59(4): 519–524.
11. Resnick D, Danzig LA. Arthrographic evaluation of injuries of the
fi rst metacarpophalangeal joint: gamekeeper’s thumb. AJR Am J
Roentgenol 1976; 126: 1046–1052.
12. Hergan K, Mittler C, Oser W. Pitfalls in sonography of the
gamekeeper’s thumb. Eur Radiol 1997; 7: 65–69.
13. Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar collateral
ligament of the thumb: MR fi ndings in cadavers, volunteers, and
patients with ligamentous injury (gamekeeper’s thumb). AJR Am J
Roentgenol 1994; 163: 1431–1434.
14. Ahn JM, Sartoris DJ, Kang HS, et al. Gamekeeper thumb:
comparison of MR arthrography with conventional arthrography
and MR imaging in cadavers. Radiology 1998; 206(3): 737–744.
15. Weiland AJ, Berner SH, Hotchkiss RN, et al. Repair of acute ulnar
collateral ligament injuries of the thumb metacarpophalangeal
joint with an intraosseous suture anchor. J Hand Surg [Am] 1997;
22: 585–591.
16. Harley BJ, Werner FW, Green JK. A biomechanical modeling of
injury, repair, and rehabilitation of ulnar collateral ligament
injuries of the thumb. J Hand Surg [Am] 2004; 29: 915–920.
17. Helm RH. Hand function after injuries to the collateral ligaments
of the metacarpophalangeal joint of the thumb. J Hand Surg (Br)
1987; 12: 252–255.
18. Mitsionis GI, Varitimidis SE, Sotereanos GG. Treatment of
chronic injuries of the ulnar collateral ligament of the thumb using
a free tendon graft and bone suture anchors. J Hand Surg [Br]
2000; 25: 208–211.
19. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green’s
operative hand surgery. Philadelphia: Elsevier, 2005.
Tendon graft
A
B
FIGURE 6.8 Tendon graft reconstruction through bone tunnels.
A One end of the tendon graft is looped through the proximal
phalanx. The two ends of the graft are then pulled though the ulnar
hole in the metacarpal head to the radial side of the metacarpal.
B The tendon ends can be secured using a button or a suture anchor
placed on the radial side of the metacarpal head.
89
C H A P T E R
7
Amputation
Grey Giddins and Ilana Langdon
INTRODUCTION
Amputation is an infrequent but important operation in
hand surgery. Unlike reconstructive hand surgery, this is a
destructive operation and usually the last resort. Patient
understanding is crucial, as the outcome is often dictated
by how they accept/come to terms with their loss and how
hard they work to adapt. When possible – and sensible – the
length of the digit, especially the thumb, should be main-
tained for functional and esthetic considerations, but this
is not dogmatic because ray amputation of a fi nger (Fig.
7.1A–C) may give a better result than partial fi nger amputa-
tion (Fig. 7.2A,B). Pain management is critical periopera-
tively and particularly postoperatively. No amputation is
ever truly pain-free, except perhaps in children, and the
result of surgery is often directly correlated with the level
of pain.
Too frequently, amputation is seen as a simple opera-
tion that can be undertaken by a junior surgeon or with
little attention to detail. A poorly performed amputation
can turn a troubled hand into a ruined one, whereas a well
performed amputation can often restore considerable func-
tion to a disabled hand (Fig. 7.1C).
INDICATIONS AND CONTRAINDICATIONS
Absolute indications
Malignancy (except for less invasive skin lesions, particu-
larly in the elderly) and avascular digits are absolute indica-
tions. A severe infection may become an absolute indication,
although more often it is a relative indication.
Relative indications
These include severe infections that may be in the soft
tissues, such as the pulp or the bone and joint. Other indi-
cations may be conditions after acute trauma, such as an
amputated fi nger that cannot be salvaged, or a partial
amputation. An example of this would be a degloving injury
or other injuries such as hot press injuries. Complex open
trauma with bone and soft tissue damage may not be sal-
vageable and require amputation. Common relative causes
are disabling deformity, for example stiffness after trauma
reconstruction, recurrent Dupuytren’s contracture, or per-
sistent pain. Other less frequent causes include benign
neoplasia, such as haemangioma, particularly multiple
recurrences, metabolic conditions, such as gout, and rarer
causes, such as macrodactyly.
Contraindications
The only defi nite contraindication is psychological, for
example a patient in whom it is felt that even a successful
amputation will give a bad result by turning a non-surgical
problem into a surgical one. Extra efforts should be made
to save the fi ngers in children and young women. In certain
specialist occupations and cultures, for example in the Far
East, even partial loss of a digit is a great stigma.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Acute injuries
The history is usually clear following an accident or a latro-
genic complication that results in a vascular problem in
the digits or hand. If there is doubt about the viability of
the digit, then either surgery should be attempted or the
patient’s condition optimized to see whether the blood fl ow
will improve. The patient should be kept warm and well
hydrated, with the fi ngers semi-elevated. This allows good
blood supply but also some venous drainage. If the fi nger
Hand and Upper Extremity Reconstruction
90
is unsalvageable, then acute amputation will be in the
patient’s best interest for faster rehabilitation. However, the
level of the amputation can be diffi cult to determine because
the patient is often not in a position to make an informed
judgment. It is better to be too conservative rather than too
radical, as further amputation can be performed in the
future.
Chronic conditions
Occasionally there will be an absolute indication, such as
an invasive malignancy. The appropriate operation will be
guided by oncological advice and the patient’s functional
and cosmetic needs. For most chronic conditions amputa-
tion will be one of a number of options. There options
include doing nothing, further treatment (such as for a pain
condition) and further reconstructive options. All medical
treatments should be exhausted prior to considering ampu-
tation. However, once amputation is agreed upon, the key
decision is the level of amputation. Considerations in the
thumb differ from those for the fi ngers.
Thumb
Every effort should be made to preserve thumb length. Loss
of the thumb equates to a loss of 50% of hand function and
bypassing it, as seen after fi nger amputation, is impossible.
A shorter thumb may require secondary reconstruction,
such as skeletal lengthening, deepening of the fi rst web
space, or pollicization.
Fingers
Finger length should be preserved when possible, provided
the amputation is not more proximal than the distal middle
phalanx. Because of the intact proximal interphalangeal
joint and the superfi cialis tendon, the fi nger should con-
tinue to be useful for grip and, to a lesser extent, pinch.
With more proximal amputation, the fi nger becomes
increasingly less useful and more cosmetically abnormal
(Fig. 7.3A,B); a ray amputation should be considered.1 For
the border digits, the hand loses some width but often has
a reasonable cosmetic appearance after ray amputation (see
Fig. 7.1). For the central two fi ngers (middle and ring), ray
amputation will require closing the cleft. This is more dif-
A
B
FIGURE 7.1 Index fi nger ray amputation. The index ray amputation is much more cosmetically appealing than partial fi nger amputation and is
still highly functional.
Amputation
91
fi cult, and on the ulnar side gives an obvious cosmetic
abnormality because of the relative shortness of the little
fi nger compared to the long fi nger. Ray amputation reduces
the width of the palm and can hamper certain manual
activities, such as hammering.
The alternative is amputation through the proximal
phalanx or metacarpophalangeal (MCP) joint. For the
border digits (index and little fi ngers) this gives a greater
but still relatively moderate cosmetic abnormality, and
retains the width of the palm (Fig. 7.4). For the central
digits, amputation at the level of the MCP joint is a major
cosmetic abnormality (see Fig. 7.3A) and allowing small
objects to escape is a functional nuisance (see Fig. 7.3B).
Most surgeons would favor ray amputation of the central
fi ngers, but some patients will have other preferences. It is
better to revise the amputation at a later date if the patient
is unhappy, rather than removing too much, which cannot
be undone. Repeat consultations and illustrative clinical
photographs are valuable.
For some patients, preservation of even some fi nger
length may permit the attachment of a cosmetic prosthesis,
which gives little functional benefi t but considerable cos-
metic improvement.
OPERATIVE APPROACH
There are three types of digital amputation: tip amputation
(terminalization), amputation within the digit, and ampu-
tation in the palm, i.e. ray amputation. All have certain
steps in common.
Common steps
The patient must give appropriate consent, and the am-
putation must be performed in a sterile surgical environ-
ment. Although the risk of infection is small in the well
vascularized hand, infection in an amputation site can be
problematic. One dose of intravenous antibiotics should
be given preoperatively, ideally 40 minutes before tourni-
quet infl ation. A second-generation cephalosporin, amoxi-
cillin, fl ucloxacillin or other equivalent antibiotics are
suitable. Metronidazole is unnecessary unless there is
unusual contamination. Postoperative antibiotics are not
typically required, unless the reason for the amputation is
infection.
The operation may be performed under local or regional
anesthesia. Tip amputations can normally be performed
under local anesthetic with a fi nger tourniquet. More distal
digital amputations may be performed with a fi nger tourni-
quet, but if more proximal an arm/forearm tourniquet is
used. Almost all patients can tolerate an arm or forearm
tourniquet for approximately 20 minutes at 250 mmHg.
Thus, if two tourniquets are applied, this gives 40 minutes
of operating time, which should be suffi cient for an experi-
enced surgeon to perform an amputation and closure. Ray
amputation requires regional anesthesia.
Tip amputation
The typical indication is crush laceration of the fi ngertip
(Fig. 7.5). If there is inadequate soft tissue cover, one can
shorten the bone or cover it suffi ciently to give a reasonable
pad at the end of the digit for pinch. Enough length should
be preserved to provide adequate support for the nail. If less
than 50% of the sterile nail matrix remains supported, a
hook nail deformity often results. In women more efforts
may be made to preserve the nail. There are secondary
reconstructive procedures that can be performed to help
support the nail. With more proximal amputations, the
insertions of the fl exor and extensor tendons should be
maintained. The fl exor tendon attaches more distally at the
base of the distal phalanx and is more likely to be detached.
Preserving the fl exor digitorum profundis (FDP) attachment
helps to maintain grip strength and active fl exion of the
distal phalanx remnant.
The fi ngertip is thoroughly debrided and dead or con-
taminated tissue removed. Prominent bone is trimmed
back to approximately 3–4 mm below the surface of the
remaining soft tissue of the pulp. If shortening is inade-
quate, the bone may become prominent as the soft tissues
heal and contract. The bone is beveled to provide a fl atter
C
FIGURE 7.1, cont’d
Hand and Upper Extremity Reconstruction
92
surface for pinch. The more dorsal length that can be pre-
served, the better the support there will be to the sterile
nail matrix and nail. This is not an exact science, and clini-
cal judgment and experience are needed. If in doubt, it is
better to remove too little bone and revise it later than to
remove too much. The skin and soft tissue are loosely
opposed as appropriate with an absorbable suture, e.g. 5/0
vicryl rapide. If there is no bone exposed, the soft tissue
wound can be treated with dressing changes. This usually
gives a better cosmetic and functional result than surgical
closure or grafting. Local fl aps are rarely indicated in
these situations.2,3 After removal of the tourniquet, a non-
adherent dressing is applied.
Amputation in the digit
This patient (Fig. 7.6A,B) presented with severe infection
and joint instability of distal tip of the little fi nger and
elected to have amputation at the level of the DIP joint.
Prior to infl ating/applying the tourniquet, the skin fl aps are
marked. It is better to leave the skin fl aps longer in order
to avoid a more proximal amputation than planned. The
only exception is in malignant neoplasia, in which an ade-
quate margin must be achieved fi rst and the closure method
is considered later. The aim of designing the skin fl aps is to
provide good palmar skin to cover the volar fi nger, because
the palmar skin is thicker, more sensate, and better suited
for pinch. In some circumstances there will be much more
dorsal skin available. It may be refl ected over the volar
fi nger, but this leaves a volar scar that can be tender. Typi-
cally the volar skin fl ap should be marked at least 1 cm
longer at the central tip than the planned level of the bone
cut. The dorsal fl ap is typically about 5 mm shorter. The
fl aps should be planned as gentle sweeping curves from the
mid-lateral point (Fig. 7.7). They will also extend proximally
about 6–7 mm along the mid-lateral lines of the fi nger.
The dorsal fl ap is cut straight down to bone, both dor-
sally and in the mid-lateral line. The extensor tendon is
divided transversely at, or just proximal to, the level of the
dorsal fl ap and raised off the bone proximally for approxi-
mately 5 mm. If the bone is too long, it is cut carefully with
bone cutters and later beveled and shaped using bone nib-
blers (Fig. 7.8). Volarly the neurovascular bundles and fl exor
tendons should be identifi ed. The fl exor sheath is opened
and the fl exor tendon(s) pulled distally with the patient’s
wrist and digit fl exed (Fig. 7.9). The tendon is divided
proximally and allowed to retract into the palm. There is
A
B
FIGURE 7.2 Index fi nger amputation through the proximal phalanx. This is unattractive and gives no functional value except some increased
hand breadth. The callosities over only the middle, ring, and little metacarpal heads suggest almost no use of the residual index fi nger.
Amputation
93
B
FIGURE 7.3 Middle fi nger amputation through MCP joint. Like
amputation of the index fi nger through the proximal phalanx, this
amputation also leaves a space in the hand where objects may drop
through and is cosmetically unattractive.
A
no value in keeping it long. Obviously, if any attachment
can be kept, for example FDP to the distal phalanx or fl exor
digitorum superfi cialis (FDS) to the middle phalanx, it
should be preserved, because it increases fl exor power and
fl exibility in the digit.
Various techniques are described for managing the neu-
rovascular bundles. The artery is divided and cauterized; in
the volar fl ap it should be left long to maximize the blood
supply. The nerve is separated from the artery (Fig. 7.10).
Some surgeons divide the nerve and suture it dorsally to
Hand and Upper Extremity Reconstruction
94
A
B
FIGURE 7.6 This is similar to a terminalization. This patient presented with a severe infection and joint instability.
FIGURE 7.4 Index fi nger MCP joint amputation. This amputation
yields a better cosmetic result than central digit MCP joint
amputations, but is not as cosmetically appealing as a ray
amputation.
FIGURE 7.5 Fingertip laceration resulting from a crush injury that is
repaired using a local fl ap.
Amputation
95
provide a dorsal neuroma to reduce pinch discomfort volarly
(Fig. 7.11). Others cauterize the nerve tip to seal the end
in order to reduce neuroma formation. No evidence exists
that these techniques reduce painful neuromas. The nerve
is divided 5–10 mm proximal to the level of the bone cut.
This may leave the tip a little insensate, but this is not
typically a problem. The bone end should be shaped to a
smooth curve, preferably with a volar bevel. This gives a
broader area for pinch and also some tapering for the fi n-
gertip to make it less bulbous.
Finally, the skin fl aps are shaped. They should taper
nicely, avoiding a bulbous end to the fi nger (Fig. 7.12). The
key is to have good coverage of the bone with the volar skin
and to place the scar dorsal to the fi ngertip, even if only by
a few millimeters. Prior to skin closure we irrigate the
wounds thoroughly with saline to reduce bacterial contami-
nation. The edges of the fl ap are sutured together with
5/0 vicryl rapide, typically with horizontal mattress-type
FIGURE 7.9 Cutting the FDP tendon short after retraction.
FIGURE 7.10 and 7.11 Cutting the nerves short but leaving the
nerve branch in the volar fl ap.
FIGURE 7.7 Conservative skin markings.
FIGURE 7.8 The bone is carefully cut with bone cutters and later
beveled and shaped using bone nibblers.