Phẫu Thuật Tái Tạo Bàn Tay Và Chi Trên

Congenital Hand Procedures
309
Indications and contraindications
● Treatment is usually not necessary in patients with type
I and some type II radial defi ciencies.
● The patient must have the ability to get the fi ngers to
the mouth with the wrist in the surgically altered straight
position.
● All patients should undergo stretching prior to surgical
release. A recent study has reported that preoperative
external fi xation placement may be the most effective
stretching treatment; however, we do not utilize this on
a regular basis in our practice.
Preoperative history
All patients warrant work-up for syndromes and associated
conditions because many have syndromes such as TAR
(thrombocytopenia absent radius), Holt–Oram, Fanconi’s,
or VACTERL (vertebral abnormalities, anal atresia, cardiac
defect, tracheotsophageal fi stula, renal abnormalities, limb
abnormalities). These conditions must be addressed prior
to any surgical treatment.
Operative approach
Many authors have advocated centralization procedures for
patients with radial dysplasia. We have found soft-tissue
release and bilobed fl ap reconstruction to be a better proce-
dure for our patients (Fig. 21.15).
A bilobed fl ap is carefully outlined over the dorsum of
the wrist. The incisions are made and the fl aps elevated
(Fig. 21.16). The extensor tendons, fl exor tendons, and
median nerve are identifi ed. These structures are usually
A
B
FIGURE 21.13 A This is type IV bifi d thumb with a shared metacarpal. Reconstruction must pay attention to reconstituting the radial collateral
ligament using a periosteal fl ap. B Appropriate skin design will produce an aesthetically pleasing reconstructed thumb.

Hand and Upper Extremity Reconstruction
310
A
B
FIGURE 21.14 Radial dysphasia showing the progressive loss of the
radius, with the most extreme type IV case where the radius is absent.
in a very abnormal radial position and careful identifi cation
is essential. The soft-tissue tethering is then released. We
do not advocate much stripping at the distal ulna to prevent
injury to the blood supply to the physis of the ulna. After
this is performed, the wrist is placed in a neutral position
and a 0.062 in Kirschner wire (or larger) is passed across
the ulnocarpal joint. The fl aps are then rotated into place
and closed using absorbable sutures (Fig. 21.17). A long-
arm cast is then applied.
Optimizing outcomes
●
Adequate preoperative stretching
●
Correct fl ap design
●
Careful identifi cation of median nerve and tendons prior to
releasing radial soft tissue
●
Pinning of wrist in neutral to allow wound/ fl ap healing
Complications and side-eff ects
The blood supply to the physis of the ulna can be damaged
if too much dissection is performed in that region. This can
ultimately lead to a very short forearm. Flap loss can occur
if the fl ap is not adequately designed, or if the wrist is not
stabilized postoperatively to allow fl ap healing. The median
nerve and tendons must be identifi ed.
Postoperative care
The patient is placed in a long-arm cast for 4 weeks. At
that time, the pin is removed and a splint fashioned for
wear.
Conclusions
The authors have found that soft-tissue release and bilobed
fl ap reconstruction is a reliable, effective procedure for

Congenital Hand Procedures
311
C
D
FIGURE 21.14, cont’d
FIGURE 21.15 Bilobed reconstruction in which the redundant skin
on the ulnar wrist after centralization is used to augment the skin
defi ciency over the radial wrist after centralization.
FIGURE 21.16 The fl ap elevation technique providing excellent full
exposure of the wrist during this operation.

Hand and Upper Extremity Reconstruction
312
FIGURE 21.17 Final closure of the fl ap without the traditional
requirement for excision of skin on the ulnar side of the wrist.
patients with radial dysplasia who need surgical reconstruc-
tion. The procedure is very dependable, and offers a pre-
dictable outcome with little morbidity. Although there is
certainly a risk of recurrence, we feel that it is no higher
than that seen with centralization or radialization proce-
dures. These latter procedures certainly have a higher risk
of signifi cant morbidity than our soft-tissue release/bilobed
fl ap reconstruction procedure.
Whatever choice is made for surgical treatment, it is
important to remember that these patients must have a
careful preoperative evaluation to assess underlying syn-
dromes, thereby optimizing their safety and appropriate-
ness for surgery.
HYPOPLASTIC THUMB
Hypoplastic thumb is most commonly seen as a compo-
nent of radial dysplasia.11 There are fi ve categories of thumb
hypoplasia, ranging from minimal defi ciency (type I) to
complete absence (type V).12 Appropriate surgical manage-
ment is related to the type of hypoplasia present.
Indications and contraindications
Patients with type I hypoplastic thumbs generally do not
require surgical treatment. Patients with types II (Fig.
21.18) and IIIA can generally benefi t from opponensplasty
and web-space deepening. This will provide opposition
function as well as an increase in fi rst web space. Patients
with types IIIB, IV, and V (Fig. 21.19) require pollicization
for reconstruction. Type IIIB thumbs usually require polli-
cization because of the presence of a very unstable thumb
carpometacarpal (CMC) joint.
Preoperative history and considerations
Because many of these patients have radial dysplasia, they
require appropriate evaluation to rule out other, more severe
underlying problems. See the radial dysplasia section for a
list of these.
Operative approach
Types II and IIIA hypoplastic thumbs
These patients usually need increased fi rst web space and
opposition. They have a stable carpometacarpal (CMC)
joint but signifi cant laxity at the metacarpophalangeal
(MCP) joint. We approach this condition using a four-fl ap
Z-plasty and ring fi nger superfi cialis opponensplasty. The
Z-plasty incisions are made (Fig. 21.20A,B) and the fi rst
dorsal interosseous fascia is released. The ulnar aspect of
the thumb MCP joint is then exposed. Next, a small inci-
sion is made over the radial aspect of the thumb MCP joint
to expose the distal metacarpal and MCP joint. The A-1
pulley of the ring fi nger is opened and the superfi cialis
tendon identifi ed. An incision is made over the volar
forearm to expose and identify the ring fi nger superfi cialis
proximally. The tendon is then transected distally and
delivered into the proximal wound. It is then rerouted
around the FCU tendon at the wrist proximal to the pisi-
form, and passed through a subcutaneous tunnel to the
radial thumb incision. A trough is made at the neck of the
metacarpal and the tendon is passed from radial to ulnar.
The thumb is placed in an opposition position and the
tendon sutured to the ulnar base of the proximal phalanx.
This technique not only accomplishes the opponensplasty,
but also stabilizes the ulnar MCP joint. The incisions are
FIGURE 21.18 Type II hypoplastic thumb with underdeveloped
hypothenar muscle. This can be treated with a Huber transfer, in
which the abductor digiti minimi muscle can be transferred across
the palm to reconstitute the thenar cavity and provide muscle
function for the thumb.

Congenital Hand Procedures
313
closed and the Z-plasty fl aps rotated and sutured (Fig.
21.20C).
Types IIIB, IV, and V hypoplastic thumbs
These children have thumbs that are usually not recon-
structable, therefore the optimum procedure is polliciza-
tion. The fl aps for pollicization are carefully outlined on the
index fi nger and the hand (Fig. 21.21). The palmar incision
is made and the neurovascular bundles are identifi ed and
isolated (Fig. 21.22). The radial digital artery may be absent,
but the transferred index fi nger is dependent on the common
digital artery to the index and middle fi ngers. The arterial
branch to the middle fi nger is ligated and the common
digital nerve is mobilized as proximally as possible to allow
transposition of the index fi nger without tethering of the
digital nerve. It is essential to assess adequate vascular
infl ow to the index fi nger before continuing with the pro-
cedure. If this cannot be assured, the procedure must be
aborted. The A-1 pulley of the index fi nger is opened and
the fl exor tendons as well as the neurovascular bundles are
isolated with vessel loops (Fig. 21.23). Attention is then
turned to the dorsum of the fi nger, where the outfl ow veins
are isolated and extensor tendons freed after incising the
dorsal skin fl aps. The intermetacarpal ligament is next
divided to mobilize the index fi nger. The interosseous
muscles are then taken down off their insertions distally
and mobilized proximally. Careful attention to preservation
of the collateral ligaments is important. A proximal oste-
otomy at the base of the second metacarpal is performed,
with epiphyseodesis being performed distally. The shaft of
the index metacarpal is then removed (Fig. 21.24). The
MCP joint is placed in hyperextension and a 0.035 or 0.045
in Kirschner wire is passed across the MCP joint in a ret-
rograde fashion. The base of the proximal index metacarpal
is shaped to accommodate the hyperextended MP joint, and
2/0 non-absorbable sutures are placed around this area. The
A
B
FIGURE 21.19 This patient has absence of the thumb and a good
indication for index pollicization.

Hand and Upper Extremity Reconstruction
314
A
B
C
FIGURE 21.20 A This patient had an FDS transfer that was looped
around the fl exor carpi ulnaris tendon as a pulley to provide thumb
abduction. B Patients with a thumb–index web space can be released
using a four-fl ap Z-plasty to deepen the web space, which can also
augment the results of the FDS abductor plasty. C Insetting of the
four-fl ap Z-plasty.

Congenital Hand Procedures
315
A
B
FIGURE 21.21 A popular fl ap option is the option proposed by Buck
and Gramcko. The C fl ap will eventually form the thumb–index web
space, the B fl ap will rest on the palmar side of the thumb and the A
fl ap will interdigitate between the C and the B fl aps.
FIGURE 21.22 The ulnar and radial neurovascular bundles are
identifi ed. The transferred thumb can survive on an intact ulnar
neurovascular bundle because in some cases the radial digital artery
is very small or may not be present.
MCP joint is then placed in its new position and the Kirsch-
ner wire advanced across this area. After correct position is
assured, the 2/0 non-absorbable sutures are placed at the
base of the proximal phalanx. It is mandatory that the
neurovascular bundles are examined to determine that no
kinking exists. Next, the interosseous muscles are reposi-
tioned into the dorsal base of the middle phalanx (lateral
bands). The extensor tendons are then examined. If two
tendons exist then the radial one is shortened so that it can
insert on the dorsoradial base of the middle phalanx. The
ulnar extensor tendon is then imbricated to shorten it to
the proper length. Skin fl aps are rotated then closed (Fig.
21.25) and the vascularity of the index fi nger is assessed.
A dressing and long-arm cast are then applied.
Complications and side-eff ects
If the viability of the pollicized digit is questionable, the
fi rst step is to ensure that the neurovascular bundle is not
compressed or kinked. Both the room and the digit must
be warm. A local anesthetic wrist nerve block is placed for
postoperative pain control and potential vasodilation effect.
These steps are usually adequate to treat a digit that may
have vasospastic problems.
Postoperative care
A long-arm cast is placed for 6 weeks. The pin is removed
after cast removal and a splint is applied for an additional
6 weeks.
Optimizing outcomes
●
Proper fl ap design
●
Careful identifi cation and dissection of the neurovascular
bundles
●
Ensure no kinking of the neurovascular bundles once the
pollicized digit is set in place
●
Proper position and length of pollicized digit

FIGURE 21.23 The A-1 pulley should be released to allow adequate transfer of the index fi nger, with the fl exor tendon acting as the FPL
tendon for the newly created thumb.
Hand and Upper Extremity Reconstruction
316

Part of metacarpal
removed
Index finger transposed to
be used as thumb
Base and head of index
metacarpal serves as
CMC joint
A
B
FIGURE 21.24 A The metacarpal is removed, but the base of the metacarpal is left intact and the head of the metacarpal will serve as the CMC
joint, the PIP joint will serve as the MCP joint, and the DIP joint will serve as the IP joint of the newly created thumb. B Recession of the index
fi nger to make a new thumb.
A
B
FIGURE 21.25 The fl ap sutured in place.

Conclusion
Hypoplastic thumb usually has an accompanying compo-
nent of radial dysplasia. For this reason proper preoperative
evaluation is mandatory. Reconstruction is based on the
type of hypoplasia present. Type I usually requires no treat-
ment. Types II and IIIA require web-space deepening and
opponensplasty, and types IIIB, IV, and V benefi t from pol-
licization. As a result, it is imperative to diagnose the type
of hypoplasia correctly.
REFERENCES
1. Kozin S. Upper-extremity congenital anomalies. J Bone Joint Surg
Am 2003; 85: 1564–1576.
2. Man L, Chang B. Maternal cigarette smoking during pregnancy
increases the risk of having a child with a congenital digital
anomaly. Plast Reconstruct Surg 2006; 117: 301–308.
3. Netscher D. Congenital hand problems: terminology, etiology and
management. Clin Plast Surg 1998; 25: 537–552.
4. McCarroll H. Congenital anomalies: A 25-year overview. J Hand
Surg 2000; 25A: 1007–1037.
5. Watson BT. Post-axial type-B polydactyly: prevalence and
treatment. J Bone Joint Surg Am 1997; 79: 65–68.
6. Cohen M. Thumb duplication. Hand Clin 1998; 14: 17–27.
7. Ogino T, Ishii S, et al. Long-term results of surgical treatment of
thumb polydactyly. J Hand Surg 1996; 21(A): 478–486.
8. Ezaki M. Radial polydactyly. Hand Clin 1990; 6: 65–68.
9. Wassel HD. The results of surgery for polydactyly of the thumb.
Clin Orthop 1969; 64: 175.
10. Bayne CG, Klug MS. Long-term review of the surgical treatment of
radial defi ciency. J Hand Surg (Am) 1987; 12: 169–179.
11. James M, Green H, et al. The association of radial defi ciency
with thumb hypoplasia. J Bone Joint Surg Am 2004; 86:
2196–2205.
12. Plancher K, Kahlon R. Diagnosis and treatment of congenital
thumb hypoplasia. Hand Clin 1998; 14: 101–118.
13. Golash A, Watson J. Nail fold creation in complete syndactyly
using Buck–Gramcko pulp fl aps. J Hand Surg (Br) 2000; 25B:
11–14.
14. Muzaffar A, Rafols F, et al. Keloid formation after syndactyly
reconstruction: associated conditions, prevalence, and
preliminary report of a treatment method. J. Hand Surg 2004;
29A: 201–208.
Hand and Upper Extremity Reconstruction
318

319
C H A P T E R
22
Techniques in Reconstruction
of the Burned Hand
C. Scott Hultman
INTRODUCTION
Reconstruction of the burned hand requires a multidisci-
plinary approach that not only combines elements of hand,
plastic, and burn surgery, but also utilizes resources that
include critical care, nursing, occupational therapy, and
rehabilitative medicine.1–9 Management of the burned hand
is essentially the art of matching the needs of the patient
with surgical solutions that yield the best functional and
aesthetic outcomes. The challenge to the healthcare pro-
vider is to create and implement a surgical plan that
addresses the goals of resuscitation, resurfacing, reconstruc-
tion, rehabilitation, and reintegration, all of which overlap
but evolve as the patient moves towards reaching his or her
potential for recovery.
RESUSCITATION
Like all patients with thermal injury, individuals with acute
hand burns must undergo a carefully coordinated resuscita-
tion that includes determination of mechanism, assess-
ment of burn wound depth, restoration of perfusion, damage
control of other injuries, appropriate wound care, occupa-
tional therapy, and consideration of systemic issues.
Mechanism
The fi rst step in taking care of the patient with a hand burn
is obtaining a reliable history to determine the mechanism
of injury. Thermal injury can be due to a spectrum of eti-
ologies, all of which yield a different constellation of signs
and symptoms. Causes of burn injury include scald, contact,
fl ame, chemical, and electrical. Patients with both high-
and low-voltage electrical injuries can have considerable
tissue damage that is not refl ected by the size of the external
burn.7 Another particularly challenging type of burn is the
hot-press injury, in which patients have a crush component
in addition to the thermal component.
Burn wound characteristics
The size, location, and depth of the burn wound all affect
the management and prognosis. Even isolated, relatively
small burns of the hand can dramatically affect fi nal func-
tion. Both isolated and non-isolated hand burns can impair
the patient’s ability to perform activities of daily living,
delay discharge, and prevent return to work. For example,
both the electrician with median nerve disruption after
electrical injury and the textile worker with a boutonnière
deformity after an industrial press injury may not be
able to re-enter the workplace at their previous level of
competence, despite appropriate care, reconstruction,
and rehabilitation.
Perhaps the most important determinant of outcome is
burn wound depth. First-degree burns are notable for ery-
thema and edema but have no tissue loss and heal without
diffi culty. Second-degree, superfi cial partial-thickness burns
are characterized by painful blistering but will heal via
regenerating dermal elements, provided adequate wound
care is available. Second-degree, deep partial-thickness
burns have desquamated areas, with signifi cant dermal
destruction. Such burns may take longer than 3 weeks to
heal and will benefi t from excision and grafting. Third-
degree full-thickness burns are leathery, dry, and insensate;
they will only heal by eschar separation and secondary
contraction, and require early excision and grafting to opti-
mize function. Fourth-degree burns damage structures
invested by the skin and can include injury to neurovascu-
lar structures, tendon, muscle, and bone; amputation
and/or fl ap coverage is often required to achieve wound
closure.
Restoration of perfusion
Patients with circumferential hand burns, electrical injury,
or large burns requiring aggressive resuscitation may develop
impaired hand perfusion that mandates immediate inter-

Hand and Upper Extremity Reconstruction
320
vention.6 Compartment syndromes of the forearm and
hand occur as edema increases due to local and systemic
capillary leakage, and as interstitial pressures exceed fi lling
pressures. Circumferential full-thickness burns often benefi t
from prophylactic escharotomy, whereas patients who
develop compartment pressures greater than 25 mmHg or
symptoms of pain and paresthesia require fasciotomy.
Waiting until the patient develops pulselessness to perform
a compartment release falls below the accepted standard of
care. Digital escharotomy remains a controversial proce-
dure but may be indicated on rare occasions. Complete
upper extremity fasciotomies include release of the dorsal
and volar forearm, carpal tunnel release, thenar and hypo-
thenar fasciotomy, and dorsal hand interosseous fascioto-
mies (Fig. 22.1A–E).
Damage control
In addition to compartment release to restore perfusion to
the hand, other damage control procedures include fracture
stabilization, reduction of dislocated joints, acute nerve
decompression, debridement of clearly non-viable tissue,
A
B
C
D
E
FIGURE 22.1 A–E This 36-year-old electrician, who sustained an arc
fl ash injury from a high-voltage transformer, later underwent skin
grafting of the fasciotomy sites and the dorsum of the hand.
Complete upper extremity fasciotomies for compartment syndrome
after an electrical injury include release of the volar and dorsal
compartments, the carpal tunnel, and the thenar, hypothenar, and
interosseous muscles. The pronator quadratus must also be explored
and decompressed, as this muscle can sustain signifi cant injury,
given its location deep to the fl exors and in continuity with the radius
and ulna. Bone is a poor conductor of electricity and considerable
heat is generated in the relatively small cross-sectional area of the
wrist.

Techniques in Reconstruction of the Burned Hand
321
and amputation. Patients with electrical injury require mul-
tiple debridements in the operating theater, prior to defi ni-
tive coverage, to ensure that all necrotic tissue has been
removed.
Wound care
Currently accepted wound care practices for thermal injury
of the hand include the application of an antimicrobial
cream that is changed daily. Burn wounds have classically
been described to include a zone of coagulation (necrosis),
a zone of stasis, and a zone of hyperemia. The depth and
size of the wound can increase if perfusion is impaired (from
inadequate resuscitation), or if the wound becomes infected
(from local organisms or distant sources, such as a pneumo-
nia). To reduce bacterial and fungal colonization, various
antimicrobial agents have been used and each has variable
penetration of the eschar. In our practice, we use silver sul-
fadiazine initially, switching to sulfamylon for pseudomonal
infections and silver nitrate for fungal infections.
Occupational therapy
In acute management of the burned hand, the early and
proactive delivery of occupational therapy is important.
Range of motion must be maintained because stiffness will
develop rapidly to cause tendon, volar plate, and joint adhe-
sions. Splinting in the intrinsic plus position to maintain
metacarpophalangeal (MCP) joints in fl exion and proximal
interphalangeal (PIP) joints in extension, and the wrist in
slight extension, is critical to keep the collateral ligaments
maximally stretched. Occupational therapy is particularly
important in critically ill patients who cannot participate
in their own care. The overall value of occupational therapy,
whether immediately after injury, perioperatively, or
through the reconstruction period, cannot be overempha-
sized. To paraphrase a famous quote: ‘the sins of the burn
surgeon can be covered by the glove of the therapist.’
Systemic issues
Because more than 80% of patients admitted to a burn
center have hand involvement,6 most patients with hand
burns have multiple factors infl uencing their overall care.
A partial list of competing priorities includes mechanical
ventilation for inhalation injury, dialysis for renal failure,
anticoagulation for deep venous thrombosis prophylaxis or
therapy, and use of vasoactive agents for cardiac failure or
septic shock. Furthermore, patients with large total body
surface area wounds may have a limited number and limited
quality of donor sites. The surgical team must remain
cognisant of all of these issues but not lose sight of the
principles of early excision and coverage of the hand,
in combination with vigilant occupational therapy.
RESURFACING
Following stabilization of the acutely burned hand, wound
excision and closure become the most important goals.
Although superfi cial partial-thickness wounds heal within
1–2 weeks and rarely require grafting, biologic dressings
such as Biobrane and cultured fi broblasts have been advo-
cated but are cost-prohibitive, compared to standard anti-
microbial cream. Deep partial-thickness wounds are
observed for 2–3 weeks and excised if not healing within
that period. Full-thickness burns of the hand almost always
require excision and defi nitive closure.
Excision
For most partial-thickness hand burns, tangential excision
of the eschar and mid-dermal elements is the procedure of
choice. Using a Weck blade or Goulian knife with a guard,
the surgeon removes devitalized tissue in a tangential plane
until fi ne punctate capillary bleeding is encountered, indi-
cating a viable bed. Extreme care must be used when excis-
ing eschar over the dorsum of the fi ngers, as the extensor
apparatus can easily be injured. The advantage of this tech-
nique is that a layer of deeper dermis is preserved, providing
structural, mechanical, and vascular support for a skin
graft. The disadvantage is that signifi cant blood loss can
occur, approaching 1 mL for every cm2 of tissue excised. To
minimize blood loss, we immediately wrap the hand in a
phenylephrine-soaked compressive gauze. The Versajet
(Smith & Nephew, Hull, UK), which debrides at a fi xed
depth via pulsed hydrosonic energy, can also be used as an
adjunct to tangential excision.
For full-thickness burn wounds, however, we prefer to
perform initial full-thickness excision under tourniquet
control. The excision is carried out in a suprafascial plane,
leaving paratenon intact to support a skin graft. The advan-
tage of this approach is that it limits blood loss and opti-
mizes visualization of critical structures such as tendons,
nerves, and vessels. A disadvantage is the potential over-
excision of viable tissue. The tourniquet is then defl ated to
observe the viability of the prepared surface. Additional
sharp debridement is usually required.
Location of the burn wound also guides our decision-
making. We have a low threshold for excision of burn
wounds over the dorsal surface of the hand, especially over
joints. In contrast, the thick glabrous skin of the palmar
surface has excellent potential for regeneration, and there-
fore these burn wounds are rarely excised or acutely
grafted.
Temporary coverage
When the viability of the wound is uncertain, as in the case
of electrical or hot-press injuries, or when defi nitive cover-
age is not available, temporary coverage is indicated.10 We
prefer to use fresh cadaveric split skin grafts, colloquially
known as ‘homograft,’ for wound closure, because of this
material’s relative availability, ease of use, comparatively
low cost, excellent take rate, and resistance to infection.
Other options include acellular dermal matrix (Alloderm),
bilaminate skin substitutes (Integra), and bioprosthetic
dermal analogues (Biobrane). Although all of these materi-
als will promote wound closure, all require defi nitive

Hand and Upper Extremity Reconstruction
322
replacement with epithelium. We have also abandoned
culture keratinocytes in the temporary or defi nitive closure
of burn wounds because of the exorbitant cost (>$100,000
to resurface 10% total body surface area), the 3-week delay
in preparing these grafts, mechanical fragility, and diffi culty
in application.11
Grafting
The gold standard for wound closure of the acutely burned
hand remains thick (14/1000-in), split-thickness sheet
autografts.12–14 Full-thickness grafts are reserved for late
reconstructive procedures, and meshed, thin autografts are
used only if there is signifi cant concern for bed viability or
if the patient has limited donor sites. Despite an improved
take rate, meshed grafts have an increased incidence of
contracture and an inferior aesthetic outcome. Although
full-thickness grafts have almost no contraction, provide
more robust tissue for vital areas of the hand, and can
become reinnervated, full-thickness grafts are limited in
size and have an uncertain take rate in freshly excised burn
wounds. Donor locations for split-thickness grafts include
the thighs and buttocks; those for full-thickness grafts
include the distal ulnar forearm, antecubital fossa, medial
arm, and lateral groin.
Flaps
Indications for fl ap coverage of the acute or late burn wound
include inability of the bed to support a skin graft or skin
substitute, and the need to cover vital structures with vas-
cularized tissue.15–27 Examples include a child with exposed
extensor tendons from a contact burn, or an electrician who
undergoes delayed ulnar nerve reconstruction with a sural
nerve graft.
Limited areas of the hand can be resurfaced with several
different types of intrinsic fl ap, such as the innervated kite
fl ap from the index fi nger (Fig. 22.2A–F), fl ag fl aps based
on dorsal digital vessels, cross-fi nger fl aps, and dorsal meta-
carpal artery fl aps. Regional options include adipofascial
turnover fl aps from the forearm (Fig. 22.3A–E), as well as
reverse fl ow fl aps, based on the posterior interosseous,
radial (Fig. 22.4A–E), or ulnar vessels (the last two of which
require a patent superfi cial palmar arch). Distant fl aps,
which need to be divided at a second stage, include the
groin fl ap (Fig. 22.5A–D), the periumbilical perforator fl ap,
and the random-pattern chest fl ap. Finally, free tissue
transfer may be the best option for wound coverage, when
regional fl aps may lie within the zone of injury or are unable
to provide an adequate surface area. Options used in our
practice have included serratus, latissimus, and rectus
abdominis for muscular coverage; lateral arm, parascapular,
and anterolateral thigh skin for fasciocutaneous coverage;
and omentum for massive defects of the upper extremity.
The most reliable and frequently used fl ap in our prac-
tice remains the groin fl ap. In addition to providing a large
paddle of vascularized skin, this fl ap can be harvested
quickly and confi dently, can be inset anywhere on the hand,
wrist, and distal forearm, and can be used in combination
with skin grafts to resurface a fairly large area. Furthermore,
the fl ap can be easily thinned with liposuction or direct
lipectomy, withstands repeat elevation for multiple recon-
structive procedures, and has an excellent esthetic result.
Our only admonition is that this fl ap should be used cau-
tiously in patients with seizure disorders (which may result
in disruption), advanced age (resulting in elbow and shoul-
der stiffness), and psychiatric illness (specifi cally anxiety
disorders, which may become exacerbated).
Amputation
Careful consideration of the patient’s functional goals,
including potential for rehabilitation, may argue toward
amputation as the best method of wound closure (Fig.
22.6A–D). For example, the laborer who has a full-
thickness, fourth-degree chemical burn to the dorsum of the
index fi nger would benefi t from ray amputation. The power
linesman who sustains a 10 000 volt injury, with a non-
viable hand/forearm and persistent myoglubinuria, requires
a below-elbow amputation, if the elbow can be safely pre-
served. Fillet fl aps are also an excellent source of innervated
tissue to resurface other portions of the hand. Amputation
facilitates wound closure and may be life-saving.
RECONSTRUCTION
Despite receiving excellent care during the resuscitative and
resurfacing phases, patients with hand burns may develop
complications and deformities that require reconstruction
to correct functional defi cits.28–34 Multiple problems may
coexist that affect the delicate relationships between joints,
tendons, ligaments, nerves, and skin. In addition to focus-
ing on the underlying problem, the surgeon must also con-
sider the soft tissue envelope and be prepared to import
vascularized tissue to ensure a successful reconstruction. In
burn patients, hand surgery is truly the surgery of the skin
and its contents.
Stiff ness
Perhaps the most common sequela after burn injury to the
hand is stiffness. The exact etiology may include a number
of different causative factors: persistent edema, shortening
of collateral ligaments, tendon adhesions, capsular contrac-
tures, and constriction of the soft tissue envelope. All of
these conditions benefi t from range of motion exercises
(active and passive) and splinting. Occasionally, patients
require manipulation of joints under anesthesia with con-
current steroid injections. Occupational therapy must con-
tinue through the postoperative period to retain these gains
in function.
Swan-neck deformity
Intrinsic tightness may occur as a result of an imbalance
between the fl exor and extensor tendons and lateral bands

Techniques in Reconstruction of the Burned Hand
323
A
B
C
D
E
F
FIGURE 22.2 A This 42-year-old electrician sustained a focal left hand burn that was allowed to heal by secondary intention, resulting in a
numb index fi nger, as well as a Tinel’s sign over the second metacarpal, proximal to the zone of injury. B Exploration of the palm revealed
disruption of the radial digital nerve. C End-to-end neurorrhaphy and neurolysis of the ulnar digital nerve plus release of the palmar
contracture. D The wound was covered with an innervated kite fl ap harvested from the dorsum of the index fi nger, over the proximal phalanx.
Contracture along the radial side of the middle fi nger was released with a fi ve-fl ap ‘jumping-man’ z-plasty. E Postoperative healing of donor site
for the innervated kite fl ap. F Postoperative healing of the recipient site of the innervated kite fl ap and healing of the z-plasty contracture
release.

Hand and Upper Extremity Reconstruction
324
A
B
C
D
E
FIGURE 22.3 A–E This 67-year-old man sustained full-thickness
burns to the volar wrist after contact with a fl oor heater following
a seizure. His radial artery developed a mycotic aneurysm that
subsequently ruptured. Following acute burn wound excision and
ligation of the radial artery, the median nerve and superfi cial fl exor
tendons were covered with an adipofascial turnover fl ap, based on
the distal radial artery perforators, plus a skin graft.
from the lumbricals and interosseous muscles. Patients
with an ischemic insult to the intrinsic muscles of the hand
or with inadequate splinting develop shortening of the
lateral bands, yielding intrinsic tightness and a deformity
that results in hyperextension of the MCP and PIP joints,
and fl exion of the DIP joints. Intrinsic tightness can be
tested by confi rming that fl exion of the MCP joint improves
the ability to passively fl ex the PIP joint (Bunnell’s sign). If
occupational therapy is unsuccessful in re-establishing the
length of lateral bands, surgical therapy to correct intrinsic
tightness includes division of the lateral bands.
Tendon adhesions
In contrast to intrinsic tightness, patients may develop
extrinsic tightness from adhesions that limit the excursion
of the extensor tendons. Passive PIP fl exion is more diffi cult
when the MCP joint is fi rst fl exed. Of note, adhesions can
form directly under skin grafts, in areas that have healed
by secondary re-epithelialization, and even outside the zone
of injury. Surgical therapy involves tenolysis of involved
tendons, which is combined with postoperative hand
therapy and immediate range of motion exercises.

Techniques in Reconstruction of the Burned Hand
325
A
B
C
D
E
FIGURE 22.4 A This 54-year-old woman sustained deep partial-
thickness burns to the hand and forerarm from a scald injury. She
underwent sheet grafting to the thumb and meshed split-thickness
grafting to the wrist. B She formed a hypertrophic scar, and
subsequently developed severe median nerve compression. C, D The
scar was excised and resurfaced with a septocutaneous, reverse-fl ow,
radial forearm fl ap, following an extended carpal tunnel release.
E Postoperative photograph showing healed radial forearm fl ap.
Boutonnière deformity
Damage to the central slip of the extensor apparatus may
result in boutonnière deformity, leading to fl exion of the PIP
joint and hyperextension of the DIP joint. The mechanism
for this injury involves lateral and volar displacement of the
lateral bands, which now serve as fl exors rather than as
extensors of the PIP joint. This occurs when the central slip
is damaged, e.g., from direct thermal or crush injury, or from
exposure and dessication after the thin, dorsal skin has been
burned and lost. Acute management includes a combina-
tion of splinting and pinning in extension, and soft tissue
coverage is secured via fl ap or graft. Late reconstruction can
be quite challenging and depends on the condition of the
overlying skin, the degree of subluxation, the condition of
the joint capsule and cartilage, and the residual stiffness of
the fi nger.29 Options that can be pursued include plication
of the lateral bands for mild cases; a fi gure-of-8 tendon graft
to restore the full function of the central slip; and 30º
arthrodesis with buried Kirchner pins and cerclage wire. The
extensor apparatus and joint are approached from the dorsal
surface of the fi nger through a curvilinear incision.
Mallet fi nger
Injury to the distal portion of the extensor apparatus over
the DIP joint can result in disruption of the extensor tendon
where it inserts onto the distal phalanx, leading to a mallet
fi nger. Splinting in extension may correct the acute defor-

Hand and Upper Extremity Reconstruction
326
A
B
C
D
FIGURE 22.5 A This 61-year-old man sustained full-thickness chemical burns to the dorsum of the hand and underwent failed attempts at
resurfacing with split skin grafts and, on a subsequent occasion, a bilaminate skin substitute. B He ultimately required a pedicled groin fl ap that
was divided 3 weeks later and thinned with each syndactyly release. C, D Postoperative photographs showing healed fl aps to the fi ngers.
mity, but arthrodesis is usually performed for chronic defor-
mities. Fusion of the DIP joint with 0–5º of fl exion is
approached through an H incision, to preserve any remain-
ing germinal matrix, and is secured via a longitudinal wire
or compression pin after residual cartilage is removed.
Claw hand
The combined forces of dorsal skin contracture, intrinsic
tightness, extrinsic tightness, joint stiffness, ligamentous
and volar plate shortening, and injury to the extensor appa-
ratus conspire to produce the claw hand. This deformity
has variable presentations, but typically includes hyperex-
tension of the MCP joints and fl exion contractures of the
PIP joints, both of which dramatically impair hand function
and need to be corrected. We proceed with reconstruction
of the claw hand via a staged approach, fi rst addressing the
soft tissue envelope and performing a groin fl ap or free
tissue transfer to improve soft tissue coverage. At the second
stage we treat the MCP region via a combination of exten-
sor tenolysis, dorsal capsulotomy, and splinting in fl exion.
Although the PIP joints may require a dorsal approach to
repair a damaged central slip, or to perform arthrodesis, we
usually perform a volar release of the fl exion contracture,
which allows for access to the volar plate, followed by full-
thickness skin grafting.
Palmar and digital contractures
A frequently observed effect of deep burns to the volar
surface of the hand is contracture of the palm that limits
full extension of the digits and mobility of the thumb.
These contractures are released under tourniquet control
and resurfaced with full-thickness grafts. The surgeon must
pay particular attention to identifying and preserving the
neurovascular bundles, which can be quite superfi cial. The
superfi cial palmar fascia is also incised to permit full release.
We usually delay release in children until they are over 2
years of age, unless the contracture has impaired growth of
the digit. Patients are splinted for several weeks as the graft
is incorporated. Choice of donor site has a major impact on
the color and texture of the resurfaced hand.

Techniques in Reconstruction of the Burned Hand
327
Web space deformities
Burn injury to the web space, with or without grafting, may
result in acquired syndactyly and adduction contractures,
reversing the slope of inclination and preventing full abduc-
tion. For dorsal syndactylies extending to the mid-portion
of the proximal phalanx, the web space can be reconstructed
via tissue re-arrangement, using VM-plasty or STARplasty
to reline the cleft with supple tissue from the digital side-
walls.31,32 For acquired syndactylies extending beyond the
mid-portion of the proximal phalanx, full release requires
the use of diamond-shaped full-thickness skin grafts to
resurface the web space.
Contractures of the fi rst web space are particularly
important to address as they involve not only thumb abduc-
tion, but also thumb opposition and fl exion.28 In addition
to releasing the web space skin contracture, which is typi-
cally dorsal, the surgeon may need to address an adduction
contracture that is caused by fi brosis and shortening of the
adductor pollicis muscle. After releasing the fascia and,
when necessary, the insertion of the adductor pollicis, per-
cutaneous K-wires are then used to place the thumb meta-
carpal temporarily in maximal abduction, and the defect is
resurfaced with a full-thickness skin graft. First web space
contractures that do not involve the adductor pollicis may
not require skin grafting and can be released and resurfaced
via a fi ve-fl ap ‘jumping man’ Z-plasty.
Nail-plate abnormalities
Burn injury to the germinal matrix, sterile matrix, or
eponychial skin may result in a hook-nail deformity, nail-
plate grooving, proximal nail exposure, or dystrophic nail
with chronic paronychia.30 These deformities may have
signifi cant psychological stigmata, in addition to the func-
tional problems related to grip and grasp. Whereas the
eponychium can be relined with a full-thickness skin graft,
A
B
C
D
FIGURE 22.6 A This 33-year-old powerlineman sustained a high-voltage injury to his left upper extremity, which was treated via fasciotomy
and eventually thumb amputation. B Poor infl ow via an attenuated radial artery, combined with a thrombosed ulnar artery, precluded safe
pollicization or toe-to-thumb transfer. Instead, the patient underwent late neurolysis of the median and ulnar nerves, complete fl exor tenolysis,
and tendon transfer of the fl exor pollicis longus to the index fi nger fl exor digitorum profundus, which had been disrupted by the original injury.
D He is now able to use a prosthetic thumb, has been able to lower his golf handicap to 18 (which is considerably better than the author’s), and
has recently returned to work as a supervisor.

Hand and Upper Extremity Reconstruction
328
or the matrix repaired with donor material from the toe,
severe injuries are best served by ablation of the nail through
surgical resection of the germinal matrix.
Nerve compression syndromes
Patients with signs or symptoms of peripheral nerve com-
pression may benefi t from decompression. The pathophysi-
ology can include a combination of extrinsic compression
from the burn scar, intrinsic compression from traditional
points of fascial and ligamentous compression, and/or pre-
existing occult disease. Although carpal tunnel syndrome,
cubital tunnel syndrome, and ulnar nerve compression at
the wrist are the most common syndromes encountered,
we have also observed and treated compression of
the superfi cial radial nerve, posterior interosseous nerve,
anterior interosseous nerve, and peroneal nerve. Tendon
transfers, such as opponensplasty for median nerve palsy,
may be indicated for long-standing or permanent nerve
dysfunction.
Caveats for surgical intervention include 1) corrobora-
tion of fi ndings on physical examination with mechanism
and history of symptoms, 2) identifi cation of a Tinel’s sign
to help guide the site of decompression, 3) release of all
potential points of constriction (including the deep motor
branch of the ulnar nerve during Guyon’s canal release), 4)
combining multiple releases under one tourniquet pass, 5)
minimizing incision length when in the zone of injury, and
6) consideration of coverage with vascularized tissue. We
obtain nerve conduction studies only when history and
physical examination are not consistent, when multiple
sites of compression are suspected, or for patients with
recurrent symptoms. Semmes–Weinstein pressure thresh-
old tests are very valuable in confi rming diagnosis and
monitoring response to surgical intervention.
Amputation deformity
Occasionally revision amputation is necessary to address
an unstable soft tissue envelope, heterotopic ossifi cation in
the stump, or neuroma formation causing excessive pares-
thesias or dysthesias. Surgical principles include shortening
the central bone or covering the distal portion of the ampu-
tation with vascularized tissue. Distraction osteogenesis
has been reported but is rarely indicated and remains
controversial.33 Thumb length can be preserved using an
innervated kite fl ap from the dorsum of the index fi nger,
or a groin fl ap to provide bulk and a larger surface area.
Maximizing forearm length for a prosthesis or retaining the
elbow may require free tissue transfer.
Thumb loss
Because the thumb represents at least 40% of the function
of the hand, extreme measures are employed to maximize
thumb length, restore innervation, and retain range of
motion. For patients who had a thumb amputation, options
include pollicization of the index fi nger or toe-to-thumb
transfer.34 If patients do not want to sacrifi ce a normal toe
or do not have an favorable recipient site (severe scarring
with no infl ow or outfl ow, absent median nerve, loss of
fl exor tendons), an alternative is a prosthetic thumb. An
artifi cial thumb can be quite stable and can be fashioned to
assist with opposition of the remaining fi ngers.
Elbow dysfunction
Patients with thermal injury to the upper extremity may
develop signifi cant problems with elbow function that
include fl exion contractures of the antecubital fossa, cubital
tunnel syndrome, lateral epicondylitis, and heterotopic
ossifi cation. All of these conditions may be present in isola-
tion or in combination. The surgical management of het-
erotopic ossifi cation begins with appropriate imaging with
plain fi lms and CT scans to identify areas of ossifi cation
that need to be excised. Unless the patient has motor loss
from ulnar nerve compression, we wait at least 6 months
from the time of injury to proceed. Operative intervention
includes release of soft tissue contractures, resection of all
abnormal bone deposits until full passive range of motion
is restored, anterior transposition of the ulnar nerve to a
submuscular or subfascial plane, and consideration of cov-
erage with vascularized tissue.
Axillary contractures
Limitations of shoulder abduction and rotation due to ante-
rior or posterior contractures dramatically affect the func-
tion of the upper extremity. Limited scars with adjacent
unburned tissue are amenable to rearrangement with mul-
tiple fl ap z-plasties, but most axillary contractures require
major release. Options for resurfacing include thick split
grafts, thin split grafts over acellular dermal matrix (Allo-
derm; LifeCell Corporation, Branchburg, NJ), or fasciocuta-
neous fl aps, but the recurrence rate is frustratingly high.
We currently prefer a two-staged approach that involves the
application of a bilaminate skin substitute (Integra; Integra
Lifesciences Corporation, Plainsboro, NJ) with a subatmo-
spheric sponge dressing (VAC device; Kinetic Concepts,
Inc., San Antonio, TX), followed 1–2 weeks later by defi ni-
tive skin grafting.
Pain
Patients presenting with debilitating pain following burn
injury to the hand may have a combination of neuropsy-
chiatric and functional components that need to be
addressed. For patients with chronic pain due to non-ana-
tomic etiologies, we initiate a pharmacotherapeutic regimen
that includes non-steroidal anti-infl ammatory drugs, anti-
depressants, anti-seizure agents, topical analgesics, and
weaning off narcotics. However, the surgeon must also
search for anatomic etiologies that can be corrected: nerve
compression syndromes, neuroma formation, basilar thumb
arthritis, and stenosing tenosynovitis.

Techniques in Reconstruction of the Burned Hand
329
REHABILITATION
Once secondary and tertiary reconstructions have been
completed, the patient continues with the process of reha-
bilitation. Occupational therapy represents the keystone for
this endeavor. Patients must undergo a rigorous, individu-
alized, and rationally designed protocol that maintains and
optimizes the gains achieved by surgery. This includes
active and passive range of motion exercises, strengthening,
conditioning, sensory re-education, and fi ne-motor retrain-
ing. Skin care involves the indefi nite use of sunscreen and
moisturizing agents. Scar management remains important
and is facilitated by deep massage, ultrasound, paraffi n, and
convective heat dry whirlpool. For patients with hypertro-
phic scars, options include silicone sheeting, steroid tape,
or intralesional steroid injections. Finally, all patients must
use compressive garments for years to mitigate the effects
of chronic edema and persistent alterations in lymphatic
drainage.
Another important component of the rehabilitative
process is the management of neuropsychiatric problems
observed after burn injury. In addition to the functional
hand problems that may compromise recovery, patients
may present with chronic pain, post-traumatic stress dis-
order, affective illness, memory loss, personality changes,
altered body image, and sexual dysfunction. Critical input
from healthcare providers in physical medicine, anesthesia,
neurology, psychiatry, and even alternative medicine
(acupuncture, hypnosis) may alleviate some of this
dysfunction.
REINTEGRATION
Management of the thermally injured hand is not complete
until patients return to their previous level of function or
have at least reached their potential for recovery. This can
be defi ned by resuming activities of daily living and by
rejoining the workforce as a productive member of society.
A rehabilitation counselor is essential for coordinating and
facilitating this process of reintegration into society.
Because the majority of hand burns in our practice are
work related, most patients have access to resources that
will aid in their transition back to employment. After com-
pleting reconstruction and nearing the conclusion of
occupational therapy, we obtain a functional capacity evalu-
ation (FCE) to determine what patients can do and what
they can tolerate. We often combine the FCE with an
assessment by vocational rehabilitation (VR), job retrain-
ing, and a site visit by the rehabilitation counselor who
confi rms that the new job description matches patient
restrictions. Following a 3-month work trial, the patient
receives a fi nal impairment rating based on the AMA
Guidelines for the Evaluation of Permanent Impairment
(5th edition).35 This pathway from injury to recovery typi-
cally takes 1–2 years to complete. Although patients with
hand burns may not require additional surgical care, the
burn team follows these individuals indefi nitely to ensure
that rehabilitative goals are maintained and that potential
recovery is fulfi lled.
Supported in part by the Ethel F. and James A. Valone
Distinguished Professorship in Plastic Surgery.
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Hand and Upper Extremity Reconstruction
330

331
INDEX
Note: APL = abductor pollicis longus; CMC = carpometacarpal; DIP = distal interphalangeal; ECTR = endoscopic carpal tunnel release; IVRA
= intravenous regional anesthesia; MCP = metacarpophalangeal; PIP = proximal interphalangeal; SLAC = scapholunate advanced collapse;
SLIL = scapholunate interosseous ligament; STT = scaphotrapeziotrapezoid; TFCC = triangular fi brocartilage complex; UCL = ulnar collateral
ligament
traumatic mechanisms, 102
vein repair, 106, 115–18
thumb reconstruction see thumb,
reconstruction
analgesia, fi nger amputation, 99
anconeus epitrochlearis, 266
Andre-Thomas sign, 204
anesthesia, 1–17
intravenous regional, 1, 3, 4, 5–6, 16
local anesthetic pharmacology, 2–3, 16
nerve blocks, 2, 4–17
surgical amputation, 91
anterior interosseous nerve syndrome
(AINS), 263–5
antibiotics
burned hands, 321
fi nger infections, 209, 210
anxiolysis, 1
arcade of Struthers, 266
arterial anastomoses
replantation surgery, 106, 108, 109–15
thumb reconstruction, 284, 286, 290–1
arthrodesis, 149–60
or arthroplasty, 163, 164, 167
Dupuytren’s contracture, 223
fi xation methods, 150–3, 160
joint surface preparation, 149–50, 151,
155
perilunate dislocations, 142
position, 149, 160
preoperative considerations, 149–50,
164
replantation surgery, 108
scapholunate instability, 146
arthrography
perilunate dislocations, 140–1
scapholunate instability, 143
TFCC injuries, 124–5, 127
arthroplasty, 163–81
or arthrodesis, 164, 167
metacarpophalangeal joint, 164, 166,
170–7
proximal interphalangeal joint, 164–5,
166, 177–80
techniques, 164–6
thumb CMC, 164–5, 166–70
arthroscopy, TFCC repair, 121, 126–32
axillary contractures, 329
axonotmesis, 245, 246
B
Bier’s block (IVRA), 1, 3, 4, 5–6, 16
bifi d thumb (preaxial polydactyly), 306–8,
309
bone anchor technique, UCL repair, 83–4,
85
bone grafts
arthrodesis, 153, 154, 155
scaphoid fractures, 137–8, 139
thumb reconstruction, 280
bone scintigraphy
perilunate dislocations, 141
scaphoid fractures, 135
bone stapler, arthrodesis, 152, 153, 155
bone tunnel technique, UCL repair, 85–6,
87
bouquet pinning, 67, 68
boutonnière deformity
after extensor tendon injury, 55, 56
burned hands, 325
MCP arthroplasty, 171
PIP arthroplasty, 177
rheumatoid arthritis leading to, 164,
165, 171
brachial plexus anatomy, 245–6, 247
brachial plexus injuries (BPI), 245–53
classifi cation, 247
complications of surgery, 252–3
contraindications for surgery, 247
delayed presentation, 252
indications for surgery, 247
MABC nerve grafts, 235
nerve transfers, 237, 251–2
operative approach, 237, 248–52
postoperative care, 253
preoperative considerations, 247–8
surgical management algorithm, 247,
248
brachial plexus neuritis, 263, 264
brachioradialis, high median nerve palsy,
201, 203
Brand transfer, ulnar nerve palsy, 204,
205–6
Buck–Gramcko fl ap, pollicization, 315
Bunnell opposition transfer, 200
burned hands, 319–29
reconstruction, 322–9
amputation deformity, 328
axillary contractures, 329
A
abductor digiti quinti (ADQ) transfer, 199,
201, 203, 312
abductor pollicis longus (APL) tendon
anatomy, 47
repair, 52, 58
suspension arthroplasty, 167–70
transfers
radial nerve palsy, 196, 199
ulnar nerve palsy, 203, 204, 206
abscesses, subcutaneous, 210, 211, 215–16
Acutrac screw, 151, 153
adductor pollicis
burned hands, 327
ulnar nerve palsy, 201, 203
adipofascial turnover fl aps, 322, 324
advancement fl aps, 277, 278
Agee method, ECTR, 259–60, 262
alkalization, local anesthetics, 3
Allen’s test, 269
amputation (surgical), 89–99
burned hands, 322, 327, 328
contraindications, 89
in the digit, 91, 92–5
fi ngertip, 91–2
indications, 89
pain relief, 99
preoperative considerations, 89–91
ray, 91, 95–9, 322
amputation (traumatic)
replantation, 101–18
arterial anastomoses, 106, 108,
109–15
heterotopic, 118
ischaemia time, 102, 106
lesion types, 101–2
nerve repair, 106, 108, 116, 118
non-replantable fi ngers, 118
patient selection, 101–2
preoperative preparation, 102–6
proximal stump preparation,
106–7
skeletal fi xation, 107–8
skin closure, 118
tendon sutures, 108–9
thumb, 101, 102, 103, 106–7, 108,
112–15, 116–17, 118, 277
transportation of amputated part,
102, 106

Index
332
boutonnière deformity, 325
claw hand, 326
elbow dysfunction, 328–9
fi nger contractures, 326
mallet fi nger, 325–6
nail-plate deformities, 327–8
nerve compression syndromes, 238
pain, 329
palmar contractures, 326
stiffness, 322
swan-neck deformity, 322–4
tension adhesions, 324
thumb loss, 328
web space deformities, 327, 328
rehabilitation, 329
reintegration, 329
resurfacing phase, 321–2
amputation, 322
excision, 321
fl aps, 322
grafting, 322
temporary coverage, 321–2
resuscitation phase, 319–21
damage control, 320–1
mechanism of injury, 319
occupational therapy, 321
restoration of perfusion, 319–20
systemic issues, 321
wound care, 321
wound characteristics, 319
C
Camitz opposition transfer, 199, 200–1, 202
capitate, four-corner fusion, 146, 156–7
carpal tunnel syndrome, 256–62, 328
anatomy, 256
anesthesia, 15, 17
electrodiagnostic studies, 257
endoscopic release, 259–62
history, 257
non-operative management, 257
open release, 257–9, 262
pathophysiology, 256
physical examination, 257
postoperative care, 259, 260
postoperative complications, 259, 260–2
surgical contraindications, 257, 259
surgical indications, 257, 259
carpectomy, SLAC wrist, 146, 147
carpometacarpal (CMC) joint
arthrodesis, 149, 152, 155, 164, 167
arthroplasty, 164–5, 166–70
dislocations/fracture-dislocations, 62, 64–
5, 66
hemihamate arthroplasty, 75
osteoarthritis, 163, 166–7
carpus
SLAC wrist carpectomy, 146, 147
ulnocarpal impaction syndrome, 128
cellulitis, 210, 211
central slip anatomy, 48–9
central slip injuries, 53, 55, 56, 325
central slip test (Elson’s test), 53
chevron osteotomy, arthrodesis, 150, 151
children
burned hands, 322, 326
congenital hand procedures, 301–18
digital amputation (surgical), 89
extensor tendon injuries, 54, 55
replantation, 102, 103, 104
thumb reconstruction, 277, 281, 287
chondromalacia, TFCC injury, 126, 128
claw hand, burn injuries, 326
Clostridia infections, 216
collateral recess pinning
metacarpal base fractures, 66
metacarpal shaft fractures, 62–3
compartment syndrome
burned hands, 320
metacarpal shaft fractures, 61
compressive neuropathies see nerve
compression syndromes
computed tomography (CT) scans
perilunate dislocations, 141
scaphoid fractures, 135
scaphoid nonunion, 136
TFCC injuries, 124
congenital hand procedures, 301–18
hypoplastic thumb, 312–18
postaxial polydactyly, 305–6
preaxial polydactyly, 306–8, 309
radial dysplasia, 301, 308–12
syndactyly, 301–5
cross-fi nger fl ap, thumb reconstruction, 277,
278
cross-side fi nger fl ap, thumb reconstruction,
277, 278
crossed K-wire fi xation
arthrodesis, 150–1, 154
metacarpal neck fractures, 67
phalangeal shaft fractures, 69, 71
CT scans see computed tomography (CT)
scans
cup and cone preparation, arthrodesis, 150,
151, 155
D
Darrach procedure, 188–91
degloved skin, replantation, 102, 107,
111–12
dermofasciectomy, Dupuytren’s contracture,
226
digital artery, replantation surgery, 112–15
digital nerve blocks, 2, 11–15, 16, 17
distal interphalangeal (DIP) joint
arthrodesis, 149, 150, 153–4, 164
arthroplasty, 164, 166
burned hands, 325–6
Dupuytren’s contracture, 221, 222,
227
extensor tendon anatomy, 49
extensor tendon injuries, 50, 53–5, 56,
325–6
fl exor tendon injuries, 30, 32, 33–4, 35,
36
ganglion cysts, 23
osteoarthritis, 163, 166
rheumatoid arthritis, 163–4
septic arthritis, 215
surgical amputation at, 92, 94
traumatic amputation at, 108, 113,
115
distal radioulnar joint (DRUJ)
piano key maneuver, 124
surgical procedures for, 183, 188–91
TFCC repair, 123, 124, 125, 127, 128,
130
distal radius fractures
TFCC tears, 123, 124
volar plate fi xation, 183–8
dorsal island fl ap, thumb reconstruction,
277, 279
dorsalis pedis fl ap, thumb reconstruction,
278–80, 291
dorsolateral island fl ap, thumb
reconstruction, 277, 278
Doyle classifi cation, mallet fi nger, 54–5
duplicated thumb (preaxial polydactyly),
306–8, 309
Dupuytren’s disease and contracture,
219–30
anatomy, 220–1
cause, 219–20
complications, 228–9
contraindications for surgery, 221–2
genetics, 219
histology, 219
indications for surgery, 221–2
nomenclature, 219
non-surgical treatment, 223
pathology, 220–1
postoperative care, 230
preoperative considerations, 223–4
surgical management, 224–30
Durkan’s test, 256, 257, 262
E
Eaton classifi cation, CMC joint disease,
166–7
Eikenella corrodens, 209, 216
elbow dysfunction, thermal injury, 328–9
electrical burns, 319–20, 321
amputation, 322, 327
fl aps, 322, 323
electrodiagnostic studies (EDS)
brachial plexus injuries, 248, 251
nerve compression syndromes, 256
anterior interosseous nerve, 264
burned hands, 328
carpal tunnel, 257
distal ulnar neuropathy, 269
pronator syndrome, 262–3
proximal ulnar neuropathy, 267
radial tunnel, 272
superfi cial radial nerve entrapment,
274
upper arm radial neuropathy, 271
endoscopic carpal tunnel release (ECTR),
259–62
epinephrine, as local anesthetic additive, 2,
16
epineurial sutures, nerve repair, 233–4
eponychium
anatomy, 20
burned hands, 327–8
deformities, 22–3
infections, 214
extensor carpi radialis brevis (ECRB)
tendon
anatomy, 47, 49
injury assessment, 52

Index
333
transfers
radial nerve palsy, 196, 197, 199
ulnar nerve palsy, 201, 203, 204, 205
extensor carpi radialis longus (ECRL) tendon
anatomy, 47, 49
chronic scapholunate instability, 143
injury assessment, 52
thumb CMC arthroplasty, 168–9
transfers, 143, 196, 199
extensor carpi ulnaris (ECU) tendon
anatomy, 47, 49
injuries
assessment, 52
with TFCC injuries, 123, 124, 125
transfers, 196, 199
extensor digiti minimi (EDM) tendon, 47,
196
extensor digitorum communis (EDC) tendon
anatomy, 47, 48, 49
injury assessment, 50, 52
injury repair, 56, 57
transfers, 196, 197, 198, 199
extensor indicis proprius (EIP) tendon
anatomy, 47, 49
injury assessment, 51
transfers
high median nerve palsy, 201, 203
low median nerve palsy, 199, 201
radial nerve palsy, 196, 198, 199
extensor pollicis brevis (EPB) tendon
anatomy, 47
injury repair, 58
thumb CMC arthroplasty, 168, 169
transfers, 196, 199
extensor pollicis longus (EPL) tendon
anatomy, 47, 49
injury assessment, 51
injury repair, 58
thumb CMC arthroplasty, 167, 168
transfers, 196, 197, 198, 199
extensor retinaculum injuries, 57, 58
extensor tendons, 47–58
anatomy, 47–9
fi nger amputation (surgical), 91, 92
injuries
assessment, 49–50, 51–3
burns, 322–4, 325–6
complications, 58
rehabilitation, 58
suture technique, 50, 53, 54
treatment, 50, 53–8
zones, 49, 50
innervation sequence, 49
preaxial polydactyly, 306–7
replantation surgery, 108, 109
transfers
chronic scapholunate instability,
143
median nerve palsy, 199, 201, 203
radial nerve palsy, 195–6, 197, 198,
199
ulnar nerve palsy, 201, 203, 204,
205
external fi xators
arthrodesis, 152
phalangeal fractures, 74–5
PIP joint arthroplasty, 180
F
fascicular sutures, nerve repair, 233–4
fasciectomy, Dupuytren’s contracture, 223,
226
fasciotomy
burned hands, 320, 327
Dupuytren’s contracture, 223
felons, 210, 214–15
fi eld blocks, 15, 17
fi nger
amputation (surgical), 89
burned hands, 322
contraindications, 89
indications, 89
operative approach, 91–9
postoperative management, 99
preoperative considerations, 89–91,
92–3
amputation (traumatic)
replantation, 102, 104, 106–10,
112–14, 117, 118
thumb reconstruction, 295, 296–7
anterior interosseous nerve syndrome,
264
arthrodesis, 149, 150, 151–2, 153–4,
164
arthroplasty, 163, 164–5, 166, 170–80
boutonnière deformity, 55, 56, 164, 165,
171, 177, 325
burns see burned hands
contractures, 326, 327
distal ulnar neuropathy, 269
Dupuytren’s contracture, 221, 222, 223,
224–30
infections see fi nger infections
joints see distal interphalangeal (DIP)
joint; metacarpophalangeal (MCP;
MP) joint of fi nger; proximal
interphalangeal (PIP) joint
mallet, 53–5, 325–6
osteoarthritis, 163, 170, 178
phalangeal fractures see phalangeal
fractures
pollicization, 292, 295, 296–7, 313–18
polydactyly, 301, 305–8
posterior interosseous nerve entrapment,
273
proximal ulnar neuropathy, 266, 267
rheumatoid arthritis, 163–4, 165, 170,
171, 178
sensory nerve transfers, 241–2
superfi cial radial nerve entrapment,
273–4
swan-neck deformity, 55, 163, 164–5,
171, 178, 322–4
syndactyly, 301–5, 327
tendons see fi nger extensor tendons;
fi nger fl exor tendons
fi nger extensor tendons
anatomy, 47–9
fi nger amputation (surgical), 91, 92
injuries
assessment, 49–50, 51–2, 53
burns, 322–4, 325–6
sutures, 50, 53, 54
treatment, 50, 53–7
replantation surgery, 108, 109
transfers
high median nerve palsy, 201, 203
low median nerve palsy, 199, 201
radial nerve palsy, 195–9
fi nger fl exor tendons, 29
anatomy, 29–30, 31
burned hands, 322–4
fi nger amputation (surgical), 91, 95
intrinsic healing, 29
purulent tenosynovitis, 211–14
replantation surgery, 108–9
transfers
high median nerve palsy, 201, 203
low median nerve palsy, 199, 200,
201
radial nerve palsy, 196
ulnar nerve palsy, 203, 204, 206
zone 1 injuries, 29, 30–5, 36
zone 2 injuries, 35–9
zone 3 injuries, 43–4
zone 5 injuries, 44
fi nger infections, 209–17
complications, 216
contraindications for surgery, 209, 211
felons, 210, 214–15
indications for surgery, 209–11
paronychia, 210, 214–15
postoperative care, 216
preoperative considerations, 211
purulent fl exor tenosynovitis, 211–14
septic arthritis, 210, 215
subcutaneous abscesses, 210, 211,
215–16
fi ngernail infections, 210, 214–15
fi ngernail preservation, 91, 92
fi ngernail reconstruction, 19–26
anatomy, 20
burned hands, 327–8
complications, 24–5
contraindications, 19
DIP joint ganglion cysts, 23
eponychial deformities, 22–3
exposure, 20
hyponychial deformities, 22–3
indications, 19
nail bed reconstruction, 21, 23–5, 26
nail bed repair, 20, 21–2, 23, 26
outcome optimization, 23–4
pincer nail reconstruction, 22, 25–6
postoperative care, 25–6
preoperative considerations, 19–20
thumb, 283, 284–6, 289
tourniquets, 20
fi ngertip amputation, 91–2
fi ngertip infections, 210, 211, 212, 214–15
fl aps
burned hands, 322, 323–6
Dupuytren’s contracture surgery, 224,
225, 228–9
fi nger amputation (surgical), 92, 94
hypoplastic thumb, 312, 313, 314, 315,
317
preaxial polydactyly, 306, 308
radial dysplasia, 309–12
replantation surgery, 118
syndactyly reconstruction, 301, 303,
304

Index
334
thumb reconstruction, 277–84, 285–9,
291, 294, 295
zone 2 fl exor tendon injuries, 35–6, 37
fl exor carpi radialis (FCR) tendon
thumb CMC arthroplasty, 168, 169–70
transfers
chronic scapholunate instability, 143,
144
radial nerve palsy, 196–8, 199
fl exor carpi ulnaris (FCU) tendon, 196, 200,
201
fl exor digitorum profundus (FDP) tendon,
29
anterior interosseous nerve syndrome,
264
fi nger amputation (surgical), 91, 95
high median nerve palsy, 201, 203
replantation surgery, 108
two-stage tendon reconstruction, 39–40,
41
zone 1 injuries, 30–5, 36
zone 2 injuries, 35, 36–7
zone 3 injuries, 44
zone 5 injuries, 44
fl exor digitorum superfi cialis (FDS) tendon,
29
transfers
low median nerve palsy, 199, 200
radial nerve palsy, 196
ulnar nerve palsy, 201, 203, 204, 206
two-stage tendon reconstruction, 40
zone 1 injuries, 32, 35, 36
zone 2 injuries, 35, 36–7
zone 3 injuries, 44
zone 5 injuries, 44
fl exor pollicis longus (FPL) tendon
anatomy, 30
anterior interosseous nerve syndrome,
263, 264
injury repair, 43
purulent tenosynovitis, 213
transfers
high median nerve palsy, 201, 203
radial nerve palsy, 196, 199
ulnar nerve palsy, 201
fl exor tendons, 29–46
anatomy, 29–30, 31
anterior interosseous nerve syndrome,
263, 264
burned hands, 322–4
fi ngertip amputation (surgical), 91, 95
intrinsic healing, 29
postoperative rupture, 35, 38
purulent tenosynovitis, 211–14
replantation surgery, 108–9
thumb CMC arthroplasty, 168, 169–70
transfers
chronic scapholunate instability, 143,
144
high median nerve palsy, 201, 203
low median nerve palsy, 199, 200,
201
radial nerve palsy, 195, 196, 199
ulnar nerve palsy, 203, 204, 206
two-stage reconstruction, 39–43
zone 1 injury repair, 30–5, 36
zone 2 injury repair, 35–9
zone 3 injury repair, 43–4
zone 4 injury repair, 44
zone 5 injury repair, 44–5
fl exor tenosynovitis, purulent, 211–14
fl uoroscopic imaging
distal radius fractures, 186, 187, 188
TFCC repair, 130
forearm amputations, replantation, 102,
105, 109
four-corner fusion, 146, 156–7
SLAC wrist, 146
fractures
complications, 75–7
distal radius, 123, 124, 183–8
metacarpal, 61–8
phalangeal see phalangeal fractures
scaphoid, 135–9
ulnar, 125, 127
Froment’s sign, 201, 203
functional capacity evaluation (FCE), burned
hands, 329
fungal infections, burned hands, 321
G
gamekeeper’s thumb, 79, 84–5
ganglion cysts, DIP joint, 23
general anesthesia, advantages, 2
Gilula’s lines, 140, 141, 143
gracilis muscle transfer, 252, 253
groin fl ap
burned hands, 322, 326
thumb reconstruction, 294
Guyon’s canal compression, 259, 268–9,
271, 328
H
hamate
degenerative TFCC lesions, 128
four-corner fusion, 146, 156–7
headless bone screws
metacarpal head fractures, 68
scaphoid fractures, 136, 137
hemihamate arthroplasty, 75, 77
Herbert screws, 150
herpetic whitlows, 211, 212
Horner’s syndrome, 251
hot-press burns, 319, 321
Houston’s tabletop test, 222
Huber transfer, 201, 203, 312
humpback deformity, 135, 136, 137
hyponychium
anatomy, 20
deformities, 22–3
hypoplastic thumb, 312–18
I
interosseous artery, TFCC, 121
interosseous muscles
extensor mechanism, 47
ray amputation, 96–7
interosseous wiring, arthrodesis, 150, 151,
152
interphalangeal (IP) joint see distal
interphalangeal (DIP) joint;
proximal interphalangeal (PIP)
joint
intramedullary nails (IMs), 64
intravenous regional anesthesia (IVRA;
Bier’s block), 1, 3, 4, 5–6, 16
ischaemia time, replantation, 102, 106
island fl aps, 277, 278, 279, 280, 282–3,
295, 296–7
J
Jahss maneuver, 66–7
Jeanne’s sign, 201, 267
juncturae tendinum
extensor tendon anatomy, 48
extensor tendon injuries, 50, 51, 57
K
K-wiring
arthrodesis, 150–1, 154, 155, 156, 158,
159, 160
metacarpal base fractures, 65, 66
metacarpal neck fractures, 67, 68
metacarpal shaft fractures, 62, 64
phalangeal head fractures, 72
phalangeal shaft fractures, 69, 71, 72
ray amputation, 97, 99
replantation surgery, 107–8, 113, 115
UCL repair, 86
Kanavel’s signs, 210
kite fl ap
burned hands, 322, 323
thumb reconstruction, 277, 278, 279
L
lag screws
metacarpal base fractures, 65
metacarpal shaft fractures, 63–4
phalangeal head fractures, 72, 74
phalangeal shaft fractures, 72
lateral antebrachial cutaneous (LABC) nerve,
235, 236, 237
lidocaine, 2, 3
ligament injuries
extensor retinaculum, 57, 58
perilunate dislocations, 139–42
scapholunate instability, 142, 143, 144
TFCC see triangular fi brocartilage
complex (TFCC) repair
ulnar collateral ligament of thumb,
79–87
local anesthetics
epinephrine with, 2, 16
IVRA technique, 4
local infi ltration, 15–17
pharmacology, 2–3, 16
use in nerve blocks see nerve blocks
lumbrical muscles, 47–8
lunate
dislocation, 139, 140, 141
four-corner fusion, 146, 156–7
radiolunate fusion, 157, 158
scapholunate dissociation, 139, 140,
142–7
lunocapitate dissociation, 139, 140
lunotriquetral joint
dissociation, 139, 140
TFCC repair, 123–4, 130, 132
M
magnetic resonance imaging (MRI)
perilunate dislocations, 141
scaphoid fractures, 135, 136
scapholunate instability, 143

Index
335
TFCC injuries, 124–5
mallet fi nger
burned hands, 325–6
management, 53–5
mallet injuries of thumb, 58
McCash operation, 225
medial antebrachial cutaneous (MABC)
nerve graft, 235–6
median nerve
compression syndromes
anterior interosseous nerve, 263–5
carpal tunnel, 15, 17, 256–62, 328
pronator syndrome, 262–3
transfer from radial nerve, 238–9, 240
transfer from ulnar nerve, 238, 241–2
transfer to radial nerve, 239–41
see also median nerve injuries
median nerve block
at wrist, 8–10, 11, 13
in mid-forearm, 4–7, 9
median nerve injuries
reconstruction
nerve grafts, 235–6
nerve transfers, 238–9, 240, 242–3
tendon transfers, 199–201, 202–3
with zone 5 fl exor tendon injuries, 30,
44–5
metacarpals
fractures, 61–8
base, 64–6
complications, 75–7
head, 68
neck, 66–8
shaft, 61–4
pollicization, 313, 317
ray amputation, 96, 97, 98
replantation, 102, 107, 114
metacarpophalangeal (MCP; MP) joint of
fi nger
arthrodesis, 149, 150, 151, 152, 154,
164
arthroplasty, 164, 166, 170–7
burned hands, 324, 326
Dupuytren’s contracture, 221, 222, 223,
224, 225, 230
extensor tendon anatomy, 47, 48, 49
extensor tendon repair, 50, 52, 56–7
osteoarthritis, 163, 170
replantation surgery, 108
rheumatoid arthritis, 163, 164, 170,
171
surgical amputation through, 91, 93
ulnar nerve palsy, 201, 203, 204
metacarpophalangeal (MCP; MP) joint of
thumb
arthrodesis, 149, 153, 154–5, 164, 167,
171
arthroplasty, 164–5, 167, 171
burned hands, 324, 326
extensor tendon anatomy, 47
extensor tendon repair, 58
hyperextension deformity, 167
hypoplasia, 312–13, 315
osteoarthritis, 163
replantation surgery, 108
rheumatoid arthritis, 163, 164
UCL injuries, 79, 80, 81, 82, 84, 85
whole great toe transfer, 285, 287–90
midazolam, 1
MRI see magnetic resonance imaging
MRSA infections, 209
mycobacterial infections, 209, 216
N
nail see fi ngernail
nerve action potentials (NAPs)
anterior interosseous nerve syndrome,
264
brachial plexus injuries, 251
nerve blocks
contraindications, 2
digital, 2, 11–15, 16, 17
local anesthetic pharmacology, 2, 3
in mid-forearm, 4, 16
median nerve, 4–7, 9
radial nerve, 7–8, 10
ulnar nerve, 7, 9
ultrasound guidance, 4, 6, 7, 8–9, 16
at wrist, 8–11, 13, 16
median nerve, 8–10, 11, 13
radial nerve, 11, 13
ulnar nerve, 10–11, 12, 13
nerve compression syndromes, 255–75
anterior interosseous nerve, 263–5
burned hands, 328
carpal tunnel, 15, 17, 256–62, 328
distal ulnar neuropathy, 268–70, 271,
328
electrodiagnostic studies, 256
nerve anatomy, 255
nerve physiology, 255
posterior interosseous nerve, 272–3
pronator syndrome, 262–3
proximal ulnar neuropathy, 266–8
radial tunnel syndrome, 272
superfi cial radial nerve, 273–5
upper arm radial neuropathies, 270–2
nerve conduction studies (NCS), 256
anterior interosseous nerve syndrome,
264
brachial plexus injuries, 251
burned hands, 328
carpal tunnel syndrome, 257
distal ulnar neuropathy, 269
pronator syndrome, 262–3
radial tunnel syndrome, 272
superfi cial radial nerve entrapment, 274
upper arm radial neuropathy, 271
nerve conduits, 236–7
nerve defects, 235
nerve gaps, 235, 236, 237
nerve grafting, 234–6, 251
nerve injuries
extensor tendon system anatomy, 49
extensor tendon system repair, 57, 58
physiology of regeneration, 245
reconstruction, 233–42
brachial plexus, 235, 237, 245–53
direct repair, 233–4, 251
nerve conduits, 236–7
nerve grafting, 234–6, 251
nerve transfers, 233, 237–42, 251–2
replantation surgery, 106, 108, 116, 118
Seddon classifi cation, 245, 246
tendon transfers, 195–206
with thumb UCL repair, 84, 87
with zone 5 fl exor tendon injuries, 30,
44–5
nerve management, fi nger amputation
(surgical), 95, 96–7
nerve root avulsion, brachial plexus injuries,
250–1
nerve transfers, 233, 237–42, 251–2
neurapraxia, 245, 246
neurolysis, brachial plexus injuries, 251
neurotization see nerve transfers
neurotmesis, 245, 246
neurotoxicity, local anesthetics, 3
neurovascular island fl ap, thumb, 277, 278,
295, 296–7
O
occupational therapy, burned hands, 321,
329
on-top-plasty, 295, 296–7
onychocutaneous fl aps, 283, 284–6
open reduction with internal fi xation (ORIF)
metacarpal neck fractures, 67–8
metacarpal shaft fractures, 63, 64
phalangeal shaft fractures, 69, 71, 72
PIP fracture-dislocations, 75
opposition, thumb
burned hands, 328
hypoplasia, 312–13
nerve transfers, 238
tendon transfers, 199–201, 203
Osborne’s ligament, 266
osteoarthritis (OA)
arthroplasty, 163, 166–7, 170, 178
SLAC wrist, 146, 147
osteocutaneous fl ap, thumb, 280–3, 285,
286
P
pain relief
burned hands, 329
fi nger amputation (surgical), 99
palmar advancement fl ap, thumb, 277, 278
palmar contractures, burned hands, 326
palmar cutaneous nerve block, 10, 11
palmar fascia, Dupuytren’s disease, 220–1,
223, 224
palmaris longus tendon transfer
Camitz opposition transfer, 199, 200–1,
202
radial nerve palsy, 196–7, 198, 199
two-stage fl exor tendon reconstruction,
40, 41, 42
UCL repair, 85, 86, 87
Palmer classifi cation, TFCC injuries, 125–6
paronychia, 210, 214–15
Parsonage–Turner syndrome, 263, 264
Pasteurella multocida, 209, 216
perilunate dislocations, 139–42
perionychium
burned hands, 327–8
fi ngernail reconstruction, 19–26
infections, 210, 211, 212, 214–15
surgical amputation, 91–2
thumb reconstruction, 283, 284–6, 289
phalangeal fractures, 61, 69–77
complications, 75–7
extensor tendon injuries, 55
fl exor tendon injuries, 30, 32–4

Index
336
head, 72–5
with nail bed injuries, 19, 20
shaft, 69–72
thumb reconstruction, 280, 282–3
Phalen’s test, 256, 257, 262
piano key maneuver, 124
pincer nail reconstruction, 22, 25–6
plantaris tendon transfer, 204, 205–6
plate fi xation
arthrodesis, 152, 156, 158–9
distal radius fractures, 183–8
metacarpal fractures, 63, 67, 68
phalangeal fractures, 69, 71, 72
pollicization, 292, 295, 296–7
hypoplastic thumb, 313–18
polydactyly, 301
postaxial, 305–6
preaxial, 306–8, 309
posterior interosseous nerve (PIN)
entrapment, 272–3
radial tunnel syndrome, 272, 273, 274
TFCC innervation, 121
upper arm radial neuropathy, 270
posterior interosseous osteocutaneous fl ap,
280–1
power pinch, 201, 203, 204, 206
preaxial polydactyly, 306–8, 309
pronation, nerve transfers for, 238, 239
pronator quadratus (PQ)
anterior interosseous nerve syndrome,
263, 264
burned hands, 320
pronator syndrome, 262–3
pronator teres (PT) transfers, 196–8
proximal interphalangeal (PIP) joint
arthrodesis, 150, 153, 154, 164, 223
arthroplasty, 164–5, 166, 177–80
burned hands, 324, 325, 326
Dupuytren’s contracture, 221, 222, 223,
224, 226–9, 230
extensor tendon anatomy, 49
extensor tendon injury assessment, 50,
53
extensor tendon injury repair, 55–6
fracture-dislocations, 72–7
osteoarthritis, 163, 178
phalangeal shaft fractures, 69
rheumatoid arthritis, 163–4, 178
septic arthritis, 215
ulnar nerve palsy, 201, 203
Pseudomonas infections, 209, 216
pullout sutures, UCL repair, 83, 84
pulp fl ap, thumb reconstruction, 277–8,
280–1
Pulvertaft weave, 194–5, 196
purulent fl exor tenosynovitis, 211–14
pyrolytic carbon (pyrocarbon) implant
arthroplasty, 165, 166, 170
MCP joint, 173–7
PIP joint, 177, 178–80
Q
quadriga effect, 32, 33
quantitative sensory testing (QST), 256
anterior interosseous nerve syndrome,
264
distal ulnar neuropathy, 269
pronator syndrome, 263
superfi cial radial nerve entrapment,
274
R
radial artery, replantation surgery, 108, 109,
112
radial artery forearm fl ap
burned hands, 325
thumb reconstruction, 280, 282–3
radial dysplasia, 301, 308–12
radial nerve
compression syndromes
burned hands, 328
posterior interosseous nerve
entrapment, 272–3
radial tunnel syndrome, 272
superfi cial radial nerve entrapment,
273–5
upper arm, 270–2
replantation surgery, 108
thumb CMC arthroplasty, 170
transfer from median nerve, 239–41
transfer to median nerve, 238–9, 240
see also radial nerve injuries
radial nerve block
at wrist, 11, 13
in mid-forearm, 7–8, 10
radial nerve injuries
extensor tendon system anatomy, 49
nerve transfers, 239–41
reconstruction, 237
tendon transfers, 195–9
radial (preaxial) polydactyly, 306–8, 309
radial tunnel syndrome, 272
radiocarpal joint, 183
radiolunate fusion, 157, 158
radioulnar joint, distal see distal radioulnar
joint
radius
distal fractures
TFCC tears, 123, 124
volar plate fi xation, 183–8
radiolunate fusion, 157, 158
TFCC biomechanics, 121–3
TFCC repair
diagnostic imaging, 124
injury classifi cation, 125–6
patient history, 123, 124
type ID lesions, 128
ray amputation, 91, 95–9, 322
regional anesthesia, 1–17
intravenous, 1, 3, 4, 5–6, 16
local anesthetic pharmacology, 2–3, 16
nerve blocks, 2, 4–17
surgical amputation, 91
replantation techniques, 101–18
arterial anastomoses, 106, 108, 109–15
heterotopic, 118
ischaemia time, 102, 106
lesion types, 101–2
nerve repair, 106, 108, 116, 118
non-replantable fi ngers, 118
patient selection, 101–2
preoperative preparation, 102–6
proximal stump preparation, 106–7
skeletal fi xation, 107–8
skin closure, 118
tendon sutures, 108–9
transportation of amputated part, 102,
106
traumatic mechanisms, 102
vein repair, 106, 115–18
resuscitation, hand burn patients, 319–21
reverse fl ow fl ap, burned hands, 322, 325
reversed island fl ap, thumb, 278
rheumatoid arthritis (RA), 163–4
arthroplasty, 167, 170, 171, 178
distal radioulnar joint, 188
wrist arthrodesis, 159–60
ring avulsion injury, 102, 107–10, 112–14,
117
ring sign
perilunate dislocations, 140
scapholunate instability, 143
Rüsse bone graft, 137, 139
S
Sauvé–Kapandji procedure, 188
scaphoid
displacement test, 142
fractures, 135–9
nonunion, 135, 136, 145–6
scapholunate instability/dissociation,
139, 140, 142–7
shift test, 142
SLIL open reduction and reconstruction,
141–2
SLIL open reduction and repair, 141
STT fusion, 146, 156
scaphoid nonunion advanced collapse
(SNAC) wrist, 136, 145, 156
scapholunate advanced collapse (SLAC)
wrist, 146, 147, 156
scapholunate dissociation, 139, 140,
142–7
scapholunate interosseous ligament (SLIL)
acute scapholunate dissociation, 143
open reduction and reconstruction,
141–2
open reduction and repair, 141
scaphotrapeziotrapezoid (STT) fusion, 146,
156
scar formation, metacarpal and phalangeal
fractures, 75
scar management, burned hands, 329
scintigraphy
perilunate dislocations, 141
scaphoid fractures, 135
screw fi xation
arthrodesis, 150, 151–2, 153, 155
metacarpal fractures, 63–4, 65, 68
phalangeal fractures, 72, 74
scaphoid fractures, 136, 137
sedation, preanesthetic, 1
Seddon classifi cation, nerve injuries, 245,
246
Semmes–Weinstein testing (SWT), 256,
328
sensory nerve action potentials (SNAPs),
251
sensory nerve transfers, 241–2
septic arthritis, 210, 215
Serratia spp. infections, 209, 216

Index
337
silicone arthroplasty, 166
MCP joint (SMPA), 170, 171–3, 174,
175–6
PIP joint, 178, 180
thumb CMC arthritis, 167
silicone rods, fl exor tendon reconstruction,
40–1
skier’s thumb, 79
skin fl aps see fl aps
skin grafts
axillary contractures, 329
burned hands, 322, 324, 325, 326, 327
Dupuytren’s contracture, 225, 226, 230
Slade procedure, scaphoid fractures, 136–7
somatosensory evoked potentials (SSEPs),
251
splints
arthrodesis, 154, 155
Darrach procedure, 190
distal radius fractures, 188
Dupuytren’s contracture, 230
extensor tendon injuries, 55, 57, 58
MCP arthroplasty, 177
PIP arthroplasty, 180
ray amputation, 99
TFCC repair, 132
thumb CMC arthroplasty, 170
thumb UCL repair, 81–2, 83–4, 86, 87
split thumb (preaxial polydactyly), 306–8,
309
Sporothrix infections, 216
Staphylococcus aureus infections, 209
staple fi xation, arthrodesis, 152, 153, 155
Starr transfer, 196–8
Stener lesion, 80, 81, 82, 84
stiffness, burned hands, 322
streptococcal infections, 209, 214
Struthers’ arcade, 266
subcutaneous abscesses, 210, 211, 215–16
superfi cial radial nerve (SRN) entrapment,
273–5
suppurative (purulent) tenosynovitis,
211–14
sural nerve graft, 235–6
suspension arthroplasty, thumb CMC,
167–70
suture anchors, thumb UCL injuries, 85,
86
sutures
extensor tendon injuries, 50, 53, 54
fl exor tendon injuries, 32–3, 34, 35, 36,
37–8
nerve repair, 233–4
replantation surgery, 109–10
surgical fi nger amputation, 97
UCL repair, 83, 84, 85, 86
swan-neck deformity
burned hands, 322–4
chronic mallet deformity leading to, 55
MCP arthroplasty, 171
PIP arthroplasty, 178
rheumatoid arthritis leading to, 163,
164–5, 171
Swanson silicone implants, 166
syndactyly
burned hands, 327
congenital, 301–5
T
tendon(s)
extensor tendon injury management,
47–58
fi nger amputation (surgical), 91, 92, 95
fl exor tendon repair, 29–46
modifi ed APL suspension arthroplasty,
167–70
replantation surgery, 108–9
transfers, 193–206
chronic scapholunate dissociation,
143, 144
contraindications, 193–4
decision-making principles, 193
donor muscle amplitude, 194, 196
donor muscle availability, 193
donor muscle strength, 193–4
indications, 193–4
line of pull, 194
median nerve palsy, 199–201, 202–3
operative techniques, 194–5, 196
preoperative considerations, 194
radial nerve palsy, 195–9
single function/synergy, 194
SLIL open reduction and
reconstruction, 142
tendon harvest, 194–5
two-stage reconstruction, 40, 41, 42
UCL repair, 85, 86, 87
ulnar nerve palsy, 201–6
tenodermodesis, 55
tenodesis, ulnar nerve palsy, 201, 203
tenodesis test, extensor tendon, 53
tenolysis, 39
burned hands, 324
tenosynovitis, purulent fl exor, 211–14
tension adhesions, burned hands, 324
tension band wiring, arthrodesis, 150, 151,
152
Terry Thomas sign, 140
thermal injury see burned hand
Thompson suspension arthroplasty, 169
thumb
amputation (surgical), 89, 90, 327, 328
amputation (traumatic)
reconstruction see thumb,
reconstruction
replantation, 101, 102, 103, 106–7,
108, 112–15, 116–17, 118, 277
anterior interosseous nerve syndrome,
264
arthrodesis
or arthroplasty, 164, 167, 171
fi xation, 153, 155
position, 149, 150, 155
procedure, 154–5
staple fi xation, 152, 155
arthroplasty, 164–5, 166–70, 171
bifi d, 306–8, 309
burned hands, 327, 328
Dupuytren’s contracture, 221
extensor/abductor tendons
anatomy, 47
preaxial polydactyly, 306–7
repair, 51, 52, 58
transfers, 195–6, 197, 199, 203, 204
fl exor tendon system anatomy, 30
fl exor tendon system repair, 43
hypoplasia, 312–18
opposition
burned hands, 328
hypoplasia, 312–13
nerve transfers, 238
tendon transfers for, 199–201, 202–3
osteoarthritis, 163, 166–7
reconstruction, 277–98
burned hands, 328
defect classifi cation, 277, 278
donor site problems, 291
hypoplasia, 312–18
objectives, 277
on-top-plasty, 295, 296–7
options, 281, 285, 298
partial great toe transfer, 281–9, 298
pollicization, 292, 295, 296–7,
313–18
preaxial polydactyly, 306–8, 309
second-toe transfer, 281, 285, 291–2,
294, 298
soft tissue defects, 278–80
soft tissue plus bone defects, 280–1,
282–5
toe-to-thumb reattachment, 290–1
trimmed great toe transfer, 287, 298
whole great toe transfer, 285, 287–91,
298
wraparound procedure, 285, 286–7,
292–3, 298
split, 306–8, 309
tendon transfers
for opposition, 199–201, 202–3
radial nerve palsy, 195–6, 197, 199
ulnar nerve palsy, 201, 203, 204, 206
ulnar collateral ligament
acute injury, 79–84
chronic injury, 79, 84–7
Tinel’s sign, 257, 262, 267, 269, 328
toe, thumb reconstruction, 277–98
transthecal digital nerve block, 13–15, 16,
17
transverse carpal ligament (TCL), 256, 257,
258, 259, 260–2
transverse K-wire pinning
metacarpal base fractures, 65
metacarpal neck fractures, 67, 68
metacarpal shaft fractures, 62
transverse retinacular ligament (TRL), 49
trapeziectomy, 167–8, 170
trapezium, STT fusion, 146, 156
trapezoid, STT fusion, 146, 156
triangular fi brocartilage complex (TFCC)
repair, 121–32
anatomy, 121
biomechanics, 121–3
complications, 131
diagnostic imaging, 124–5, 127
indications, 123
injury classifi cation, 125–6
nerve supply, 121, 131
non-operative, 123
patient history, 123–4
postoperative care, 132
type IA lesions, 125, 126–7
type IB lesions, 125, 127

Index
338
type IC lesions, 125, 127–8
type ID lesions, 125–6, 128
type II degenerative lesions, 126, 128–
31, 132
vascular supply, 121
triangular ligament, 49
triquetrum, four-corner fusion, 146, 156–7
see also lunotriquetral joint
twisted-toe fl ap techniques, 287
U
ulna
fractures, 125, 127
impaction syndrome, 128
TFCC repair, 121–3, 124, 125, 127,
128–31
see also distal radioulnar joint
ulnar artery
replantation surgery, 108, 109, 112
TFCC vascular supply, 121
thrombosis, 269
ulnar artery forearm island fl ap, 280–1
ulnar collateral ligament (UCL) of thumb,
79–87
acute injury, 79–84
chronic injury, 79, 84–7
ulnar nerve
compression syndromes
burned hands, 328
distal, 268–70, 271
proximal, 266–8
replantation surgery, 108
TFCC innervation, 121
transfer to median nerve, 238, 241–2
see also ulnar nerve injuries
ulnar nerve block
at wrist, 10–11, 12, 13
in mid-forearm, 7, 9
ulnar nerve injuries
nerve grafts, 235–6
nerve transfers, 238
tendon transfers, 201–6
with zone 5 fl exor tendon injuries, 30,
45
ulnar (postaxial) polydactyly, 305–6
ulnocarpal impaction syndrome, 128
ultrasound-guided regional anesthesia, 4, 6,
7, 8–9, 16
V
vein grafts, 109, 111, 112, 115, 117
vein repair, 106, 115–18
Verdan zones, extensor tendon injury, 49,
50
vibrometry, 256
vincula system, 30, 32
volar plate arthroplasty (VPA), 75, 77
volar plate fi xation, distal radius fractures,
183–8
volar V-Y advancement fl ap, thumb, 277
W
wafer procedure, TFCC repair, 128, 130–1
wallerian degeneration, 245
Wartenberg sign, 267
web space
burned hands, 327, 328
hypoplastic thumb, 312, 314–15
sensory nerve transfers, 241–2
syndactyly reconstruction, 303, 304,
305
wraparound procedure, thumb
reconstruction, 285, 286–7, 292–
3, 298
wrist
anatomy, 121, 122
arthrodesis
limited, 155–7
perilunate dislocations, 142
position, 149, 160
replantation surgery, 108
SLAC wrist, 146, 156
total, 157–60
median-to-radial nerve transfer, 240
nerve blocks at, 8–11, 12, 13, 16
perilunate dislocations, 139–42
posterior interosseous nerve entrapment,
273
scaphoid fractures, 135–9
scaphoid nonunion, 135, 136, 145–6
scapholunate instability, 142–7
superfi cial radial nerve entrapment,
273
tendon transfers
radial nerve palsy, 195–9
ulnar nerve palsy, 204
TFCC repair, 121–32
traumatic amputation, replantation, 102,
109
ulnar-sided pain diagnosis, 121, 123
wrist blocks, 8–11, 12, 13, 16
X
X-rays
distal radius fractures, 184, 185
fi nger infections, 211
metacarpal base fractures, 64–5
metacarpal head fractures, 68
perilunate dislocations, 139–40
PIP fracture-dislocations, 73, 74
scaphoid fractures, 135
scapholunate instability, 142–3
TFCC injuries, 124
thumb UCL injuries, acute, 81
Z
Z-plasties
burned hands, 323, 327
hypoplastic thumb, 312, 314
syndactyly, 301, 303, 304