Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

arteries divide.
FIGURE 67.7 Volar hand with the palpable pisiform, hook of the hamate, distal pole of the scaphoid, and trapezial ridge
identified in black. The transverse carpal ligament (brown) as well as the relationship of the median and ulnar nerves (green)
and ulnar artery (red) to the palpable bones are drawn. The arterial branches as well as the nerve branches have a more
variable location from hand to hand.
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Dorsal Hand
Lister’s tubercle is the key to identifying the important dorsal structures (Figure 67.8). 7 It marks the distal
lip of the dorsal radius. Immediately distal to the tubercle is the midportion of the scapholunate ligament,
which links the scaphoid and the lunate. The head of the capitate is approximately 1 cm distal to the
palpable tubercle. The ulnar surface of the tubercle serves as a pulley for the extensor pollicis longus; the
fourth extensor compartment is 1 cm ulnar with its extensor digitorum communis and extensor indicis
proprius tendons. The second dorsal extensor compartment with its palpable extensor carpi radialis
longus and brevis tendons is on the radial border of the tubercle. Proximal to Lister’s tubercle is the radial
metaphysis, a good source of bone graft.
FIGURE 67.8 Dorsal hand with Lister’s tubercle identified (black circle in center) and the underlying bony anatomy drawn
(distal radius and ulna and metacarpal bases in black, carpals in purple). The ECRL and ECRB in the second compartment and
the EPL in the third compartment are drawn in orange. The extensor retinaculum is drawn in brown.
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Radial Hand
The radial styloid, the abductor pollicis longus and extensor pollicis brevis tendons, and the extensor
pollicis longus tendon all form the anatomic snuffbox (Figure 67.9). 8 The first dorsal compartment, the
artery used in the 1,2 intercarpal radial artery pedicled bone graft, and the sensory branch of the radial
nerve all overlie the dorsal radial styloid. The dorsal branch of the radial artery and its venae comitantes
are located deep in the snuffbox, easily and reliably identifiable for free flap anastomoses. The thumb
CMC joint is the firm bony structure, which creates the distal lid of the snuffbox. The bony floor deep is
the distal scaphoid and the trapezium.
FIGURE 67.9 Radial wrist with the bony anatomy drawn (the radial styloid and metacarpal base in black, scaphoid, and
trapezium in purple). The EPL and EPB/APL ridges are clearly visible. The dorsal branch of the radial artery (in red) courses
diagonally on the surface of the wrist capsule from volar-proximal to dorsal-distal.
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Ulnar Hand
The palpable ulnar styloid is the origin of the TFCC as well as the border of the sixth dorsal compartment.
The bone palpable 1 cm distal to the styloid is the hamate, and the next bony prominence distal is the
base of the little finger metacarpal with its concomitant CMC joint. Analogous to the radial snuffbox
configuration, the tendon that is palpable dorsal to the styloid and hamate is the extensor carpi ulnaris
tendon while the volar border is the flexor carpi ulnaris tendon.
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Digit
The junction of the glabrous and nonglabrous skin marks the midlateral line of a finger (Figure 67.10).
Points on this line can be found when the PIP and DIP joints are flexed. Incisions in this line are
preferable to minimize scar contractures of the joints. The digital neurovascular bundles and flexor
tendon sheath are volar to this line, and the bony phalanges are dorsal, a fact to keep in mind when
placing percutaneous K-wires.
FIGURE 67.10 CT cross-section of the proximal phalanx of the thumb, the volar surface is on the top. The dots are at the
junction of the glabrous and nonglabrous skin, which is also the midlateral line. The arrows point to the neurovascular bundles
in the 2 o’clock and 10 o’clock positions.
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Principles of Upper Extremity Surgery
Assessment
Hand surgery is a discipline in which the practitioner is still a detective. Many patients present with a
general concern of pain, stiffness, numbness, weakness, etc, and it is incumbent upon the hand surgeon to
perform a history and physical sufficient to determine the correct diagnosis. A standard template for
asking questions is provided in Table 67.1; note the emphasis on functional concerns. There are two
particularly important aspects of the patient’s narrative that should be elucidated: those circumstances in
which the deficit is noted and the amount of traumatic energy involved. Symptoms specific to a particular
motion or job begin to point the surgeon to the affected anatomy. A fracture from a fall has different
accompanying injuries and expected outcomes than a fracture incurred during a high-speed collision.
TABLE 67.1
Elements of a Hand History
History Component
Data Collected
History of present illness
Time of onset of symptoms
Mechanism of injury or inciting event, or nature of repetitive trauma
Type of trauma—blunt, sharp, mechanism, hand position, contamination; estimated amount of
force/energy involved
Duration of symptoms; continual or intermittent
Severity of symptoms
Factors that worsen and/or improve the symptoms; cold intolerance
History of infection
Care to date
General demands on the hand
Hand dominance
Occupation, hobbies
Activity status, walking aids
Social status
Medical history
Nicotine use
Chronic disease—autoimmune, diabetes
Surgical history 
 and prior
treatments
Prior hand trauma and outcomes
Prior surgical interventions and outcomes—remaining hardware
Family history
Dupuytren’s contracture
Lipomas
Congenital conditions
Medications/allergies
Anticoagulation
Immunosuppressants
Nonsteroidal anti-inflammatory agents
Steroids
Opioids
Having established a differential diagnosis based on the history, the physical exam is used to hone in on
the underlying diagnosis; again, the focus is on function (Table 67.2). It is important to be thorough and
examine seemingly uninvolved structures. For example, patients with carpal tunnel syndrome often have
thumb CMC arthritis, but unless the arthritic component of their thumb pain is explained prior to
surgery, the patient will expect the pain to resolve after carpal tunnel release and be disappointed when it
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does not. In addition, a thorough functional exam may demonstrate other abnormalities that should be
addressed.
TABLE 67.2
Physical Examination of the Hand
Physical Examination
Finding
Soft tissue appearance
General
Gross deformity
Cascade
Congenital anomalies
Wounds—dimension, location, contamination, or presence of foreign body
Rashes
Nail deformities
Masses
Contractures versus posturing
Symmetry
Vascular
Skin color and temperature
Atrophic skin changes
Allen’s test
Capillary refill
Motor
Flexor and extensor tendon function including forearm musculature
Thenar and hypothenar muscle function or atrophy
Intrinsic muscle function or atrophy
Sensory
Subjective numbness, comparison for symmetry
Provocative nerve tests (e.g., Tinel’s sign, Phalen’s sign)
Two-point discrimination
Joint range of motion
Arc of rotation:
DIP, PIP, MP
Wrist, forearm rotation
Elbow
Joint stability
Bone
Angulation/rotational deformity
Pain or instability
Prominences
Tables 67.1 and 67.2 can also be used to develop a standard history and physical template for use in an
electronic medical record. The value of an individually developed standardized evaluation is that
repetition allows the clinician to recognize abnormalities and disruptions of patterns better. Subtle
diseases are easier to spot in a background of well-understood normal states.
Table 67.3 lists the imaging modalities available to hand surgeons. It is important to choose the proper
test for the patient. On one hand, magnetic resonance imaging is overly sensitive and not specific enough
to use when a diagnosis is unclear. 9 On the other hand, recent advances in ultrasound make it an
excellent investigative and therapeutic tool for multiple conditions involving the soft tissues. Fractures
and dislocations are best identified with plain radiographs; palpating a suspected fracture site to make a
diagnosis causes pain, tissue damage, and is not diagnostic. The new technology now allows for
subtraction of hardware artifact in computerized tomography and has significantly improved resolution.
TABLE 67.3
Imaging Modalities for Use in the Hand
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Imaging Modality
Evaluation
Plain Radiographs
Most common, most useful, most cost effective imaging
modality
Good for assessing fractures, dislocations, arthritic changes
Rule of 2’s:
Two views minimum
Joint above and below level of injury
Injured and contralateral side
Before and after treatment
Special views (e.g., carpal tunnel view, scaphoid view)
Instability series
Evaluation of the image—quality of the radiographs, alignment
of the skeleton
CT
Provides improved bony detail
Good for assessing
Bone tumors
Fracture healing
Carpal or fracture alignment
MRI
Not to be used as a screening test, only order to evaluate a
suspected diagnosis
Provides improved soft tissue detail—ligaments, cartilage,
muscle
Good for assessing possible bony avascular necrosis
T1
Black = fluid and cartilage
Gray = tendon and muscle
White = bone and fat
T2
Black = bone, tendon, ligament, and cartilage
White = fluid
Bone scan
Three phase assesses vascularity
Delayed phase useful for assessing chronic hand pain
Angiography
Provides vascular detail for occlusion, aneurysm, ischemia
Magnetic resonance angiography is replacing traditional
contrast angiography
Ultrasound
Identifies and localizes fluid collections (e.g., abscess, ganglion)
Localizes radiolucent foreign bodies
Identifies ligament and tendon ruptures
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Treatment
Once a diagnosis has been made, the patient and surgeon collaborate on choosing a treatment plan. Not
all hand patients will require surgery. In fact, most patients seen in a hand clinic will be treated
nonoperatively with a combination of immobilization, anti-inflammatory medications, therapeutic
modalities, and pain management. In patients who have been sent to see a surgeon and are treated
without surgery, it is important to make sure the patient understands that the concerns have been taken
seriously and are being appropriately addressed.
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Preoperative
Patient education and a discussion about expectations are critical in surgical patients. Enhanced Recovery
After Surgery (ERAS) is a multidisciplinary and multimodal approach to the care of a surgical patient.
Primary elements of ERAS protocols include preoperative patient education, nutritional optimization,
early mobilization, and standardized analgesic and anesthetic regimens. 10 Implementation of the ERAS
protocol across surgical specialties has demonstrated the decreased average length of stay, complication
rates, readmissions, and costs. 11 There has been much research done on improving outcomes in hand
surgery patients, and many institutions are utilizing these strategies to decrease costs and improve
patient satisfaction. A comprehensive approach to hand surgery utilizing these strategies is outlined
below.
Patient education is an important but often overlooked aspect of patient care. A patient’s clear
understanding of their diagnosis, perioperative plan, and long-term functional expectations has been
shown to improve patient compliance and health outcomes. These are also the key elements of informed
consent. Additionally, patient education can benefit the provider by cutting down on unnecessary calls,
clinic visits, and medication refills. Providing patients with appropriate educational materials that explain
the perioperative course may also reduce patient anxiety and create more reasonable expectations,
particularly in the realm of pain control.
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Operative
Surgery begins before the patient enters the room. Equipment, positioning, and the anesthetic plan are
discussed with operative personnel beforehand and confirmed during the time-out. Surgical site
preparation, the operative plan, and subsequent surgical markings should all be performed prior to
inflating the tourniquet since the tourniquet time is precious. The safe duration of tourniquet-induced
ischemia in the upper extremity is 2 hours, but there are few studies other than Wilgis’ to confirm this
time. 12 His study also suggests that the tourniquet time can be extended by releasing the tourniquet and
then reinflating it after the blood supply has had time to circulate to prevent reperfusion injury. 13
Forearm tourniquets may be used in hand cases performed under local anesthesia. These are well
tolerated by the patient and provide a bloodless field, but they can encroach on the surgical field. 14
Details of specific procedures will be provided in the upcoming chapters, but there are several principles
that should be followed when operating on the upper extremity.
Incisions should be longitudinal. This minimizes the number of cutaneous nerves that might be
transected, allows for wider exposure through simple extension of the incision, and facilitates re-
excision of the scar if needed in the future. Transverse incisions at the volar wrist with their attendant
stigmata should be avoided.
Incisions should not cross flexion creases. A combination of Bruner and midaxial incisions provides good
exposure and can incorporate most traumatic lacerations.
Incisions should be long enough to do the job. A common cause of struggling during surgery is
insufficient exposure. The chief goal of hand surgery is restoration of function; patients will trade an
additional 2–4 cm of scar for improved use of the hand.
Work from normal to abnormal, known to unknown. Another cause of surgeon distress is the inability to
identify structures. The incision should be long enough to expose uninjured, unaffected tissues in
order to provide orientation. The temptation to explore a wound through an insufficiently extended
traumatic laceration should be resisted.
If it does not look right, it will not work right. Incisions that violate the aesthetics of the hand and
closures that produce distortions in hand architecture will result in a wound that may heal, but the
functional outcome will be suboptimal.
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Postoperative
As noted, optimal postoperative outcomes start with following the principles of ERAS preoperatively.
The important points of patient education are reviewed with the patient and his or her support system.
Proper dressings, elevation, and activity levels are important and should be described in concert with
their concomitant procedures. The key elements of any dressing are edema control, protection of repairs,
pain minimization, immobilizing parts of anatomy that must not move, and allowing motion in all other
locations.
Pain management in the upper extremity is an important determinant of recovery and overall function.
Insufficient pain control in the acute phase increases inflammation and scarring; concerns about opioid
dependence are real, but the role of narcotics and nonsteroidal anti-inflammatory medications in the
acute phase should be discussed prior to surgery in order to establish expectations. Medication-adverse
patients should be reminded that the use of opioids will be limited, and that it is more important to use
appropriate pain medication and move the hand than not use pain medication and not move the hand.
One of the most important aspect of postoperative care is the rehabilitation plan. Many hand surgical
procedures depend equally on specified hand therapy protocols. The hand surgeon should have an open,
well-established line of communication with the hand therapist. The importance of good hand
rehabilitation cannot be overstated. In fact, there are numerous procedures in the hand that should not be
attempted unless the therapy plan has already been outlined to the patient, compliance has been
demonstrated, time off and transportation issues addressed, and insurance coverage for the therapy
assured. This last item is important to establish preoperatively because many insurance policies will
cover surgery but not rehabilitation.
Since form follows function in the hand, a good hand surgeon should master three areas: functional
anatomy, basic surgical techniques, and principles of rehabilitation. Knowing the anatomy allows the
surgeon to make a correct diagnosis and construct a plan to restore the anatomy to as close to normal as
possible. Because all surgeries are composed of the same basic movements, a good surgeon does not have
to memorize a series of specific steps but can apply well-established component steps to create a surgical
plan that is tailored to the specific needs of the case at hand. Rehabilitation is the process of returning
control of the hand back to the patient. People use their hands in infinite ways; the focus of the hand
surgeon is to use all the operative and nonoperative modalities available to return injured or diseased
structures to their proper configuration so that the patient can carry on effectively with life.
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Questions
1. Surgical exposure of the dorsal carpus should attempt to preserve which of the following anatomic
structures?
a. Dorsal radiocarpal ligament
b. TFCC
c. Gilula’s arcs
d. Dorsal intracarpal ligament
e. Radioscaphocapitate ligament
2. Which of the following is correct regarding the bony anatomy of the metacarpal?
a. The condyloid nature of the MP joint allows for motion in two planes, flexion/extension and
rotation.
b. The MC head is wider on its volar surface contributing to CL tightening in flexion.
c. There is a natural radial cant to the MC head of about 10 to 14 degrees.
d. The volar plate is contiguous with the superficial transverse MC ligament.
e. The volar convexity of the MC lends to dorsal apex fracture patterns.
3. Which of the following anatomic relationships is correct?
a. Lister’s tubercle is just proximal to the lunotriquetral joint.
b. The palmaris longus is radial to the median nerve.
c. The distal palmar crease is at the proximal end of the A1 pulley.
d. The web space is at the proximal portion of the proximal phalanx.
e. The distal wrist crease is at the level of the DRUJ.
4. Which of the following anatomic relationships is correct?
a. The neurovascular bundle in the proximal phalanx is deep to the midlateral line.
b. The ulnar artery and nerve are radial to the palpable hook of the hamate.
c. The trapezoid can be palpated in the depths of the space between the EPL and EPB tendons.
d. The flexor wad is ulnar to the visible brachioradialis muscle.
5. Which of the following imaging modalities is best suited to locate a suspected mesquite thorn deep
in the thenar eminence?
a. Plain film radiograph
b. Ultrasound
c. MRI
d. CT
6. Which of the following ERAS protocols in hand surgery is false?
a. Primary elements of protocols include patient education, nutrition optimization, early
mobilization, and standardized analgesic and anesthetic regimens.
b. Implementation of ERAS protocols has demonstrated decreased average length of stay but not
complication rates.
c. ERAS protocols across surgical specialties have been seen to lower readmission rates and
hospital costs.
d. The use of ERAS protocols in hand surgery specifically has not been well established.
1. Answer: a. The dorsal ligaments consist of the dorsal radiocarpal ligament and dorsal intercarpal
ligament, and a surgical exposure of the dorsal carpal bones, such as a dorsal ligament sparing
capsulotomy, attempts to preserve the integrity of these structures, thereby improving postoperative
stability and mobility. This is a V-shaped flap elevated from the midpoint between the DRUJ and
Lister’s tubercle to the tubercle of the Triquetrum and then transversely to the tubercle of the
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scaphoid. This divides the above to noted ligaments along their midsubstance preserving their
integrity. The TFCC is a 7 part soft tissue structure which stabilizes the DRUJ. Gilula’s arcs mark the
radiographic aspect of the distal and proximal carpal rows. The intracarpal ligaments connect carpal
to carpal and are not in the dorsal wrist capsule. The radioscaphocapitate ligament is a volar
structure.
2. Answer: b. The MP joints are condyloid in nature allowing for motion in three planes:
flexion/extension, abduction/adduction, and rotation. Because the MC head is wider on its volar
surface, flexion increases joint stability by tightening the CL and elongation of the VP. Thus, the MP
joint should be immobilized in flexion to reduce the occurrence of joint contractures. There is a 10- to
14-degree natural ulnar deviation. As a result, the slight ulnar cant to the MP head predisposes to
ulnar subluxation of the extensor hood and ulnar drift. The volar plate is contiguous with the deep
transverse MC ligament, which connects the metacarpal heads of the index, long, ring, and little
fingers and helps maintain the MCs in a slight dorsal arch in the transverse plane. The dorsal
convexity to the MC bone results in tension on the dorsal surface with loading, leading to dorsal
apex fracture patterns.
3. Answer: c. Lister’s tubercle is just proximal to the scapholunate ligament and is the radial border
of the third dorsal compartment. The palmaris longus is ulnar to the median nerve and serves as a
landmark for median nerve blocks. The distal palmar crease is distal to the superficial palmar arch
and at the level of the proximal A1 pulleys. The web space is at the mid portion of the proximal
phalanx. The distal wrist crease is at the level of the midcarpal joint.
4. Answer: d. The neurovascular bundle in the finger is anterior to the midlateral line. The hook of
the hamate, which is palpable in the palm, is radial to the ulnar neurovascular structures. The
trapezium is palpable in the depths of the anatomic snuffbox. The origin of the flexor wad is the
medial epicondyle, which is ulnar to the origin of the brachioradialis on the humerus.
5. Answer: d. Like most plant thorns, a mesquite thorn is radiolucent and will not be detected using
X-rays. MRI will locate the thorn but is expensive and time consuming. Ultrasound is both sensitive
and specific, costs much less than an MRI, and can be used during surgery.
6. Answer: b. Primary elements of ERAS protocols include preoperative patient education,
nutritional optimization, early mobilization, and standardized analgesic and anesthetic regimens.
Implementation of ERAS protocol across surgical specialties has demonstrated decreased average
length of stay, complication rates, readmissions, and costs. Although recent research has aimed at
improving outcomes in hand surgery, little data are available specific to ERAS protocols.
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References
Linscheid, RL, Dobyns, JH, Beabout, JW, Bryan, RS. Traumatic instability of the wrist: diagnosis, classification, and pathomechanics. J Bone
Joint Surg Am. 1972;54(8):1612-1632.This is the sentinel article on wrist biomechanics and instability patterns of traumatic conditions. It reviews the
diagnosis, classification, and pathomechanics and relates to radiographic findings of carpal angles.
Berger, RA, Landsmeer, JMF. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. Iowa Orthop J. 1985;5:32-41.
Berger, RA, Bishop, AT, Bettinger, PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg. 1995;35(1):54-59.
Mayfield, JK. Patterns of injury to carpal ligaments: a spectrum. Clin Orthop. 1984;187:36-42.
Bugbee, WD, Botte, MJ. Surface anatomy of the hand: the relationship between palmar skin creases and osseous anatomy. Clin Orthop Relat
Res. 1993;(296):122-126.The volar creases were marked with wires on 50 adult female volunteers. Distance measurements were obtained and analyzed
to establish normal anatomic relationships between the creases and radiographic finding.
McLean, KM, Sacks, JM, Kuo, YR, et al. Anatomic landmarks to the superficial and deep palmar arches. Plast Reconstr Surg. 2008;121(1):181.
Ağır, I, Aytekin, MN, Küçükdurmaz, F, et al. Anatomical localization of Lister’s tubercle and its clinical and surgical importance. Open
Orthop J. 2014;8:74-77.
Hazani, R, Engineer, NJ, Elston, J, Wilhelmi, BJ. Anatomic landmarks for basal joint injections. Eplasty. 2012;12:e2.
Michelotti, BF, Mathews, A, Chung, KC. Appropriateness of the use of magnetic resonance imaging in the diagnosis and treatment of wrist
soft tissue injury. Plast Reconstr Surg. 2018;141(2):410-419.A retrospective review of 140 patients who had an upper extremity MRI demonstrated
that the results only affected treatment recommendations in 28%. The predictor of impact on treatment was the presence of a specific suspected
diagnosis.
Kehlet, H, Wilmore, DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641.
Ljungqvist, O, Scott, M, Fearon, KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292-298.Enhanced Recovery After
Surgery (ERAS) process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician
assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international
nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations. ERAS
protocols have resulted in shorter lengths of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are
reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured
implementation programs that are currently in use in more than 20 countries.
Shahryar, N, McEwen, JA, Kragh, JF, et al. Surgical tourniquets in orthopedics. J Bone Joint Surg Br. 2009;91(12):2958-2967.This article reviews
the literature regarding tourniquet use including size, pressure, location, and duration.
Wilgis, E. Observations on the effects of tourniquet ischemia. J Bone Joint Surg Am. 1971;53(7):1343.
Cousins, GR, Gill, SL, Tinning, CG, et al. Arm versus forearm tourniquet for carpal tunnel decompression: which is better? A randomized
controlled trial. J Hand Surg Eur. 2015;40(9):961-965.
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C H A P T E R 6 8
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Hand Infections
Anne Argenta and William W. Dzwierzynski
Key Points
Obtain a thorough history and physical exam; this will guide treatment.
Know when urgent surgical intervention is warranted and always be suspicion.
Persistent symptoms require further review and workup.
Clearance of infection alone will not always result in a functional hand; stiffness and pain must be
addressed.
The hands play a significant role in the way humans communicate and interact with the external
environment. Because of this, the hands are particularly vulnerable to infection. Hand infections present
in a variety of ways, but they will uniformly have a better outcome when managed expeditiously. When
there is suspicion of infection, it is incumbent on the plastic surgeon to be knowledgeable, efficient, and
vigilant.
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Presentation and Workup
There are two main players during an infectious process: the insulting pathogen and the body’s defense
mechanism. A thorough workup of each will guide appropriate treatment. Important factors to elicit in
the history are the duration and progression of symptoms, history of blunt or penetrating trauma,
unusual exposures (animals, water, travel, and sick contacts), alleviating or aggravating factors, and
systemic symptoms including fever, nausea, malaise, and altered mental status. Prior treatments and
tetanus immunization should be documented.
The same pathogen may present differently in different individuals. Therefore, the patient’s
comorbidities and risk factors, including occupation, must be identified. Diabetes, obesity, intravenous
(IV) drug use, malnutrition, human immunodeficiency virus (HIV/AIDS), autoimmune disease, and use
of immunosuppressive medication can predispose patients to infection. Patients with these conditions are
more susceptible to opportunistic pathogens and require more aggressive monitoring, with a lower
threshold for intervention. Patients who use tobacco should be expected to have slower healing. 1
On physical exam, the hand should be inspected for swelling, color changes, focal pain, guarding,
puncture wounds, lacerations, and active and passive range of motion (ROM). The location of wounds
can influence decision-making. For example, a wound over a joint warrants washout and investigation
for joint involvement in the setting of a sterile environment, whereas a wound on the dorsum of the hand
can usually safely be washed out and explored at the bedside. Similarly, the location of focal swelling
should be documented. The compartments of the hand dictate how an infection may spread and,
consequentially, influence incision placement during surgery. Signs of progressing infection, such as pain
with passive ROM and ascending lymphangitis, should be noted and be treated.
The history and physical exam will guide need for further work up with imaging, cultures, and lab work.
Ancillary tests should be used judiciously. Three view X-rays should be done when there is trauma
and/or suspicion of foreign body. However, when there are signs of acute rapidly worsening infection,
such as with necrotizing fasciitis, imaging will only delay treatment. Computed tomography (CT) and
magnetic resonance imaging (MRI) should be reserved for cases where the diagnosis is unclear. A culture
or tissue biopsy, if needed, can be taken expeditiously and easily in the emergency department setting
before administration of antibiotics, without delaying treatment. Any labs, such as chemistries, complete
blood count, and coagulation tests, can be drawn while the physician is examining the patient, thus
avoiding treatment delays.
A critical step in the workup of hand infection is determining whether a patient needs hospitalization
versus outpatient management. Hospitalization is required in patients with ascending lymphangitis, a
failed trial of oral antibiotics, systemic symptoms, elevated white blood cell (WBC) count, a reasonable
chance of needing operative intervention, or a high risk of not following-up. When an infection is
managed as an outpatient, it is imperative to follow up culture results and adjust antibiotics as
appropriate.
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General Principles of Treatment
Most hand infections are mild and can be managed in the outpatient setting, but the surgeon should have
a low threshold for inpatient care, particularly in rapid onset infections or high-risk patients. Fluctuance,
purulent drainage, and worsening pain are all indications for surgical management. Knowledge of
anatomy optimizes surgical outcome and minimizes complications.
Antibiotics are the cornerstone of infection management. Cultures of drainage or tissue should ideally be
obtained before any antibiotics are given. The most common infections are a result of inoculation of
tissues by bacteria normally found on human skin. Staphylococcus and Streptococcus species are by far the
most common and should be covered in initial treatment. A first-generation cephalosporin is usually
adequate. Methicillin-resistant Staph aureus (MRSA) is becoming 
 more common as both a hospital-
acquired and a community-
 acquired infection. MRSA infections tend to present with more skin necrosis,
though cultures should be done to confirm diagnosis. In regions of high MRSA rates and in patients with
a
history
of
MRSA
or
recent
hospitalization,
empiric
coverage
with
clindamycin,
trimethoprim/sulfamethoxazole, a tetracycline (doxycycline or minocycline), or linezolid is indicated. 2
The choice of antibiotic is directed by the patient’s community or hospital antibiogram.
Immunocompromised patients are more susceptible to fungal, mycobacteria, and other less common
pathogens. A high suspicion or an initial lack of response to standard antibiotic regimens may warrant
broad-spectrum coverage and tailoring as culture results are obtained. Tissue culture will be more
reliable than culture swabs. Confirm with the laboratory proper sampling and storage protocols for
adequate testing of fungal and atypical mycobacteria.
Elevation and rest are standard treatment adjuncts for infection and are important components of pain
management. Elevation of the hand above the heart level will limit edema. A short period of hand rest for
24 to 48 hours will not have a negative effect on long-term hand function. Hands should be splinted in the
position of function (wrist extended 30°, MCP flexed 90°, digits extended) during this rest period. As the
acute swelling improves, resumption of ROM exercises is important to limit stiffness and loss of strength.
Hand soaks are commonly used in the acute setting and rehabilitation phase, although their efficacy has
not been fully established. Multiple solutions have been advocated. The most important principle is to
dilute the betadine or chlorhexidine to a level that is nontoxic to healthy tissue. Soaks are generally
performed two or three times a day, 5 to 10 minutes per session. Patients often report better pain control
and ability to perform ROM exercises when the hand is submerged in warm solution.
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Common Hand Infections
Digits
Paronychia
Paronychias are caused by infection of the skin around the nail fold. Initial violation of the skin barrier is
often the result of a hangnail, manicure instruments, or nail biting. Symptoms include swelling,
erythema, and pain around the nail plate. Exam should note swelling, discoloration, fluctuance, and
drainage. The most common pathogen isolated from culture is Staph aureus. If caught early, treatment
comprises hand soaks, oral antibiotics, and hand elevation. A first-generation cephalosporin is usually
adequate. If an abscess has formed, as indicated by fluctuance and swelling, incision and drainage (I + D)
is required. I + D is performed by incising the skin longitudinally with a no. 11 or 15 blade directly over
the most prominent area of swelling, bluntly dissecting the cavity with a hemostat, culturing drainage,
and copiously irrigating the wound with saline. When the decompressed cavity is large, a gauze wick is
placed in the wound for 24 hours to help prevent reaccumulation and early skin closure. A paronychia
may extend into the eponychium; in this case, the eponychial fold will need to be elevated. If purulence is
noted under the nail plate, part or the entire nail should be removed. All of this can usually safely be
performed under a digital block in the emergency room or clinic.
Chronic paronychias present as longstanding induration, pain, erythema along the nail fold, nail plate
ridges, elevation of the skin off the nail plate, and occasional drainage. The nail plate may be thickened
and discolored due to concomitant onychomycosis. Chronic paronychias are more common in diabetics,
immunocompromised patients, women who get manicures, and people who frequently immerse their
hand in water (dishwashers, nurses, or swimmers). Antibiotics are less effective and antifungal coverage
for Candida albicans with nystatin or itraconazole is generally required, along with marsupialization
(excision of semilunar patch of eponychial skin and subcutaneous tissue down to the germinal matrix).
Topical gentian violet is a historic treatment for chronic paronychia that is gaining popularity again. 3
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Felon
Felons are focal infections within the pulp tissue of the fingertip (Figure 68.1). They are usually initiated
by a puncture wound. Because of the extensive septae within the pulp, infection remains localized within
a small compartment; this results in abscess formation with throbbing pain, often without visible external
swelling until infection is advanced. The most common pathogen is Staphylococcus aureus. Very early
presentations may resolve with oral antibiotics alone, but usually a focal abscess has formed by the time
of presentation. This requires incision and drainage. Incision should be designed longitudinally over the
most prominent point of pain, avoiding damage to neurovascular bundles and unnecessarily long
incisions over the pulp, as the scars can become hypersensitive. The cavity should be bluntly probed with
a hemostat to break up septae and ensure full drainage, and then irrigated. Placing gauze wick in the
incision for 24 to 48 hours will help prevent reaccumulation. I + D in the outpatient setting under digital
block is generally adequate. Delay in I + D of these abscesses can result in pulp necrosis, osteomyelitis, or
extension of infection into the flexor sheath.
FIGURE 68.1 Felon, presenting in a 12-year-old boy with no recalled history of trauma.
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Flexor Tenosynovitis
Flexor tenosynovitis presents as an acutely swollen, painful digit (Figure 68.2). Often, there is history of a
puncture wound, animal bite, or scrape on the volar surface of digit. When a pathogen, usually S aureus,
inoculates the flexor tendon region and expands, the flexor sheath guides the infection proximally up the
sheath, into the hand and forearm. The four identifying characteristics, known as the Kanaval signs, are
as follows:
Fusiform swelling, or a sausage-shaped digit
Digit resting in flexed position
Pain with passive extension
Tenderness to palpation along the flexor tendon sheath into the palm
FIGURE 68.2 Flexor tenosynovitis, presenting 3 days after a cat bite to the digit.
Untreated infectious tenosynovitis can lead to stiffness, chronic pain, osteomyelitis, and ascending limb-
threatening infection. One should have very low threshold for hospitalization and early operative
intervention. If caught within 24 to 48 hours with mild or equivocal Kanaval signs, some patients may
improve with IV antibiotics, rest, elevation, and inpatient monitoring alone. Broad-spectrum antibiotics
should be considered.
Anyone presenting with symptoms longer than 48 hours, Kanaval signs, or worsening symptoms with
conservative management should undergo surgical decompression in the operating room (OR). A variety
of incisions have been described. Most cases can be treated with two incisions: a standard palmar oblique
incision over the A1 pulley (as for trigger finger release), and a midaxial, transverse, or Bruner incision at
the distal P2 level. Proximally, blunt dissection with tenotomies will expose the A1 pulley, which is
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incised longitudinally to view the flexor tendons. A culture should be taken of any fluid in this area.
Distally at the midaxial incision, blunt dissection deep to the neurovascular bundle will expose the flexor
sheath distally. A small incision in the sheath should be made to inspect the tendons. Any wounds or
focal abscesses in the finger should be debrided and cultured. The flexor sheath is then thoroughly
irrigated using a 14 to 18 gauge angiocatheter or a no. 5 pediatric feeding tube attached to a syringe of
saline and inserted into the tendon sheath through the proximal incision. Saline is pushed though the
sheath and drains out the distal incision until the irrigation is clear. The irrigation system can also be
inserted into the sheath from the distal incision, if easier but risks pushing the infected fluid proximally
into the palm. At least 1 L is irrigated, ensuring that the saline is flowing well through the entire sheath. If
there is significant frank pus, Bruner incisions may be used to connect the proximal and distal incisions
for further exposure. The irrigation system is removed at the end of the case or sutured in place for serial
irrigations overnight in the hospital room. Retrospective reviews have not demonstrated that continuous
irrigation has better outcomes compared to intraoperative irrigation alone. 4 The palmar and midaxial
incisions can be left to close by secondary intention or loosely approximated. Extensive Bruner incisions
should be loosely tacked together.
Postoperatively, the hand should be monitored, elevated, and rested for 24 hours in an inpatient setting.
If improving, hand therapy can be started 24 to 48 hours after surgery. If pain and swelling persist, return
to the OR is necessary. IV antibiotics are generally continued for 5 to 7 days and tailored by the culture
results. Subcutaneous purulence and digit ischemia on presentation are indictors of a poor prognosis. 5
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Hand
Cellulitis
Cellulitis is the most common hand infection (Figure 68.3). Patients present with diffuse erythema and
nonfocal swelling in the extremity. There may be history of a scratch or insect bite. Exam demonstrates
generalize warmth, erythema, stiffness, lymphadenopathy, and edema. Patients rarely have one focal
area of pain on exam. Staph and Strep species are the most common offenders. If the inciting trauma was
caused by an animal scratch, additional bacteria may be involved (Pasturella multocida in dogs and cats;
Bartonella henselae in cats). Ascending lymphangitis, elevated WBC, altered mental status, or lack of
response to oral antibiotics warrants inpatient admission and IV antibiotics. Erythema should be outlined
and dated in permanent marker to monitor progression. High-risk patients should be monitored for
septic shock. Surgery is not indicated for cellulitis, but local debridement at the site of inoculation may be
necessary if there is tissue necrosis or a localized abscess.
FIGURE 68.3 Cellulitis in a patient with necrotizing fasciitis (dorsal arm view in Figure 68.7).
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Fight Bites
Fight bites are caused by penetration of a foreign body, usually a tooth, through a joint capsule, resulting
in inoculation of sterile joint space with bacteria (Figure 68.4). Patients typically present to the emergency
room with a swollen, painful hand 2 or 3 days after punching another person in the face. Exam findings
include pain, erythema, swelling over the dorsal metacarpal-phalangeal joint (MCP) region, a benign
appearing scab over the dorsal MCP, and pain with axial loading of the joint. X-rays should be performed
if there is suspicion of a retained foreign body or fracture.
FIGURE 68.4 Fight bite, presenting 3 days after assault.
Fight bites require exploration of the wound to rule out joint-space infection, as the MCP joint is violated
in 70% of cases. This is best performed in the OR. The wound should be excised in an elliptical fashion.
Because the extensor mechanism glides with ROM, punctures in the extensor mechanism may not
directly underlie the skin puncture site. The joint should be fully explored during wound exploration to
find violations in the extensor mechanism. If violation is suspected, the extensor should be opened either
by longitudinally splitting the tendon or by incising between the extensor and sagittal band. Violation of
the underlying joint capsule requires capsulotomy. After cultures are taken of the joint fluid, the patient
should be started on broad-spectrum antibiotics covering for S aureus and oral flora (Eikenella corrodens
and Bacteroides sp. in human bites) and the joint should be thoroughly irrigated with saline. A small
gauze wick is placed in the joint space and the overlying capsule, extensor mechanism, and skin is loosely
closed. Postoperative inpatient monitoring is advised. Persistent symptoms require return to the OR.
Delay in surgical treatment can result in extensive joint destruction (Figure 68.5).
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FIGURE 68.5 A. Delayed presentation of a fight bite to the left middle finger MCP, 7 months after assault. B. X-rays
demonstrating joint destruction and osteomyelitis.
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Deep-space Infections
Deep-space infections comprise 5% to 15% of all hand infections.
6 Because the hand is
compartmentalized by fascial septae, these infections are often naturally confined to predictable locations.
A brewing abscess in the thenar region after a puncture wound will be blocked from moving ulnarly
toward the small finger by the midpalmar septum. Instead, it travels up flexor pollicis longus into the
wrist, where the Parona space allows the infection to cross over to the flexors of the small finger and
distally into the ulnar hand, circumventing the mid palm and creating the classic horseshoe abscess. A
collar button abscess is an infection originating volar webspace and confined distally, because the strong
palmar aponeurosis blocks infection from spreading proximally. Instead, the infection spreads dorsally
into the dorsal subcutaneous tissues, forming the classic puckering, swelling, and abducted position of
the digits.
Patients with deep-space infections will present with pain, swelling, erythema, and increased pain with
ROM (Figure 68.6). A CT with contrast, ultrasound, or MRI will help localize and identify the extent of
infection when the exam is vague. All deep-space infections require formal I + D and culture, preferably
in the OR setting. Care should be taken in designing incisions, ensuring drainage of all areas but avoiding
scars over critical structures. Thenar abscesses can be managed with a dorsal incision and dissection
between the first dorsal interosseous and adductor pollicis muscles. The midpalmar abscess is accessed
with an extended carpal tunnel incision or curved longitudinal incision in the palm. Collar button
abscesses generally require volar and dorsal incisions for complete drainage; transverse incisions within
the webspace cause adduction contractures and should be avoided. The most commonly isolated
pathogens are S aureus and group A Streptococcus. Gauze wicks should be placed in the wound for
continued egress of infection. Inpatient monitoring, broad-spectrum IV antibiotics, and early hand
therapy are advised.
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FIGURE 68.6 Thenar deep-space infection in an IV drug user.
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Necrotizing Fasciitis
Necrotizing fasciitis is one of the few emergent life- and limb-threatening hand infections. Patients
present with cellulitis, discoloration, limited ROM, and rapidly ascending pain. Inciting trauma, if any, is
often a minor cut or scrape. Immunocompromised patients (diabetics, chronic steroid use), the elderly,
and IV drug abusers are more susceptible to necrotizing fasciitis and have higher mortality rates. There
are two types of presentations: type 1, involving multiple anaerobic and aerobic bacteria, and type 2,
involving group A Streptococcus and Staphylococcus sp. More recently, MRSA has been isolated in up to
39% of cases. 7
Exam reveals erythema, streaking lymphangitis, pain, blistering, and crepitus (Figure 68.7; see Figure
68.3). Signs of hemodynamic instability, such as hypotension, tachycardia, and altered mental status are
indicative of septic shock. Stat gram stain should be done without delaying definitive treatment of broad-
spectrum IV antibiotics, aggressive resuscitation, and emergent operative debridement. A classic sign of
necrotizing fasciitis is cloudy dishwasher drainage, due to necrosis of the fascia. Aggressive debridement is
vital, as infection spreads rapidly along fascial planes and leads to skin and muscle necrosis. Amputation
must be considered in the setting of advanced muscle necrosis and septic shock. Tissue samples should
be cultured. Patients should be placed in the intensive care unit if there is any concern of hemodynamic
instability. Return to the OR for a second look should occur within 24 to 48 hours. Patients will generally
need extensive soft tissue reconstruction once infection is cleared.
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FIGURE 68.7 Necrotizing fasciitis, presenting in a healthy 60-year-old man 4 days after scratching his dorsal hand on a piece
of metal (volar arm view in Figure 68.3).
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Wrist
Septic Arthritis
Similar to a fight bite, septic arthritis of the wrist results from inoculation of the joint with a pathogen.
Because joints are avascular immune privileged sites, meaning that they do not mount a strong immune
response to infection, infection can rapidly progress to permanent cartilage and bone destruction. These
infections can arise from a direct penetrating trauma or from hematogenous spread. S aureus,
Streptococcus sp., Haemophilus influenzae (in children), and Neisseria gonorrhoeae are the most common
pathogens. Patients present with gradually worsening pain in the wrist, severe pain with ROM, and
swelling. A history of trauma, immunosuppression, autoimmune disease, gout, and sexually transmitted
disease should all be noted. Exam reveals pain with wrist ROM and axial loading, swelling, warmth
around the joint, and often overlying cellulitis. In delayed presentations, X-rays can identify bony erosion
(Figure 68.8).
FIGURE 68.8 Advanced septic arthritis and osteomyelitis of the carpus and distal radius in a 50-year-old male with extensive
psychiatric history presenting with 7 months of wrist pain. A. Anteroposterior radiograph. B. Oblique view.
Septic arthritis of the wrist must be distinguished from simple cellulitis and from acute flares of gout or
pseudogout. The history may provide some clues. Prior flares and patchy calcifications of the wrist joint
on X-rays would lean toward autoimmune etiology, whereas history of penetrating trauma, fever,
erythema, and lymphangitis would be suspicious for infection. A wrist aspiration and joint fluid analysis
will confirm diagnosis. This should only be done in the setting of high suspicion, as aspiration risks
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introduction of pathogen into a joint, creating septic arthritis when it may not have been present initially.
To perform a wrist joint aspiration, the 3 to 4 interval on the dorsal wrist is palpated just distal and ulnar
to Lister tubercle. The skin is anesthetized, the site sterilized, and the wrist flexed slightly to facilitate
entry. A sterile large bore (18–20 gauge) needle is inserted at an angle to avoid the dorsal lip of the distal
radius. Ideally, 2 cc of fluid is aspirated. Normal joint fluid is clear or straw colored. The fluid should be
sent for crystal analysis and culture, after confirming with the laboratory that the sample is properly
packaged for analysis.
Although septic arthritis due to N gonorrhoeae can often be treated with IV antibiotics alone, the presence
of any other bacterial strain in the joint fluid warrants operative washout and aspiration of frank pus is an
indication for urgent surgery. The wrist joint is opened via a longitudinal dorsal skin incision. The wrist
capsule can be opened longitudinally or in a ligament-sparing approach to expose the wrist joint. The
joint space should be cultured and extensively irrigated with 3 L of saline. Automated pulse lavage is
avoided, because the excessive pressure can damage cartilage. The cartilaginous surfaces are inspected.
Any frankly necrotic bone is debrided with a rongeur; this is generally only seen in late, advanced cases.
The capsule, extensor retinaculum, and skin can be loosely closed, leaving a gauze wick to allow
continued egress of bacteria. Arthroscopic wrist washout has been reported to achieve similar results
with less postoperative stiffness. 8 Postoperatively, the hand is placed in a wrist splint and elevated for
comfort. Patients should be admitted for observation, pain control, and IV antibiotics. One should have a
low threshold for a second look in 24 to 48 hours. Once improving, ROM exercises are started while the
patient is still admitted.
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Special Cases
Fungal, Mycobacterial, or Viral Infections
The vast majority of hand infections are bacterial in origin. When infections do not respond rapidly to
standard antibiotic regimens, one should consider fungal, mycobacterial or viral sources. These
pathogens tend to be more indolent. Chronic paronychia, for example, is usually due to candida infection.
Mycobacteria are notoriously difficult to culture; suspicion should be raised for mycobacteria when rice
bodies are found at time of debridement or granulomas are found on pathology.
Immunocompromised patients and specific patient populations are more susceptible to these less
common infections. Hand infections due to Mycobacterium avium-intracellulare are increasing in the HIV
population. Mycobacterium marinum tends to affect fisherman and fish handlers; the infection causes
indolent progression of papule clusters on the hand and fingers. Pain is variable. The four other most
common pathogens associated with water animal exposure are Aeromonas sp., Edwardsiella tarda,
Erysipelothrix rhusiopathiae, and Vibrio vulnificus. Sporotrichosis is a fungal infection more common in
gardeners who have been pricked by a rose thorn. Coccidioidomycosis in the southwestern United States
and histoplasmosis in the midwestern United States are rare fungal causes of synovitis and
microabscesses of the hand.
Herpetic whitlow is a viral infection due to the herpes simplex virus, which causes a burning sensation
for 1 or 2 days, followed by erythema and blistering around the thumb of fingers (Figure 68.9). 
 It is seen
more commonly in children, dentists, and other medical professionals exposed to oral secretions, and in
immunocompromised patients. Tzanck smear confirms diagnosis. The infection is self-
 limited in 2 to
3 weeks; treatment with oral acyclovir or similar antivirals may be used in severe cases or to speed
resolution. Aggressive debridement and unroofing of vesicles is ill-advised and can predispose patients
to bacterial superinfection.
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FIGURE 68.9 Herpetic whitlow in a dental hygienist.
(Courtesy of Dr James Sanger.)
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Osteomyelitis
The ideal time to treat a hand infection is within the first 24 hours. Unfortunately, a lingering infection in
the hand, even a simple paronychia, can lead to underlying osteomyelitis if neglected. The standard for
diagnosing osteomyelitis is bone biopsy. Any frankly necrotic bone encountered during an I + D should
be debrided back to hard, bleeding bone and sent for culture, or it will continue to act as a nidus for
further infection. It is prudent to consult an infectious disease (ID) specialist in these cases, to help narrow
antibiotics, determine duration, and monitor for any medical side effects caused by the antibiotic use. The
ID specialists are often more familiar with community antibiotic resistances and cost comparisons of
different antibiotics. Patients with osteomyelitis generally require formal hand therapy to limit stiffness
and disuse atrophy of the hand during extended treatment. One must consider the pros and cons of
amputation over salvage.
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Drug Abuse
IV drug use is an unfortunately common cause for hand infections, either by use of a dirty needle, by
introduction of skin bacteria by the needle, or by contamination of the substance injected. When the
concern is present, patients should be asked directly about drug habits. Particular attention should be
paid to track marks along the forearm or antecubital fossa. Puncture marks within the webspace may
indicate direct drug injection into the subcutaneous tissues, an increasingly common form of drug
delivery known as skin popping. A recent history of IV drug use should raise suspicion for both cellulitis
and deep-space infections. Mixed flora and anaerobic infections are more common in IV drug use. A drug
screen and basic laboratory workup should be performed for anesthesia clearance, if needed. Workup for
hepatitis C and HIV should be discussed with these high-risk patients.
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Immunocompromised Patients
Immunocompromised patients, including those with diabetes, chronic steroid use, HIV, and
malnutrition, require special attention. A higher level of vigilance is needed when monitoring infections
in this population. Simple infections can progress rapidly to limb-threatening problems. Because this
group has a muted immune response, common presentations such as elevated WBC, fever, erythema, or
significant pain may not be present. Inpatient observation and serial exams are recommended.
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Problems That Mimic Infection
Several problems can masquerade as an infection. Most commonly, inflammatory arthritis flares,
including gout and pseudogout, are confused with septic arthritis of the joints. Proper diagnosis is
imperative, as treatments differ dramatically. Factors such as recurrent episodic pain, lack of trauma,
elevated blood uric acid levels, and calcium deposits in joints on X-rays may indicate gout or pseudogout,
but the presence of crystals on joint aspiration must be confirmed. When in doubt, assume a septic joint
until proved otherwise.
Chronic hand wounds that have been maintained on long courses of antibiotics with minimal
improvement warrant further investigation. Any wound present for longer than 6 months should be
biopsied to rule out cancer, pyogenic granuloma, or pyoderma gangrenosum. Biopsy incisions should be
designed longitudinally to allow extension as needed for a wide excision in the future.
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Optimizing Long-term Outcome
The outcome of hand infections is dependent on rapid diagnosis, efficient treatment, and early
rehabilitation. Long after the infection has been treated, the body’s inflammatory response may cause
residual swelling, stiffness, and pain. As with many other hand conditions, early hand therapy is critical
to optimizing function and should, in most cases, be started in the postoperative period while the patient
is still in the hospital. When treating hand infections, the ultimate goal is not clearance of infection, but
the restoration of a functional hand.
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Questions
1. A 40-year-old homeless diabetic man presents to the emergency room after spontaneous onset of
exquisite pain, swelling, and blistering of the dorsal hand 6 hours ago. He is appropriately
communicative, tachycardic to the 110s. He has a WBC of 20 and a blood glucose level of 160. On
exam, there is blistering and streaking erythema up the forearm and palpable crepitus in the hand
and forearm. What is the next step?
a. X-ray to rule out trauma
b. MRI to rule out abscess
c. Emergent surgery
d. Tissue biopsy
2. A 35-year-old woman with type 1 diabetes presents with worsening pain over the volar index
finger after being bitten by her cat yesterday. She has a 2 mm open wound with expressible
purulence over the volar surface of the second phalanx. She has full active ROM of the digit with
mild pain, no fusiform swelling, and no pain over the volar P1 and palm. Her WBC is 7, her
glycosylated hemoglobin is 9.5, and she is afebrile. What is the next step?
a. X-ray to rule out underlying fracture
b. I + D of localized abscess and inpatient IV antibiotics
c. I + D of abscess and discharge with clindamycin
d. Emergent decompression of the flexor sheath
3. A 75-year-old man with rheumatoid arthritis was referred to you for a persistent infection on the
dorsal hand. He reports bumping the hand on a metal railing 10 months ago, resulting in an open,
intermittently draining 1 × 1 cm wound overlying the dorsal fifth metacarpal. There is mild cloudy
drainage and thickened scar tissue along the wound edges, but no exposed tendon or bone. What is
the next step?
a. Biopsy
b. IV antibiotics
c. Formal debridement and closure
d. Local wound care
1. Answer: c. Patient has signs and symptoms of necrotizing fasciitis, which is limb and life
threatening. Treatment involves emergent and often serial debridement, broad-spectrum IV, and
supportive inpatient care. A tissue sample can be obtained in the OR. Imaging will delay definite
treatment.
2. Answer: b. Patient is a poorly controlled diabetic with a localized infection that has high risk of
developing into flexor tenosynovitis. At present, her wound should be I + Ded and cultured.
Monitoring as an outpatient or inpatient can be debated, but clindamycin is not an appropriate
antibiotic for Pasteurella species, which are most commonly associated with animal bites. At this
point, patient does not have flexor tenosynovitis, though she has potential to develop it.
3. Answer: a. A biopsy is the necessary next step to rule out skin cancer, which can masquerade as a
chronic infection. The other options are appropriate once cancer has been ruled out.
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References
Siverstein, P. Smoking and wound healing. Am J Med. 1992;93(1 suppl A):22S-24S.
Liu, C, Bayer, A, Cosgrove, S, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillin-
resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18-e55.
Merritt, W. The Impecunious Treatment for Chronic Paronychia and Ingrown Toenails: Back to the Future. Presented at American Association of
Hand Surgery Annual Meeting; January 21-24; Paradise Island, Bahamas. 2015.
Lille, S, Hayakawa, T, Neumeister, M, et al. Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative
flexor tenosynovitis. J Hand Surg Br. 2000;25(3):304-307.This study is a multicenter retrospective review of 75 patients that compares intraoperative
and continuous postoperative irrigation (standard of care; n = 55) versus intraoperative flush alone (n = 20) for treatment of suppurative tenosynovitis.
Outcomes were not statistically different between the two groups. Intraoperative flush alone simplifies treatment, reduces patient discomfort, and allows
for earlier postop range of motion exercises.
Pang, H, Teoh, L, Yam, A, et al. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg. 2007;89(8):1742-1748.
Jebson, PJ. Deep subfascial space infections. Hand Clin. 1998;14(4):557-566.
Lee, T, Carrick, M, Scott, B. Incidence and clinical characteristics of methicillin resistant Staphlococcus aureus necrotizing fasciitis in a large
urban hospital. Am J Surg. 2007;194(6):809-812.
Sammer, D, Shin, A. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am. 2009;91A:1387-
1393.This is a retrospective review out of Mayo clinic that compares open irrigation and debridement (standard of care; n = 19 wrists) versus
arthroscopic irrigation and debridement (n = 21 wrists). For isolated septic arthritis of the wrist, arthroscopic treatment resulted in fewer procedures
and shorter hospitalization. No differences in procedure number or hospitalization length between the two groups were seen when patients had multiple
sites of infection.
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C H A P T E R 6 9
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Soft Tissue Reconstruction of the Upper Extremity
and Management of Fingertip and Nail Bed
Injuries
Sirichai Kamnerdnakta and Kevin C. Chung
Key Points
The primary goals of soft tissue reconstruction of the hand are restoration of function and
appearance.
As opposed to the historical reconstructive ladder approach, reconstructive elevator approach is
more suitable for soft tissue defects of the hand, in which the surgeon selects any procedure that will
achieve the desired outcomes.
Early postoperative mobilization and rehabilitation will achieve maximal functional outcomes.
A functional hand should possess a stable wrist and at least two opposing, sensate, and painless
digits. One finger should be mobile and opposed with another stable finger, with a space between
the digits.
In a mutilated hand injury, pedicle flaps can be used to provide coverage in preparation for a
microsurgical procedure, such as a toe transfer or microsurgical bone reconstruction.
An acceptable hand consists of a thumb and at least three fingers that have supple interphalangeal joint
motion, adequate length, and preserved sensibility. 1 However, these minimal conditions are sometimes
not achievable in extreme reconstruction cases. In such cases, function is prioritized. The minimal
functional requirements include a stable wrist and two opposing, sensate, and painless digits. The two
fingers should be separated by a gap and should include one mobile finger, along with an opposing,
stable finger. 2 Although the functional requirements should be considered during the development of the
reconstruction plan, the surgeon should also aim to achieve optimal appearance of the hand. 3 In
particular, the surgeon should consider color and texture match, donor/recipient tissue interface,
hairiness, and the size and location of the final scar.
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Principles of Reconstruction
One of the fundamental principles of plastic surgery regarding soft tissue reconstruction is the
reconstructive ladder, in which surgical decisions are made following a stepwise approach that increases
in complexity the higher the ladder goes. The ladder starts with simple primary closure and ends with
complex microsurgical free flap surgery. However, modern advancements in plastic surgery suggest a
new approach, the reconstructive elevator. With this approach, optimal function and appearance guide
the decision that surgeons make regarding reconstruction. 4,5
Starting with the simplest procedure, definite wound closure should be planned expeditiously. The
ultimate goal is to obtain primary wound healing to diminish scar formation and lessen the possibility of
contracture and stiffness. However, before any definitive wound coverage is done, wound bed
preparation is mandatory before any coverage to ensure proper wound healing of the reconstructed
defect. Coverage should be delayed until the wound shows stability and clear demarcation of nonviable
tissue, with minimal risk of infection. Although temporary, negative pressure wound therapy (NPWT)
provides optimal wound dressing during the serial debridement period because it bridges the gap before
definite wound closure and promotes healing. Applying NPWT can reduce exudate, improve local tissue
perfusion, and lessen swelling. However, surgeons must exercise caution during prolonged application of
NPWT because granulation tissue may form over the wound bed and cause scarring over time. 6 NPWT is
often used to promote granulation tissue prior to skin grafting in the lower extremities. However,
prolonged use in the hand causes contracture and stiffness. If a patient has vital structures that are
exposed, the surgeon must consider an immediate flap coverage. Subsequent debridement and irrigation
can be performed to ensure viability of the tissue. Once the wound bed has been prepared adequately, a
definitive flap can be performed.
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Clinical Consideration
An analysis of a defect is crucial prior to initiating any mode of reconstruction. The surgeon should try to
preserve the essential structures as much as possible so that they can maintain their own function. The
most effective way to preserve the vital components is to consider early soft tissue coverage as the first
step in the management of the severed hand.
In certain scenarios, single-stage reconstructions are not appropriate (e.g., tendon or nerve reconstruction
with substantial bony and soft tissue loss) because the formation of scar and fibrotic tissue will hinder
functional recovery. Thus, a staged reconstruction is often better than trying to accomplish too much at
the onset of the injury. Each defect requires an individualized treatment protocol. While formulating the
treatment plan, the surgeon should consider all relevant factors that could affect the success of the
reconstruction 7 (Table 69.1). Although treatment options vary, all reconstructive procedures of the soft
tissue envelope of the hand must follow the basic principles of coverage: replacing like with like,
restoring function, and preserving sensibility and mobility. For example, in the effort to reconstruct a
mutilated hand that requires secondary reconstruction, surgeons prefer the use of a fasciocutaneous flap
over a muscle flap. A fasciocutaneous flap is more pliable and has greater gliding capacity, which
facilitates tendon gliding without impairment during motion. On the other hand, a muscle flap can
adhere to the wound bed and make a secondary procedure more tedious.
TABLE 69.1
Influential Factors for Perioperative Considerations
Factor
Implications
Wound
Size
Site
Side (volar/dorsal)
Amount and type of tissue loss
Donor site
Functional loss
Scar location
Morbidity
Flap
Texture
Color
Volume
Hairiness
Sensibility
Patient
Handiness
Age
Sex
Occupation
Medical comorbidities
Preferences
Surgeon
Knowledge
Technical skill
Preference
Choosing the optimal flap for each individual defect is an important factor of the hand reconstruction.
Choices include a pedicle locoregional flap, a distant flap, and a microsurgical free flap, which all abide
by the basic principles of coverage. Depending on the origin site, flaps are defined as the following:
Local flap: Originates from a site directly adjacent to the defect and is typically completed in a single-
stage reconstruction (e.g., V-Y advancement flap or Z-plasty)
Regional flap: Originates from areas not adjacent to the defect but is still confined within the ipsilateral
limb (e.g., thenar flap, cross-finger flap, radial forearm flap)
Distant flap: Originates from areas that are not from the ipsilateral limb of the defect and almost
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always requires two stages for harvest and inset (e.g., groin flap)
Surgeons should preferentially consider the use of pedicle locoregional flaps. The defect can be used as a
template to simulate the flap design. Pivot point, movement, and length are all factors that should be
considered when designing the flap. If a locoregional flap cannot be designed to cover the defect
adequately, a distant flap or microvascular free flap is needed. A free flap is advantageous because it
requires only one procedure, encourages composite reconstruction, allows mobility, and permits earlier
rehabilitation. 8 However, the operation is technically demanding and requires advanced microvascular
surgery skills. Unstable patients, including those with multiple comorbidities, are normally not the best
candidates for free flaps. Additionally, vessel paucity, mutilating hand injuries, or prior history of free
flap failure may be indication for a pedicle distant flap. 9 Common scenarios for which the surgeon
should consider performing a pedicle distant flap include coverage of digital stump defects in
preparation for toe-to-hand transfer, high-voltage electric injuries with diffused thrombosed vessels, and
multiple defects. 10-14
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Modes of Reconstruction for Individual Defects
Partial or Full-Thickness Skin Loss
Skin Grafts
Partial or full-thickness skin defects that do not require additional volume or functional tissue can be
covered using a skin graft. Split-thickness skin grafts (STSGs) are more pliable, have an easier “take,”
conform better on a convoluted surface, and provide more surface coverage than full-thickness skin grafts
(FTSGs). However, a FTSG can restore more durability and sensibility, while it can minimize the risk of
contracture. Despite their benefits, there are certain contraindications for skin grafting:
Nonvascularized wound bed such as a bare bone or bare tendon defect
Exposure of vital structures such as neurovascular bundle
Defects that are overlying a joint area
Active infectious status
Planned secondary reconstruction; tendon graft, nerve graft, implantation, tenolysis, or joint release
The most notable contraindication is that grafts can adhere to the underlying structures, making further
reconstruction impossible.
The palmar and dorsal skins of the hand are functionally and anatomically different. The dorsal skin is
thin, pliable, and loose, which facilitates smooth tendon gliding and unrestricted movement of the
underlying joints. Conversely, the palmar skin is thick, durable, glabrous, and inelastic, which enables to
withstand constant external forces and enhance prehensile function through the formation of skin creases
and folds. The thick dermal layer of the glabrous skin is rich in exocrine sweat glands, blood vessels, and
sensory nerve endings. Therefore, STSGs are typically used for reconstruction of defects of the dorsum of
the hand; whereas, volar skin defects almost always require resurfacing by FTSGs. To obtain similarity of
the glabrous volar skin, the donor site of FTSGs is harvested from the hypothenar eminence or instep
plantar area.
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Dermal Substitute
A dermal substitute, in conjunction with an STSG, will provide better quality, thickness, and pliability in
comparison to reconstruction with an STSG alone. 15,16 Dermal substitutes are advantageous because they
provide a scaffold for growth of neovascularized tissue from the wound bed. Therefore, a dermal
substitute can take on tendons devoid of paratenon, cartilage without perichondrium, and bones without
the periosteum. Dermal substitutes require a noninfected and well-vascularized wound bed. However,
the amount of vascularized tissue necessary for successful incorporation of dermal substitutes is not well
defined. 17 Dermal substitutes are used for the reconstruction of acute and chronic burns of the hand, but
it lacks evidence-based support to be used over traditional modes of reconstruction in nonburn-related or
traumatic wounds. 18-20 Nonetheless, dermal substitutes are a good alternative if the patient cannot
tolerate a prolonged operation or needs a shorter period of immobilization. Soft tissue reconstruction
using dermal substitutes may deliver acceptable functional and aesthetic outcomes in select situations.
20,21
However, dermal substitute templates lack many essential components of normal skin, such as hair
follicles, sweat glands, or other skin appendages. Furthermore, sensory recovery is unsatisfactory.
Injuries that need reconstruction with high sensory demand, such as those in the palm or pulp of the
finger, are better suited to be reconstructed with a flap to optimize functional outcomes.
Reconstruction of soft tissue defects via dermal substitutes typically requires STSG. In a two-stage
reconstruction, split-thickness skin grafting can be done 2 to 3 weeks after dermal substitute placement.
NPWT can be used to bridge the wound before definitive skin graft placement. Full-thickness skin
grafting with a dermal substitute is not recommended because there is a high metabolic demand of the
FTSG, leading to a risk of ischemia and necrosis of the FTSG. 22
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Fingertip Defect
The goals of reconstructing a fingertip amputation are to restore the padding of the finger to provide
maximum tactile gnosis, preserve the length of the finger, keep an intact nail bed, and minimize
downtime. Although replantation achieves optimal appearance and functional results, this is not always
possible. Surgeons should consider the following factors while formulating the best treatment method:
the location of the injury, the dimension of the defect, and any involved structures, such as bone or
tendon.
Small fingertip defects that are less than 1 cm2 with minimal bony exposure or nail matrix involvement
should be healed by secondary intention. Secondary intention can restore sensation, appearance of the
fingertip, and achieve comparable functionality to skin grafts. 23-25 In cases of defects larger than 1 to
1.5 cm2, presence of volar oblique injuries, or the exposure of tendon or bone, the mode of surgical closure
will be determined. 26 Defects with the largest dimension of less than 1 cm may indicate reconstruction
using local tissue coverage, such as V-Y volar or lateral advancement flaps. The V-Y advancement flap is
most suitable for coverage of transverse or dorsal oblique fingertip amputations that have exposed bones
but sufficient length and bony support of the nail bed. Previous studies have demonstrated near-normal
or normal recovery in sensation for most patients after V-Y flap reconstruction. 27-29 However, larger or
composite defects will require more soft tissue, suggesting homodigital, heterodigital, locoregional, or
free tissue transfers. The location, geometry, and mechanism of the injury will dictate the mode of
reconstruction. The indications and contraindications of the available flaps are in Table 69.2. Although
some locoregional flaps do not require a two-stage reconstruction, cross-finger and thenar flaps do.
During a two-stage reconstruction, the affected finger is usually restrained for 2 to 3 weeks before a
secondary flap division is performed. This waiting period will delay the onset of rehabilitation, possibly
resulting in joint stiffness.
TABLE 69.2
Flap Options for Fingertip Reconstruction (PIPJ: Proximal Interphalangeal Joint)
Flap
Indication
Contraindication
V-Y
advancement
flap
Bony exposure defect from a transverse or dorsal oblique
fingertip amputation with adequate length and bony
support of the nail bed.
Amputation is usually a the midportion of the nail bed.
Insufficient tissue on the volar area, such as a
volar oblique amputation.
Amputation injury proximal to the lanula.
Cross-finger
flap
Volar soft tissue defects with exposed bone or tendon at
the middle or distal phalanx.
Defects with exposed bone or tendon at the distal
phalanx that cannot be covered with a V-Y advancement
flap.
Extensive dorsal skin loss and the involvement of
the adjacent fingers.
Thenar flap
Volar skin avulsion with bony or tendon exposure of the
finger pulp of the index, middle, or ring finger.
Reconstruction of a near-total or total distal phalangeal
pulp loss.
Extensive volar and dorsal tissue loss of the
finger.
Risk of flexion contracture is markedly high when
performing this flap in patients who has a
concomitant PIPJ injury.
Homodigital
island flap
Patients with extensive but not complete pulp defects
(<2 cm) of the fingers.
A negative digital Allen test showing inadequate
or nonexistent collateral perfusion.
Extensive soft tissue injury of the affected digit.
Avulsion injury that affects the digital artery.
Heterodigital
island flap
A defect with tendon, bone, or neurovascular exposure
An extensive injury that involves multiple digits
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