Review of Plastic Surgery – Donal W. Buck II

Lower Extremity Reconstruction and Lymphedema
139
13
Cheng, M.H., Chen, S.C., Steven, L.H., et al., 2013. Vascularized groin lymph
node flap transfer for postmastectomy upper limb lymphedema: flap anatomy,
recipient sites, and outcomes. Plast. Reconstr. Surg. 131 (6), 1286–1298.
Cheng, M.H., Huang, J.J., Nguyen, D.H., et al., 2012. A novel approach to the
treatment of lower extremity lymphedema by transferring a vascularized
submental lymph node flap to the ankle. Gynecol. Oncol. 126 (1), 93–98.
Cheng, M.H., Huang, J.J., Wu, C.W., et al., 2014. The mechanism of
vascularized lymph node transfer for lymphedema—natural lymphatico-
venous drainage. Plast. Reconstr. Surg. 133 (2), 192e–198e.
Chim, H., Drolet, B., Duffy, K., et al., 2010. Vascular anomalies and
lymphedema. Plast. Reconstr. Surg. 126 (2), 55e–69e.
Clemens, M.W., Colen, L.B., Attinger, C.E., 2013. Chapter 8: Foot
reconstruction. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 189–219.
Colohan, S., Saint-Cyr, M., 2013. Chapter 2: Management of lower extremity
trauma. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 63–91.
Dellon, A.L., 2013. Chapter 6: Diagnosis and treatment of painful neuroma
and of nerve compression in the lower extremity. In: Neligan, P.C. (Ed.),
Plastic Surgery, 3rd ed. Elsevier, pp. 151–173.
Fix, R.R., Heinz, T.R., 2010. Chapter 93: Reconstruction of the lower
extremity. In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed.
Mosby, pp. 610–615.
Follmar, K.E., Baccarani, A., Baumeister, S.P., et al., 2007. The distally based
sural flap. Plast. Reconstr. Surg. 119 (6), 138e–148e.
Griffin, J.R., Thornton, J.F., 2003. Low. Extreme. Reconstr. Sel. Readings Plast.
Surg. 9, 1–44.
Henry, G.I., Kleiber, G.M., 2013. Chapter 1: Comprehensive lower extremity
anatomy. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 1–62.
Hijjawi, J.B., Dumanian, G., 2006. The diabetic and the ischemic lower
extremity. In: McCarthy, J.G., Galiano, R.D., Boutros, S.G. (Eds.), Current
Therapy in Plastic Surgery. Saunders Elsevier, Philadelphia, pp. 658–665.
Hollenbeck, S.T., Toranto, J.D., Taylor, B.J., et al., 2011. Perineal and lower
extremity reconstruction. Plast. Reconstr. Surg. 128 (5), 551–563.
Hong, J.P., 2013. Chapter 5: Reconstructive surgery: lower extremity coverage.
In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 127–150.
Hong, J.-P., 2013. Chapter 10: Lower extremity reconstruction. In: Neligan,
P.C., Buck, D.W. (Eds.), Core Procedures in Plastic Surgery. Elsevier,
pp. 166–184.
Kasabian, A.K., Karp, N.S., 2007. Lower-extremity reconstruction. In: Thorne,
C.H., Beasley, R.W., Aston, S.J., et al. (Eds.), Grabb and Smith’s Plastic
Surgery, 6th ed. Lippincott Williams & Wilkins, Philadelphia, pp. 676–688.
Kovach, S.J., Levin, L.S., 2013. Chapter 7: Skeletal reconstruction. In: Neligan,
P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 174–188.
Lin, C.H., Ali, R., Chen, S.C., et al., 2009. Vascularized groin lymph node
transfer using the wrist as a recipient site for management of postmastectomy
upper extremity lymphedema. Plast. Reconstr. Surg. 123 (4), 1265–1275.
Lu, T.C., Lin, C.H., Lin, C.H., et al., 2011. Versatility of the pedicled peroneal
artery perforator flaps for soft-tissue coverage of the lower leg and foot
defects. J. Plast. Reconstr. Aesthet. Surg. 64 (3), 386–393.
Mackinnon, S.E., Dellon, A.L., 1988. Tarsal tunnel syndrome. In: Surgery of
the Peripheral Nerve. Thieme Publishing Group, New York, pp. 305–317.
Mathes, S.J., 1997. Muscle flaps and their blood supply. In: Aston, S.J.,
Beasley, R.W., Thorne, C.H. (Eds.), Grabb & Smith’s Plastic Surgery, 5th ed.
Lippincott-Raven, Philadelphia, pp. 61–72.
Medina, N.D., Kovach, S.J., Levin, L.S., 2011. An evidence-based approach to
lower extremity acute trauma. Plast. Reconstr. Surg. 127 (2), 926–931.
Microsurgery Atlas, Techniques and Principles. Found at: > Accessed on: July 2, 2014.
Suami, H., Chang, D.W., 2010. Overview of surgical treatments for breast
cancer-related lymphedema. Plast. Reconstr. Surg. 126 (6), 1853–1863.
Teo, T.C., 2010. The propeller flap concept. Clin. Plast. Surg. 37 (4), 615–626.
Yazar, S., Cheng, M.H., Wei, F.C., et al., 2006. Osteomyocutaneous peroneal
artery perforator flap for reconstruction of composite maxillary defects. Head
Neck 28 (4), 297–304.
Suggested Readings
Ali, R.S., Bluebond-Langner, R., Rodriguez, E.D., et al., 2009. The versatility
of the anterolateral thigh flap. Plast. Reconstr. Surg. 124 (6 Suppl.),
e395–e407.
Baumeister, R.G.D., Chang, D.W., Neligan, P.C., 2013. Chapter 3: Lymphatic
reconstruction of the lower extremities. In: Neligan, P.C. (Ed.), Plastic
Surgery, 3rd ed. Elsevier, pp. 92–100.
Brem, H., Sheehan, P., Rosenberg, H.J., et al., 2006. Evidence-based protocol
for diabetic foot ulcers. Plast. Reconstr. Surg. 117 (7 Suppl.), 193S–209S.
Figure 13.12.  A, The tarsal tunnel and its neural contents—the
terminal portion of the tibial nerve, medial plantar nerve, lateral
plantar nerve, and medial calcaneal nerve—as well as the digital
nerves. B, The sensory distribution of the five nerves that supply
sensation to the sole of the foot. (Reprinted from Dyck, P.J., Thomas, P.K.
[Eds.], 2005. Peripheral Neuropathy, 4th ed. Elsevier, 1487–1510.)
Abductor hallucis m.
Flexor
retinaculum
MEDIAL PLANTAR N.
MEDIAL PLANTAR
PROPER DIGITAL N.
INTERDIGITAL N.
TIBIAL N.
MEDIAL CALCANEAL N.
LATERAL PLANTAR N.
Abductor digiti quinti m.
MEDIAL CALCANEAL N.
SAPHENOUS N.
MEDIAL PLANTAR N.
LATERAL PLANTAR N.
SURAL N.
A
B

SECTION 4: Hand
Table 14.2  Signaling Pathways During Embryogenesis
SIGNALING CENTER
RESPONSIBLE SUBSTANCE
ACTION
ANOMALY
Apical ectodermal ridge
Fibroblast growth factors
Proximal-to-distal limb
development, interdigital
necrosis
Transverse deficiency
Zone of polarizing activity
Sonic hedgehog protein
Radioulnar limb formation
Mirror hand
Wnt pathway
Transcription factor Lmx-1
Ventral and dorsal limb axis
Nail-patella syndrome, abnormal
nail and pulp arrangement
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 1295–1301.
Congenital Hand Disorders
Chapter
14 
General Embryology
1. Hand development occurs during the 4th to 8th gestational
weeks (see Table 14.1).
●
3 to 4 weeks’ gestation: Upper limb bud formation
●
4 to 5 weeks’ gestation: Proximal-to-distal upper limb
development
●
By week 5, the upper limb is formed without digital
separation.
●
By week 8, complete development of the upper limb and
hand occurs.
Classification of Congenital Hand Disorders
1. Type I: Failure of formation of parts
●
Includes cases of longitudinal or transverse arrest
2. Type II: Failure of differentiation (separation) of parts
●
Includes all cases of inadequate separation of parts
■
Syndactyly
■
Camptodactyly
■
Clinodactyly
■
Symbrachydactyly
3. Type III: Duplication disorders
●
Includes all cases of duplication
■
Whole limb duplication and/or mirror hand
■
Polydactyly
■
Triphalangeal thumb
4. Type IV: Overgrowth
●
Includes macrodactyly or hemihypertophy
5. Type V: Undergrowth
●
Includes brachydactyly
●
Thumb hypoplasia
6. Type VI: Constriction band syndrome
7. Type VII: Generalized skeletal deformities
●
Includes all generalized syndromes
■
Apert syndrome
■
TAR syndrome
■
Poland syndrome
Table 14.1  Timing of Hand Formation
TIME AFTER
FERTILIZATION
HAND DEVELOPMENT
27 days
Development of arm bud
28-30 days
Further development of arm bud
34-36 days
Elongation of arm bud
34-38 days
Formation of hand paddle
38-40 days
Early separation of digits
44-46 days
Digits separated
Week 9-10
Formation of fingernails begins
Reprinted from Neligan, P.C., Chang, J. (Eds.), 2013. Plastic Surgery,
vol. 6, 3rd ed. Elsevier, 526–547.
2. Signaling pathways involved in upper limb development (see
Table 14.2)

Radial Deficiencies
141
14
3. Hypoplastic thumb
●
Occurs most commonly as part of radial deficiency
●
Blauth classification (see Table 14.4)
■
Correlates with degree of deficiency and necessary
treatment
●
Treatment
■
The main determinant for thumb reconstruction and/
or pollicization is the presence (Type IIIA) or absence
(Type IIIB) of a stable carpometacarpal (CMC) joint.
 Type-IIIA thumb: The child incorporates thumb
into routine use.
♦ Reconstruction is warranted
♦ Great toe to thumb transfer is an excellent
option when most of the metacarpal is
present.
 Type-IIIB thumb: Thumb is ignored by child and
grasp actions occur between fingers.
♦ Pollicization is the procedure of choice.
➔ Movement of the metacarpal and
neurovascular (NV) pedicle for a finger
➔ Also indicated for Type-IV and -V thumbs
●
Options to release/deepen the web space
■
4-flap Z (4Z) plasty (see Figure 14.1)
■
5 Z (5Z) plasty or “jumping man” flap (see
Figure 14.2)
Table 14.3  Syndromes Associated with Radial Deficiency
SYNDROME
CHARACTERISTICS
Holt-Oram
Heart defects; most commonly,
cardiac septal defects
TAR
Thrombocytopenia–absent radius
syndrome; present at birth but
improves over time
VACTERL
Vertebral abnormalities, anal
atresia, cardiac abnormalities,
tracheoesophageal fistula,
esophageal atresia, renal
defects, radial dysplasia,
lower limb abnormalities
Fanconi’s anemia
Aplastic anemia not present at
birth; develops at about 6 years
of age. Fatal without bone
marrow transplant; chromosomal
challenge test now available for
early diagnosis
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed., Elsevier,
1371–1403.
Radial Deficiencies
1. Deficiencies can range from mild thumb hypoplasia to
complete absence of the radius.
2. All forms of radial deficiency warrant systemic evaluation for
syndromes or associations (see Table 14.3).
Table 14.4  Thumb Deficiency Classification and
Treatment Paradigm
TYPE
FINDINGS
TREATMENT
I
Minor generalized hypoplasia
Augmentation or
no treatment
II
Absence of intrinsic thenar
muscles, first web-space
narrowing, UCL insufficiency
Opponensplasty,
first web
release, UCL
reconstruction
III
Similar findings as Type II,
extrinsic muscle and tendon
abnormalities, skeletal deficiency
A: Stable CMC joint
B: Unstable CMC joint
A: Reconstruction
B: Pollicization
IV
“Pouce flottant,” or floating
thumb
Pollicization
V
Absence
Pollicization
CMC, Carpometacarpal; UCL, ulnar collateral ligament.
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1371–1403.
Figure 14.1.  The standard four-flap Z (4Z) plasty often used for
deepening broader webs such as the thumb web. A, Incisions are
outlined. B, Flaps have been mobilized and crossed. C, Closure.
(Copyright, Elizabeth, Martin, 2011. In: Wolfe, S.W., Hotchkiss, R.N., Pederson,
W.C., et al. [Eds.], Green’s Operative Hand Surgery, 6th ed. Elsevier,
1303–1369.)
C
A
D
B
A B CD
A
B
C

Congenital Hand Disorders
142
Figure 14.2.  A and B, Incomplete first web release with 5Z plasty.
(Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6,
3rd ed. Elsevier, 603–633.)
A
B
Syndactyly
1. Failure of differentiation disorder (Type II)
2. Abnormal interconnection between adjacent digits
●
Familial form inherited in an autosomal dominant
pattern
3. Classified according to the degree and extent of the
interconnection
●
Simple syndactyly involves only skin and fibrous tissue.
●
Complex syndactyly involves skin, fibrous tissue,
and bone.
●
Complete syndactyly: The entire length of finger is
involved, including the fingertip/nail.
●
Incomplete syndactyly: The fingertip/nail is spared.
●
Complicated syndactyly: Syndactyly that occurs with
other anomalies or syndromes (e.g., Apert syndrome)
4. Treatment
●
Separation of border digits by 4 to 6 months of age to
limit tethering and growth disturbances
●
Can delay separation of other digits up to 18 months
●
If multiple fingers are involved, release only one side of
the digit to prevent vascular compromise.
Camptodactyly
1. Signs: Painless flexion contracture of the small-finger
proximal interphalangeal (IP) joint
●
Often progressive
2. Epidemiology
●
Occurs during infancy and adolescence
●
The majority of cases are bilateral.
●
Most often involves the small finger, but other fingers can
be affected.
■
Prevalence of finger involvement decreases as you
progress to the radial side of the hand.
3. Pathology: Can involve an imbalance of flexion/extension
secondary to abnormal lumbrical insertion, tightness of the
flexor digitorum superficialis or volar plate, and/or hypoplasia
of the finger extensor.
Figure 14.3.  A proximally based rectangular flap from the
dorsum of the syndactyly is the most frequently used method to
reconstruct the commissure. (Courtesy Shriners Hospitals for Children,
Philadelphia. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011.
Green’s Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
●
Release often involves a combination of full-thickness
skin grafts and local flaps.
■
Occasionally, incomplete syndactyly can be closed
with local flaps alone.
●
Dorsal skin flaps should be used for web-space resurfacing
(see Figure 14.3).

Polydactyly
143
14
Polydactyly
1. Duplication disorder (Type III)
2. Can be preaxial (radial/thumb) or postaxial (ulnar/small
finger)
●
Preaxial duplication is more common in Caucasian
patients.
●
Postaxial duplication is more common in patients of
African descent.
■
Postaxial duplication in Caucasian patients is often
associated with an underlying syndrome or
chromosomal abnormality.
2. Epidemiology
●
Familial form is inherited in an autosomal dominant
pattern.
●
Nonfamilial form is present in many syndromes and
chromosomal abnormalities (e.g., Down syndrome, Apert
syndrome).
3. Treatment
●
Observation
●
Surgery is advised for progressive deformities or those
with significant angulation (delta phalanx) that can affect
functioning of adjacent digits.
4. Treatment
●
Observation, passive stretching, and splinting
●
Surgery for progressive deformities that are fixed or lead
to functional impairment
Clinodactyly
1. Congenital curvature of a digit in the radial-ulnar plane (see
Figure 14.4)
●
Most often affects the middle phalanx of the small finger,
causing angulation of the distal IP joint.
●
The presence of a C-shaped physis and delta phalanx on
imaging is pathognomonic.
Figure 14.4.  Radiograph (A) and clinical picture (B) of left small finger clinodactyly. (Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C.,
et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
B
A
3. Postaxial polydactyly
●
Often inherited in an autosomal dominant pattern
●
The supernumerary digit is classified according to degree
of development.
■
Type A: Well developed, with articular attachments
 Requires operative ablation and transfer of the
important functional structures to the adjacent
finger.
■
Type B: Rudimentary, pedunculated digit, or nubbin
 Can often be treated with excision or suture
ligation at birth.

Congenital Hand Disorders
144
●
Type IV is most common. Duplicated proximal and distal
phalanges with a shared bifid metacarpal head.
■
Treatment requires operative ablation of the radial
part, with repositioning and transfer of important
functional structures to the ulnar part to construct a
properly aligned and functional thumb.
 The ulnar part is preserved because it is critical to
preserve the ulnar collateral ligament (UCL) to
stabilize pinch function.
●
Type IV: Triphalangeal thumb (see Box 14.1)
Table 14.5  Classification of Duplicated Thumbs
TYPE
DUPLICATED
ELEMENTS
I
Bifid distal
phalanx
II
Duplicated distal
phalanx
III
Bifid proximal
phalanx
IV
Duplicated
proximal
phalanx*
V
Bifid metacarpal
phalanx
VI
Duplicated
metacarpal
phalanx
VII
Triphalangeal
component
*Most common type.
Adapted from Wassel, H.D., 1969. The results of surgery for
polydactyly of the thumb. A review. Clin. Orthop. Relat. Res. 125,
175-193. Table reprinted from Neligan, P.C., Chang, J. (Eds.), 2013.
Plastic Surgery, vol. 6, 3rd ed. Elsevier, 603–633.
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1397.
BOX 14.1  TRIPHALANGEAL THUMB
• Triphalangeal thumbs can be divided into two distinct
forms. The first type has an extra phalanx of variable
size within a relatively normal-appearing thumb. The
second variety has a fully developed phalanx that
lies in the plane of the fingers and is considered a
five-fingered hand.
• The inheritance pattern is usually autosomal dominant
with variable expressivity and high penetrance. Genetic
consultation is warranted.
• The extra phalanx in a triphalangeal thumb may be
triangular, trapezoidal, or rectangular in shape. The
growth rate of the extra phalanx is variable, and initial
treatment consists of observation to assess growth
potential.
• A large, wedge-shaped extra phalanx requires fusion
of the abnormal phalanx with an adjacent phalanx
combined with bone removal. The joint with the
greatest motion is preserved and the joint with the
least movement is fused.
• A five-fingered hand is treated by pollicization of the
nonopposable radial digit.
Mirror Hand (See Figure 14.5 and Box 14.2)
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1321.
BOX 14.2  MIRROR HAND
• Mirror hand is rare and characterized by symmetric
duplication of the limb in the midline. Typically, there is
a central digit with three digits on each side and
absence of the thumb.
• The forearm often has two ulnae and no radius.
• The etiology has been attributed to transplantation or
replication of the zone of polarizing activity from the
posterior margin of the limb bud into the anterior
region.
• Treatment consists of reduction of the number of digits
to four and reconstruction of a thumb from the deleted
digits.
4. Preaxial polydactyly
●
Most common in Caucasian patients
●
Wassel classification: Thumb duplication (see Table 14.5)

Brachydactyly 14
145
Figure 14.5.  A and B, One-year-old girl with a left mirror hand
and seven digits. (Courtesy Shriners Hospitals for Children, Philadelphia.
In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s
Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
B
A
6. Flatt’s classification of macrodactly
● Type I: Macrodactyly and lipofibromatosis of involved
nerve; most common form
●
Type II: Macrodactyly and neurofibromatosis
●
Type III: Macrodactyly and hyperostosis (e.g., polyostotic
fibrous dysplasia)
●
Type IV: Macrodactyly and hemihypertrophy (e.g.,
Klippel-Trenaunay syndrome)
7. Treatment options include digital nerve stripping,
epiphysiodesis, staged debulking, bulk reduction, and ray
amputation as a last resort.
Figure 14.6.  Macrodactyly. (Reprinted from Wolfe, S.W., Hotchkiss, R.N.,
Pederson, W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed.
Elsevier, 1303–1369.)
Brachydactyly (See Figure 14.7)
1. Undergrowth disorder (Type V)
2. Characterized by shortening of the digit or ray within the
hand.
3. Impact of brachydactyly is dependent on the degree of
shortening, number of digits involved, and presence of
associated anomalies (e.g., syndactyly, clinodactyly,
symphalangism).
●
Treatment of isolated brachydactyly can include lengthen­
ing via bone graft, distraction osteogenesis, or toe
epiphysis transfer.
■
Surgery is often indicated only for significant
functional deficits because lengthening can lead to
stiffness or joint contracture of the involved digit.
Macrodactyly (See Figure 14.6)
1. Overgrowth disorder (Type IV)
2. Characterized by overgrowth of all structures in the involved
digit, including bone and soft tissue.
3. Can affect one digit or multiple digits, typically on the radial
side of the hand.
4. Two major forms: Static and progressive (more common)
●
Static: Enlarged digit is present at birth and grows
proportionately over time.
●
Progressive: Enlargement begins in childhood and the
involved digits increase in size throughout growth until
physical closure occurs with skeletal maturity.
5. Most commonly an isolated anomaly
●
Can occur with other syndromes, including neurofi­
bromatosis and Klippel-Trenaunay syndrome.

Congenital Hand Disorders
146
Figure 14.7.  Ten year old with isolated bilateral short long-, ring-,
and small-finger metacarpals. A, Loss of knuckle contour on fist
formation. B, Shortened long, ring, and small fingers apparent on
hand opening. C, X rays with shortened long-, ring-, and small-finger
metacarpals. (Courtesy Shriners Hospitals for Children, Philadelphia. In:
Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s
Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
B
C
A
 For example, lengthening the small and ring
fingers to restore power grip, pinch, and
opposition
 In this setting, surgery is typically performed
between 8 and 12 months of age.
Central Hand Deficiencies
See Figure 14.8, Table 14.6, and Box 14.3.
Table 14.6  Characteristics of a Cleft Hand
TYPICAL CLEFT HAND
ATYPICAL CLEFT HAND
(SYMBRACHYDACTYLY)
Autosomal dominant; limbs
involved
Sporadic limb involvement
(not the feet)
“V”-shaped cleft
“U”-shaped cleft
No finger “nubbins”
Finger nubbins may occur
Syndactyly (especially the first
web)
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1303–1369.
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1337.
BOX 14.3  CENTRAL HAND DEFICIENCIES
• True cleft hand is distinct from atypical cleft hand, which
is recognized as part of the teratologic sequence of
symbrachydactyly.
• Cleft hand is commonly inherited as an autosomal
dominant trait and is associated with split hand/split
foot (SHSF) and ectrodactyly, ectodermal dysplasia, and
cleft lip/palate (EEC) syndrome.
• Surgery is considered for a variety of indications,
including progressive widening of the cleft secondary to
transverse lying bones, a narrowed first web space, and
the widened cleft.
• Indications for early surgery are separation of syndactyly
between digits of unequal length, especially the thumb
and index finger, and removal of the transverse bones
that result in progressive widening of the cleft.
• In cases of thumb–index finger syndactyly, the first web
space requires reconstruction. The technique depends
on the severity of the syndactyly. Complete syndactyly
can be released and the cleft closed in a single setting.
The skin from the cleft is rotated into the first web
space to create supple tissue.

Amniotic Band Syndrome 14
147
Figure 14.8.  A-F, These images illustrate the Manske and Halikis classification and also some aspects of the teratologic sequence in cleft
hand. A, Type-I hand with a normal web space between the thumb and index finger. A very minor cleft is present between the second and
third rays as is syndactyly between the third and fourth rays. B, Type-IIA hand in which the thumb web space is mildly narrowed. Note the
suppression of the central ray with a deep cleft and minor syndactyly between the ring finger and the little finger. C, Type-IIB cleft hand with
a severely narrowed first web space and deletion of the third and fourth rays. D, Type-III cleft hand (untreated) on the right side and Type-IV
cleft hand on the left. On the right side, the thumb and index fingers have untreated syndactyly that completely obliterates the first web
space. The central ray is absent, and the fourth and fifth rays are also syndactylized. E, Type-IV cleft hand with a merged web space.
The two border rays are present, but the index ray and other central rays are suppressed, and the first web space merges with the cleft.
F, Bilateral Type-V cleft hands. The thumb web space and the thumb are absent, and only the ulnar digit remains. (Reprinted from Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
B
D
E
F
C
A
Amniotic Band Syndrome (See Figure 14.9)
1. A Type-VI congenital hand disorder
2. Characterized by complete or incomplete circumferential
constrictions that can lead to amputation, near amputation
with distal edema, or ischemia.
●
Can see secondary acrosyndactyly of the involved digits
with distal fusion and a proximal sinus between them.
3. Embryology
●
Sporadic disorders
●
Most commonly affect the central long fingers
●
Risk factors: Prematurity, low birth weight, young
multigravida mothers, and oligohydramnios
4. Pathology: Entrapment of developing embryonic tissue by
amniotic bands
5. Treatment
●
Mild constriction rings: Excision and Z plasty
●
Acrosyndactyly: Follow standard techniques for
release of syndactyly, with excision of the proximal
sinus.
●
If overt distal ischemia is present, emergent surgical
release may be appropriate and amputation required.

Congenital Hand Disorders
148
Figure 14.9.  Manifestations of the amniotic disruption sequence. A, Typical ring constrictions of digits. B, Pallor of the finger distal to the
ring constriction in a neonate. C, Acrosyndactyly with the digits fused at their distal parts and proximal cutaneous clefts. D, Amputation
secondary to constriction rings. (Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed.
Elsevier, 1303–1369.)
B
D
C
A
Apert Syndrome
1. Generalized congenital skeletal/hand disorders (Type VII)
2. Apert syndrome (acrocephalosyndactyly): Combination of
bicoronal craniosynostosis, midfacial hypoplasia, and severe
complex syndactyly of the hands and feet
3. Pathology: Mutation of the fibroblast growth factor receptor
Type-2 gene (FGFR2)
4. Often characterized by complex, complete syndactyly of the
index, long, and ring fingers (see Figure 14.10).
5. Classification of the Apert hand deformity (see Table 14.7)

“Congenital” Trigger Fingers
149
14
Table 14.7  Classification of the Apert Hand Deformity
FIRST WEB
CENTRAL MASS
FOURTH WEB
Type I:
“Obstetrician” or
“spade” hand
Incomplete simple
syndactyly
Digital mass flat in the palmar plane, good MPJs with
variable degree of symphalangism at the IPJs
Incomplete simple
syndactyly
Type II: “Mitten” or
“spoon” hand
Complete simple
syndactyly
The digital mass forms a palmar concavity with splaying of
the metacarpals proximally, tight fusion of the fingertips
distally, and synonychia of the central digital mass
Complete simple
syndactyly
Type III: “Hoof” or
“rosebud” hand
Complete complex
syndactyly
The thumb is incorporated into the mass, which is tightly
cupped; synonychia of all digits apart from the small finger;
skeletal abnormalities of the index ray, complicated by
paronychial infections and maceration of the palmar skin
Simple syndactyly,
usually with synostosis
of the fourth and fifth
metacarpals
IPJ, Interphalangeal joint; MPJ, metacarpophalangeal joint.
6. Treatment: Must be performed in concert with the
craniofacial anomalies
●
Goal: Complete separation of the digits and correction of
the thumb deformity before two years of age to allow for
growth and development
●
Release of the thumb and creation of an adequate first
web space is often the first priority, followed by staged
release of the finger syndactylies.
■
The distal bifurcation of digital arteries and nerves
often seen in the Apert hand makes separation
difficult.
Figure 14.10.  Complex multiple syndactyly associated with Apert
syndrome. The hand deformity includes complex syndactyly of the
index, long, and ring fingers, simple syndactyly between the ring
and small fingers, and an incomplete first web space. (Reprinted
from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s
Operative Hand Surgery, 6th ed. Elsevier, 1303–1369.)
Figure 14.11.  Symbrachydactyly and pectoralis major anomaly and
smaller breast on the right side. (Reprinted from Neligan, P.C., Chang, J.
[Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 603–633.)
Poland Syndrome
1. Generalized congenital skeletal/hand disorder (Type VII)
2. Characterized by absence of the sternal head of pectoralis major
muscle and symbrachydactyly (short, fused fingers), often
affecting the index, long, and ring fingers (see Figure 14.11).
●
Can also have severe hypoplasia of the chest wall and
hand, including breast hypoplasia, aplasia of the pectoralis
minor m. and latissimus dorsi m., skeletal thoracic wall
abnormalities, and cleft hand.
●
The severity of the hand and chest-wall disorders do not
correlate.
3. Treatment of the hand deformity depends on the severity of
the disorder.
●
Can include syndactyly release and web-space deepening.
“Congenital” Trigger Fingers
1. Not truly “congenital” and may be present at birth or up
to age 3.
Reprinted from Upton, J., 1991. Apert syndrome: classification and pathologic anatomy of limb abnormalities. Clin. Plast. Surg. 18, 321–355.

Congenital Hand Disorders
150
2. Can involve any digit, although the thumb is 10 times more
likely to be involved.
3. May be difficult to diagnose in infants because they tend to
carry their hands with fingers in the clinched position.
4. Characterized by fixed flexion contracture of the IP joint,
with a palpable nodule over the flexor pollicis longus tendon
(“Notta’s node”).
●
Presence of Notta’s node distinguishes trigger finger from
camptodactyly in the small finger.
5. Treatment: Observation or splinting in children younger than
1 year of age; surgical release of the A1 pulley in children older
than 3 years.
●
Surgical release of trigger thumb is highly successful,
whereas trigger finger release may require additional
resection of a slip of the flexor digitorum superficialis
tendon if triggering is persistent.
Suggested Readings
Hovius, S.E.R., 2013. Chapter 28: Congenital hand IV: Disorders of
differentiation and duplication. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, China, pp. 603–633.
Kay, S.P., McCombe, D.B., Kozin, S.H., 2011. Chapter 40: Deformities of the
hand and fingers. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), Green’s Operative Hand Surgery, 6th ed. Elsevier, Philadelphia,
pp. 1303–1369.
Kozin, S.H., 2003. Upper-extremity congenital anomalies. J. Bone. Joint. Surg.
Am. 85, 1564–1576.
Kozin, S.H., 2011. Chapter 41: Deformities of the thumb. In: Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, Philadelphia, pp. 1371–1403.
Kozin, S.H., 2011. Chapter 39: Embryology of the upper extremity. In: Wolfe,
S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, Philadelphia, pp. 1295–1301.
Tonkin, M., Oberg, M., 2013. Chapter 25: Congenital hand I: Embryology,
classification, and principles. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, China, pp. 526–547.
Upton, J., Taghinia, A., 2013. Chapter 27: Congenital hand III: Disorders of
formation—thumb hypoplasia. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, China, pp. 572–602.

Hand Masses, Vascular
Disorders, and
Dupuytren’s Contracture
Chapter
15 
Hand Masses
1. Excluding cutaneous malignancies, the majority of hand
masses are benign (~95%).
• Ganglion cysts are the most common mass found on the
hand and wrist.
• Cutaneous malignancies are the most common malignant
masses found on the hand and wrist (accounting for 90%
of all hand malignancies).
■ Squamous cell carcinoma > basal cell carcinoma
> melanoma
• Enchondroma is the most common bone tumor found in
the hand.
• Although rare, chondrosarcoma is the most common
malignant bone tumor found in the hand.
• Epitheliod sarcoma is the most common malignant
soft-tissue sarcoma found in the hand.
2. Evaluation of hand masses
• Thorough history and physical examination
■ Include examination of regional nodal basins if
concerned for malignancy
• Imaging studies
■ X ray: Useful for evaluation of bony definition
■ Computed tomography (CT) scan: Better bony
resolution than plain radiographs, useful for anatomical
evaluation of soft-tissues and when plain radiographs are
equivocal
■ Magnetic resonance imaging (MRI): Better soft-tissue
resolution than CT scan, useful for determining the
exact location of gross involvement
■ Ultrasound: Useful in determining if lesion is cystic or
solid
■ Bone scan: Useful in assessing for bony metastases or
osteomyelitis
• Tissue biopsy
■ Aspiration or core needle biopsy: Useful for lesions with
a cystic component
■ Core needle biopsy: Useful for cell sampling of a lesion
before formal excision or to assist in determining best
method of treatment
■ Incisional biopsy: Useful for lesions that are too large to
be excised completely without affecting adjacent
structures
■ Excisional biopsy: Complete excisional biopsy is the
preferred method but may not be the best primary
diagnostic approach (e.g., when excision could
compromise function or cosmesis).
○ Careful consideration of incision placement is critical
in the event that further resection is necessary (e.g.,
most incisions should be placed longitudinally).
■ When performing a biopsy for an unknown diagnosis,
the extremity should not be exsanguinated.
Common Benign Hand Masses
1. Ganglion cyst (see Figure 15.1)
• Most common soft-tissue mass in the hand and wrist
• Etiology: Mucoid degeneration
• Characterized by pseudocysts (not epithelial lined) that are
closely connected to a joint or tendon sheath and filled
with mucinous material
• Most common locations (in order of frequency)
■ Dorsal wrist: Emanates from scapholunate ligament
■ Volar wrist: Emanates from radioscaphocapitate
ligament or scaphotriquetral ligament
○ Often in close proximity to radial artery and venae
comitantes
■ Flexor tendon sheath
■ Dorsal distal interphalangeal (DIP) joint: Mucous cysts
• Treatment
■ Aspiration and corticosteroid injection
○ High recurrence rate
■ Excision of the cyst stalk and debridement of the origin

Hand Masses, Vascular Disorders, and Dupuytren’s Contracture
152
3. Epidermal inclusion cyst (see Figure 15.3)
• Often caused by penetrating trauma and located on the
tactile surfaces of the hands
• As it grows in size, it can cause pressure erosion of the
underlying bone.
• Treatment: Excision is the mainstay of treatment.
■ Complete cyst wall removal reduces risk for recurrence.
■ In cases of significant pressure erosion of bone, bone
grafting may be necessary.
2. Mucous cyst (see Figure 15.2)
• Ganglion cyst that originates from the DIP joint and is
present on the dorsal aspect of the distal phalanx
• Frequently associated with arthritis of the DIP joint and
osteophyte formation
• If the mucous cyst affects the germinal matrix, it can cause
nail plate grooving.
■ Cyst treatment will resolve nail plate issues.
• Treatment
■ Elevation of the terminal extensor tendon, debridement
of the cyst origin at the DIP joint, and removal of any
associated osteophytes
Figure 15.1.  Ganglion cyst. The cyst is a mucinous-filled structure
associated with joint capsules, tendons, and tendon sheaths. The
etiology of these cystic structures is presumed to be secondary to
synovial herniation and trauma. (Reprinted from Neligan, P.C., Chang, J.,
[Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 311.)
Figure 15.2.  Mucous cyst. A, Ganglions found on the dorsal
proximal interphalangeal joint associated with osteoarthritis are
termed mucous cysts. B, To treat this clinical entity completely,
must perform excision of the cyst along with excision of
osteophytes. (Reprinted from Neligan, P.C., Chang, J., [Eds.], 2013. Plastic
Surgery, vol. 6, 3rd ed. Elsevier, 311.)
A
B
Figure 15.3.  Epidermal inclusion cyst. These masses, which
originate from an invagination of epithelium, can follow trauma,
injection, or an incision. The epithelium is internalized, resulting in
subcutaneous keratin deposition. (Reprinted from Neligan, P.C., Chang, J.,
[Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 311.)
4. Lipoma
• Very common benign fatty tumor
• Lipomas in the hand may cause peripheral nerve
compression with growth.
• Most commonly located within the thenar eminence of the
hand
• MRI is useful for differentiating lipomas from other hand
masses.
• Treatment: Resection, especially if symptomatic or
enlarging
5. Giant cell tumor (see Figure 15.4)
• Benign nodular tumor found on the tendon sheath
■ Most commonly found on the palmar surface of the
index and long fingers.
■ Second most common soft-tissue tumor of the hand and
fingers
• Signs: Nontender, firm, enlarging nodular mass that does
not transilluminate
• Histology: Proliferating histiocytes with multinucleated
giant cells

Common Benign Hand Masses
153
15
• Treatment: Marginal excision
■ High recurrence rate, even with excision
Figure 15.4.  Giant cell tumor (pigmented villonodular synovitis). A
benign tumor containing multinucleated giant cells and xanthoma
cells found in synovial fluid-producing sites such as joints, capsular
ligaments, and tendon sheaths. (Reprinted from Neligan, P.C., Chang, J.,
[Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 311.)
6. Pyogenic granuloma (see Figure 15.5)
• Benign reactive vascular tumor frequently found on the
upper arms and hands
• Characterized by a rapidly growing, reddish nodule that is
friable and frequently ulcerates and bleeds
• Treatment: Excision of the lesion with a margin of normal
appearing tissue, shaving of the lesion, and coagulation of
the tumor base
Figure 15.5.  Pyogenic granuloma. Rapidly progressing benign
vascular lesion commonly found in the finger. Etiology is unknown.
(Reprinted from Neligan, P.C., Chang, J., [Eds.], 2013. Plastic Surgery, vol. 6,
3rd ed. Elsevier, 311.)
7. Schwannoma (see Figure 15.6)
• Most common benign, solitary, peripheral nerve tumor
• Characterized by asymptomatic masses along the course of
a peripheral nerve that are mobile in the transverse
direction
■ Typically without sensory or motor deficits, although
paresthesias can occur
• MRI often demonstrates a homogenous “egg-shaped”
lesion within the nerve.
• Treatment: Enucleation without disruption of the nerve
fascicles
Figure 15.6.  Schwannoma/neurilemmoma. This soft-tissue mass
arises from Schwann cells and is typically found on the volar
surface of the hand and forearm. (Reprinted from Neligan, P.C., Chang, J.,
[Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 311.)
8. Enchondroma
• Most common primary bone tumor
• Arises from cartilage and most commonly occurs in the
proximal phalanx, followed by the metacarpals and/or the
middle phalanges
• X rays typically demonstrate a well-defined radiolucency
within the metaphysis or diaphysis, often with a sclerotic
rim and/or scalloping of the endosteal cortex.
• Enchondromas can lead to pathologic fractures.
• Treatment: Curettage of the lesion and fracture repair
when necessary

Hand Masses, Vascular Disorders, and Dupuytren’s Contracture
154
Malignant Hand Masses
1. Cutaneous malignancy
• Most common malignant masses found on the hand and
wrist
■ Squamous cell carcinoma > basal cell carcinoma >
melanoma
• See Chapter 24 for more specific information on cutaneous
malignancies.
• General treatment guidelines for cutaneous malignancies of
the hand: Wide local excision with negative margins
■ Mohs micrographic surgery may be useful at
anatomically sensitive areas.
■ Amputation at the level of the joint proximal to the
lesion is often indicated when the tumor involves bone
or the nail bed.
■ Sentinel lymph node biopsy may be indicated depending
on pathologic features, depth, and tumor characteristics.
2. Epithelioid sarcoma
• Most common soft-tissue sarcoma in the hand
• Characterized by a painless nodule on the volar aspect of
the hand that can ulcerate
• High risk of proximal spread and metastasis to lymph
nodes
• Treatment: Wide excision or amputation and adjuvant
radiation therapy
■ Sentinel lymph node biopsy may be necessary.
■ Adjuvant chemotherapy is considered for recurrent or
metastatic disease.
3. Chondrosarcoma
• Most common primary malignant bone tumor of the hand
• Arises from cartilage cells near joints or can develop from
malignant transformation of benign cartilaginous tumors
(e.g., enchondromas or osteochondromas)
• Most commonly affects the metacarpals and proximal
phalanges of men older than 60.
• Characterized by slow-growing, firm, painful masses
• X rays demonstrate poorly defined lesions with lytic areas
and stippled calcifications.
• Most common site of metastasis: Lung
• Treatment: Excision or amputation depending on the
location and size
4. Osteosarcoma
• Most common pediatric bone tumor, although rarely
affects the hands in children
• Hand osteosarcoma typically affects the proximal phalanges
and metacarpals of patients older than 40.
• Characterized by painful, rapidly enlarging masses
• X rays demonstrate intramedullary lesions with sclerotic
and lytic areas and overlying periosteal elevation
(“sunburst”).
• Treatment: Excision or amputation with adjuvant or
neoadjuvant chemotherapy
5. Ewing sarcoma
• Rare, malignant bone tumor that most commonly affects
the metacarpals or phalanges
9. Osteoid osteoma
• Benign, bone-forming tumor of osteoblast origin
• Typically affects the distal radius, carpus, and/or phalanges
• Characterized by a persistent, painful hand mass that is
relieved by nonsteroidal antiinflammatory drugs (NSAIDs)
• X rays typically demonstrate bone sclerosis around a
central lucency.
• Treatment: Observation and NSAIDs; curettage or surgical
resection may be curative
10. Osteochondroma (see Figure 15.7)
• Most common bone tumor in the pediatric population
• Arises from the bony surface near the epiphysis and
contains bone with a cartilage cover
• Characterized by a firm, fixed, painless mass near joints
■ Can occasionally cause pain with activity, or
paresthesias, depending on location
• May present with a solitary mass or multiple masses
■ Familial pattern inherited in an autosomal dominant
manner and presents with multiple osteochondromas
■ Solitary lesions are typically benign, whereas the risk of
malignant transformation is greatest for familial
osteochondromas.
• Treatment
■ Observation
○ Indicated for small, asymptomatic osteochondromas
with a benign appearance on imaging studies
■ Surgical resection
○ Indicated for large, symptomatic osteochondromas
(e.g., pain, functional limitations, sensory deficits,
etc.) or any osteochondroma that has a malignant
appearance on imaging studies (e.g., thick cartilage
cap, growth, etc.)
Figure 15.7.  Osteochondroma. The most common benign bone
tumor. Seen here in the distal phalanx of the thumb, it is a benign
bone prominence with a cartilage cap. (Reprinted from Neligan, P.C.,
Chang, J., [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 311.)

Vascular Tumors of the Hand
155
15
• Characterized by a lesion that is present at birth, grows
proportionately with the child, and never involutes
• Categorized based on vascular flow: Low or high
■ High-flow VM
○ Contains an arterial component (e.g., arterial
malformation, arteriovenous malformation)
♦ Painless mass that is not compressible
♦ May lead to distal ischemia or high-output cardiac
failure
■ Low-flow VM
○ Venous malformation
♦ Most common low-flow VM
♦ Bluish discoloration, compressible, painful,
secondary to thrombus formation or dependent
position
○ Lymphatic malformation
♦ Enlarges as a result of fluid accumulation,
cellulitis, or inadequate drainage
♦ Propensity for infection
♦ May cause bone hypertrophy
• Treatment: Options include selective embolization,
ligation, and surgical excision.
■ High-flow VM: Preoperative embolization followed by
surgical excision are often recommended.
3. Hemangioma (see Figure 15.8)
• Vascular tumor that frequently appears within the first 4
weeks of life
■ Affects females more commonly than males
• Characterized by a red, spongy lesion with a rapid growth
phase, followed by involution
■ In general, 70% of hemangiomas will involute by 7 years
of age.
■ A noninvoluting variant is possible.
• Histology reveals characteristic sheets of small, round cells.
• Characterized by pain, swelling, and systemic symptoms
(fever, leukocytosis)
• X rays demonstrate a characteristic “onion skin” pattern
along the cortex.
• Treatment: Chemotherapy (neoadjuvant and adjuvant) and
surgical excision
■ Ewing sarcomas are also radiosensitive, although
radiation is rarely used for hand tumors.
6. Synovial sarcoma
• Aggressive, malignant tumor that arises from a joint,
tendon, or bursae
• Characterized by a painful mass near a joint that can have
a period of slow or rapid growth
• Most commonly affects the carpus in the hand
• High rate of lymph node metastases (~25%)
• Treatment: Wide surgical excision or amputation with
adjuvant radiation therapy
Vascular Tumors of the Hand
1. Vascular aneurysm
• Typically arises following blunt trauma
■ Example: Hypothenar hammer syndrome
○ Arises from repeated blunt trauma to hypothenar
region of the hand and ulnar artery (e.g., hand usage
of manual laborers, carpenters, etc.)
○ May have an associated ulnar neuropathy from
compression of the ulnar nerve within Guyon’s canal
or digital ischemia from spasm ulnar artery thrombus
or distal emboli
• Characterized by a gradually enlarging mass that may be
associated with pain and ischemia
• Gold standard for diagnosis is an angiogram
• May be true aneurysm or false aneurysm
(pseudoaneurysm)
■ True aneurysm contains all three vessel wall layers:
Intima, media, adventitia
■ Pseudoaneurysm results from an arterial wall injury with
extravascular hematoma that organizes and forms a false
lumen lined only by endothelium.
• Treatment: Recommendations are generally dependent on
the location of the aneurysm and the source artery
involved.
■ Perform an Allen’s test preoperatively to evaluate for
superficial palmar arch patency and the dominant source
of hand perfusion.
■ Aneurysm excision and arterial repair or reconstruction
with vein graft are indicated when the source artery is
critical to hand perfusion.
■ Aneurysm excision and ligation of source artery are
indicated when the source artery is not critical to hand
perfusion.
2. Vascular malformation (VM)
• Arises from disorders in the embryologic development of
the vascular system
Figure 15.8.  Hemangiomas present as (1) superficial in the
cutaneous form; (2) deep, which represents cavernous lesions; or
(3) a mixture of both. Not present at birth, they are characterized
by a rapid growth phase during the first year. Expected involution
is 50% by 5 years of age and 70% by 7 years of age, respectively.
(Reprinted from Neligan, P.C., Chang, J., [Eds.], 2013. Plastic Surgery, vol. 6,
3rd ed. Elsevier, 311.)

Hand Masses, Vascular Disorders, and Dupuytren’s Contracture
156
• Characterized by pinpoint, paroxysmal pain, and cold
insensitivity
• Diagnosis
■ Subcutaneous nodules, most commonly in the
subungual region, that are painful with cold exposure
and/or focal pressure (Love’s sign)
○ Pain is often ablated with proximal tourniquet
insufflation (Hildreth’s sign).
○ May have a violaceous discoloration of the nail bed
■ X ray demonstrates a scalloped, osteolytic lesion of the
distal phalanx.
■ MRI demonstrates a high-signal-intensity lesion of the
distal phalanx.
• Treatment: Excision
5. Acquired arteriovenous fistula
• Arises after trauma or surgical intervention (e.g., radial
artery cannulation)
• Characterized by communication between an artery and a
vein that results in vascular shunting of blood flow into the
low-resistance venous system and bypassing of the
higher-resistance capillary system
• May result in an enlarging mass with a palpable thrill or
bruit or ischemia secondary to vascular steal or shunting
• Treatment: Resection of the fistula with arterial repair and/
or reconstruction in the setting of unstable fistulas or those
with ischemic sequelae
Other Vascular Disorders of the Hand
1. CREST (calcinosis, Raynaud’s phenomenon, esophageal
dysmotility, sclerodactyly, and telangiectasia) syndrome
• Also known as systemic sclerosis or scleroderma
• Hand involvement is characterized by cutaneous calcinosis,
Raynaud’s phenomenon (exaggerated vasoconstriction of
the digital vasculature in the settings of stress and cold
temperatures), taut shiny skin, and finger ulcerations.
• Treatment
■ Large, painful calcium deposits can be excised, but
surgical debridement should be conservative and include
good local wound care.
■ Digital sympathectomy or arterial bypass may help
alleviate symptoms; however, amputation may be
indicated with large ulcerations/wounds or persistent
progressive ischemia.
2. Buerger’s disease
• Also known as thromboangiitis obliterans
• Characterized by recurring progressive inflammation and
thrombosis of small vessels in the hands and feet secondary
to tobacco use (e.g., heavy smoking and smokeless
tobacco)
• Signs: Severe pain, cold sensitivity, digital ischemia and
discoloration, and ulcerations
• Treatment: Smoking cessation
• Diagnosis: Often made through history, physical
examination, and growth patterns
■ MRI and CT scan are useful for evaluation and
demonstrate a well-defined vascular tumor.
• Treatment options
■ Initial observation
■ Involution may be induced by steroid administration or
propranolol treatment.
■ Surgical excision indicated for persistent bleeding, when
tumor location or growth impairs function or cosmesis,
or if patient develops a platelet-consumptive
coagulopathy (Kasabach-Merritt syndrome)
■ Laser ablation is also a possibility.
4. Glomus tumor (see Figure 15.9)
• Benign lesion containing cells of a glomus apparatus (an
afferent vessel, a Sucquet-Hoyer canal, and multiple
vascular shunts beneath the nail bed and within the
glabrous skin)
Figure 15.9.  Glomus tumor. A benign tumor of the
neuromyoarterial apparatus responsible for controlling skin
circulation, presenting in a subungual location. A, Glomus tumor in
situ. B, Glomus tumor excised. C, MRI scan of glomus tumor distal
phalanx. (Reprinted from Neligan, P.C., Chang, J., [Eds.], 2013. Plastic Surgery,
vol. 6, 3rd ed. Elsevier, 311.)
A
B
C

Dupuytren’s Contracture
157
15
Dupuytren’s Contracture
1. A benign, progressive fibromatosis of the palmar and digital
fascia
2. Genetic predilection with an autosomal dominant pattern of
inheritance with variable penetrance
• Highest incidence in men of Northern European descent
• May be associated with repetitive trauma, alcohol abuse,
hepatic disease
3. Typically affects the metacarpophalangeal (MCP) joint first,
followed by the proximal interphalangeal (PIP) joint (see
Table 15.1)
• Ring finger > small finger > thumb > long finger > index
finger
3. Compartment syndrome
• Arises from increased pressure within soft-tissue
compartments, resulting in ischemia and necrosis of
compartmental contents (e.g., muscle, nerves)
• Tissue necrosis from compartment syndrome can lead to
significant functional deficits, systemic organ failure (e.g.,
renal failure from myoglobinemia), neurologic deficit, and
amputation.
• In the upper extremity, the most common causes include
fractures (e.g., distal radius fracture, supracondylar
humerus fracture), crush injuries, contusions, gunshot
wounds, tight circumferential casts/dressings, extravasation,
postischemia-reperfusion edema, and arterial injuries.
• Compartments of the upper extremity
■ Forearm: Volar, dorsal, mobile wad
○ Deep muscles of the volar compartment are most
commonly affected first (e.g., flexor digitorum
profundus).
■ Hand: Hypothenar, thenar, adductor, 4 dorsal interossei,
3 palmar interossei, and the carpal canal
• Signs of compartment syndrome: The “5 Ps”
■ Pain
○ Out of proportion to the injury or exam
○ With passive stretch (most sensitive sign)
■ Palpable swelling and tense compartments
■ Paresthesias
■ Paralysis
■ Pulselessness
○ Late finding
• Diagnosis
■ History, physical examination, and high index of clinical
suspicion
■ Compartment pressure measurements
○ Absolute value above 30 mm Hg
○ In patients with low diastolic blood pressure:
Compartment pressure measurements within
30 mm Hg of the diastolic blood pressure
• Treatment: Emergent fasciotomy
■ With arterial injury and repair in the forearm, consider
prophylactic fasciotomy because of anticipated ischemia-
reperfusion swelling.
■ Forearm: Volar and dorsal incisions
■ Hand: Longitudinal incisions over radial side of 1st
metacarpal, dorsal aspect of 2nd and 4th metacarpals,
ulnar side of 5th metacarpal, carpal tunnel release
• Complications
■ Volkmann’s ischemic contracture: Muscle necrosis
resulting in irreversible muscle contractures in the
forearm
■ Treatment: Depending on severity, ranges from splinting
and tendon lengthening to tendon transfers and/or free
functional muscle transfer
Table 15.1  Fascial Anatomy of Dupuytren’s Disease
DISEASED
STRUCTURE
ANATOMIC ORIGIN
CLINICAL
SIGNIFICANCE
Palmar Cords
Pretendinous
cord
Pretendinous band
MCP joint flexion
contracture
Vertical cord
Vertical fibers of
McGrouther or septa
of Legueu and Juvara
Causes painful
triggering
Palmodigital Cords
Spiral cord
Pretendinous band,
spiral band, lateral
digital sheet,
Grayson’s ligament
Displaces the
neurovascular
bundle medially and
superficially (spiral
nerve)
Natatory cord
Natatory ligament
(distal fibers)
Web-space adduction
contracture
Digital Cords
Central cord
Pretendinous cord
(digital extension)
PIP joint flexion
contracture
Retrovascular
cord
Retrovascular band of
thomine
PIP and DIP joint
flexion contracture;
prevents full correction
of PIP joint contracture
Lateral cord
Lateral digital sheet
(often closely
associated with
pretendinous and
natatory cord)
PIP and DIP joint
flexion contracture;
displaces
neurovascular
bundle medially
Abductor digiti
minimi cord
Abductor digiti minimi
tendon
PIP joint flexion
contracture
Thumb and First Web-Space Cords
Proximal
commissural cord
Proximal commissural
ligament
First web adduction
contracture
Distal
commissural cord
Distal commissural
ligament
First web adduction
contracture
Thumb
pretendinous cord
Pretendinous band
MCP joint flexion
contracture
DIP, distal interphalangeal; MCP, Metacarpophalangeal; PIP, proximal
interphalangeal.
Reprinted from Neligan, P.C., Chang, J., (Eds.), 2013. Plastic
Surgery, vol. 6, 3rd ed. Elsevier, 347.

Hand Masses, Vascular Disorders, and Dupuytren’s Contracture
158
■ Results are relatively good with treatment of MCP joint
contractures but poor with treatment of PIP joint
contractures.
■ Complications: Localized skin tears/reactions, edema,
pain, flexor tendon rupture
• Surgery
■ Indications: MCP flexion contracture >30 degrees or any
flexion contracture of the PIP joint
■ Techniques (see Table 15.2)
■ Palmar fasciectomy is the preferred surgical technique.
• Complications
■ Injury to the neurovascular bundle
○ The neurovascular bundle is pulled to a more volar
position primarily by the spiral cord, placing it at risk
for direct injury during surgery.
○ Release of flexion contracture and placement of the
digit in extension can put excessive stretch on the
bundle, resulting in ischemia. In this instance,
remove the splint and allow fingers to be in a more
flexed position.
■ Complex regional pain syndrome
○ A spectrum of posttraumatic pain that is
characterized by regional pain combined with
autonomic dysfunction, atrophy, and functional
impairment
○ Classed in 3 stages
♦ Stage I (0 to 3 months): Pain out of proportion to
injury, hyperesthesia, edema and stiffness,
erythema, hyperhidrosis
♦ Stage II (3 to 9 months): Pain, stiffness, edema,
warmth, cyanosis, hair loss, decreased moisture,
osteopenia secondary to disuse
♦ Stage III (9 to 18 months): Decreased pain,
increased stiffness, dry, cool, pale skin
4. Occasionally associated with other benign, progressive
fibromatoses
• Plantar fibromatosis: Ledderhose’s disease
• Penile fibromatosis: Peyronie’s disease
5. Characterized by the transformation of normal palmar and
digital fascial structures into diseased cords with high levels of
type-III collagen and myofibroblasts
6. Signs: Characteristic progression from pitting/dimpling of the
palm and nodule formation to fibrotic cord development and
contracture of the MCP and PIP joints
• Patients may present with overt flexion contractures and
Garrod’s nodules (knuckle pads over the dorsum of the
PIP joint).
■ Garrod’s nodules more common in bilateral disease and
patients with other associated fibromatoses
7. Treatment: Generally dependent upon severity of disease;
high rate of recurrence
• Steroid injection may have a role in the treatment of
painful palmar nodules
• Collagenase injection
■ Has become a first-line treatment for many surgeons
■ Indications for injection are the same for surgery: MCP
flexion contracture >30 degrees or any flexion
contracture of the PIP joints.
Table 15.2  Surgical Options for the Treatment of
Dupuytren’s Disease
SURGICAL
TECHNIQUE
DESCRIPTION
Fasciotomy
Division of diseased cords without excision
Local fasciectomy
Removal of segment of diseased cord
Regional fasciectomy
Removal of all diseased fascia as well as
local region of grossly normal tissue
Radical fasciectomy
Removal of the entire palmar and digital
fascia
Open-palm technique
(McCash)
Division of the palmar aponeurosis without
closure of the skin deficit created
Dermatofasciectomy
Removal of the diseased fascia as well
as the overlying skin; closure typically
obtained with the use of a full-thickness
skin graft
Reprinted from Neligan, P.C., Chang, J., (Eds.), 2013. Plastic
Surgery, vol. 6, 3rd ed. Elsevier.

Dupuytren’s Contracture
159
15
Suggested Readings
Athanasian, E.A., 2011. Chapter 65: Bone and soft-tissue tumors. In: Wolfe,
S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 2141–2196.
Beckert, B.W., Molnar, J.A. Malignant Hand Tumors. Emedicine.com. Found
at: <> Accessed on:
September 10, 2014.
Finkel, R., Kasdan, M., 2010. Chapter 110: Surgical treatment of vascular
tumors of the hand. In: Wiesel, S.W. (Ed.), Operative Techniques in
Orthopaedic Surgery, 1st ed. Wolters Kluwer/Lippincott Williams & Wilkins,
pp. 2992–3003.
Haase, S.C., Chung, K.C., 2011. Chapter 64: Skin tumors. In: Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 2121–2140.
Hurst, L., 2011. Chapter 5: Dupuytren’s contracture. In: Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 141–158.
Kleinert, H.E., Burget, G.C., Morgan, J.A., et al., 1973. Aneurysms of the hand.
Arch. Surg. 106 (4), 554–557.
Koman, L.A., Poehling, G.G., Smith, B.P., et al., 2011. Chapter 59: Complex
regional pain syndrome. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C.,
et al. (Eds.), Green’s Operative Hand Surgery, 6th ed. Elsevier, pp.
1959–1988.
Koman, L.A., Smith, B.P., Smith, T.L., et al., 2011. Chapter 66: Vascular
disorders. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.),
Green’s Operative Hand Surgery, 6th ed. Elsevier, p. 2197.
Leversedge, F.J., Moore, T.J., Peterson, B.C., et al., 2011. Education objectives:
compartment syndrome of the upper extremity. J. Hand Sur. 36 (3), 544–559.
Lin, S.J., Molnar, J.A., Benign Hand Tumors. Emedicine.com. Found at: emedicine.medscape.com/article/1286448-overview.> Accessed on:
September 10, 2014.
Sacks, J.M., Azari, K.K., 2010. Chapter 141: Tumors. In: Weinzweig, J. (Ed.),
Plastic Surgery Secrets Plus, 2nd ed. Mosby, pp. 912–923.
Sacks, J.M., Azari, K.K., Oates, S., et al., 2013. Chapter 15: Benign and
malignant tumors of the hand. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, p. 311.

Hand Fractures
and Dislocations
Chapter
16 
General Treatment of Metacarpal and
Phalangeal Fractures
1. Metacarpal and phalangeal fractures are the most common
fractures in the upper extremity.
2. Diagnosis requires a thorough history, physical examination,
and radiographic images.
• Specifically, look for open lacerations, digital shortening,
malrotation (see Figures 16.1 and 16.2), scissoring, gross
deformity, and angulation (see Figure 16.3), which affects
hand motion/function.
3. Most fractures can be treated nonoperatively; however, the
unique anatomy of the hand and associated muscular
attachments can result in displacement, rotation,
misalignment, and significant functional deficits.
Figure 16.1.  Malrotation of metacarpal or phalangeal fracture must
be corrected. A, Normally, all fingers point toward region of
scaphoid when fist is made. B, Malrotation at fracture causes
affected finger to deviate. (Reprinted from Canale, S.T., Beaty, J.H. [Eds.],
2013. Campbell’s Operative Orthopedics, 12th ed. Mosby, 3305–3365.)
A
B
Figure 16.2.  Observing plane of fingernails helps in detecting
malrotation at fracture; compare with opposite hand. A, Normal
alignment of fingernails. B, Alignment of fingernails with malrotation
of ring finger. (Reprinted from Canale, S.T., Beaty, J.H. [Eds.], 2013.
Campbell’s Operative Orthopedics, 12th ed. Mosby, 3305–3365.)
$
%
Figure 16.3.  Angular deformity associated with fractures of the
metacarpal and phalanges. A, Metacarpal fractures typically
have apex dorsal angulation secondary to the location of the
interosseous muscles, whereas the proximal phalanx fractures
(B) have an apex volar angulation. The angulation of middle
phalanx fractures is dependent on the location of the fracture,
relative to the insertion of the FDS tendon: Fractures proximal to
the insertion (C) will have apex dorsal angulation, whereas those
distal (D) will have apex volar angulation. (Reprinted from Neligan, P.C.,
Chang, J. [Eds.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)
Proximal phalanx
Proximal middle phalanx (metaphysis)
Distal middle phalanx
A
B
C
D

Distal Phalanx Injuries
161
16
5. Numerous fixation techniques are available, although many
fractures can be adequately fixed with percutaneous pinning
(see Table 16.2).
Distal Phalanx Injuries
1. Mallet finger (see Figure 16.4): Disruption, either tendinous
or bony, of the terminal extensor tendon at or distal to the
distal interphalangeal joint (DIPJ)
4. General indications for fixation of these fractures are shown
in Table 16.1
Table 16.1  Indications for Fixation of Metacarpal and
Phalangeal Fractures
• Irreducible fractures
• Malrotation (spiral and short oblique)
• Intra-articular fractures
• Subcapital fractures (phalangeal)
• Open fractures
• Segmental bone loss
• Polytrauma with hand fractures
• Multiple hand or wrist fractures
• Fractures with soft-tissue injury (vessel, tendon, nerve, skin)
• Reconstruction (i.e., osteotomy)
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
pp. 239–290.
Table 16.2  Fracture Stabilization Techniques
TECHNIQUE
INDICATIONS
ADVANTAGES
DISADVANTAGES
Kirschner pins
Transverse
Available and versatile
Lacks rigidity
Oblique
Easy to insert
May loosen
Spiral
Minimal dissection
May distract fracture
Longitudinal
Percutaneous insertion
Pin tract infection
Requires external support
Splint and therapy awkward
Intraosseous wires
Transverse fractures (phalanges)
Available
May cut out (especially
osteopenic bone)
Avulsion fractures
Low profile
Supplemental fixation (butterfly fragment)
Relatively simple
Arthrodesis
Composite wiring
Transverse
More rigid than Kirschner pins
Pin or wire migration
Oblique
Low profile
Secondary removal
(sometimes)
Spiral
Simple and available
Exposure may be significant
Intramedullary device
Transverse
No special equipment
Rotational instability
Short oblique
Easy to insert
Rod migration
No pin protrusion
Minimal dissection
Interfragmentary fixation
Long oblique
Low profile
Special equipment
Spiral
Rigid
Little margin for error
Plates and screws
Multiple fractures with soft-tissue injury
or bone loss
Rigid (stable) fixation
Exacting technique
Markedly displaced shaft fracture
(especially border metacarpals)
Restore or maintain length
Special equipment
Intra-articular and periarticular fractures
Extensive exposure
Reconstruction for nonunion or malunion
May require removal
Refracture after plate removal
Bulky
External fixation
Restore length for comminution or bone
loss
Preserves length
Pin tract infections
Soft-tissue injury or loss
Allows access to bone and soft tissue
Osteomyelitis
Infection
Percutaneous insertion
Overdistraction: Nonunion
Nonunion
Direct manipulation of fracture
avoided
Neurovascular injury
Fractures through pin holes
Loosening
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
pp. 239–290.

Hand Fractures and Dislocations
162
• Treatment (see Figure 16.5)
■ Types I, II: Direct tendon repair or tendon reinsertion
with a dorsal button
○ Indications: Acute injuries (<4 weeks)
○ Complications: Advancement of the FDP tendon
>1 cm can lead to DIP contracture or quadrigia
(functional shortening of FDP tendon, leading to a
flexion lag of adjacent fingers).
■ Types III, IV: ORIF of the fracture fragment with a K
wire, screw, or pull-out wire
■ Two-stage flexor tendon grafting indicated in patients
with chronic injuries and full passive range of motion
(PROM).
■ DIPJ arthrodesis: Salvage procedure in patients with
chronic injuries and limited range of motion (ROM)
Figure 16.4.  Hanging fingertip (mallet finger). (Reprinted from Neligan,
P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier,
414–426.)
• Etiology: Forced flexion of the DIPJ due to an impaction
force to tip of extended finger
• Characterized by a painful, swollen DIPJ, with the fingertip
resting in flexion without active DIP extension
• Treatment
■ Extension splinting of the DIPJ for 6 to 8 weeks; keep
proximal interphalangeal (PIP) joint free
■ Operative repair is indicated with volar subluxation,
>50% articular surface involvement, and/or >2 mm
articular gap. Can be performed with
○ Pin fixation
○ Dorsal blocking pin
○ Open reduction internal fixation (ORIF)
■ Terminal tendon reconstruction in chronic injuries
(>12 weeks)
■ DIP arthrodesis is reserved for treatment of chronically
painful, arthritic DIP joints.
• Complications
■ Extensor lag
■ Swan-neck deformity
2. Jersey finger: Avulsion of the flexor digitorum profundus
(FDP) tendon from its insertion at the base of the distal
phalanx
• Etiology: Forced DIPJ extension of an actively flexed DIPJ
(i.e., athlete grasping a moving object such as a jersey, etc.)
■ The ring finger is involved in most cases because it is the
most prominent fingertip exposed to the force of
gripping.
• Characterized by pain, tenderness over the volar distal
finger, with the finger in extension relative to others, and
no active DIPJ flexion.
Table 16.3  Leddy-Packer Classification of Flexor
Digitorum Profundus Avulsion Injury
(Jersey Finger)
LEDDY-PACKER
TYPE
DESCRIPTION
TREATMENT
Type I
FDP tendon retracted
to palm. Leads to
disruption of the
vascular supply
Prompt surgical
treatment within 10 to
14 days to avoid need
for tendon graft
Type II
FDP retracts to level
of PIP joint (caught
on A3 pulley)
Can repair within 3
months without need
for tendon graft;
however, over time can
convert to type-1 injury
Type III
Large avulsion
fracture limits
retraction to the level
of the DIP joint
(caught on A4 pulley)
Can often be repaired
at any time without
need for tendon graft,
even if after 3 months
Type IV
Osseous fragment
and simultaneous
avulsion of the
tendon from the
fracture fragment
(retraction of the
tendon into palm)
If tendon separated
from fracture fragment,
first fix fracture via
ORIF, then reattach
tendon as for type-I
and -II injuries
DIP, Distal interphalangeal; FDP, flexor digitorum profundus;
ORIF, open reduction and internal fixation; PIP, proximal
interphalangeal.
• Leddy-Packer classification (see Table 16.3)
■ Based on the level of tendon retraction and presence of
fracture
■ One of the only classification systems where the lowest
type (type I) is associated with the worst pathology
■ Type II is the most common.

Distal Phalanx Injuries
163
16
■ Shaft fracture
○ Closed reduction and splinting
♦ Indicated in nondisplaced transverse fractures
♦ Reduction can be blocked by nail matrix.
○ Closed reduction percutaneous pinning (CRPP)
♦ Considered in displaced transverse fractures and
longitudinal fractures
○ ORIF with or without autologous bone grafting is
indicated for fracture nonunion.
3. Distal phalanx fractures and DIPJ fracture dislocations
• Most commonly encountered fracture in the hand
• Classified into three types: Tuft, shaft, and intra-articular
■ Tuft fractures: Typically a result of a crush injury and
often associated with a nail-bed laceration
• Treatment
■ Tip or tuft fracture
○ Address subungual hematoma: Remove nail plate
and repair nail bed as necessary; replace nail plate to
splint eponychial fold.
○ Splint immobilization of fracture
Figure 16.5.  Methods of making a tendon-to-bone junction in zone 1. A, A conventional method of anchoring the flexor digitorum profundus
(FDP) tendon to the bone by pull-out sutures through the nail tied over a button. Alternative ways to anchor the distal tendon stump to the
bone by (B) directly suturing the stump to the residual FDP tendon, (C) looping the tendon through the bone, (D) pull-out suturing over the
fingertip, (E) using minianchors, and (F) looping the sutures through a transverse hole in the bone. (Reprinted from Neligan, P.C. [Ed.], 2013.
Plastic Surgery, 3rd ed. Elsevier, 179–210.)
Minianchors
Sutures
FDP tendon
Button
$
'
(
)
%
&

Hand Fractures and Dislocations
164
■ Dorsal fracture dislocation (see Figures 16.7 and 16.8)
○ Dorsal extension block splinting
♦ Indicated for fractures that involve <30% to 40%
of the articular surface and require <30 degrees of
flexion to maintain reduction
○ ORIF or CRPP
♦ Indicated if >30 degrees of flexion is required
to maintain reduction or if the fracture
involves >30% to 40% of the articular surface
(see Figure 16.10)
○ Force-coupler dynamic splinting or hemi-hamate
reconstruction
♦ Indicated for more complex injuries, including
those with comminution
Proximal Phalanx/Proximal Interphalangeal
Joint (PIPJ) Injuries
1. PIPJ dislocation/fracture dislocation (see Figure 16.9)
• Dorsal dislocations are more common than volar
dislocations.
• Dorsal dislocation results in injury to the volar plate and if
left untreated can become a swan-neck deformity
(hyperextension of the PIPJ and flexion of the DIPJ),
secondary to weakened volar plate with dorsal migration of
the lateral bands.
• Volar dislocation results in injury to the central slip and if
left untreated can become a boutonniere deformity (flexion
of the PIPJ and hyperextension of the DIPJ) secondary to
volar migration of the lateral bands.
• Treatment
■ Dislocation
○ Closed reduction and buddy taping to adjacent finger
for 3 to 6 weeks
♦ Indicated if dislocation is reducible
♦ Inability to obtain reduction in dorsal dislocations
is often related to volar plate obstruction in closed
injuries and the FDP tendon in open injuries.
♦ Inability to obtain reduction in volar dislocations
is often related to central slip obstruction.
Figure 16.6.  Radiograph of DIP dorsal dislocation of index finger.
(Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier,
138–160.)
■ Intra-articular fracture/DIPJ fracture dislocation (see
Figure 16.6)
○ Bony “mallet finger” (see above)
○ Inability to reduce dorsal DIPJ dislocations is most
likely due to interposition of the volar plate or FDP
tendon in open injuries
K2
K1
1 cm
$
Figure 16.7.  A, Fabrication of external fixator from K wires (K1, K2).

Distal Phalanx Injuries
165
16
Preoperative radiograph (B) of PIP fracture dislocation involving the small finger. C, Radiograph with external fixator in
place, allowing motion. D, Postoperative results in flexion. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)
&
'
%
Figure 16.7, cont’d. 
$
%
&
Figure 16.8.  Technique of hemi-hamate replacement arthroplasty. A, Preoperative posterioanterior (PA) and (B) lateral radiographs and
clinical photographs in extension (C) and flexion (D).

Hand Fractures and Dislocations
166
'
(
A
A
B
B
D
D
D
G
C
C
E
E
F
F
4th MC
5th MC
Hamate
Volar view
PIP joint
Middle phalanx
Lateral view
Dorsal view
)
*
+
E, Diagram of configuration of hemi-hamate graft. F, Intraoperative photograph of graft secured (note articular wear on
the head of the proximal phalanx due to delay in presentation). G, Postoperative clinical photograph; H, lateral radiograph. MC, Metacarpal.
(Reprinted from In Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)
Figure 16.8, cont’d.

Proximal Phalanx/Proximal Interphalangeal Joint (PIPJ) Injuries
167
16
2. Proximal and middle phalanx fractures (see Figure 16.11)
• Treatment is dependent on fracture stability and pattern.
• Splint immobilization (~2 to 3 weeks) followed by
protected motion with buddy taping
■ Indicated for stable, nondisplaced fractures without
malrotation
• ORIF or CRPP
■ Indicated for fractures with malrotation; oblique and/or
spiral fractures that are inherently unstable; fractures
with angulation, shortening >2 mm, or articular step-off;
unstable condylar fractures
○ Volar plate arthroplasty
♦ Often reserved for chronic injuries that involve
<60% of the articular surface
○ PIPJ arthrodesis
♦ Reserved as a salvage procedure for chronic
injuries with chronic pain and for PIPJ arthritis
■ Volar fracture dislocation: Treatment similar to dorsal
dislocations
○ Extension splinting for injuries involving <40% of the
articular surface
○ ORIF or CRPP in unstable injuries or those involving
>40% of the articular surface
Figure 16.9.  Classification of PIPJ fracture dislocations. A, Volar
base fracture resulting in dorsal subluxation of the middle phalanx.
B, Dorsal base fracture resulting in volar subluxation of the middle
phalanx. C, Pilon-type fracture with dorsal and volar base fractures
and comminuted, depressed central articular surface. (Reprinted from
Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)
&
%
$
Figure 16.10.  Stability of PIP fracture dislocations. Fractures
involving <30% of the articular surface are typically stable, those
involving 30% to 50% are tenuous, and those involving >50% are
unstable and have resultant dorsal subluxation. (Reprinted from
Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)
Unstable
Tenuous
Stable
$
%
Figure 16.11.  Preoperative and postoperative PA radiograph of
proximal phalanx shaft (A,B) and base (C,D) fractures treated with
K wires (vertical lines). (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic
Surgery, 3rd ed. Elsevier, 138–160.)

Hand Fractures and Dislocations
168
&
'
Figure 16.11, cont’d. 
Metacarpal Phalangeal Joint (MCPJ) Injuries
1. MCPJ dislocation
• Dorsal dislocations are most common, with the border
digits being most commonly involved (see Figure 16.12).
• Occurs from hyperextension force with rupture of the
volar plate
• Classification: Simple versus complex
■ Simple: Reducible dislocation
○ Can be treated with closed reduction and splinting
■ Complex: Irreducible dislocation, often secondary to
obstruction from the volar plate (most common); in
the index finger, obstruction can also occur from
the lumbrical (radial) and flexor (ulnar) tendons;
in the small finger, obstruction can also occur from the
lumbrical and flexor tendons (radial) and the flexor
digiti minimi (ulnar)
• Treatment: Open reduction in irreducible dislocations
Figure 16.12.  Radiograph of MCP dorsal dislocation. (Reprinted from
Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 138–160.)

Metacarpal Phalangeal Joint (MCPJ) Injuries
169
16
Table 16.4  Acceptable Angulation and Shortening
of Finger Metacarpal Fractures
ACCEPTABLE
SHAFT
ANGULATION
(DEGREES)
ACCEPTABLE
SHAFT
SHORTENING
(mm)
ACCEPTABLE
NECK
ANGULATION
Index finger
10
2-5
10-15
Long finger
20
2-5
10-15
Ring finger
30
2-5
30-40
Small finger
40
2-5
50-60
Figure 16.13.  The Jahss maneuver for reduction of a metacarpal
neck fracture. The DIP and PIP joints are flexed and dorsal
pressure is applied to the PIP joint (top arrow), while counter
pressure is applied to the metacarpal shaft proximal to the fracture
(bottom arrow). (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery,
3rd ed. Elsevier, 138–160.)
2. MCJ fracture dislocation
• Often results from fights, crush injuries, motor vehicle
accidents
• Examine for rotation deformity (scissoring), angulation,
shortening, carpometacarpal joint (CMCJ) dislocation, and
“fight bite”
■ Angulation is better compensated for in the ring and
small fingers (up to 40 to 50 degrees) compared to the
index and long fingers (10 to 15 degrees) because the
CMCJ of these digits allows for greater compensatory
motion.
• Treatment: Depends on stability, rotation, and angulation/
shortening
■ Closed reduction
○ Indicated in simple dislocations with stable fracture
pattern, no rotation, and acceptable angulation/
shortening (see Table 16.4)
○ Performed with the wrist flexed, to relax the flexor
tendons, and application of distal pressure to the base
of the proximal phalanx (see Figure 16.13)
■ ORIF or CRPP
○ Indicated for complex dislocations and/or fractures
with intra-articular involvement, rotation
(scissoring), shortening, displacement, multishaft
fractures, or unacceptable angulation
♦ Can be opened volarly or dorsally. The volar
approach is more direct but places the
neurovascular structures at risk. The dorsal
approach may require splitting of the volar plate.
■ MCPJ arthrodesis
○ Indicated in persistent MCPJ injuries with chronic
pain, arthritis, and decreased ROM
♦ Appropriate positioning for arthrodesis
➔ Thumb: 15 degrees of flexion
➔ Index: 25 degrees of flexion
➔ Long: 30 degrees of flexion
➔ Ring: 35 degrees of flexion
➔ Small: 40 degrees of flexion
4. Metacarpal fractures
• Often occur from a direct blow
• Many can be treated nonoperatively if stable
• Consider open wounds over the MCPJ with associated
fractures “fight bites” and treat accordingly until proven
otherwise.
• Metacarpal base fractures
■ 5th metacarpal base fracture (also known as “reverse
Bennett” or “baby Bennett” fracture) (see Figure 16.14)
○ Results in proximal and dorsal subluxation of the
metacarpal shaft
○ The proximal fragment is held in place by the
intermetacarpal ligaments, whereas the distal
fragment and digit is displaced secondary to pull the
extensor carpi ulnaris, flexor carpi ulnaris, and the
abductor digiti minimi.

Hand Fractures and Dislocations
170
Figure 16.14.  Deforming forces of 5th metacarpal base fractures.
The hypothenar muscles and extensor carpi ulnaris muscle act in
different force vectors to produce a characteristic displacement of
fractures of the 5th metacarpal base. Note how the
intermetacarpal ligament between the 4th and 5th metacarpal
bases stabilizes the baby Bennett fragment. (Reprinted with permission
from Niechajev, I., 1985. Dislocated intra-articular fracture of the base of the
fifth metacarpal: a clinical study of 23 patients. Plast. Reconstr. Surg. 75,
406–410.)
Hypothenar
muscles
Extensor
carpi
ulnaris
■ Treatment: ORIF or CRPP
• Metacarpal shaft fractures
■ Often stable and amenable to nonoperative management
■ Indications for operative treatment include open
fractures, malrotation, unacceptable angulation
■ ORIF or CRPP
○ K-wire fixation
○ Lag screw fixation requires an oblique fracture, with a
fracture length that is twice the diameter of the bone.
○ Dorsal plate fixation indicated when multiple shaft
fractures are present
• Metacarpal neck fractures
■ Neck fracture of the 5th metacarpal is also known as a
“boxer’s fracture”
■ Treatment is dependent on the presence of malrotation
and angulation.
○ Closed reduction and immobilization (with MCPJ
flexed and IPJ extended) are often adequate.
♦ Jahss maneuver for reduction (see Figure 16.13):
Flexion of the DIPJ, PIPJ, and MCPJ, with dorsal
pressure over the flexed PIP and simultaneous
volar force over the apex of the fracture
○ ORIF or CRPP indicated with unacceptable
angulation, rotation, and intra-articular fractures.
• Metacarpal head fractures
■ Requires anatomic reduction and stabilization
■ Rigid fixation is preferred, often with screws
Thumb Injuries
1. Thumb distal and proximal phalanx and metacarpal fractures
are managed similarly to those of the fingers (see above).
• The thumb metacarpal can tolerate significant rotation and
angulation because of the motion allowed at the thumb
CMCJ.
2. Ulnar collateral ligament (UCL) injury (also known as
“gamekeeper’s thumb” or “skier’s thumb”)
• Results from tear of the UCL, characterized by instability
of the thumb with grip, radial deviation, and pain
• The UCL is composed of two structures
■ The proper collateral ligament, which resists radial
deviation of the flexed thumb
■ The accessory collateral ligament and volar plate, which
resist radial deviation of the extended thumb
■ Laxity of the thumb in both flexion and extension is
consistent with a complete tear of the UCL.
• Diagnosis: The thumb MCPJ is stressed with a radial
deviation force in neutral and in flexion, and the degree of
“opening” and/or variation between injured and uninjured
sides is recorded.
• “Stener lesion” (see Figure 16.15): Complete avulsion of the
UCL (with or without a bony fragment), with proximal
retraction and interposition of the adductor aponeurosis
precluding primary healing
■ Requires operative repair
Figure 16.15.  A 64-year-old woman presents with marked pain and
instability at the ulnar aspect of the MCP joint. A, Stress testing of
the ulnar collateral ligament reveals marked laxity with greater than
35° of rotational deformity. B, At the time of surgical exploration, a
Stener lesion is identified. The bony insertion of the ulnar collateral
ligament can be seen sitting on top of the aponeurosis of the
adductor pollicis muscle (fragment at the end of dental probe).
(Reprinted From Carlsen, B.T., Moran S.L., 2009. J. Hand Surg. 34 [5],
945–952.)
A
B
• Treatment
■ Nonoperative immobilization is acceptable in
incomplete UCL tears that have <20-degree side-to-side
variation of instability.
■ Operative repair is indicated in injuries with >20-degree
side-to-side variation instability or >35 degrees of
opening due to a Stener lesion.

Thumb Injuries
171
16
Figure 16.16.  Gedda classified the Bennett fractures into 3 types. A, Type 1 represents a fracture with a large single ulnar fragment and
subluxation of the metacarpal base. B, Type 2 represents an impaction fracture without subluxation of the thumb metacarpal. C, Type 3
represents those injuries presenting with a small ulnar avulsion fragment in association with metacarpal dislocation. (Reprinted From Carlsen,
B.T., Moran, S.L., 2009. J. Hand Surg. 34 [5], 945–952.)
$
%
&
3. 1st metacarpal base fractures/fracture dislocations (also
known as “Bennett” or “Rolando” fractures; see Figures 16.16
and 16.17)
• Etiology: Axially directed force through the partially flexed
thumb metacarpal shaft
• Bennett fracture: A two-part fracture with a proximal volar
lip fragment that is stable and a distal fragment that
subluxates radially, proximally, and dorsally
■ Displacement of the distal segment is secondary to the
combined pull of the thumb extensors, the abductor
pollicis longus, and the adductor pollicis longus.
• Rolando fracture: An intra-articular metacarpal base
fracture with a Y or T shape or one that is comminuted
• Treatment
■ CRPP is often adequate with ORIF reserved for
irreducible fractures.
Figure 16.17.  A, The term Rolando fracture is classically used to describe a 3-part intra-articular fracture of the thumb metacarpal base
with a Y- or T-fracture pattern, as seen in this radiograph. B, A radiograph of the same fracture after transosseous K-wire fixation. Such
fractures often require transmetacarpal pinning to stabilize and suspend the metacarpal shaft during the healing process. C, A Robert’s
view of the same thumb 3 months postoperatively, showing adequate articular congruity. (Reprinted From Carlsen, B.T., Moran, S.L., 2009. J. Hand
Surg. 34 [5], 945–952.)
$
%
&

Hand Fractures and Dislocations
172
General Complications of Metacarpal and
Phalangeal Fractures
1. Stiffness: Most phalangeal fracture patients will have residual
stiffness.
• Stiffness related to adhesions from plates and screws to
extensor tendons may benefit from hardware removal and
tenolysis.
2. Infection often occurs at pin sites. Treatment includes
antibiotics and possible hardware removal if the fracture site
is stable or if the hardware is loose or grossly infected.
3. Malunion: Most commonly occurs as abnormal angular or
rotational deformities
• Angular deformities: Frequently treated with opening or
closing wedge osteotomies
■ Opening wedge osteotomies require bone grafting.
• Rotational deformities are typically treated with
osteotomies, rigid fixation, and early motion.
4. Nonunion: Rare with metacarpal or phalangeal
fractures.
• Treatment is similar to the principles for long-bone
reconstruction and nonunions and includes
debridement and bone grafting and/or vascularized
bone grafting.
Suggested Readings
Blazar, P., 2009. Chapter 79: Finger instabilities and ligamentous injuries. In:
Guyuron, B., Eriksson, E., Persing, J.A. (Eds.), Plastic Surgery: Indications and
Practice. Saunders/Elsevier, China, pp. 1033–1043.
Bushnell, B.D., Draeger, R.W., Crosby, C.G., et al., 2008. Management
of intra-articular metacarpal base fractures of the second through fifth
metacarpals. J. Hand Surg. 33 (4), 573–583.
Calandruccio, J.H., 2013. Chapter 67: Fractures, dislocations, and ligamentous
injuries. In: Canale, S.T., Beaty, J.H. (Eds.), Campbell’s Operative
Orthopedics, 12th ed. Mosby, pp. 3305–3365.
Carlsen, B.T., Moran, S.L., 2009. Thumb trauma: Bennett fractures, Rolando
fractures, and ulnar collateral ligament injuries. J. Hand Surg. 34 (5),
945–952.
Day, C.S., Stern, P.J., 2011. Chapter 8: Fractures of the metacarpals and
phalanges. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.),
Green’s Operative Hand Surgery, 6th ed. Elsevier, pp. 239–290.
Egeland, B.M., Sebastin, S.J., Chung, K.C., 2012. Chapter 7: Acute repair of
zone 1 flexor digitorum profundus avulsion. In: Chung, K.C. (Ed.), Operative
Techniques: Hand and Wrist Surgery, 2nd ed. Saunders, pp. 55–63.
Hammert, W.C., 2013. Chapter 7: Hand fractures and joint injuries. In:
Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, 3rd ed. Elsevier, pp. 138–160.
Merrell, G., Slade, J.F., 2011. Dislocation and ligament injuries in the digits.
In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s
Operative Hand Surgery, 6th ed. Churchill Livingstone, Philadelphia,
pp. 291–332.
Neligan, P.C., Buck, D.W., 2013. Core Procedures in Plastic Surgery. Chapter
21: Flexor tendon injury and reconstruction. Elsevier, pp. 358–374.
Neligan, P.C., Buck, D.W., 2013. Core Procedures in Plastic Surgery. Chapter
24: Extensor tendon injuries. Elsevier, pp. 414–426.
Oak, N., Lawton, J.N., 2013. Intra-articular fractures of the hand. In: Lawton,
J.N., Chung, K.C. (Eds.), Hand Clin. 29 (4), 535–549.
Strauch, R.J., 2011. Chapter 6: Extensor tendon injury. In: Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 159–188.

Nail-Bed Injuries, Soft-Tissue
Amputations, and Replantation
Chapter
17 
General Fingernail and Nail-Bed Anatomy
1. Perionychium
• Nail plate
• Nail bed
• Surrounding skin (nail fold, paronychium, hyponychium)
2. Paronychium: The lateral skin that surrounds the nail bed
and nail
3. Hyponychium: The skin and keratin along the distal edge of
the nail bed
4. Eponychium: The skin proximal and dorsal to the nail fold
5. Lunula: The white part of the proximal nail that corresponds
to the distal extent of the germinal matrix
6. Matrix: The nail-plate growth centers
• Germinal matrix
■ Accounts for almost 90% of nail-plate production
■ Soft tissue deep to nail plate at lunula and nail fold
■ Insertion of the terminal extensor tendon is
approximately 1 to 1.5 mm proximal to the germinal
matrix.
• Sterile matrix
■ Accounts for 10% of nail production
■ The soft tissue located deep to the nail plate, distal to the
lunula/germinal matrix
■ Responsible for adherence of nail plate to nail bed (see
Figure 17.1)
Nail Growth and Physiology
1. Nail-plate growth is estimated to be 3 to 4 mm per month;
complete nail-plate growth takes ~6 months.
• Factors that speed the rate of nail-plate growth: Longer
digits, summer months, persons <30 years old, and nail
biting
2. The nail has a natural convex curvature from proximal to
distal because more of the nail-plate substance is produced
proximally.
3. Nail growth occurs in the germinal matrix, sterile matrix, and
dorsal roof of the nail fold.
• The germinal matrix produces cells that migrate distally
and dorsally in a column toward the nail plate. As they
abut the nail plate, they flatten and elongate. Initially, the
nuclei of these cells are retained and produce the white
color associated with the lunula. As they move distal, they
become nonviable cells and lose their nuclei.
• The sterile matrix provides some nail growth but primarily
contributes strength and thickness to the nail plate. In
addition, it plays a significant role in adherence of the nail
plate to the nail bed.
• The dorsal roof of the nail fold produces nail-plate cells
similar to those of the germinal matrix and has a
significant role in producing the shiny appearance of the
nail (see Figure 17.2).
Nail-Bed Injuries
1. Subungual hematoma
• Most commonly caused by crush injury
• Signs: Pain and bleeding underneath nail with
discoloration, signifying an injury to the nail bed
• Treatment
■ <50% of the nail involved or hematoma with nail-plate
edges intact: Percutaneous drainage (trephination) with
battery microcautery or heated paper clip
■ >50% of the nail involved or disruption of the nail
edges: Nail-plate removal and nail-bed repair (see
Figure 17.3)
2. Nail-bed lacerations
• Signs: Subungual hematoma >50% of the nail if nail plate
intact or avulsion of nail plate and portion of the
underlying nail bed with obvious injury
• Commonly associated with distal phalanx fractures
• Treatment: Nail-plate removal with nail-bed repair
■ If distal phalanx fracture is present, it may require
management.
■ If significant avulsion injury and loss of nail matrix is
present, may require nail-matrix graft from adjacent
injured finger or second toe.
• Nail-bed repair can be performed with 6-0 absorbable
sutures or 2-octylcyanoacrylate (Dermabond).
• After repair, splint the eponychial fold to prevent fold
adhesions and obstruction of nail growth.
■ Can be performed with the original nail plate, aluminum
foil, or nonadherent gauze

Nail-Bed Injuries, Soft-Tissue Amputations, and Replantation
174
Figure 17.1.  A, The nail, the sterile and germinal matrices, and the surrounding tissue marked here compose the perionychium.
B, A lateral view of the nail bed showing the ventral floor (germinal matrix), the nail bed (sterile matrix), and the dorsal roof of the nail
fold. C, The keratinous plug is shown at the hyponychium. (Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier,
117–134. © Southern Illinois University School of Medicine.)
$
Dorsal roof
Nail fold
Eponychium
Hyponychium
Lunula
Nail bed
Ventral floor
%
&
Figure 17.2.  Components of the nail are produced in three areas.
(Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6,
3rd ed. Elsevier, 117–134. © Southern Illinois University School of Medicine.)
Dorsal nail
Ventral nail
(sterile matrix)
Intermediate nail
(germinal matrix)
Either dorsal or
intermediate
3. Complications of nail-bed injury
• Nonadherence (onycholysis)
■ Most common nail deformity after trauma
■ Secondary to nail-bed scarring
■ Treatment: Scar excision and primary closure or
split-thickness sterile matrix graft from the adjacent nail
bed or toe
• Hook nail deformity
■ Secondary to inadequate bony support from the dorsal
tuft of the distal phalanx
■ Nail growth hooks volarly over the fingertip
■ Treatment: Removal of redundant nail bed or
advancement flap of volar fingertip tissue with no
tension (see Figure 17.4)
• Pincer nail deformity
■ Excess transverse curvature of the nail plate that is
progressive and ultimately leads to an unesthetic, painful
nail
■ Treatment: Elevation of the nail plate with dermal
grafting (see Figure 17.5)

Nail-Bed Injuries
175
17
Figure 17.3.  A, Time-honored method of burning a hole through
the nail with a heated paperclip. B, The authors’ preferred method
of burning a hole through the nail with an ophthalmic battery-
powered cautery. (Reprinted from Sommer, N.Z., Brown, R.E., 2011. The
perionychium. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.],
Green’s Operative Hand Surgery, 6th ed. Elsevier, 333–353.)
$
%
Figure 17.4.  A, Hook nail deformity caused partially by some loss
of bony support but primarily by the nail bed being pulled over the
tip to close the amputation. B, Loss of bony support to hold the
nail bed flat. (Reprinted from Sommer, N.Z., Brown, R.E., 2011. The
perionychium. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.],
Green’s Operative Hand Surgery, 6th ed. Elsevier, 333–353.)
$
%
$
%
Figure 17.5.  A, Unilateral pincer nail. B, The perionychium is freed from the bone, and a graft of dermis or dermal substitute is placed into
the tunnel to flatten the nail bed.
Continued

Nail-Bed Injuries, Soft-Tissue Amputations, and Replantation
176
• Split nail deformity
■ Scarred nail matrix after injury
■ Treatment
○ Germinal matrix scar: Excision of scar tissue,
full-thickness matrix graft from second toe
○ Sterile matrix scar: Excision of scar tissue, split-
thickness matrix graft from second toe
○ Eponychial fold adhesion: Incision and eponychial
flap
Fingertip Soft-Tissue Injuries
1. In general, treatment options depend on wound size, location
and orientation of injury, and presence or absence of exposed
critical structures (e.g., bone, tendon, vasculature).
• Volar soft-tissue loss ≤1 cm2: Secondary intention
■ May have superior restoration of sensation and function
compared to other options
• >1-cm defect, without exposed bone or tendon: Skin graft
■ Full-thickness grafts give better restoration of sensation.
■ Split-thickness grafts will contact more, which may be
advantageous in certain instances.
• Large defects or defects with exposed tendon or bone:
Local flaps (see Figure 17.6)
Figure 17.6.  Schematic of soft-tissue reconstructive procedures based on location of the primary defect. DMCA, Dorsal metacarpal artery;
FDMA, first dorsal metacarpal artery; IP, interphalangeal. (Reprinted from Biswas, D., Wysocki, R.W., Fernandez, J.J., et al., 2014. Local and regional flaps
for hand coverage. J. Hand Surg. Am. 39 [5], 992–1004.)
Reverse cross finger (dorsal)
Cross-finger (palmar)
DMCA flap
Adipofascial turnover flap
V-Y advancement (zone 4)
Cross-finger (palmar)
thenar flap
Radial forearm flap
(fasciocutaneous vs.
fascial only)
Posterior interosseous
flap
Axial flap (DMCA)
Zone 1 (distal to IP):

V-Y

Moberg flap

FDMA (dorsal defect)

Neurovascular island (volar

defect)
Zone 2 (IP):

Replantation

Distraction lengthening

Pollicization
Zone 3 (MCP):

Replantation

Toe transfer
C, 1 year after correction. (Reprinted from
Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier,
117–134. © Southern Illinois University School of Medicine.)
&
Figure 17.5, cont’d.

Fingertip Soft-Tissue Injuries
177
17
2. Common local flaps
• Bilateral V-Y advancement flaps (Kutler flap)
■ Useful with volar oblique amputations (see Figure 17.7)
• Volar advancement (Atasoy-Kleinert/Tranquilli-Leali)
■ Useful with dorsal oblique amputations
■ Good for coverage of distal phalanx and support of the
nail bed
■ Generally cannot be advanced >5 to 10 mm
■ May be at increased risk for contracture of the distal
interphalangeal (DIP) joint (see Figure 17.8)
• Thenar flap
■ Useful for young patients with volar defects of the index
or long finger
■ Requires second stage for flap division, inset, and donor
site closure
■ Older patients may be at increased risk for finger
stiffness and/or joint contracture (see Figure 17.9)
• Cross-finger flap
■ Useful for volar defect of over middle phalanx of
adjacent finger
■ Skin graft over donor site (see Figure 17.10)
• Reverse cross-finger flap
■ Useful for dorsal defect over middle phalanx of adjacent
finger
Figure 17.7.  Kutler lateral V-Y technique. (Reprinted from Jebson, P.J.L.,
Louis, D.S., 2005. Amputations. In: Green, D.P., Hotchkiss, R.N., Pederson, W.C.,
Wolfe, S.W. [Eds.], Green’s Operative Hand Surgery, 5th ed. Churchill
Livingstone, New York, 1943.)
A
B
C
D
Figure 17.8.  Patient presenting with a transverse fingertip injury. A,B, More than 50% of the nail bed remains. C-E, A V-Y advancement flap
is used to treat this defect. F,G, The patient demonstrates a fully sensate, pain-free digit at final follow-up. (Reprinted from Biswas, D., Wysocki,
R.W., Fernandez, J.J., et al., 2014. Local and regional flaps for hand coverage. J. Hand Surg. Am. 39 [5], 992–1004.)
D
B
G
E
C
F
A

Nail-Bed Injuries, Soft-Tissue Amputations, and Replantation
178
Figure 17.9.  Thenar H flap. (Reprinted from Jebson, P.J.L., Louis, D.S., 2005. Amputations. In: Green, D.P., Hotchkiss, R.N., Pederson, W.C., Wolfe, S.W. [Eds.],
Green’s Operative Hand Surgery, 5th ed. Churchill Livingstone, New York, 1947.)
A
B
C
Figure 17.10.  A,B, Patient sustained a soft-tissue injury with extensive palmar tissue loss over the middle and distal phalanx of the little
finger. C,D, A cross-finger flap was harvested from the dorsal middle phalanx of the ring finger and (E) was inset into the defect; (F) the
donor site was covered with a skin graft. The flap was divided at 2 weeks, and the patient reported a fully sensate digit with no appreciable
flexion contractures of the proximal interphalangeal (PIP) or DIP, with excellent cosmesis (G). (Reprinted from Biswas, D., Wysocki, R.W., Fernandez,
J.J., et al., 2014. Local and regional flaps for hand coverage. J. Hand Surg. Am. 39 [5], 992–1004.)
A
D
B
E
G
C
F

Thumb Soft-Tissue Injuries
179
17
■ Adipofascial flap and skin graft used for coverage of
defect; donor site closed with skin flap (see Figure 17.11)
• Adipofascial turn down flap
■ Open skin as an “H”, elevate flap from proximal to
distal, turn flap over to cover defect, close skin incision
and, perform split-thickness skin graft (STSG) to
recipient site.
• Free toe pulp flap
■ Useful for providing bulk and sensation to volar finger
pad injuries (especially in musicians)
■ Often used in setting of failed secondary intention healing
■ Toe pulp harvested from the great toe or medial aspect
of second toe
Thumb Soft-Tissue Injuries
1. First dorsal metacarpal artery flap
• Useful for
■ Volar tip defects that are 2 × 3 cm in size
■ Midthumb defects
■ Coverage of exposed flexor pollicis longus
• Donor site is the first ray, which must lie outside of the
zone of injury (see Figure 17.12).
2. Littler neurovascular island flap
• Useful for defects where first dorsal metacarpal artery flap
is unavailable
Figure 17.11.  A, Patient presented with a fingertip defect with volar soft-tissue loss of the middle finger. B, A reverse cross-finger flap was
performed to provide coverage by using donor tissue overlying the dorsum of the ring finger, first by elevating a 3-sided, full-thickness skin
flap only to the level of the dermis, with the hinge on the ulnar aspect of the flap. The paratenon was preserved overlying the extensor
mechanism atop the middle phalanx of the ring finger. C, A 3-sided flap consisting of fat and subcutaneous tissue was then elevated in the
opposite direction, with its hinge on the radial side of the donor site and rotated to cover the volar defect of the middle finger. D, The
original skin flap was then sutured to cover the donor site and a full-thickness skin graft was applied to cover the rotated subcutaneous
flap at the recipient site (E). (Reprinted from Biswas, D., Wysocki, R.W., Fernandez, J.J., et al., 2014. Local and regional flaps for hand coverage. J. Hand Surg.
Am. 39 [5], 992–1004.)
A
B
C
D
E

Nail-Bed Injuries, Soft-Tissue Amputations, and Replantation
180
Figure 17.12.  A, First dorsal metacarpal artery flap is designed over the dorsal aspect of the index finger. B,C, First dorsal metacarpal
artery lies within the fascia of the first dorsal interosseous muscle. The pedicle is elevated with the fascia and care is taken to keep the
superficial veins to allow appropriate drainage of the flap. D,E, Final appearance of the defect on the thumb and donor site. (Reprinted from
Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 117–134.)
$
%
&
'
(

Thumb Soft-Tissue Injuries
181
17
• Donor site is the dorsoulnar aspect of the long or ring
finger.
• Disadvantages: Small flap, poor donor site, venous
congestion, requires significant cortical reorientation (see
Figure 17.13)
3. Moberg flap
• Useful for 1- to 1.5-cm tip defects of the thumb
• Characterized by a volar, rectangular advancement flap
• Risk of interphalangeal (IP) joint contracture in defects >1
to 1.5 cm (see Figure 17.14)
4. First web-space free flap
• Useful for large volar thumb defects (~6 × 3 cm) or defects
when local flaps are not available
• Donor site is the lateral aspect of the great toe and the
medial aspect of the second toe.
• Vascular supply: First dorsal metatarsal a. (off of the
dorsalis pedis a.)
Figure 17.13.  The Littler neurovascular island flap uses the skin
subcutaneous tissue and neurovascular bundle from the
nondominant side of the long or ring fingers. The dissection is
carried down into the palm and the flap is transposed to the defect
on the thumb. (Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic
Surgery, vol. 6, 3rd ed. Elsevier, 117–134.)
Figure 17.14.  A, Patient presents with a chronic soft-tissue defect of the volar tip of the thumb and (B,C) underwent a Moberg
advancement. D, Postoperatively, the patient experienced excellent cosmesis with full extension of the IP joint. (Reprinted from Biswas, D.,
Wysocki, R.W., Fernandez, J.J., et al., 2014. Local and regional flaps for hand coverage. J. Hand Surg. Am. 39 [5], 992–1004.)
A
C
B
D

Nail-Bed Injuries, Soft-Tissue Amputations, and Replantation
182
Replantation (See Box 17.1)
1. Relative indications for replantation
• Amputations of the thumb
■ Thumb contributes significantly to overall hand
function.
■ Can consider vein grafting to avoid zone of injury
■ Length is more important than function; thus, in injuries
with severe muscle belly damage, the interphalangeal
joint can be fused.
■ If the thumb is not salvageable, consider pollicization or
great-toe-to-thumb transfer.
○ Pollicization preferred in proximal amputations
○ Great toe flap preferred in amputations distal to the
metacarpal phalangeal joint.
• Multidigit amputations
• Single-digit amputations distal to the flexor digitorum
superficialis tendon insertion
• Pediatric patients
2. Relative contraindications
• Crush injuries or severe avulsion injuries
■ Avulsions have a large zone of injury, including traction
injury to vasculature; thus, often require vein grafting or
adjacent digital artery transfer when replantation
attempted in this setting.
• Single-digit amputations involving the index or long finger
• Single-digit amputations in manual laborers who wish to
return to work quickly
■ Revision amputation will allow faster return to work.
• Single-digit amputations proximal to the flexor digitorum
superficialis tendon insertion
• Warm ischemia >6 hours proximal to the carpus or >12
hours for any digit
■ May be able to tolerate 12 to 24 hours of cold ischemia
3. Transport the amputated part dry inside of a plastic bag that
is placed in a saline ice slurry (see Figure 17.15).
Reprinted from Wolfe, S.W., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, p. 1592.
BOX 17.1  CRITICAL POINTS: REPLANTATION
Indications/Contraindications
• See the “Critical Points” box in the section “Patient
Selection.”
Preoperative Evaluation
• Level of injury and number of digits
• Type of injury (sharp vs. crush vs. avulsion)
• General condition/stability of patient
• Radiographic evaluation of the amputated part and
residual limb
• Patient’s vocation, avocations, expectations
Pearls
• Take the amputated part to the operating room before
the patient arrives to begin identifying vessels and nerves
and debriding.
• May insert the distal fixation in part
• Keep the part cool on ice in a sterile container.
• Plan to vein-graft arteries early if there is any question of
injury.
• Avoid tension on the skin closure.
Technical Points/Sequence of Replantation
• Locate and tag vessels and nerves (6-0 Prolene or
hemoclips).
• Debride soft tissues after the identification of vessels and
nerves.
• Shorten and fix the bone.
• Repair the extensor tendons.
• Repair the flexor tendons.
• Anastomose the arteries.
• Repair the nerves.
• Anastomose the veins (two for every artery repair).
• Obtain skin coverage.
Pitfalls
• Make absolutely certain that the vessel for anastomosis
is not damaged or stretched (perform a vein-graft if there
is any question).
• Shortening of bone may allow primary vessel repair.
• Avoid tight wound closure or tight dressing.
Postoperative Care
• Keep patient warm.
• Watch volume status: Keep blood pressure and urine
output at adequate levels.
• Heparinize with a crush or avulsion injury or with a
problem involving blood flow in operating room.
• Monitor digital temperature and observe capillary refill,
color, and turgor for signs of arterial insufficiency or
venous congestion.

Replantation
183
17
Figure 17.15.  Wrap the amputated part in moist gauze placed in a
plastic bag chilled in an ice-water mixture. Direct contact of the
part with the ice must be avoided. (Reprinted from Neligan, P.C., Chang,
J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 228–249.)
Early care of amputated part
Amputated
part
Saline-
moistened
gauze
Within
Sealed
plastic bag
Into
Saline ice slurry
4. Methods for multidigit replantation
• Part by part: Perform replant by structure, rather than digit
by digit.
■ Typical order includes bone, extensor/flexor tendons,
arteries, nerves, and veins.
○ Neural repair: Use a maximum of 4 sutures to
prevent neuroma formation.
• Digit by digit: Perform replant one digit at a time, rather
than replant based on structure.
■ Preferred approach when warm ischemia times differ
between digits
■ The digit in the best condition is replanted first.
■ Digits may be replanted either orthotopically (in same
location) or heterotopically (in different location)
depending on functional circumstances.
○ In severely injured hands, the functional goals are
restoration of 3-point pinch grip, functional thumb,
and two opposing fingers.
○ Heterotopic replantation is preferred if ulnar digits
are all in poor condition.
Suggested Readings
Biswas, D., Wysocki, R.W., Fernandez, J.J., et al., 2014. Local and regional
flaps for hand coverage. J. Hand Surg. Am. 39 (5), 992–1004.
Dzwierzynski, W.W., 2013. Chapter 11: Replantation and revascularization.
In: Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, vol. 6, 3rd ed. Elsevier,
pp. P228–P249.
Goldner, R.D., Urbaniak, J.R., 2011. Chapter 48: Replantation. In: Wolfe,
S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 1585–1601.
Neumeister, M.W., Zook, E.G., Sommer, N.Z., et al., 2013. Chapter 6: Nail
and fingertip reconstruction. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, pp. 117–134.
Sommer, N.Z., Brown, R.E., 2011. Chapter 10: The perionychium. In: Wolfe,
S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative Hand
Surgery, 6th ed. Elsevier, pp. 333–353.
Zienowicz, R.J., Harris, A.R., Mehan, V., 2010. Chapter 121: Fingertip
injuries. In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Elsevier,
pp. 787–793.

Carpal Injuries and
Hand Arthritis
Chapter
18 
Carpal Anatomy
1. The distal radioulnar joint (DRUJ) allows for supination and
pronation of the hand.
2. The proximal carpal row consists of the scaphoid, lunate,
triquetrum, and pisiform and allows for wrist extension,
flexion, and radial/ulnar deviation.
Figure 18.1.  Palmar and dorsal views of the bones of the wrist. (Reprinted with permission from Copyright Elsevier Inc. All
Rights Reserved.)
1
2
3
4
5
5
4
3
2
1
Metacarpal bones
Posterior (dorsal) view
Radius
Dorsal tubercle
of radius
Scaphoid
Radial styloid
process
Trapezium
Trapezoid
Ulna
Ulnar styloid
process
Lunate
Pisiform
Triquetrum
Hamate
Capitate
Ulna
Ulnar styloid process
Lunate
Triquetrum
Pisiform
Hamate
Hook of hamate
Capitate
Anterior (palmar) view
Radius
Radial styloid process
Scaphoid
Tubercle of scaphoid
Trapezium
Tubercle of
trapezium
Trapezoid
Metacarpal bones
• The proximal row articulates primarily with the distal
radius through the scaphoid and lunate.
3. The distal carpal row consists of the trapezium, trapezoid,
capitate, and hamate and forms the fixed unit of the hand
along with the second and third metacarpals (see Figure 18.1).

Carpal Anatomy
185
18
4. The extrinsic carpal ligaments help to anchor the proximal
row with the distal radius and ulna.
• The proximal row is anchored to the distal radius and ulna
by the strong extrinsic palmar radiocarpal ligaments and
the palmar portion of the triangular fibrocartilage complex
(TFCC), as well as the dorsal intercarpal ligament (from
scaphoid to triquetrum) and the dorsal radiocarpal
ligament.
5. The intrinsic carpal ligaments are strong structures that link
the carpal bones together, and/or the carpal rows together.
The two most important intrinsic carpal ligaments are the
Dorsal intercarpal
ligament
Dorsal radiocarpal
ligament
C
L
P
S
R
U
Tm
H
1
2
3
4
5
Td
$
Radioscaphocapitate
ligament
Ulnotriquetral
ligament
Ulnocapitate
ligament
Ulnolunate
ligament
Palmar
radioulnar
ligament
Pisohamate
ligament
Long radiolunate
ligament
Short radiolunate
ligament
C
H
Tr
L
P
S
Tm
1
2
3
4
5
Td
%
Figure 18.2.  A, Dorsal extrinsic wrist ligaments; B, volar extrinsic wrist ligaments; C, intrinsic wrist ligaments. C, Capitate; H, hamate;
L, lunate; P, pisiform; R, radius; S, scaphoid; Td, trapezoid; Tm, trapezium; Tr, Triquetrum; U, ulna. (Reprinted from Neligan, P.C., Chang, J. [Eds.],
2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 1–46.)
scapholunate (SL) ligament and the lunotriquetral (LT)
ligament. Disruptions of these ligaments lead to carpal
instability.
• The SL ligament allows synchronous motion of the
scaphoid and lunate
■ It is U-shaped with a dorsal, proximal, and palmar
component. The dorsal component is the strongest and
most important for stability.
• The LT ligament anchors the lunate and triquetrum
together and allows less motion than the SL ligament (see
Figure 18.2).

Carpal Injuries and Hand Arthritis
186
6. The distal radius slopes 22 degrees in the radioulnar plane
and 12 degrees in the dorsal/palmar plane.
7. The ulna should complete the smooth curve of the articular
surface of the radius. The relationship of the ulna to this
imaginary curve is called ulnar variance.
• Ulnar positive variance: The ulna extends distal to this
imaginary curve.
■ Associated with ulnar impaction syndrome (ulnar-sided
wrist pain)
• Ulnar negative variance: The ulna is short of this imaginary
curve.
■ Associated with Kienböck’s disease (avascular necrosis of
the lunate)
8. Gilula’s lines: Imaginary curves within the carpus that
indicate normal extracarpal and intracarpal architecture (see
Figure 18.3).
• Disruptions of these lines suggest ligamentous or bony
carpal abnormalities.
Capitohamate
ligament
C
H
Tr
L
P
S
Tm
1
2
3
4
5
Td
Triquetrohamate
ligament
Triquetrocapitate
ligament
Lunotriquetral
ligament
Scaphotrapezium
trapezoid ligament
Trapeziotrapezoid
ligament
Capitotrapezoid
ligament
Scapholunate
ligament
Scaphocapitate
ligament
&
Figure 18.2, cont’d.
Figure 18.3.  Gilula’s lines, showing the greater arc and lesser arc
of the carpal bones. (Reprinted from Hentz, V.R., Chase, R.A., 2001. Hand
Surgery: A Clinical Atlas. WB Saunders, Philadelphia.)

Common Wrist/Carpal Fractures
187
18
Common Carpal Ligament Injuries
1. SL dissociation
• Results from an injury to, or tear of, the SL ligament or
scaphoid fracture
• Characterized by pain and swelling over the radial dorsal
wrist with widening of the gap between the scaphoid and
lunate on plain X ray (“Terry Thomas” sign)
■ Must compare with unaffected hand
■ A gap >2 mm is suggestive of an injury.
• Disrupts the synchrony between the scaphoid and lunate,
allowing the scaphoid to flex and lunate to extend
■ As the scaphoid flexes, the cortex of the distal scaphoid
pole projects as a ring on radiographs (“cortical ring
sign”).
■ On physical exam, a clunk can be palpated as the
scaphoid is subluxed and relocated with radioulnar
deviation of the wrist (“Watson scaphoid shift test”).
■ A DISI (dorsal intercalated segment instability)
deformity develops with SL injury as the lunate assumes
a dorsally tilted posture and the scaphoid flexes. This
can be identified on lateral X ray by an increased SL
angle.
• Treatment options
■ Immobilization for 3 to 4 weeks is generally acceptable
for partial tears
■ Open repair of the ligament is indicated with acute,
complete tears or partial tears with persistent pain after
immobilization.
■ For chronic SL injuries, severe arthritis can develop,
creating an SL advanced collapse (SLAC) wrist
deformity.
○ Characterized by radioscaphoid, capitolunate, and
scaphocapitate arthritis. In severe cases, the capitate
can become impacted between the scaphoid and
lunate.
○ Treatment: Proximal row corpectomy (removal of the
scaphoid, lunate, and triquetrum) or “4-corner
fusion” (removal of the scaphoid with fusion of the
lunate, triquetrum, hamate, and capitate)
2. LT ligament injury
• Characterized by wrist swelling and pain, with a disruption
in Gilula’s line from a step-off between the lunate and the
triquetrum
• Disrupts the synchrony of the lunate and triquetrum,
allowing the lunate to flex with the scaphoid
■ On physical examination, pain and instability with
“ballottement” or “shucking” of the lunate and
triquetrum suggests injury.
■ A VISI (volar intercalated segment instability) deformity
develops as the lunate tilts volarly.
• Treatment options
■ The ligament is often too short to repair primarily; thus,
pinning of the LT interval is often performed, with or
without ligament reconstruction.
3. Perilunate dislocation
• Caused by wrist hyperextension and supination with
ligamentous injuries around the lunate, which progress
from radial to ulnar
■ When all of the ligaments are torn, the lunate can
dislocate volarly into the carpal tunnel through the space
of Poirer (“spilled tea cup sign” on lateral X ray).
• Characterized by a high-energy injury, with wrist swelling,
pain, and potentially acute carpal-tunnel-syndrome
symptoms
• Can also develop with scaphoid fracture and/or other
carpal fractures (see Figures 18.4 and 18.5)
Figure 18.4.  Arrow, A perilunate dislocation, when the lunate stays
in its fossa, whereas the rest of the wrist subluxes dorsally.
(Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier,
161–178.)
• Follows a natural progression of injury around the lunate
complex
■ Mayfield classification (see Figure 18.6)
• Treatment
■ Closed reduction and splinting in the emergency room
to relieve carpal tunnel symptoms (especially if no
operating room is available)
■ Urgent operative fixation and carpal tunnel release
Common Wrist/Carpal Fractures
1. Distal radius fracture
• The most common fracture of the human skeleton
• Often caused by a fall onto an outstretched hand