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Atlas of Hand Surgery Sigurd Pechlaner, M.D. University Cnc of Trauma Surgery Department of Hand Sutery Leopold rans Univesity Innabrck, Aust Fridun Kerschbaumer, M.D. Profesor, Orthopedic University Cini Beporament of Rheumatic Orthopedics Joann Walgang Goethe University Franti, Germany ‘Anatomy by Sepp Poisel, M.D. Profi iste of Anatomy leopla Frazens Universi Tonebrck, Austria Iustratios: ood Grater 1459 austatons ye Thieme Stuttgart - New York 2000 Heribert Hussl, M.D. Professor, ln of Paste fand Reconstructive Surgery topo Franzen University Innsbruck, Asta Preface ‘The many queries the authors received about techniques they used and recommended in hand surgery provided the mothation for eeating this las of Hand Surgery This atlas provides am sight nt the author's personal ‘ews and into sug techniques the authors practice, ‘ich have evalved in many years of cinical experienc, Ds result, many af the teehniques presented ere are deviations from er further developments of wel-knoven triginal techniques, Ths the reasoning behind the Suthor's decison to deliberately focus only on selected {echniques without any claim to compreteasive eat ‘ment ofthe subject The als ts atmed primarily at prac- ficing orthopedic surgeons wo deal withthe specific problems of hand surgery. However, also allows the beginner to obtain an overview of various proven surgi- cal procedures and suggestions for the treatment of Specie injuries and disorders. ‘The clinieal authors specaliies—trauma surgery plastic 2nd reconstructive surgery, orthopedi¢s, and theumati ‘Srgery-emphasize that hand surgery has become a dlscpline nits own ght within varous specaltes The tstensive knowledge demanded of today's hand su eons requires specialization above and beyond the in- fevasciptnary approach. The Als of Hand surgery is organized acording to prac- thei considerations, Preceding the main section of the book an introductory anatomic chapter tat presents sil-major detalls. ll subsequent portions of the book fefer Dac to tis chapter We would like oak this op- Dorunity to express our special thanks to Pro. r. Sepp Poise for successfully bridging the gap between ana ‘omic terminology and cincal usage ‘Nehapleron skin and saft-ussu injuries introduces the main clineal section, This followed bya section ox i= ‘rosurpcal techniques. The next chapters handle the treatment of compression neuropathies ad tendon transfers, fllowed by chapters on tendon injures dist ations and fractures A Selection of procedures fr the Suigleal managermeat of selected seumatic disorders nd Dupuytrens contracture rounds ou the volume, i= tially a chapter on surgical management of infections ‘iseases war planned, but this Rad tobe elisnated for Several reasons I wl be included ina revised edition ‘particular advantage ofthe Aas of Hand Surery 35 3 ‘dy tool isthe consistent outline ase to present the = tividual procedures an techniques. Indieation surgical technique, and postoperativemanagement are primarily presented in illustrations and legends orin concise de- crite text passages Despite ths restrictive approach ‘hose by the authors inthe terest of ensuring a jd ‘ous presentation of information, every effort has been made fo malnainthe character of readable atlas suhose stations provid immediate access to dale infor. Imation in reacily comprehensibe form. Some practicing ‘rgeons may find feuusual tht the chapters area ange stitly by region. However, the compreliensive fable of conten also permits Une more conventional ap- proach of lecating information by syndrome. Fhe scope ofthis foreword doesnot pera us to thank ‘AVof our colleagues whose advice ana assistance have Sccompanied the cretion ofthe Aas of Hand Surgery, Sind we ak their understanding However we woul ike totake this oppereunity to offer thanks to our teachers in fn appropriate manner. Recogniing the signs of the times they introdiced us os ascinating ateaof work fand paved the way for us. Among them are Professors Hane Andetl, Rudo Bauer, Eri! Beck, Walter Blauth, Jorg Bahle, eter Suei-Grameko, Ulich Lane, Lennart MManperet Hanno Miles, Wayne A. Morrison, Henry Nisse Berard O'ren, Gnther Pailadtphy, Werner Patee, Reinhard V, Put, Otto Russe, Gustav Sause mt Searizes, Walter Vogl and Paul Wifingseder. Georg Thieme Verlag Kindly supervised the work, Weare especialy grateful that it was pssbleto presente atlas Inthielaborate ection, The vivid drawings are the work (of Mr Jakob Gratzer, who created them with great per Sonalintiatve, workingtromoperatingroomanddissec- tion foom subjects. The authors extend ther special thanks to Ms, Renate Put, who showed enormous com mitment, exceptional attention te deta and clinical pprecationinbinging te existing material inoitscu tent ll frm nthe ial phases a the book. ‘The authors wish thatthe Alas of Hand Stogery wil fegeh 2 broad readership and they hope inthis manner {ohave made contribution to more enlightened teat- ‘nent ofthe "hand patient” The authors view their atlas SE topic for discussion among thelr ealeagues and ‘would be happy to ear any responses Innsbruck and Frankfurt Fall 1999 Sigur Pechaner Herbert tus Fridun Kerschbaumer v Contents ” 20 a 2 2 24 26 2% 1_ Systematic and Topographic Anatomy ‘Systematic Anatomy 2 Dorsum and Pam ofthe Hand Passive Sructres, 2 long inger Steal system 2 _ Thumb Ligaments 5 Toposraty ofthe Nerves ofthe Arm sctive Strutares 9 "Median Nerve Utnar Nerve ‘Topographic Anatomy 14 Radial Nerve Regional Topography 14 cross-sectional Anatomy Forearm 4 2 Skin and Soft-Tissue injuries ‘Skin nesions 35 Rotated Advancement ap (Random Pattern Map. Free Skin Grats 36 —_igenilds Neurovascular san ap frm ‘Anatomy and Types of Skin Gratis 36 the Dorsal Aspect ofthe Inex Finger Casa Spl Thicknes hin Grat 38 Pater lap), Fll-Thickness Skin Graft 37 Neurovascular island ap from the Distal Ulnar Aspect ofthe Rng ger (Aa Pattern Prodecures wit Small Local Skin Faps 33 Flap) “Plasies 38 Sil 2p 38 Large Peeled Axial Patter Skin Flaps. Contiuaus Malpiepasy 40 aeuinal Hap Reverse Zplasty (Buttery ap)... 41 Rall Frear Fap| vevepastis ry Palmar V¥ pias (Al ater Microsurgla Free Flaps rap) 43 Tara Upper atm ap Bilateral pissy (ial ater Fup) 444 Injuries and Secondary Changes ofthe Finger- Volar avancereat ap onthe Tham wit Ful-thickness Skin Gat (Axa Pattern ‘nator ap) 45 Teatment of fnjuries tothe Fingernail and Nall Volar vancenent ap onthe Thumb wi Bel a V-¥-plsty (Axial Pater Hap). 46 treaiment o's Subungaal Femara Volar Advancement-Flap onthe Other tan ‘Treatment af Crush Ingres tote Wa Bed the Thumb Fingers (Axil Pattern Flap 47. Treatment of Secondary Changs nthe Fingernail ross Finger Flap (Random Pattern fap)... 48 and Nall Bed Reversed Cross Finger lap (Random Pte ‘Treatment ofa Spit Fingeral ap) 50 Naieied Grae Dorsal Vascla Pedicle ap (Axa Patan Treatment of aychoaypsis ap) 82 38 34 7 60 50 8 6 5 oo 6 0 % 7” n n 2 2B 3. Microsurgery Microsurgery ofthe Peripheral Nerves ‘Anatomy of the Peripheral Neves ‘Types af Nerve Inures Complete Nerve Divison (Newiormesis) Histopathologic Changes inthe Nerve stumps Surgical Tecnigues Epineural Suture Perineural Suture Nerve Graft : Example of a Nerve Graft Using the Sura Nerve Microvascular Surgery ‘Applications Replantaton : 4 Compression Neuropathies Compression Neuropathy ofthe Median Nerve bratomy Funtion China Pics Comoression ofthe Median Neive atthe gic ment of Struthers Compression ofthe Median Nerve atthe Bicipital ‘Aponeurosis Pronator Syndrome [Anterior Interosseous Nene Syirome Carpal Tunnel Syndrome ‘utnae Nerve Compression Syndromes ‘anatomy : Function Clinical Pte : 5 Tendon Transfers “Median Nerve Palsy Function Clinica icare Proximal Median Nerve Palsy ‘Surgical Principle Distal Median Nerve Palsy ‘Surgical Principle ‘Ablcta Dit Mini Teaser ‘Transfer ofthe Flexor Digtorum Superficial ofthe Ring ger ‘nar Nerve Palsy Function lineal Picture Proximal Ulnar Herve Palsy Distal Ulnar Nerve Palsy : ‘Surgical Principle 16 78 ” 7 7 7 * n 0 8 8 8 12 m2 m2 2 us 20 12 133 126 28 26 26 145 145 145 us 145 145 135 148 9 158 ist 134 134 154 134 Contents ‘vascular Bundle Grafts Donor Site ofthe Thoracodorsl Avery and Vein free Toe Transfer Pallczaion surmeal Tecniges [terial End to-End Anastomosis for Similac Sie Vessels ‘terial End-to-End Anastomosis for Dissimiar Size Vessels ‘Aerial End-o-Side Anastomosis ta Elastic Arteries ‘eral Ené-to-Sde Anastomosis in ‘Arteries with Artenosceronie Changes Interpose Vein Grits Compression ofthe Ulnar Nerve at the Elbow Srpla Treatment Options Subcutaneous Transposition ‘compression ofthe Ulnar Nerve inthe Wrist, (Guyor's Canal, Radial Nerve Compression Syndromes ‘anatomy i. Function linia etare| ‘Compression ofthe Radial Nerve at is Point of nay into the Lateral HumeralItermuscular sepium . Posterior inteoseous Nerve Syndrome ‘Wartenbergs Syndrome Static Corection ofthe Metacarpo Dhalangeal Join with a Zancol Capsulotess| Dynamic Correction afte Metacarpo phalangeal Joint withthe Fexor Ten Sons Dynamic Correction of the Metacarpo- phalangelJont withthe Extensor Tendons Transfer ofthe Extensor ndicis uscie Tendon Radial Nerve Palsy Proximal ada Neve Pals Function China care Surgical Principle ot 105 103 105 106, 10s. 130 130 130 13 135 135 133 Bs 138 139 ma 154 158 161 166 166 198 188 168 vil Contents Merle dAubigné Tendon Transfer Distal Rahal Nevve Palsy ‘Combined Median and Uinar Nesve Palsy unction Proximal Combined Median and tinae Nee Paley ‘Gini ietare Surgical Principle Distal Combined Nledian ad iar Nerve Palsy Cleat Pierre Sutpcal Principe Transfer ofthe Exiensr Indies and 6 Tendon Injuries Suture Material and Suture Technique ‘Core Sutures Pullout suture Pullout Wire Modied Krehimayr Stare Z-Shaped Tendon Splice Advancement Bunnet Suture Incerlace Suture (Paivrtai) Extensor Tendon injuries ‘Anatomy and Tendon Zones Treatment of Acute Injures Fingers Cassifcation of Subcutaneous Extensor Tendon injuries in Zone Ddt and Da, Zone Da ‘Avulsion ofthe Extensor Aponeurosis ype) ‘Consevatve Treatment Surgical Treatment Attachment with Pullout Wie Auulsion of the Extensor Aponeurosis ype it). ‘tachment with Paloat Wire Attachment with Wire Suture Palmar Fracture Dislocation of the Distal Imerphalangeal ine Type W Pin talizacion with Retrograde Driting Technique Zone Dd 2 Closed Rupture of tne Extensor Aponeuro™ sis Type Conservative Teatment ‘pen Injures tothe Extensor Aponeurosis (ype) Tendon Suture Zones Dé and Dd 4 Isolated Avulsion. Bony avulsion or Cased Rupture ofthe Medial Part of the interme sate Band Conservative Treatment Attachment with Pullout Satire Tendon Suture vil 168 3 m4 1% 4 4 114 175 18 15 180 180 im 182 183 185 186 188 189 190 183 m 193 194 194 194 194 195 196 196 196 197 197 199 199 199 199 199 200 200 200 200 aor "Extensor Digit Minin and Tendons Radils Longus Tendon Riordan vor Carpi Radilis Tendon Transfer Flexor Digiorum Supericiais Tendon ‘Transfer Casto Fixation") Brachiocadiais Tendon Tranter Opponens Pasty Using the Tendon of ‘he Extensor Inics Opponens Pasty Using the Tendon of the Extensor Carp Radial Brevis, 15 175 115 15 18 15 5 ‘Avulsion, Bony Avulsion, Closed Ruptie, ‘9 Laceraton ofthe Mecial and tateral Pats ofthe Intermediate Band and the Lateral and Dorsum of ce Hand one Dé S [iceration of the Extensor Tendon a the Level ofthe Metaca'pophalangea Joint “Tendon Repair with Core Sutures ‘Tendon Suture with Pallot Suture Zone Dab {craton of an Exiensor Tendon Prosimal to the intetendinous Connection Tendon Suture Using Modified Xirchmayr Teennigue Extensor Tendon injures with Defects Proximal tothe Intertencinous Connection Bridging Extensor Tendon Delects Weist ana Forearm ‘Zone Dd"? laceration of the Extensor Tendon inthe Tenvian Suture Zone 048 laceration ofthe Bxienior Tendon inthe Forearm Tendon Sure ‘Thum Gosed tendon Raptures in Zones Pat and Pez Conservative Treatment Tendon Suture ‘Treatment of Poorly Heald injuries All Fingers Zones Ba 1, ii ana 3 Insufficiency ofthe Extensor Aponcureis ‘Due to Searing in the region of itl) Incerphalangal int Sar Shortening to Reconstr the Extensor Aponeuross Zone Dds Insuciency ofthe eda Pato the Inermediate Band Due to earring 201 208 203 203 203 204 2s 205 205 207 207 209 200 209 210 20 210 an 2 22 22 22 20 213 213 23 25 as Pathoanatomy Reconstruction ofthe intermediate and by Reflecting 2 Tendinous Flap (0 Restore continelty Reconstruction ofthe intermediate Band with Tendon Grat Zone Das ‘Rupture of the Extensor Pols Longs tendon “rans of the Extensor Indies Tendon ‘lexor Tendon injures Preliminary Remarks ‘Anatomy and Tendon Zanes ‘Treatment of Acute Injuries gers “Zone Oi Forms of injuries Fvulson ofthe Tendon of the Fixer Dig torum Profundus Musee frm the Distal Patan ‘Attachnent with Plo Suture ony Avulsion of the Tendon ofthe Fexor Digtorum Profundus fom the Distal Phalanx vith AaitonalAvulsion ofthe Tendon trom the Bone Fragment Tnvernal Fixation ofthe Avulsed Bone Fragment and Attachment ofthe enon of the Distal Palant sss... Laceraton ofthe Tendon ofthe Fexor Digitorum Profundis Muscle in Zone Dp 1 ‘with Short Distal Stump “Advancement in Zone Dp 1 Tendon Suture in Zanes Dp i and Dp2 Zone Dp? TeoatedLaceaion of the Tendon ofthe Flexor Digitorum Profundus [iceration of Both Fexor Tendon Tendon Suture 7 Fractures and Dislocations enerat Finger, Excluding the Thumb ‘Anatomy Treatment of Acute injures Fractures ofthe Distal Phalsas "Tue Fractures Conservative Teatment Removal of the Fragment shat Fractures (Conservative Treatment Pin Fixation sla and Aria Faces. (Conservative Treatment | Pin Fixation Screw Fixation as 216 28 20 20 2 223 223 2 26 26 226 26, ns 26 a am ns 228 no 20 230 231 2H 265, 253 287 367 267 267 207 269 267 287 268 268 268 268 Contents atm ‘ones Dp 3 and bp 4 Taceration of Both Flexor Tendon “fencon suture ist and Forearm “Zones DPS eration of ai Flower Tendons “Tendon Suture Zones Bd Through Du 3 Postoperative Management to Enhance Rnetional Rehabilitation (Kleinert), itera Flexor Tendon Sature inthe Fingers Thum Zone PI sed Injris tothe Tena of the Foxor Polis tongus [iceration af the Tendon af the Hexor PollcsLangus with a Shor Distal Stump ‘advancement Zone Pp 2 ‘aceraton of he Tendon a the Flexor Poles Longus atthe Level of the Proximal Phalanx Splice Advancement ofthe Tendon Tendon Suture zone Pp 3 Taceration ofthe Fexr oii Longs ‘Tendon in the Thenae Region “Tendon Suture Zone Pp 1 thvouth Pp 3 Postoperative Management to Eibance Functional Rehabilitation (Kleiner) tera Flexor Pllc Longs Tendon Suture “Treatment of Pooty Head lnjries ‘Chronic Flexor Tendon Lacerations Immediate Tendon Graft Two-Stage Tendon Reconaclon, First and Second Stage “Tenodesisin Zone Dp 1 Injures to the Capsular Ligaments ofthe Distal Toterpalangeal Joint uptore ofthe Collateral igamiens or Volt Prate ‘Conservative Teatment Combined Ligament Rupture (Dislocation) ‘Consevative Treatment Reconsnctions of the Ligimenis Fractures of he idle Phalanx Condvlar Fractures (Conservative Treatment Pin Faavion Screw Fination sate Fractures (Conservative Teatnent in Ftaton 24 2a 2a 24 27 237 337 2 29 29 20 240 2a 2a 241 2a 22 2a 2a 2s 245 245 2a 2a 2a 248 Das 248 2st 269 260) 269 269 269 269 20 20 20 270 20 mn m co Contents Wire suture Screw Fixation Bastar and Ariular Faces. ‘Conservative Treatment Pin Foation Screw Fixation and Canclios Gra Injuries othe Capsular Ligaments ofthe Prox ‘mal interphalangeal fine Rupture of the Collateral Ligaments (Conservative Treatment Ligament suture tion ofthe Ligaments Rupeure ofthe Volar Plate Conservative Treatment Comisned Ligament Rupture (Dislocation) Conservative Treatment Reconstruction ofthe Ligaments Fractures of the Proximal Phan Coneylar Fractures ‘Conservative ieatment in Faxaton Screw Foation Comisined Techie Shaft Fractures Conservative Treatment PinFisation Serew Fation Stabilization with External ator Basil and Artiular Fractures {Conservative Treatment Pin Foarion Screw Fhation Combined Teeaigie Plate Fixation Injuries co the Capsular gare of the het ‘arpophanlageal Joints of te Fingers, Excluding the Thum Rupture ofthe Cee igamenis Conservative Treatment Fxatin of a Distal Ligament Avision ation of Proximal Ugament Avul- Rupture of te Vata Pate ‘Conservative Treatment Rupture ofthe Collateral Ligaen and Volar Plate: Dislocation ofthe Metacarp- Dhalangeal Joint Conservative Treatment Reconstruction ofthe Ligames Treatment of Perly Heed injuries Distal nterphalangea Joints Tnreparable Join Damage Tension Band Artvoesis Proximal interphalangeal Joints Instability ofthe Collateral Ligaen. Ugament Reconstruction by Sar Reinforcement Volar instability Superficiatis Tenodesis Inreparable Joint Damage’ “Tension Band Artrodetis Lag Screw arthrodesis m 23 24 an 25 26 2 on a 279 280 280 280 280 280 280 2st 281 281 281 281 a2 283 283 283 234 234 286 26 286 286 287 288 22 292 295 204 294 24 24 295, 205, 295 296 296 208 298 500 Metacarpophalangeal Joints of the Fingers, Excluding the Thumb Instablity ofthe Coliateal ligaments Volar inetbicy Shortening the Cental Sear ‘Metacarpals of the Fingers, Excluding the Thumb ‘Anatomy Treatment af Acute Features Fracturesof the metacarpal oie Fingers, Excluding the Thumb ead Fractures Conservative Treatment Screw Fixation Neck Fractures Conservative Trestinent PlateFixation Pin Faation ofa Separated piphysle Shatteracures Conservative treatment Plate Fation Screw Fixation Pin ation Stabilization with Exerral nator SBaslarand Arcular Fractures Conservative Treatment : Fracture Close tothe Metacarpal as. tated inthe Little Finger ‘Screw Fsation Plate Fhation : Bony Avulsion ofa Tendon, ascrated inthe Second and Fit Metacarpals, Screw Fxation Tension Banding Fracture Dislocation ofthe Metacarpal ase with Bony Ligament Avision, state n the ith Metaarpal Bennetts FractuteDislo- ‘tion! in Fixation : Compression Fracture te Mietacarpal Base, Iystratedin che Thira Mecacarpals (Combined Technique Injuries othe Carpometacarpal joints of te Fin: ses, Excluding te Thumb Tears and Atulsions ofthe Campmetacarpal Ligaments ‘Consevatve Teatment Usamentsucure Screw Fatlon of ony Ligament vulsion Treatment of Poory Heald injuries Malrotation of the Fingers Fllowing Metacarpal Proximal Phalangea! Fractures, Derotation Osteotomy Thumb ‘Anatomy’ Treatment’ o Acute injuries Fractures ofthe Phalanges Injures to ene Incerphalangea joint Injures tothe Metacarpophalangeal joa the Thum’ 303 303 303 303 305 5053 306 306 306 308 306 307 307 308 308 310 310 310 an. 313 aa 315 315, 315, 318 316 a6 a6 36 318 38 us 38 220 320 320 a 321 Eva a2 322 326 26 0 330 20 Injures othe Ulnar Collateral Ligament (Clssifieation of Usa Collateral Ligament Injures inthe Tourn Treatment ofa Rupture, Avision or Bony ‘vulson ofthe Ulnar Collateral Ligament of fhe them Conservative Treatment Repairof an intasubstance Rape ‘with Ligament suture Foation ofan Avulsed Ligament with a Palloat Suture Through te Bone Foatlon ofan avulsed Liameat (with ‘orwithout a Bony avulsion Fracture) ‘tha Pllout Wire Trough the Bone ation ofan Avulsed Ligament with Bone Suturesvia Anged Drill oles PinFiation ofa Distal Bony Ligament pvulson Screw fixation ofa Distal Boy Liga ‘ment Avulsion . Pin Fationof Proximal Bony Liga- sent avulsion Injures othe Volar Ligaments ofthe Metaca pophalangeatoineof she Thum Classification of juries tothe Volar Ligaments ofthe Metacarpophalangeal Jeantof the Thumb ‘Treatment ofa Rupture Avision oF Bony Avision ofthe Volar Ligaments Conservative Teatment ration of roximal Avision of the ‘Volar Longitudinal Ligaments with a Pullout suture Trough te Bone Repair ofan avulsion ofthe Volar Longitudinal Uigament rom the Sesamoid witha Ligament Suture Repair ofan avulsion ofthe Inter~ Secamoié Ligament fom the Sesamoid ‘with igamene suture Pia Fcation ata Bony Avuson ofthe Intersesamoid Ligament rom the Sesamoid witha Longitudinal Sesamoid Fracture Fractures ofthe Fst Netacapal Head and Neck Fractures Shaft Fractures ‘Conservative Treatment ination Pia Fsation ° Fest Metacarpal Base Fractures Fracture Close tothe Bare, Distal the Insertion ofthe Abductor Polls Longus Muscle. : ination Pate Faation Fracture Close to the Base, Proximal the Insertion of the Abductor Poles Longus Pia Fxation| PlateFixaion ‘racturDislocatan of Fist Ntacapall base: Bennet ractre Dislocations ‘Conservative Treatment 230 330 a a1 a cry 336 a8 238 339 a9 339 20 3a a0 aaa as us 345 us 345 548 3a7 aa 38 349 350 350 351 351 Contents Pin Fixation 352 Screw Foation 352 compression Fracture ote Fist Ntacar- pal ase: Rolando’ Fracture 353 Pin ation 353 Plate Fixation 354 Harvesting Cancelous Graft from the Distal Radius 355 Injuries tothe Fst Carpometacarpal joint." 356 Dislocation 355 Conservative resent 336 Ligament suture 357 ‘Treatment of Poorly Heaed injuries 358 nar Instability ofthe Metacarpophalangeal Jointof the Thumb 358 Reconstruction f the Uinar Caiateral LUgamene 2 358 Volar instablty ofthe Metcacrpophalangea Joint ofthe Tum Reconstruction of Ligaments fr Vata Instability 360 Instabiliy ofthe Pst Carpometacarpaljoine + 363, Reconstruction af ames 353 wrist 365 ‘nator 365 ‘Treatment of Acute injuries 538? ‘Clssitcation of Dislocations ad Fracture Disio- cations . 367 Fractures ofthe Wrist Bones 37 Fractures ofthe Trapentum mm ‘Conservative Tate a Serew ration a Fractures ofthe Seaphold a4 Cassfieation of Hactures athe Scaphoid -. 374 Location of fractures ofthe Scaphoid 2... 374 TWeatment of ractres ofthe Scaphoid <=» 374 ‘Conservative Treatment 314 Surgical Treatment 374 Injures othe carpal Ligaments 315 Clssfaton of Carpal Instability 315 ‘Treatment o Carpal instability 35 Paral Instability of Joint (woated Carpal Ligament inury) .- 375 ‘Conservative Treatment 36 ‘Closed Redvetion and Pin Fixation «== 376 Fxation ofthe SeaplunateInteros: seous Ligament 3 ‘Triqutrolonate stabi 38 Concervative Treatment a8 Closed Reduction and Pin ixation ==. 378 Fination ofthe LunoriqutrlInteros: Sseous Ligament 319 Complex instatlity fa ont Regional Car palLigamentinjury) x79 ‘Seapholutate Dissociation 319 Conservative Treatment -cnncesess 380 Closed Reduction and Pin iation =. 380, Screw Fixation ofthe Scapolunate Ligament 381 Fixation of the Scaphalunate ligament ‘vith Bone Suture via Angled Drill oles 382 x! Contents Suture ofthe Scapholunat Liament Faation and Suture ofthe Radiosea- hocapate Ligament Compe istabiry of Severai joints (Bx tensive Carpal Ligament Injury) Perilunate Dislocation ‘Conservative Treatment ‘Gsed Reduction and Pin Fixation Suture apd Fixation ofthe Carpal Liga ‘Treatment of Poony Head injuries ‘seudarthrsis in che Carpal Bones ‘Seaphotd Pseudarthross Volar Apprach in Scaphold Surgery Russe Bone Grate Herbert Sere Fixation Ender Pate Foation Pochlaner-Husl Vascultied Bane Graft agp tnt ‘eapholunateisibiyy Dorsal Scapholunate Ligament Recon” sructon Dorsal and Volar Ligament Recontrue- tion in Seapholunate Dissociation Radioscapolunate Ligament Recon ‘Wrist and interearpalAtivds Plate Arthrodests of che Wit and Carpal Joints Radius and Distal Radioulnar Joint -nstomy 8 Rheumatoid Disease, Degenerat Avascular Necrosis, Instabilities, Fingers, Excluding the Thum Distal interphalangeal Joints Rheumatoid Artis and Erosive Osteoar= Uts with Heberden's Nodes ‘arhcodesis Proximal Inerphalangeai ins Reurate Artis Synovectony Arthroplasty ‘rhrodesis Distal Incerphalangeai snd Proximal inter halangea Joints Rheumatoid Arthritis sind outage Defority Surge Corection ofthe Boutonnigve Deformity “Metacarpophslangel Joints Rheumatoid Arts ‘synavectomy, Arthoplasy Xi 382 386 386 386 387 387 389 380 380 389 389 392 392 394 337 397 08 400 402 405, 405, 208 Treatment of Acute Injures Fractures of the Distal Rags Chssifcation of Fractures oft Distal Radius Treatment of Factres ofthe Distal ads Conservative Treatment Pin Fixation Percutaneous Serve Fixation Stabilization with Extemal Fastor Pate Fisation Through Volar Approach Plate Fixation Though a Borsa Appreach Piste Fixation Trough a Combined Volar and Dorsal Approach. Injures ro te Distal Radial oie Fixation of the Teangulat brocar- tlageinan Umar Avusion| “Tension Banding ofa Bony Avision of the Trangular Fibrocartage ina Frac- ture ofthe Ulnar Stylo ‘Treatment of Poorly Heald Injuries Distal Raia! Deformity ‘Osteotomy to Carect a Deformity af the Distal Radius Sauve-Kapandj Athvodess ofthe Dis! ‘al Radioulnar Joint with Segmentat Ulnar Resection Chronic tstailty ofthe Triangular Fiboca sage Pocilaner Decompression Gxteatomy ofthe Ulnar Head ive Changes, Stenosing Tenosynovitis, 409 409 409 43 43 45 a8 419 a 28 a 42 43 aaa a4 38 38 43 48, Wrist Ganglia, and Dupuytren’s Disease as a8 a8 as a1 431 431 454 459 462 462 4682 486 466 470 Rheumatoid Arthritis and Swan Neck Deformity Intrinsic Release Retinacular Reconitracion. Extensor Tendons ofthe Fingers, Excluding the Tham Ruptures ofthe extensor tendons Side-to-Side Sutures, Tendon Transfers, and Free Tencon Grafts Fexor Tendons of te Fingers, Exchiing the Tham Renate Arts oF Tenosynovitis ‘Synovectomy ofthe Flexor Tendons ‘Ruptues of the Fexor Tendons ofthe Fine gets Excluding the Thumb ‘Synovectomy, Tendon Transfers, nd Fre Tendon Grafts Stenasng Tenosynovitis or Tager Finger 'Ai Pulley Release and Synovectomy 478 a8 479, 492 482 486 86 486 490 490 492 42 ‘Thumb Metacaepapisngeal joint of te Thums ‘Rheumatoid Artis and Boutonniere Detority ‘synovectomy ‘Athrodes txtensorTendons of Thum Ruptures of Extensor Tendons “ranser ofthe Extensor indils Tendon Fexor Tendon ofthe Thumb Rupee ofthe Tendon ofthe Flexor Polis longus Muscle Reconstiction witha Free Graf fiom the Palmaris Longus Tendon «... Stenosing Tenosymovitis or Trigger Thumb "Tendon Sheath Release De Quervains Disease “Tendon Sheath Release First Capometacarpal oi “rth ofthe ist Carpometacaipal Joint ‘Ashworth batt Arthroplasty ofthe Fist Carpometacarpal Joint Resection Interposton Anhropasty vith an Autologous Pedicled Graft Contents ao a4 494 aod a8 500 500 500 503 503 506 506 508 508 510 510 510 sia Metacarpals Dupuytiens Disease Rescection ofthe Palmar Aponeursis Wrist Waist ins Rheumatoid Artiits ‘smnovecomy Radiotunate artnodesis Arthroplasty Arthrdesis of the Wrist Joints Instability Artis and AvaseularNecro- ‘Sciponrapeato- Trapezoid Triscaphe) arthrodese Scaphoia-captateArtvodesis. Wrist Ganglia Resection ofthe Dorsal Ganglion Resection ofthe Volar Ganglion Bibliography Index 518 318 518 524 524 54 504 50 52 5a 546 sas 58 550 550 553 556 558 xill 1 Systematic and Topographic Anatomy 1 Systematic Anatomy Systematic Anatomy Passive Structures ‘Skeletal System (Figs 11-16) Fie Lt anes of the hand 4 si per aed eco Foran 1 5 pc it a 12 ones ofthe hand eer a 2 Ee ae Bb ballot Passive Structures 13. ones of the hand Figs 14a and Bone fhe fang agers (ie finger) adsl aspect, 2 ool sect, Badal pce 1 agen 2 Raeaot api 1 bard tle) 5 ope 2 betel 4 fan 5 toc ne ae 5 Sp 4 aot ne recy 5 pats ac 4 6 Poa he 8 Se recs te ts 5 Feast arp 3 ee 4 thie meacaral too W Cte 5 Metal te nme 18 Spa pce fed macs 1 Came 0 Cota 1 Systematic Anatomy j Fis 15a-e Bons of he long fingers (lenge) 2 besa ect Passive Structures Ligaments (Figs.17-119) Fgh 7aand Ugements ofthe hand} O20 mtoons genes 1 lean ote eter cans Donal apt 2 Paton netcnpa igor met operat tne 4 eimchiermremrrnis 1 Une ein toe & Deep plane 4 en ofthe enter capirecats 35 Bl aula gree 5, a exponen igre ‘ian 1, ana gm ener ni) 1 Systematic Anatomy Fis. 19 ronal wrist (aio artulton, dosed i Boral apect 2 aot aire {Siege teoscos inet tiestnasccigene F110 Dia interphalangeal joint 55,112 Mtacapoptaloageal jot of lng ager eal spc il pee 1 mrs ote edn heath pA an 2) 3 Arr parasols a A) 2 a tromae meen 2 Externe rng she 3 Giecventgenee 3 it pase 4 Peep 5 peer art Cele genet 1.31 Prox interpalanges jot ape 5 Ar rtf fr eos tis 22, and 4) 2 Gre purl he tenon seth ge 1 Phage ee ear iret 4 Gectren igo 1 oer pan 6 Passive Structures 1.213 Mhscaar insertions at the metacarpophalangeal Jott of he tam Soros 5 ities opted 3 rid 2 Stet P aati 3 Spm ns ig 115. Muscle ingrtions at the mtcarpophalangca Joint fee thar Bison ape fg, 14 Metacarpphalngea aint f the thu Nelo pet 3 Pein tli 6 fem 2 Giemsa 5 Eptindene 2 Fo a hte pl Igarent 6 arin ee ia" | Bea Lee, See gee be ieee Pee feue Roe 1 Systematic Anatomy Hig 18 Musclar Insertons at the metacxpophaangeal ric. 1.17Atacarpophalangea jit ofthe thumb Joint of he tm Ua sie, tina ose co plies 2 hor lng pina inet 1, Shoe aa 3 heehee 3 Key tes one ig. 1.18 carpometacapa jit af the thumb Ft rvonetnaa tf esha Bowl eps ears er ge 9 Sonaetacspalinman Active Structures Active Structures (Figs. 120-126) 1 Systematic Anatomy Marler and tendons of the hand sages escapee et Active Structures Fie123_oesalapancuresis of the nde finger rl ape, a 1 Be am Foaman 13 oi ees re {loser sexe patient 5 Ko ate lc po me 5) eect ecm itn made ender se ‘Systematic Anatomy i. 1.24 Fleer tendon sheath of lng finger 19.225 oul poner oben fa aspect Davata 5 Péter lor) Rao eat ne 2 Dep tenene etc 2 Sout apnava 5) Tedonsl th fe dgtrorreste 5 Fecnette etern pote bee 1 Execs tor agnor 1 Sorento & ister genet 5 mst ha othe act ple 5 Fedora ene 3 ftoomi eames o kerio ea omg om ta ( Figs 1.268 andl Finger Ula eect, 2 With sho apd sudataneos tue removed 1 Opponent! ii apse ae reftng he ‘dear di nian the evar it mine bess Active Structures . ae eae, oases 3 1 Topographic Anatomy Topographic Anatomy Regional Topography Forearm (igs.127-132) Regional Topography g.129- Waar aspect ofthe forearm, subcutaneous ayer 9.1.30 Voor aspect of the forearm, supefial subfasci 1 Topographic Anatomy Regional Topography Dorsum and Palm of the Hand (Figs 133-138) Fig 133_orsum of the hand, sbeutaneous "he dsl vero ea as ban rest eompearenoved fhe nar cts var) 1 Topographic Anatomy Regional Topography 1 Topographic Anatomy Long Finger (Figs 139-142) io 139 Dorsal aponeuross and cutaneous ligaments of + 5-140 flexor tendon sheath and cutaneous Uapmens of & tong finer {ong finger Dona space Vela + cabs ig 1 ton ast 3 ee taney 2 Goer emer 3 er eer tl ee pg he daa 20 Regional Topography 1 Topographic Anatomy ‘Topography of the Nerves of the Arm ‘Median Nerve (rss. 144-148) Fig 144_ origin and course ofthe mean nervein elation to Fs 1453°<_ Medan nerve in relation tothe pronatr tres eiceon Disease omens se 1 ahem aie eter or oe eee a tee, — 22 ios 1462 and. Variants ofthe course of the median nee lnthe pronto teres du toa supracondylr proces (pro 3 2 hatonsip tthe bones Bight pont tres 3 Stpecontiiepeaces Topography of the Nerves of the Arm ig 147 Course of the median nerve nthe pl of the hand cam col ain ee tht ee See gt ee ‘ci en on Fg 148a-< Orin an course ofthe muscalar(theae branch ointatanmento He 68) B Sibigamertoes pe (13) Tangumenous pe 313) 3 ie a 5 cate tea anh 23 1 Topographic Anatomy Ulnar Nerve (Fis. 149-151) F149 Ong and couse ofthe una eee in relation to ‘he boner af he am 4 Deep bnch 24 Topography of the Nerves of the Arm Fig 1S0aand Schematic lagram ofthe course ofthe ar 1 Pima rpc of he rear appl f te hand 1 Cayo a 2 Cama pia dated ees » enn pam longs P15) gee me 5 Rh 9 ow ott ee mene 25 1 Topographic Anatomy Radial Nerve (Fis. 152-154) | ig, 152_ Origin and course ofthe ada nerve In celstion to Fa, ofthe rail ere tnough the regions ofthe I {he bones of te arm ‘am an forearm | i 26 Topography of the Nerves of the Arm Fo 154. course of tho deep branch ofthe raat nore ‘through the spinator pane seen See eee Shor 2 1 Topographic Anatomy Cross-Sectional Anatomy (Fis.155-161) fete atten Cross-Sectional Anatomy fig,157_ saga section trough Jong finger ofthe hand rd digit) 29 1 Topographic Anatomy 9.158 Asal scion though the dtl forearm 1 Antares ae (nein ee) $e dota es 18 Sent ee aterm apts 1 Rodintt pans 2 fiero 2 Une ote cto re msedosanes ner) 1 Sacre he 3 Steno pts ow aaa 30 "eens agen ie ini en 12 rrr Sct hen ene 2 se 2 ee crore rn 3 ietaeetesee Sa Cross-Sectional Anatomy pe een dt mn 4 Fett ee a iper dkmers| 2 wee te 1 Conn pt i ee ne "5 Spon pe 1.60, Ail section tough the dtl carats 32 Tonbn fe for copiee 1.61 Asal section doug he meta acpi te ak geRses 3 Bendimenan tees 2 umbrate 17 tae lit) 2 techn 28 Sree fear dgnmamime 1 Mie Systematic Anatomy Fig. 161s scion through Th metacpepnges oa hea es Red 1 sil ete i oe 2 de ens 16 Tete fe i pu si i EEeaoe Sa ise 3 xoarsamc 32 2 Skin and Soft-Tissue Injuries 33 2. Skin and Soft-Tissue Injuries General “The structure ofthe integument of the hand vates. The war epidermis is thick, contains numerous sven ands, atl corpuscles and melted orpuseles ot ho hair or sebaceous glands. The dorsal epidermis i thin, can be raised in folds, and contains hata Se baceous lands. 34 Reconstruction o ost ares of skin onthe hand is partc- lary important co protect undecying structures and 9 ‘estore the sensitivity ofthe han Skin incisions Skin incisions ‘kin incisions ae determined by the position of static hand lines and cutaneous olds. Asin nesion should never course perpendiculaely across 2 Mexion cease ie 20), » 2 Sannin nthe pm fhe and Sin incios nthe dorm of he hand { Skninclns nthe Gor fhe hand 4 Later sn nen he ger 35 2_Skin and Soft-Tissue Injuries Free Skin Grafts Preliminary Remarks Split-Thickness Skin Graft sitskin: Consists oeidermis and portions ofthe det Skin grafts require a wound bed with good vascular SP Supply. Full-hikness skin grafts are sed to caver small oF varying thickness, defects thicker splteskn grafts are use for ltger de- Removal From the frearm ortigh with a dermatome, a Management: Removal siti covered with a fine mesh nonadherent dressing The woud will heal by «pon ‘Anatomy and Types of Skin Grafts taneous epithelazation in about 10 days (fig.22) Fi.22 Skin and sn rats 1 eps of he vas sn grat 2 Pyro Per canen ieee 4 Sete cant 36 Free Skin Grafts Full-thickness Skin Graft (Figs.23 and 24) 1 Full-thickness skin: Consists of epidermis, the entire ‘dermis, and portions ofthe subcutaneous faty tse. Remova: Grafts are removed witha scalpel. Small de- fects ae closed lth skin fom the forearm, larger fects with skin fom the Inguinal region, Management: Primary closure of the removal site i in- dicated Surgical technique: Fig.24 0.23. Shin defect on the proximal phalane ofthe nex fine bat aspect 5 ger day a 4 4 he a a. a ® Fige24a and b_ fll thidnes sin aa fb Te satus at nr foam ruber presse bandon Pring a fabtcnes sm ga th retention Stes bine the ga 37 2. Skin and Soft-Tissue Injuries Procedures with Small Local Skin Flaps Skin Naps should be use to close and stabilize skin de. fects with a poorly vascularized wound bed and exposed tendons and bone. We ierentiate between skin Maps with vascular supply tothe edges (random pater Naps) and skin laps ‘with vial vascular supply axial patter Naps). The aa Vessels make it possible to rene an especialy Tena, vwelvascilarized lap Monofilament suture (5-0 oF 4-0) is used, Sutures are ‘usualy removed after 10 to 14 days ' fo Fig 25. Scarcontractre inthe fest intergal space 38 ZPlasties 2plasies are a special form of skin Nap that can extend the skin longitudinally at che expense of width. This achieve by making 2Zshaped tnison and advancing the resting triangular Naps, The sides of the Z-past ‘must be of equal length 8 60-deyree angle can result 1 an increase in length of 70-75%. Maliple successive or Tevetsing Z-plstes can be performed, The rhombord flap described by Limberg is 9 special form of Z-pasty Simple Z pasty (Figs. 25-27) Indication: Scar contractures aross che joint in the fis. interdigtal space. Surgical technique Fig, 2.6 Postoperative management: immobilization in aster: ie, tabling hand bandage for one week, Free Skin Grafts Fin 26-€. Simple sty The wars comanatney ace and 97 created The stn fp» advanced sath resto he Sear se csi Silty oan acaneg 25 of pte iiapesrom ath ve shape sen cose Flos 2.7 and bSchomsle agra of simple Zpsty ~~ 1 Faty eee bance ‘ \ Flay ser sdanceme 39 2_Skin and Soft. ue Injuries Continuous Multiple Zesty (Pgs, 28-210) Indication: Long car contractures onthe volar aspect of the hand, ‘Surgleal technique: Fig, 29, Postoperative management: Immobilization ina ster- ie, stabilizing hand bandage for one week. [296° Canina maple ay Te strisconenstly eee 1 Succession 9 shed sn nos are made The es of ach Zs be fel ert at angle of «The Zshaped skin pete sane 9.28. Searcontrature onthe nex finger 2 Skin and Soft-Tissue Injuries Continsos Multiple Zloty (Figs.28-2.10) Indication: Lng scar contractures. onthe volar aspect of the han, ‘Surgleal technique: Fig.28, ative management: lmnobl2ation ina ter- se, stabilizing hand bandage for one week F.294-€ Continuous mule Zplasty 2° the war constrtacy eed B ASoccesion af Shope sn inns are made. The eof tach Z ust of equaling at an ah «The Zshaped sn apse stance wo Free Skin Grafts Figs 2302-€ Medel of as B Movaneaent eta ng cease reverse 2 psy (Battery lp) (Figs 2.11 and 2.12) Indication: Scar proximal the PIP joints or sear on= traces inte interdigital fol. Surgical technique: Fig 2.12 Postoperative management: Immobilization in ster- uv, j ie stabilizing and bandage for one week, Fig. 211 Sear contracture nthe the intertalspace 2 Skin and Soft-Tissue Injuries onze. Reve Zaye a) inion dtl spt 8 eso, vl pt nd ede The trans lps are sanced tr dose, the per ‘rom prontal dtl t pert the bet pombe ronson oF te eagle, 4 esting ngtnseas th econsuctonof he eterna fo fcantcton fhe tr fod di ven vv.plasties Palmar vet (An Patern Flop (Figs 213 and 2.18) Indication: Reconstruction of fingertip defects. Surgical technique: Fi.2.4 Postoperative management: Sterile hand bandage and Finger splint for 10 days a ® « ‘ 0.2.42 Stump of amputated finger The ry cone by dey aang the wards Ae 4 Shaped sn dose shed palmar hin aon othe ta pha & Theskin fap bilaed an spice of ubctaneaus tise ‘aha sels a pre eves Sop B 2. Skin and Soft-Tissue Injuries tera psy (il Potter Hep (Fig 2.15) Indieation: Reconstruction of fingertip defects. ‘Surgical technique: Figs.2.15b-e ‘Postoperative management: Sterile hand bandage and finger splint for 10 days Figs. 2359-8 Batwa Vplasty of am amputated finger 2 Raped ions made tay om bh sides of he tal pate in the apt ge tmp € Bethneuracl sf are mized and ache They fee then need ng the median ne «The stump covered th shaped donee san Ing the hn aps tothe ean ne Magnified view ofthe esecton of he aul pede 4 Magnes view ofthe neurons pele 1 ope pia il rer 2 Rope Sor eee 3 Rip ot Free Skin Grafts \Volar Advancement Flap on the Thumb with Full: “Thickness Skin Graft (Axial Pattern Flap) (gs. 216 and 207) Indication: Reconstruction of age defects ofthe thumb up Surgical technique: Fig 2.17 Postoperative treatment: Sterile hand bandage wit ‘thumb spline for 10 days. The foam rubber pressure ‘bandage shouldbe removed on postoperative dy seven fig 217-4 Volaradvancemn pon the thumb ith ‘here sn gat “he pmar ips ct wh both neurons bares ghee 0.236 Amptated thumb stamp «Meneses ap mobitzed and adaneedto caer ‘ 2 Sint 4 Traps aban to com the snp, a te donee 3 lat i sein sane te atin ste scone wh ofan nat 45 2. Skin and Soft-Tissue Injuries Volar Advancement Flap on the Thumb with a ‘verplasty (Axial Pattern Flap) (figs 216, 2.174 and b, and 2.18) Indication: Reconstruction of elects ofthe thumb ip, Surgical technique: Figs. 2.172 and b, and 2.18, Postoperative treatment: Sterile hand bandage with ‘the thumb insight flexion. Figs 2388 nd boar advancement lp om the tam wn east "Tae pearac n ap mobi and adanced th a Vincion eve he stp, The dors od th 8 2 Poa par ga rey pe pa a aay a ee a ha ‘dab: 46 6 1 Aap shin clone coves the stamp ter aang the Volar Advancement Flap on the Other Fingers than the Thumb (Axial Pattern Flap) (Fes. 219 and 220 Indication: Reconstruction of large fingertip defects. ‘Surgical technique: Fig 220. Postoperative treatment: Sterile hand bandage with the finger insight fleson, 14.219, Amputaed finger sump Figs 2202 Volar advancoment lap onthe the agers ‘the thm 2 ate sm esin (0 2.14) 1 trai! pima sn lap is bid wth proxi neu ‘nar ed tling fre to pes the vase tures emerging he dos spect ofthe Map Tendon toe dara rine Nitra bate png fe oa tne einige leet ore {Theva perrsar ap coves the sump. The ger must ‘tay be pled in sgh eslon alow rion ee do ‘hes tenon ences consequent compere 1s peste Free kin Grafts a7 2 Skit and Soft-Tissue Injuries ‘ros Finger Flap (Random Pattern Flap) (figs 221 nd 222) Indication: Skin and soft-tissue defeets on the volar aspect of the proximal and middle phalanges of the fther Singers than the thumb. Surgical technique: Fi.222, Postoperative treatment: The ingeris immobilized ina splint for 2103 week, at hich time the fap is divided under local anesthesia, 5.221 Deep waar defect om the mide palo finger ‘The rconstucted dap flea tendon exposed. 48 Fig.2.226-d_ Cross ige ap 2 pedi ap Soba onthe dorsal aspect the agent finger Free Skin Grafts IG) 1 ~] - : ¥ y LY ; i ¥ | ad p> 1 Thefupuithts bt pede plac owerthevlardsecty€ The cos ge fp cones the vor sin defect. te api the acer ger Fad th eto 4 The donor ste onthe dorsal pect henge cond with ‘Tatelaes agate The sre ns ofthe rein 5. tures are Kt kg forthe oo ber peer banaages 2 Skin and Soft-Tissue Injuries Reversed Cross Finger Flap (Random Pattern Flap) (Figs 223 and 224) Indication: Skin and sofcissue defects on the dorsat aspect ofthe lng Tnger especially onthe proximal and ‘mile phalanges. ‘Surgical technique: Fig. 2.24 Postoperative treatment: The ingeris immobilized ina splint fortwo to three week, at which tine the Nap is divided under leal anesthesia Fig.228. Deep dorsal defect extending tothe bone inthe ‘mie phan 2 Sond 3 Sigma tac [0.224 eid cos ges ap he pane tiger op donpenlaied 208 rected to el the ec nthe nacent ge Th tc sn (gat crested sate asd to eo the deft ested 2 he ora ste. Ths procedure rere extemal earl daecion ‘th thes of maging oupe, 3 Spates sen gat boys 50 1 Dissecting the despite pt cnet asl defect tne adocent rer + xg cs tro casa Free Skin Grafts ‘ « é « Reape tates coment dh wd po cn wh et aoe IRs sin gra een ate 4 opine 1 Seana nae 5 Sorenson oak aes 4 h © ‘ 1 Thea sed hee woos ter The wound closed wth tention ates 51 2. Skin and Soft-Tissue Injuries Dorsal Vascular Pedicle Flap (Axial Pattern Flap) (fie 225) Indication: skin and sof-tissue defects on the dorsal aspect ofthe proximal and middle phalanges ofthe long Finger or on the volar aspect ofthe proximal phalanx of the long finger. ‘Surgical technique: Fig. 2.25. Postoperative treatment: The ingerisimmoblized ina splint fortwo to thee weeks, at whic time the Nap Is Alvided under local anesthesia, Figs. 2254 and Doral vascular peice lap ina deep drs {fect eatenang tothe one ofthe Finger 23° AtUp tha voscuse peice crest onthe acento Dasa beaches ofthe pins itl artery the ves sclera pater ap con 0b cat the Fatt second tnd pce Feit dt fy Botan dhe oe dg 2 note 52 1 The Fos placed oe the detect in the ace fs, The leno te dlc cover ths allies shin go Rotated Advancement Flap (Random Pattern Flap) (Figs.2.26 and 227) Indication: Skin and sot-ssue defects on the mide and prema phalanges of the finger. ‘Surgical technique: Fig, 227, Note: This rotated advancement flap can be created as fn asl pattern flay that Includes the proper palmar ‘ig artery and vein Postoperative treatment: immobilization in str ‘Stabling hand bandage for one week. Fo2aramnd feted stance ap "bose ste shin Rap ths pron peice Free Skin Grafts Fig.236 sep volar defect onthe proximal plane . bb The fap insta a covert dee. The donor ste delet 53 2_ Skin and Soft-Tissue Injuries Hilgenfeldt’s Neurovascular Island Flap from the Dorsal Aspect of the Index Finger (Axial Pattern Flap) (Figs 228-231) Indication: Skin and sof-issue defects onthe volo ane dorsal aspects of the thumb, Surgical technique: Fig. 231 Postoperative treatment: The ingesis immobilized ina spline fortwo to three Weeks, a which time the fap i= divided under local anesthesia. "3.228 Deep war elect nthe data phlanc ofthe thumb 1g. 229_ Anatomy ofthe donor ste ofthe nerovscu ‘xtondng tthe bone Tan lap rom the dort pct ofthe sand ger shown ‘he schematic dogs in fg 230 54 Fi.220.Sehemate ogram of the nro {Jva neurnara ap rom he proximal ph supply ofa Dl gaan Free Skin Grafts and Soft-Tissue Injuries 1 the neovascular sand fap coves the defet 56 fx 231a-e Rewrwasaar sand fap trom the dort sept ol teins ner ihe mera Wn pi dsc, tlng cate ope ‘re the petenon a he dono se Branching vse ‘rll evponed and ignte the pee petra eves Shot needy pepe ning Dap Mista ota Sy Dra aie nee ‘he delet cone with the flap ad daar te witha ‘hates sin Tes cons ae dosed rma. Free Skin Grafts Neurovascular island Flap from the Distal Ulnar Indication: Skin and soft-tissue defets of the thumb [Aspect ofthe Ring Finger (Adal Pattern Flap). (figs 232-234) ‘Surgical technique: Fig.234. Postoperative treatment: sterile hand bandage. The foam rabber pressure bandage should be removed on postoperative day seven. 0,232 Anatomy ofthe donor se ofthe meurovatele fig 233_ schematic dagram ofthe neurovascular soy of ttn tap rm the unr asguc of the ng ger shown nthe hela ap frm tea aspect ofthe ving finger Sema agro in Fi. 230 ro ne ' ‘gear rr me) ean) wa 6 Son ooh eral atey fal ay tho 2. Skin and Soft-Tissue Injuries Fig, 23¢a-d_Newovsclr land ap rom the tal lnar [pet ofthe eng finger 2 Ohsetn a tenes ad fap wth magne ew rang’ naan of eth {omit plement of thea regres hosting ad ans Ing the ral pope alr geal sey a thei fre "Te reper palma il nee exposed td teres by ‘arf sping the pesneosom a separating thom the ermon dtl ene 1 Saal poe per gta tery 2 ope plot tl mane er) 3 Satna paraitl ee 5 smart 5 Bit at 2 Teka pt ogus 18 onan in Stas reson ree) Specular ban! aa stey Mito the neonse a p fro the ing ge "he prope! pala itl pee of eral fm tr sedi and bought dee opposition th the prope Pa ‘ar dgtl nee of th nd ap 58 Free Skin Grafts «Shame dara and magni view renin te proper Palmar dtl nerve of he ada thm to sppesten with “he proper kos itl nee ofthe and ap Tene Snr fe pt oes oe ote smn fe ap ‘nh Senaton te thn, 4 Foe par ta eo eg age) The dtc onthe pana spect othe umd covere wth The revovasar Han ap he dono ite elec ores wit fultheiness si grt ane fosmebe presse Sande pps The sen esis sed pearly ith ‘stein soe, 59 2 Skin and Soft-Tissue Injuries Large Pedicled Axial Pattern Skin Flaps Inginal Fp (fg 238-237) ester reatmen Theorem fee in enn ecsinne Gael Woon wale baa Bras sae oe Indeaton tense skin and sotssuedetects inthe Eytan aes moe ies vane ‘thee weeks, at which time the flap is divided. Sarge technique: Fic 27 Nae: Te nia Np ea be slated athe super ‘itunes a ese tn cei fice fap oth mites nae '4.235- Deep sin detect with thesecond ad thedmetcar-Fg.2.36. Anatomy ofthe Inguinal gion palbones exposed ater intra ation wth plates Extensor ferdons have been pry reconstructed 1 ia os 1 Sle seeany onsen tel rate wt at) 60 Large Pedicled Axial Pattern Skin Flaps ‘Around pad formed tthe bt of he gulp The ‘ot cnered wth the wel vse ap. The delet (fete atthe owe ns cael recy ah enon Fign 2372 Inguinal Fp anna ap of the esd see died ff the subeu- {Gres ot twa tome A thee he rar ‘pet ln pe the apn patn ofthe slat the store fo ene te the spe! crc Bac ary and vein ae aed diced ee a Se ermine iia The det sev, a the peed nul Tp sed com the dosem lthe hang 1 murat 2 Haba rpeee) 61 2. Skin and Soft-Tissue Injuries Radial Forearm Flap (Fgs.238-241) Very stir eincal criteria shouldbe applied to deter- mine i this procedure is inaicated the defect creates atthe donot site i a significant cosmetic impairment, land treduces arterial blood supply tothe hana Alterna tively this sciocutaneodsforerm lap can aleo be used a5 a free Map with mietorasculat anastomoses or 38 3 purely fascial ap covered witha split thickness skin [rN A portion ofthe radius bone may a0 be included Inthe Map. ‘The radial artery maybe preserved with smaller defects In the palm. The distal ofthe fascia foeatm, which Is Supplied by’ minor perforating branches of the radial atey, canbe rotated int the defect on a pee. 5.238 Donrsite ad possi acon ora peed a forearm flap to cover a defect on the desu ofthe hand 9.239. Sehematcdagram ofthe atrial blood spp to the forearm and hand ithe preenes of well developed ep sil pa es the mast fg cm 62 Indication: Large skin and sot-tisue defects over the dorsum of the hand and reconstruction of the thumb, ‘Surgical technique Fig 24 Note: The medial and lateral antebrachlal cutaneous nerves and the superficial branch of the radial nerve ‘st be preserved Postoperative treatment: The forearm should be sus pended and vascular supply checked regula. Anasto- ‘mosis ofan additional vein may be indicated if venous 5.2.40 far anatomic vrlanf atrial bleed upp) tothe had without communication beter theses supped by the ral an nar stees ‘The ral oar lpn eable with hi anata A preoperatie hls indeed Te eam smn {Sinptsses headlong ara thn sesso oe tery and hentia determine tere sped yee fi 21a ada res fp 1 Thelresm laps desectes to epos thee ary adits ‘Mca ve thew eed fh ac tet ‘Sat suppes the stn above » led Axial Pattern Skin Flaps The frum fap tmobile ons vase pode (al te and act i) and pled the cet on he do {Somethenand. The dro ef bod theoghthe fap {evosed which snow supple by be Uno sen the pa Schema agam ofthe advanced il fap Th aon inde {Ste thera recon of atl Bad om, 1 alate ada ene 64 The Alpi placed nthe defect The ral ater ie econ Sted ug Ieposed secton of the gle Saphenous ‘in janet the displaced al aey wh am endo ie {ssamani The proce ron yn. he die tan venous dranage severe deo sas tie inthe lps sing the ft days postopera. Same ‘ses may rete ntrposing vent pre eae “The forearm psn place in the defect. The defected ‘he dna see covered witha spices sn gat Microsurgical Free Flaps Lateral Upper Arm Flap (Figs. 2242-246) We prefer the fee fsciocataneous upper arm fap for covering lage delecs on the hand. Creating the flap ‘doesnot require changing the patient’ position during ‘the procedure Extending the donot sient he forse creates avery thin Map with 3 long vascular pedicle Indication: age skin and softtssue defects in the hnand sn reconstruction ofthe thumb, Surgical technique Fy, 246, Postoperative treatment: Heparinization, antbitcs, hourly evaluation of bid supoly tothe ap for three dys, stabllzing hand bandage; hand should be sus- pended 9.248. Anatomy othe dnor ste forthe upper ar fap » tee § on 2 Rides stoysntn 2 Secunda 65 2 Skin and Soft-Tissue Injuries 9.248. Schamtidagram ofthe puson of the alo latefl artery ative oer hueral nest 9 {um ral neve, and anstomode th the roel rece Sept ay 1 earer Bch oe Una earn tery 66 g.248_ posing he trl Huma etermusealar septum, the radial alt amy with Re ace veg, te he poster anebacil xtaneour nerve ote he ds presi tothe i ree 2 Beever emda gs Microsurgical Free Flaps . \ > i, 2408-€ Lateral upper arm fap b Microzupeal anatomist ate pvonned to comet the Pincltesihenesintensebsseptnsdisecegtom le: "tel upp’ apt te ate ain anda dace ven ‘Giee pein Te doetonloes the ada colmteral fr tbe stare sulfa endsesastonest othe Seat sdacrveny athe pater saben and ea ornd frre ve A go Dos spy {immous seve Tevareuarpeacieo he scoctnenuap sures god pracy asimation ofthe Hp wea ection. iStamsced ter the aero he deep breil sry to Sensory svpy tothe ap nb esabsed ywching the (ete he ep. Postne rtachal tens ere 2 Tend a te nar pts bes 4 fede maemo beeen eo 2 elite 4 ud coated ney nd 67 1 The shape ofthe fap ens ensasee coverage of the ‘er pede 68 2 Skin and Soft-Tissue Injuries Injuries and Secondary Changes of the Fingernail Preliminary Remarks ‘often too ite attention s given to injures ote finger rail or the mallee Good surgical rsuls require precise Feconstrction af all structures. Anatomy (Fgs.247 and 248), igh 2473 and ital ong fe 2 Gapniar nymers an eas seins 1 Sagal seton crn Sct nd Loe) fig 2480-c_ Arterial sap ofthe dtl plane acording& Vol spect te crit and Lana) € Lateral apet 2 Dol eget 69 2 Skin and Soft issue Injuries Treatment of injuries to the Fingernail and Nail Bed slated injures tothe nail hed can be treated using 3 ‘erve block (Oberst and focal exsangeinaton Perish. {ng te issection with the ad of loupe magnifies recommended, ‘Suture materia: Fine absorbable monofilament suture ‘om atraumatic neales Should be used Figs 249 and b_Subungual hematoma 2 by ecmpee by pratima wth 3 se Drang he heats 70 ‘Treatment of a Subungual Hematoma (Fig.2.49) Primary treatment: Fig. 2.49, ‘Treatment of Cush Injuries tothe Nail Bed (Figs 250-252) ‘Surgical technique: us. 281 and 252. Note: Any primary defect ofthe nail bed should be re- constructed witha nai-bed grat eee riz 2 54). 250, rus ry tothe nat bet ly ta the cit phar par ou of eral arsaped ‘Seen the a bed ans tare edit pln 2 | .251Recantacton ofthe sl ed ‘Absorb fine ste ater on atacnot needs shod to ‘df eng para the toa, esha bees Danced to poet te atte na be Injuries and Secondary Changes of the Fingernail Figs 2522 and bing theatre stl phalanx with 3 pir ondspoting the nal be Eh taston a sping ih he pte’ com i 1 fan faaton an pt wth 2 este late ‘Treatment of Secondary Changes in the Fingernail and Nail Bed ‘Treatment ofa Split Fingemal (Figs.253 and 2.54) Cause of split fingernail Scaring nthe germinatve and sterile mati Surgical technique: Fig 254 Noe: Using his fee matrix grat often yields unsats- factory resus. v 5.25% oumetie impioment by = postoperative mall de- fg. 254are_ Reconstruction ofthe nl bed formity at ijry of heal bed She mts enacted ste damaged na Bd eploed 7 2. Skin and Soft. sue Injuries 1 The sana parton ofthe malted is eaced fhe geist Where rma sre ot pou sae artiste ‘navn shes the mateo rom eo in the eet ung fine suture mater ena Saumatie nde, Nallted Graft Indication: Damage or treumaticlssaf te nalbed and splifingernal, ‘Surgical technique: Figs 2.84 and 2.5, Postoperative treatment: immobilization in a Finger splin for two to teee meets, Flos. 2554 and b Nite gate 2 The nals exacted em the ge toe. Oth donr sess lee the ure gee or anaes spurte fae tat 1 th portion femal mato te deste Se eed fromthe donor ste tha sepel ns ngetal exc The pacton of ml enoved the pared to tc he ma a 7 Injuries and Secondary Changes of the Fingernail ‘Treatment of Onychogryposs (Figs 256 and 257) Causes of onychogryposis: Traumatic partial amputs- tion of che dsl phat with injury to te nal bed Surgical technique: Reconstruction and reduction of the nail Bes, A one raf Is sed to reconstruct the ‘nisin distal phan, after which the sft issue ofthe Fingertip is reconstructed (Fg. 257) Postoperative management: The reconstructed distal phalanx shouldbe immobilized in a volar finger splint for two weeks, after which physical therapy 8 incicated to corect ne slight flexion deformity, 9.256, stra onpeheorypoc follwing parti amputs- ‘on ofthe 3st phialane s.2872-9 Recostnuton ofthe nil bein onychoaypo 3° The nai exacted the pala cava of the bed ‘Came by catelilyspsatng te na bea fe he ing tse 1b thesng bony sup recanted th a cortcocan (ce grat tan om the a es 3 ois ose) B 74 2 Skin and Soft-Tissue Injuries ‘Af cresig the sina curva of he al be ae dering the bone galt thelr vattasve a be gare Died to asthe det Ts proces 9 wel aca Beaters bore got. erst ao ge Rp ora pay ype « 4 . 1 The gf is inetd int the pons! stip ofthe da ils ne wth | 2 it pan roi) 8 (9 Thewounds dom wth tention snes 3 Microsurgery 75 3. Microsurgery sy General ‘With the ad of an operating microscope ine tractures «canbe highly magifed. The pimary indestions frie rosurgery of the hand include nerve grafting or epsir apd anastomosé of tiny vascular structures Microsurgery of the Peripheral Nerves Preliminary Remarks ‘Clase injuries othe peripheral nerves (motor, sensory, ‘or both) such asa contusion, hyperextension, teat, of avulsion ae frequently terest of Sune tauma andor {tacion injuries. Immediate repair isnot indeated in ‘hese cases. Te damage tothe nerve must be sessed In regular follow-up examinations and by evectroneuro- _tapiy. The ime interval between injury si neve ev sion may no exsed sic months, tense the increas Jing muscle atrophy canbe expeciedto produce lvevers- ible damage inthe target area, especialy to the motor endplates, In open injuries, the nerve can be completely or in «completly severed, Primary reconstruction ofthese in- Juries is only inceated when the extent of he compces- Sion can be really identified Nerve stumps are de- Drided and repaired with epineural or perineral sutures 5035 to minimize cerson onthe nerve Nerve alse indicated where iarger defects must be bridge. Anatomy of the Peripheral Nerves ‘A we variety of asciular stractures are discemible in the coss section ofa peripheral nerve Neves may have 4 single fascicle or 2 few fascicles, They may De ut ‘rouped polyfaccular grouped polyasleular src- ‘ues (Figs 3.1 and 32) Fg.2Sehemate eat amay diagram ‘tenes Har terete oc En oe 76 9.21 Cros Scion of a grouped muliscle pripheral 4 Bien Types of Nerve Injuries 1. Neuraprasa(swoling ofthe nerve without Walk degeneration) Nete rapidly regenerates. 2. Axonotmesi (axon i interrupted with endone and sheath structures intact) Proximal: nerve wil re- ‘enerate. Distal: Wallerian degeneration and re- {Eeneration may be expected, 3. Interruption of the axon and endoneurium with sheath Succes inact: regeneration simpatrd. 4 Interruption of the axon, endoneurium, and sheath structues with endoneural scarring where the ¢n- tinutgy'of the nerve is preserve regeneration i severely impaired 5, Neurotmesis (complete nerve division 6, Neuroma where the continuity af the nerve is pre- served (combined form). Microsurgery of the Peripheral Nerves Complete Nerve Division (Neurotmesis) Htopathologe changes in the Nerve Stumps Proximal stung Retrograde degeneration axonal ud Sings aegee'ator neuroma whee the conta ofthe eve cote ese Disa stump: Wala degeneration sinegratin of the aon) Camtegiaien a he myelin, atopages {Breskown) protean of contectoe tise. cele {Schwan eke and schwannoral bse aoptes swe generation do nt ota [End organs: Motor endsates, sensory receptors ‘Surgical Techniques rincura Sutre Indication: cleanly severed single fasccleor nerve with ew fascicles ‘Suture rechnique: Fig. 53. Figs 33nd b pico suture ‘he tev stumos af owe Io apoostn wth lose te "bed stures trough eprom Fie gps and asc Iarsvetresin the epee. 2 epmcten 77 3. Microsurgery Pernerl Sure Indication: Grouped multifsice nerve ‘Suture technique: Fig. 54, gn 3.42-¢_ Pearl satu 2 tuatsie nowe wth grouped fs, the einer ‘emo and tenes goups ae onan. Dan ‘nf pened unde te peting rcsete, ’ 4 Bande me ascites are rot nto appcton ni hed wth twotesonee sues (0 monotaet saute ‘Matt. Te elnariom pay ested Irv Graft “The primary onor nerve is the sural nerve: other possble donor sites inelbde the posterior interosseous, Feeialantebrachial cutaneous, and lateral antebrachial Fig. 3Seandb Exposing the fare roups ina nave defect larger thn 4m Foe 36a.andb Nerve galt 2° ceprte nee al laced to recoset ech fale (run nfcsthe ae ens re tee Microsurgery of the Peripheral Nerves Indication: Nerve defects arger than 4 em where direct, tension-fre repats n longerpossiole (35), Suture technique: Fi 36 1 the cl glug af recartrcted wth ere gas paced se tetrad bee 79 3 Microsurgery xampleo Herve Craft sing the Suro Nerve ‘The sural nerve is the most Frequent donor site. The advanages of using this nerve Inclue Is length and ‘minimal donor site morbidity. A circumscribed lss of Sensation will result onthe lateral edge of the Too, ‘which is genealy well tolerated ‘Anatomy’ Figs 37 and 3.8, ‘Approach: Fis.38, ‘Surgical technique: Fig 3.1, Postoperative ment: Immobilization in 2 plaster eae fort to tree woeks. This is followed by {hetapy and gehabtation. Regeneration i evaluated by ‘Checking for Tine sgn (Sensation of nging with per- tuston over the sie of the nerve). Neurophysiolegle Sodies are indicated a thiee-month intervals. Fig.27 Anatomie diagram of he course of thes neve Fg. Anatomie dorm ofthe origin fhe mada root of thesuranerve andthe media urs ctaneos nerve fromthe ‘bla neve ne pote Fossa 80 Fig9_ Posie course ofthe sin eon or harvesting the fips. 3.108-€ Harvesting te sural eve ‘a nerve Thc turd nae seas sling we lcs, ad 3 ‘pacal rene sper 6 todiced The so nin Ie iEede posts the mallcka ts inprow xpse 3 Sestphee ein 81 3. Microsurgery witht uation appt the eal nee, ther sp- The tea ranch the sul nie ddd A oe rt pes aeance ang te ete cal he esiance of sate mayb obtained by advance De hve spp Sneath he Ene ok the nea med athe pon ena hetateal_ Tal othe ppl nc kina lve sat 0 the brant Wen 2 soe ffs eae the pasa! orate malt fhe rae th ml a fede hes neve pce nt the dep plan to min. tatons eer a ola nee er the Jeseel gt nth ius neseara pan, TS been atid sn neon rade the te aloes ‘he eve The nee tended and emo 1 sate ee ee ine oc 82 Microvascular Surgery Preliminary Remarks ‘raumatially severed or crushed peripheral vascular structures a: small 05 aim a dlametr can be recon- ‘raced by microsurgery. A dvect end-to-end anasto- tosis may be made, rte se may be cebrided andthe defect bridged with asutably sized vein raft. Micosur eal end-to-end serial anastomoses are usally used to maintain the peripheral pattern of blood ow when revascularizing fee las. elnsare usually anastomosed fd to end, Veins have extremely thin vascular wal ‘This reqs repeatedly Mashing te site witha dlted heparin solution ocistend the vascular lumen and faci Hate performing the anastomosis Miccosuegcal anastomoses ae performed using atau ‘matic monofilament sure material (9-0, 10-0, 001-0) th intenruped sucues, ‘The various techniques of arterial anastomosis with {heir posible compilations are shawn in Figures 336- 3a, ‘Applications Replantation (Figs. 3.1-3.14) Successful replantation requires a well-trained enero- Surpcl team and 9 well-equipped specialize hospital finger thats not seltable for eplantaton ay be used 8 source of tissue graft foe 3 finger tobe preserved [Absolute indications: Amputations through oF prox- thal to the metacarpus, amputations ofthe thumb, at puutations in eilren a mulipe-cgi amputations. Relative indication slated long Finge: ‘The patient’ general condition, age, sx, and oeupa- tion te ype of ilar he restoration of fuction that may Be expected: and the patent atte ae impor tant conscerations in evaluating wether replantation ie indicated, ‘Transportation: The amputated part should be kept on cen sale plastic bag a a temperature of °C Note: The ischemia time (the tne from amputation to revasculaization) fora paft amputated throug or pro- imal othe meacresCncung muscaaie) may ot exceed se hours Postoperative management: A sterile hand bandage shoule. be applied. and the atm shouldbe elevated ‘aseular supply to te replanted finger shout be moni= 1g. Compete amputation of the Indee finger with ‘Sultaneos es ofthe mie fgee 1 sina phat 3 tlie agioun tint ‘ored every hour fr throedas, after which the monitor= Ing intervats may be extended, The vse of sysemlc he prinization and high-molecly-weight dextran should Beconsidered inthe presence of extensive crush wauma “Aiba are indicate. Postoperative treatment: Careful active and passive ‘mation exerts should egin on postoperative day 10 Complications: Thromlosis in the arial andlor ‘venous microvascular systems can secu, in which case prompt revlsion surgery is indicated. Other complica tions include skin nd sfe-ussue necrosis and infection. 83 3 Microsurgery a3: Disection of important structures on the vol peat fnger tga amped gh ore Sot purser bundles ae maha with 6-0 ronan 1 Gace ute en heh ey) 2 Donate 3 etn eget 5 Roe yt cn 5 Prin pine 9 Pamir it ef Srna py 2) 1320, cit gn sco ed cree me et ae Poa dit emt Reser, {Seas See ies Ho Microvascular Surgery fps tag. Reptaon ee beta eaten fhe posal pane ached sing ‘Sd hepsi. ‘anim pee wit nb ea 2 nate ue ton age 85 3. Microsurgery The dora poner recone with arabia & Mirourgkalanatamast te tw rope lar alr Sates (ed ares) {rari eomat ring apron Lena od the ds the oroper lar dg ness re ght to oppo {on Langer entire tothe neroasaas bn ae tie sate he var bn tah damage p= tion ses fe recomyeted wang ied em gs avested omit esos of the deta fen, Tess ‘stecorstuted wah an erased gra rom hes eve 1 alan pat ftw sent ley 2 oer po dane 4 oer par hey 86 of the props dail dal ens (too rcontveted aries resure See venous net reece nepal Bo epee 4 Tesi sts ncn nde won eh ‘ot tenon 3p ies Sen gal 37 3. Microsurgery © The dra ponewoss recor with norsk Sutures fred toes) I Maopelntamstott veep amr dtl ing apron Cap ‘le poper pana de esse bowen aa tn, Lger cash ee athe nears tune ‘ure shores ever de othe undanaecs po on Vesa fe castle sing ies veh ea ‘esteem heen se he dara. The ee ‘secostrced wth an epee gat torte sel nee 3 tem erent sea ty) pe pn gta 5 pera on 36 icrovascular Surgery mrs! anstnas of the prope dal digital ens (two ocoatcted mrss rege dee venous srt ese speromed. Where css errs ven aa 4 orl duntrne 9 Ine un sro nto capostion ante wounded vn % Meme stures FFs oo pole ce th en tenn sis sre ed. 37 3. Microsurgery Vascular Bundle Grafts (Figs.3:15-220) Indication: Insulficient vascular supply 10 a fully Surgical principle: Free microvascular transplant of 2 Functional finger with atrophy and sensation ofcoldnest vascular bundle (as described by Huss and eo-norkers) Tollowing reptantaion or severe crush injury (Figs. 3.16 with simultaneous exploration and possibe ceconstrc- and 316, Won ofthe proper digital nerves, Sear a Siam F238 Sevier ee eee ones mgr Dp Donor site ofthe Thoracodorsal Artery and Veln: "ished vascular buna (Fg, 2.20), ae an lal 4 4i ff Mya gy 9.245 Rostaumat atrophic index finger with sly im F316 Injury to the index Hager rl gl artery and paved vasa sappy roper palmar dit artery demonstrated y snleyoahy. aber relations very poor 1 connor pana dil es 2 bemoan 5 oper pa gait ep es 4 eternal ney np) 5 Spinach 88 | 1ig.217_Anatomle diagram ofthe donor se ofthe thors esl artery and vel She vanedar uel died penal 2 the el of the ‘ops The ances fo the nsdn! ae Hed rout banc s tated a moe cin he “he ttl length ofthe are cle mast Be 3p. 2 fen oe 1 Tet ea he tore arr wih wo en Ws * comm ay Fig. 3.18. skn isos inthe hand for miosur ans- Pntation of the vascular bundle of te horcadorl artery raven 89 3. Microsurgery Microvascular Surgery Free Toe Transfer (#gs. 321-332) Congenital and traumatic deformities of the hand occur Ina widevarey offorms. tee te wansfer is indicatee after all other recnstrctve procedures have proven “unsuitable for achieving the requted grasping function, Indication: Apasizof the fingers with severe hypoplasia oF loss of the thumb and one or more fong fingers (Fig 3.21), loss of al long fingers with an intact thumb. ‘nd loss al fingers necessitating multiple te tans- fen. ‘Time of operation: Surgery for congenital hand de- formes shold be performed between the ages of six fnd tvehe mont Following crush injuries that render the amputated digs unsultable for replantation, an immediate toe transfer may be performed vee indicate, Later te- onstruction algo possible Preoperative diagnostic studies: Doppler ultesound, Brterogram ofthe fot (lateral aspect) and oe hand if Saeclar structures are uneear [Anatomy ofthe donor site: Figs. 324 and 325. Approach: In the foot Figs. 3.22 and 323, n the hand Fgs3d £4,321. complete amputation of the thumb an indextinger Bin ea ofthe prouna phan ‘a mp were opting {rsh oro) ae near ofthe toe sete ‘Surgical technique Inthe foot Figs.3.27, 328, and 330; Inthe hand Figs: 331 an 2.32. Nove: sttaumaticdssectonis indicated. Ischemia ime Soule be as short as possible. The patients body {ermperatur and ambient temperature shoud be mon {ored The microvascular system of the foe is very sen tive; loca inteaoperative sminsration of papaverine indicated if spasticity ocars. Postoperative management: Cushioned stabilized hand bandage with te atm sigh elevated. A warming fotton bandage. shoule be applied snd ambient ‘emperature sould be high Vascular supply should be "reitored every hour for tree days the patient should be cortined Yo bed for one week Postoperative medication: Sjemic heparinization fand high-moleculacsweght destan should. be con ‘dened. Anibioacs ae indicated Postoperative treatmert: Careful active and passive notion exercises should begin two weeks postape tively. Intensive physical therapy” and reabitaion ‘Should follow ater four weeks. (Or 4,222. sla incon for emoing the second toe on the esa aspect of te fot 1 3. Microsurgery foe (sper pened rae) omyot te deep aye ofthe dorsum he ook ofthe sca toe 92 Microvascular Surgery figs $262 shemati dagram of the most important vat- ms inthe couse of the fst dorsal metatarsal artery 3" pe dering tery restr to frm te fet dol lsat teeseoi, ed te cep las tery. The acuar Seppo soonest dsl meta artery = {he os fequnt vin: The der mettre arty urs watn the dol ntoueo «These dosimetry pet devoped or bent. ‘he dep olen str s wel Censope and eral Sp 19.327 Dosadtaction ofthe donor seo the second toe tr 13 wale eh ae 93 3. Microsurgery <— {938 Par con ote dvr se fhe Second ys. 2298 Oa osttoy oe ond mett- {o ated posible hyperentersion in the mettao ‘eaanaa ose te alr g.330- Toe removed for taser 1 Tonal ees gtr ns 940 licrovascular Surgery j » ign 321 4°e Teaaplantion ofthe second te to the amp tate tmp of the st mec ncn ton schwe ng 38 trois were sate ein (putt cp ats ln ove fe eon ein ‘sgt meraanopszgea pn meses) bb Thetendona ead drainer of te second toe toned aor ples Tetra sel inero ‘Sota ihe cond te sd the fae pole Seis are cone ‘ted othe seco pac bea esr plies es, She tenon ofthe lg evar othe te ued with De ‘Rin ofthe tendon af he fone flexor ofthe han The Prop trl ere ae thr orale mi opaston ithe pope palmar dig Rane the on jpeg tom Bee ete 1H Beiaeteeee ci etiam «Peart for ning he xn edo andor mrs (eslvacs roto ae nee ng 4 hace mer ey ANG ope rents anton 3. Microsurgery tener often exer theo ed wn estar crceteie thet Arica ro he dela ges ary ery he dor mata weno ede of eur anv ace fe fda ‘endtoend antares The medal calc Tine ere ted wo te sapere the ad «Softinue dour show 3 go eto nd. The rans feed woe aby oppo tothe ip ofthe mile nae: Microvascular Surgery Figs, 332aand Managementot the donor ste aftertranser Sk cra wth goed eposton of the get toe an thi ‘tthe second toe tee very prtinal resection ofthe second metatactl bane pe formed to som spoon sf tw fet ng the ms ‘eohsnged i Sabatan af he tanner eta ‘fehmay be ached yautaring te dep trasvse meat Saliganens Dee nese metal ianen 97 3. Microsurgery Pollicization (Figs.2.33-335) Pollcication refers to replacing the missing thumb by transposing along finger or par af one (especialy the index finger) on its neurovasule pedicle ‘The missing thumb can be congenital plasi) or the re sult of trauma. Where the index finger is intact, pic ation isa method that inated especially to correct ® congenital deformity (Buel-Grameto} Where the MCP oF CMC joint i intact a microvascular raft obtained ftom part ofthe distal phalane of the reat te can be used as 2 replacement forthe thamd (Mocrso’s wrap-around. method) Coricocancllout graft harvested fom the la eest must sso be inter= Dosed, Reconstruction af the joint il noe be possbie, Indications: Aplasa ofthe thumb, hypoplasia of the thumb (grade I, partial aplasia ofthe fis metacarpal and shortening af the proximal and distal phalanges 3nd Severely impaired function; grade Iv lating thumb grade ¥, four-finger and), and complete oss of the thumb, ‘Approach: Glau’ incision (Fig. 3.34) is used. Buck- Gramclo's mexified version Invoves 3 raia-palna, Shallow 5-haped incision. ‘Surgical technique: This is shown fr grade I congeni- tal hypoplasia of the hum (Fig 338)° Postoperative management: The arm shouldbe placed ina long arm thumb spea for tvee weeks, after which Specialize! active ad passive motion exercises and te- hubiliation should begin. A night-time splint should be sed for an additional three weeks . » Figs 3342-€ blots cons fr plication 98 Fig.333_typoplasn ofthe that aioe % | ! t gh. 2350. Paeation 1 tutaneos pe se raved the dos poner, dsl Sgt {olen he pervor tenn ner a xs. Hy pine thumbe lack ay tendon sects, Teo exter Fanon th dex ger oe ly ded prone tothe escapophsimgea ew tere te an the Joel Sponeoose thant ote ones nesses shor rede corepond tothe recon ofthe second eta Ste sutres tgeter Tbe teaon he tersoe aig inetnder ngs als shortened od hed tothe ba he Ferme rol pine gs 335d and 335, coral Doral ea ene Sorte 1 merece conecon 1 crewing the ceo fap The vss ofthe typo ‘hombre cowie etd. and ce Me enero ob haan painorogin neve o he mabe gers pa 3 ‘ong! poets ebtan te necesey nerve ath forthe parsed poston Supe pa 2 mn pa een 3 Sule fee ee ¢ Rrra 2 Caps pl itl ate 3. Microsurgery «fost ote pels thamb. Te terns etn of the dal and palmar nesses mus ot ud ‘ret eiseted. Soper! mebizason of the second taal one peared pir to prt eseton (oe adie preneedabd the ea ip of the doa apne 100 ‘A puta vesectie ofthe sand acral spertonmed Spang the rtaczpoptngel amt ta il te ss ‘helunckonafthe poets nthe posed le. gee dep wertee metal gare ded. the Poor tears are scene he eure th Stent mcr iene 1 Tenn the eter dtr Microvascular Surgery (eThe hes ofthe seer metacarpal sad wth aonb {orl stars in oni yperenteson 70™A0) 0 {od ypeentnson deformity Inte reveted. Gorton in wht ma gia) the pat sue kth heads ow eae proxy. 1 nn of he feeding nd inn 2} sceeriiensi bh The ebondindetingeris shanti the nen postion um sista erate O16" Per sco: 40" aa bon 20" 1 tered of tat metaphase aed oe cpl fagon the tenors ae cone ‘eta esl inten jad ie alte sp of ‘he dori poneuross (cer oc be) ‘het paar intosen oad te ue ate stot tie cal poner (acuta). “Teena ne ened to he cent ip ofthe dasa “ponerse estanor pees og.) Theesonar tone! thetndex geispne the base ofthe seen pra lane deo alles on 5 fens od pone 5 Retna te emer oe & Meacaptmedo 101 3. Microsurgery 102 Surgical Techniques ‘Arterial Ent nstomose or Siler Sie Wesel: Fig 336 b GA gh. 2364-8 Arterial endo anastomeri ofr ie Theta ofthe stay sus ar tue expt the poor a wae ee boc wat che then ced wih erupted th escurstmps ae debiled ange adeno renaweé, ts {mented tue ae pce 20 spat nthe bak all fe opel The tle ae let long toot asta SRE. amoung tere ster lt expose the bac alt otros 12.3, nd 4 ar gested, ad the anata. Alocepsis carl abanced wo the vcr anen fp ‘alte wh erp ses ‘dete nee «Carpeted aston 16 Grderefnte pcoet 103 3. Microsurgery ArteiolEnd-ondAnostomess fr isi Sice Vessels ‘Where there are slight differences in the sizeof the ‘mina, one can attempt to date the end of the smaller vessel to match the large" one, Larger cifferences lumen size can be overcome By obliquely incising the end ofthe smaller vascular samp (Fig 3.37) 23 Te sale vascular tmp obgualy ced to match the leper one 1 the anstrasis s completed with tart ste, The eco cater fst spre 104 Microvascular Surgery ‘Arter End to Se Anastomosis in ltl Artore: fie 338 ys 338d Arterial entre natomons bb Asay nur laced tert scents ha bee ered Tr te lared ans tomo ite, stn ofthe poopie se ace nthe ‘Sit wath ase sept le beste vee, ths Sn cay tel arate oy te etroped tie re fst laced on he pooty acd Competed anasto ‘be bck wala the ocr anen Ts poet Pour ofthe patos forth ret fh precede 105 3. Microsurgery ‘Arter Ende Anasomoss in Arteries with trios schrte Changes Fg. 339 Complications: Thrombosis at the anastomosis site Therapy: Fg 3.40. ig.338 Atrial end-tose anastomosis arteries wth (rerindote canges [parton othe steal wal ieee ith eos to eat an pein forte anasto whteseconverel Me snatome SBleaated azar tothe posse shown figs 2.388 Figs 3.40a-d_ Management of homboss a he anastomeds 2 he ara fw terpteeywtclcamp lcd net sie of the atom ste, en the aston 3 ‘pore 106 Microvascular Surgery {With he var clags tin place the te i used ih hpi ss (ied 16) vere eve fe é 4 4 Th atte ow is temparanity eapened by eesng be oval dao Th san she the kman a pers be {Eigen ey ooo! arteal flow. The parily opens nate then ove 107 3. Microsurgery re Interposed ei rots Whete the extent ofthe defect ceners direct arterial anastomosis unfeasible, a vein graft must be interposed to restore vascular supply. Te fetr sie ofthe forearm 'Sespecilly well suited as adonor site Prior tothe enas. Lorna, the graft shoul e Mashed witha jet of heparin ‘soltion (thinned 1:40). Vasculrlamps are tien paced {0 occlude the arterial blood Now while creating the anastomosis, aa 341 tterposed vin raft Ineo. en ated with the vn aes ged in (ecto! Ba ow ‘Once the proximal anastomesis is complete, the ateial ‘oe fo s bry reopened andthe vein gat aligned in the proper psitin. Another vascular clamp is then placed to fellate creating the distal anastomosis (Fen), Complications can occur trom improper alignment of the venous valves ifthe interposed grafts placed inthe ‘wrong direction Fg 342). rom placing the interposed woingrattsoas allow excessive mobility (Fig 543) oF tom twisting ofthe interposee vein sat (Fig 3.48) ed 9.342 complations resulting from improper ve align: ent ofthe interposed in grt The veto vahes ht eHow lad though he tay VO Microvascular Surgery Figg 2.422 an Complications resulting rom pling the o- terpored ve tft soot allo excess mebity ssiey cb epad vein ge 8 Wen ater od Tow 5 reopened the need sa ‘pressure dines ad nga the ierponed vein al “Tit cance he gf kan prayer ty erp the How flog eh the ae Fig 348 completions eesuting rom twisting ofthe inte posed vlog Fetal orton erpatment of Bood fw 109 4 Compression Neuropathies mM 4 Compression Neuropathies General ‘Compression neuropathies can be the result of trauma br continuous compression along the course of peri fal nerves de i variety of causes including fens hovitis, bematoma, rumors, nd muscular ad vascular anomalies. The dajnosis is made on the basis of cca ‘symptoms, supported by electromyography (EMG) and evaluation of nerve conduction velocity. Occasionally, Uluasound, Cr and MR suds are also required Compression Neuropathy of the Preliminary Remarks Five sites along the median nerve are prone to compres- son neuropathies 12 ‘Therapy consists of decompression ofthe affected pe ripheral nerve and eplneuroyss where indieate, This chapter shows te anatomic courses, areas of motor and sensory supply, aid most common entrapment ses Ofte median, ena and vada nerves, Median Nerve Anatomy (Fes.42-46) Function (Fig 47, see also Fig 418) linical Picture ‘© Los offevion nthe thu. index finger, and mide finger due to paayss of the following musces: Meir poles longus (anterior inerosseous nerve), fletor digitorum superficial of the fingers, exor {igitonum prfundss of the index and mile fingers {anterior iteossesus nerve}, superfcta head ofthe Nexor polis brevis abactor poli revs and op- ponens pals. + Tena opty wm weakened opposition sn a- ig Posstle ntopmentsiter lng the course fhe me ‘Ban neve 1 ersten { Societe ESSE RI EE yn o Rg cuegreeeemrter ee © Cap inl romero mh al ae Compression Neuropathy of the Median Nerve 113 4 Compression Neuropathies Fo. Diagram of the muscle he hon supe by the megan nese gh 50-¢ Most frequent anatomic variant the rain of i the moter bane ofthe median nerve 1 nen fe tng gs | 14 ‘Compression Neuropathy of the Median Nerve . ’ ign 46aand_Catanousinnertiony the medin nerve Dosim 1 per i ales 1 foe acne gta etl ene 3 ara mean ene gy 47aand b cette fit be ipatos offuntn ad api tha wih igh Sharma entian not the madan new 15 4 Compression Neuropathies Compression of the Median Nerve at the Ligament of Struthers (4 in Fig 4.1) Approach: Fig. 4.8. ‘Anatomy and course: Figs. 49-411. ‘Surgical technique: The median nerve is decompressed by releasing the gament of Struthers ie. an Fig.68 Shininesion teapot median nerve atthe sow \ 5 Neda Fig.29_ The medan nerve ic xpotd inthe repon of the me- mera ttermuscuar septa to eal pa of etty int the pronstor tres, 16 Compression Neuropathy of the Median Nerve Fig.410. Powe entrapment ofthe madan nerve where H.411_ High exign of the haar head of the pronstor pases trough the medial hima Itermurculr septum interes inthe presen of 2 upraconl proces fhepeeumce of 2 supraondyae process (igament of Struthers in 9.4) 1 apart oe 4 spon ees 3 Medan 2 pine Svmer neon Be apr ee the tons athe mad ona oper) 17 4 Compression Neuropathies Compression of the Median Nerve at tthe Bicipital Aponeurosis (0 in 41) Approach: Fig 48. Anatomy and course: Fig. 4.12. ‘Surgical technique: The median nevve f decompressed by eivding the Biciptalaponeurosis (Fg. 413) Fig12 course ofthe median nerve athe level of th bp ‘alone 118 Compression Neuropathy of the Median Nerve Fig.429 the median ere xpoted ‘er dviston and reaction af the bet! sponcrons antecubital ons 1 Bean nm ne (tates 119 4 Compression Neuropathies Pronator Syndrome: Compression of the Median Nerve by the Pronator Teres Muscle (cin ig.1) Clinica symptoms: Pain on the flexor sie ofthe fore- arm, sensory diets on te radial aspect af he thumb lane is ere Fnges, total or paral loss of Nexon in the proximal interphalangeal Joint of the thumb, Palen’ sign s negative (ost lle symproms by Nox: Ing the wns). ‘Approach: Fig. 48 Anatomy and course: Fig. 4:14 Surgical technique: the median nerves decompressed by pesforming aascocomy inthe region ofthe pronator (eres. In are cases, the muscle must be dlsecte ois origin Postoperative management: The elbow s immobilized In medium flexion for one week, after which peysical ‘erapy begins ig are. Vins of he course of the median mere in the elon of he ponstor tres. "ire cores toca the hertalangUnarhess ofthe po- by Nene eauos haves the haar of the promises Mere Berea the pronstor ees Compression Neuropathy of the Median Nerve Anterior Interosseous Nerve Syndrome: ‘Compression of the Median Nerve by the Arch Forming the Origin of the Flexor Digitorum Superficialis, (DinFe.an) ‘tinct symptoms: Pain in the proximal forearm, par= {ator tora fossa function in the ex ditorum pro- Findus afte thumb and index ger, exor pollicis un and prontor quadrtus. There sno sensory less. Anatomy and couse: Fig 418 Surgial technique: Fig. 4.16. Postoperative management: The arm is immobilized forten dys na fongarm plaster cat with the wristina ‘etal postin, the foreasm pronated 45% and the low Nexed 45 Physical therapy for te elbow begins fe week postoperative, F435 Madan nerve branchor ln te deep planes atthe ‘bow 1 Tendo acho te gna ta Stone (Guicicofcomprto a he neo neve es te 121 Fig416 the tendinus arch ofthe oii ofthe fer di torum superiors nce to deconpart the medion ee ans ta) on 122 Compression Neuropatiy of the Median Nerve Carpal Tunnel Syndrome: Compression of the Median Nerve in the Carpal Tunnel (ein Fig. 41) nical symptoms: Night pain in wrist and distal fore= arm at rest, sensory dees inthe fingers supplied by the median nerve, and loss” Tine motor function (aenar atrophy). hale’ sign Is postive tet tilt symptoms by lening the wrist. Function: Fig. 4.17 lineal picture: Thenar atopy due ro pass of the superficial head of the abductor polis revi op ‘Ponens polis. and se and Second lumbrials (hardly ‘decetable in ciel examination), There i los of se sation in the region supplied by the median nerve distal (0 the carpal rane ‘Approach: Fig 4.18. ‘Surgical technique ig, 4.19, Note: The flesor retinaculum is usually not recon- structed. A Z-plasty closure ofthe retinaculum may be ‘considered for young patents in vans! cecupations. ostream of he hum and te inger 1 ypc af fncton and atopy wth compression of the esan tenet all pan ee a Alternatively he Nexor retinaculum may be divided en oscopicaly. Closure: The wound i closed in a single layer. Nonad- Sorbable maonoflasent sutire (4-0 or 5-0) 1s use, Postoperative management: The wrist i immobilized for ten days ina stalizing bandage or dorsal psster Complications: These include damage to the thenar branehof the median nerve (Fg 419), damage tothe palmar branch of the median nerve, and recent Sympions. 123 4 Compression Neuropathies Cates bee noe a cpr he mean neve carpal tne yo {a 4300-4 agree med ne capt ‘ein "hx por pores inc andthenprton of the Isarrenaculomis cde oan tat thethena ban 3 Bega Compression Neuropathy of the Median Nerve & ‘> The capul tunel is opened a the mada rare wth smatoran emo branches ose 2 sgt ao en 2 Nes tte tag apes 5 trv ran 5 Menino gor oat «© The orm hc dvd substan 2 pi or smato the enropmert te The ylar branch a the mean ane presaned. Osco Wal be pecs deat res Be eso ranch fhe mean seve 1 Rome tina iad) 2 Nr an of ma ee 4 rina bar fe mada ere its of he median nerve athe erbapret Se 125 4 Compression Neuropathies Ulnar Nerve Compression Syndromes Preliminary Remarks ‘Three sites along the ulnar nerve ae prone to compres- sion neuropathies (Fg. 420, Anatomy (rigs 421-425) Function (rs.426) 126 nical Picture {© Pronounced yyerextension in the metacsepo phalangel joints of the rng gee and lite finger. ‘Theres ossof function inthe Interosseous muscles and the third ane fourth Tumbrcals © Moverate hypesaxtension in the metacsepo- pllangeal joints of ce index finger and mide n= et, There Is los of funetion in the interosseous ‘uscles but there no les of funtion in the second 8nd curd lumbei, which are supplied by the me tian nerve «# Thering Finger and sina finger ace abducted Loss of fusetion in the interessl resis in unt deviation caused by the unchecked action ofthe extensor dig Hypereatenson in te metacarpophalangeal ont of the thumb, Theres loss of fonction in te deep ead ofthe Axor pals brevis. © Te fingers cannot be spread: thereis oss of function inthe palmar an dorsal interosse 4 The pinching vip between thumb and index finger is is loss of function in the adctor © Avopy ofthe fist interdigial space is seen. Func tion's replaced by the flexor pollicis longus supplied by the median neve) ‘» Froment' sign is sitive (pronounced flexion in the Imerphalangeal jie dug exercise} ‘slated flexion ofthe distal phalan of the smal fin- gets nt possibledue to ass ofeton ofthe fourth 8nd filth Resor digterum proueus. | | | | | | | | | Ulnar Nerve Compression Syndromes 2.820 foe epment ste ong he reo 4 nmin ete an fn aba st! were ampn in apt at Fie-621- Schematic dag ofthe course ofthe lar nerve 127 4 Compression Neuropathies 428, Sehamatc gram of the potential conection be: teen the motor rch of the ulnar eve an the eceret branch of the mc neve esrb by Cannievche 1 cape nr ee 2 ter benn o teure 3 Spent eons 5 rma ach ofthe man nee ith te dn ee ig.22. Schematic dapram of the musi of the fore Fig. 4.24. Schematic agra of Caye's anal [iivand hand spied by he uno ete 1 Marat pt oe) oper pa a es 3 Sha eove 128 Ulnar Nerve Compression Syndromes . » Figg 420 and. ataneous fneration by the atar nerve 2 far ache 5 oral bah learn . > gg. 4263 and b_ Hand in nea postion 2 Na neton B Totti function othe hand wah esion fhe ae ree (ew hr ear) 729 4 Compression Neuropathies ‘Compression of the Ulnar Nerve at the Elbow (a snd in Hg. 420) Surgical Treatment Options ‘After decompression the ulnar neve can be replaced in the tunnel. This is done when compression is due roa tumor ‘© Subcutaneous transposition ‘© Submmuscular of intramuscular transposition ‘Resection of the meal epiondye (indicated in the presence of artritechanges in the elbow) Subcutaneous Tonspestion Approach: i. 427 Surgical technique: Fig, 28. Postoperative management: The wrist is immobilized ina mide pesto for ten days ina stablizing bandege or dorsal plaster ease Motion therapy and electrother= apy beain three aceks.posineratvey. Electromyo- fraphic follow-up studies (EMG) ate abtained three ‘months postoperatively 327 km neon i cubital tunel syndrome 1 Med ane ecane 130 op 4280-4 Decompression of the war nerve i eubital tunel syndrome 2h ee xan ey vr et Ulnar Nerve Compression Syndromes 1 etl ac ofthe ails cana rene 3 he enone 4 Sonatas te nes 1 dlrs sen 1 subautneous antrorvansposton ofthe br pre, The enemas acho corel ana me ed The ‘wo muscles re thn crily nope > pert Spang nasa ep at tot ‘enon tered expe tava jut tthe hee. fae of Shuts died prsialy and he mec Me Fase spur esata 131 4 Compression Neuropathies anda Aer stetaeos apn ses ped shot tanto te can thane 2 edleiare tansy wong) 5 rae abe 4 Aer neon te 132 Ulnar Nerve Compression Syndromes Compression of the Ulnar Nerve in the approaches: Fg. 428, ‘Wrist (Guyon’s Canal) (cin i420) ‘Anatomy: Fg 430, ser ls Fi. 24 Surgical technique: Fs. 431 and 432 Postoperative managerent: The wis is immobilized forten daysin s dorsal plaster st Motion therapy and ‘ectthorapy begin the weeks postoperatively. le tomographic flowy studies (EMG) are obuained fhrce months postoperatively. Quy Ae \ { 7 . , seat Sn meee re apse syst es Seton pine pte ae 4 Ral bury hea ec, ar margin the pur 5 oct buy a min oa ee 4 Compression Neuropathi 2 The oor pene exposed Gaye's aa Fc fu oan Tenn of i coy 1 ert ett eae 18 eaten the sci te rca died 1 expose te enrapnart ‘Se tthe vel the prone! Dey, 1 pel hans aoe 3 recta fig,432 Decomprasion ofthe ae neve in Gayo anal The ls ere eased reveals gangn eompening the es) ban thar ere the the eat boy 2 Gedion 134 Radial Nerve Compression Syndromes Preliminary Remarks Four sites along the cadial nerve are prone to compres- slon neuropathies (Fig 433). Anatomy (figs.4.34-4.36) Function (ris.237) Clinical Picture ‘Inability to extend te writ in radial deviation (loss ‘of function in the extensor capi lars, extensor ‘acpi radials longus, and. extensor carpi radials brews ‘+ Inabil o extend the finger (lass of funtion in the ‘extensor digtorum and the extensor indi), ‘+ Inability to extend or abduct the tum (loss of fanc- tion inthe extensor polls longs, extensor polis brews, and abductor pollicis longus), fj28 foe etopeen ite sog the cue fe etna tke Rivera naneton ‘SS mee mre aes 135 4 Compression Neuropathies 5g.438 Schomti agra ofthe course of he real neve toes ee ; Sten rate Zeros Bee 36 Fig,435_ Motor inmrvation by heal nerve 1 gett oe Sr Serene iS ieee PEE natmtmmtprm tect Bepahmaeteatamerer tse 3 oer i eect i emcee i eaaie Seems R Nerve Compression Syndromes Fip.436 cutaneous inervatin by the eda narve Spl anh the al ene ed ns Fig. 427aandb union ofthehandin extesanofhe fib yp yhoo nthe hand wth a praia igh) eon of oes ‘eral rvs fp vit deter amore dtl lesen 3 Norms function the impaent othe con ote tenon ay ding on hee ol ws B37 4 Compression Neuropathies Compression of the Radial Nerve at its Point of Entry into the Lateral Humeral Intermuscular Septum (Ais Fe.433) Approaches: ig. 438. Surgical technique: Fi. 438. 438 Decompresion of the rail neeve a 8 paint of ‘enty It the tral humeral terms sept and he SRpintor ome! (in fig #53 se Bing 83) Tera new expe ad th el etl area 1 Set ht ene 3 cha teu (sae) 138 Eero, 3 EEE cIS Eat Thy ateanen * eitemins Radial Nerve Compression Syndromes Posterior Interosseous Nerve ‘Syndrome: Compression of the Deep Branch of the Radial Nerve at its Point of Entry into or Exit from the Supina- tor Tunnel (01 and 62 in Fig. 433) ‘Approaches: Fig. 4.38 and 440 Anatomy: Figs 441 and 442, Surgical technique: Fix 438, 9,440 Dorsal kin incin fran erm approach tthe ‘aia mere the supiatr tel 9.441 Schematc lagram othe course ofthe deep branch ofthe ada ere trough the spinator tre! 2 rp ban of tad nae Petocicneioy 5 eof ete poet wey a a ne neti 139 4 Compression Neuropathies ig.442 the rail nevis exposed i the spinor tunnel lncean the enters cri radi Breve nd the extensor aigtoran 2 Pasar mos 1 ier ote 140 Radial Nerve Compression Syndromes Wartenberg’s Syndrome: Compression of the Superficial Branch of the Radial Nerve at the Point where it Penetrates Fascia of the Forearm (cin Fis.443) Anatomy: Fig. 443, see als Fg. 128, Surgical technique: Fig. 4.44, 9,443 Anatom gram of the superficial branch of he ‘nerve ats pol of nyt the fora asa 2 Sper rach of dal ve 4 Rolie palo te rere he 7 9.448 Oecompresion of the supertal branch ofthe ‘a ere st point of entry into te fi of the rears eteun the brachorale apd tenor carl els angus Pati eeon ote ea ac. 1 Poet ony te peal tae ea nee 3 wn ace py ie) 1 Sipe Se of hal ne 3 Glaerenpadah tome 141 5 Tendon Transfers 143 5 Tendon Transfers General If satistacory function does not occu after microsurgi- ‘al reconstuction or decompression of peripheral nerves, pecforming tendon tanslers may significantly Improve or restore compromised oe abyent hand Tunc- Optimum results depend on selecting the proper muscle tendon unit tO. tansy, achieving. the. sralghtest possible cretion of pull, anon the proper initial ten- Slon in the muscle, Stabilizing procedures such as ar- thodesis and tenodests mist be considered in planning the transfer, Indications: Congenital deformities, muscle desiruc- ‘on ad tendon injuries, 144 Median Nerve Palsy Function (see Fg 570) Clinical Picture ‘Loss of exon inthe dumb index finger, and middle Finger due to paralysis of the following. muscles: flexor polis longus (anterior interosseous neve}, Nexor digitorum superticais of the fingers, Nexo? dittorum profi ofthe nex and mle fngers (terior imerosseous nerve) superficial head ofthe fexor poles brevis, abductor polics brevis, and op ponens polis ‘+ Thenar atrophy with reduced opposition and abduc- tion Proximal Median Nerve Palsy ‘Surgical Principle ‘© Flexion inthe index nd mide ger is restored by ‘suturing the lxor digitorum profundus tendons of the ring inger andl finger to the flexor digitorum, profundus tendons ofthe index and miele tinge. ‘Flexion inthe thumb is restored by suturing the ten- ‘dono the achoracals wi the Hexor paths ln {us tendon ‘+ Opposition i restore inthe thumb by transferring ‘one ofthe tendons ofthe extensor indi, extensor ight minimisextensorearpiradilis longus, or exten- Sor expt wats Distal Median Nerve Palsy ‘Surgical Principle ‘+ Opposition (opponens, abductor pollicis brevis, and stiperficial head of the flexor pollicis brevis) i re ‘Stored by tendon transfers to replace the opponens polis Abdur Digit Nini Ter (Figs. 51 ae 52) Preliminary remarks: The abt digit minim ap an also be raised asa myocutaneous sland fp to im prove the thenar coniout Indication: injury tothe median nerve and prima in congenital hand deformities. Approach Fig. 5.1 ‘Surgical technique: Fig 52 ‘management: The hand is immobilized ‘eth the writin sigh exion and palmar abduction for three weeksin a dorsal plaster forearm cast After hist is maintained in a removable nighttime spine for nates four weeks and ate and passive motion excr- ‘ses can begin Fig9shinincons oan abductor ig i transfert replace the eponens pis 145, 5 Tendon Transfers Fig. 2a-t Abdutordigt minim tasertoreplaethegp- The suc clgt minis dived a ito mati {ed roumay Cae stan to peeve WS eure 0h 2 peed mit 146 Median Nerve Palsy The apis ected to rset mobaed bc gt tn on ts pele. om nkenta preserve Sauron es 1 oes bao earn 3 oes « 4 Gtr ch ft on eve 4 Thesbeucor dt mint tafe btanecny othe reaarpoptlangel orto he hub ‘ 1 mdr at mere 147 5 Tendon Transfers 1 Once the scans ase as en competed the - The dé terns si of the abductor Ba iin ‘ons the spar dt moi fede lange. | ued te tenors te etensr oles longus ana abd ay {or pales bes tthe metscapephalnges Jot ofthe ono il 2 felnetcn oa 148 Median Nerve Palsy ofthe Fer Dita Superfasofthe ing Fin or ges.) Indication: Injury 0 the median nerve Approach: kin incision athe level ofthe distal palmar Figs. 54-57, see also Figs 5.13 ‘The Nexor digitorum superfialis ofthe rng finger i = cated and dvided between the AI and 2 pulleys. the Tengeh of the tendon is not sufcent, ics separated farther cstal at the level of the proximal phalanx tough a mediolateral shin incision. ‘Complications with removal can include a flexion con- tracturein the presimalintesphalangea joint or aswan- neck deformity (8% ofall cases) Possible technigues for redirecting the tendon: Fig. 5 Possible techniques for reinserting the tendon of the flexor digitorum superficials of the rng finger atthe ‘metacarpophalangea inc of te thumb include Brand's ‘method (Fig55) Bunnel and Royle Thompsons ‘netliod (ig. 56) and Rlorda’s method (ig.5.7) Fig. 52 Schematic diagram ofthe tendons of the exo dig {ovum sper he agers andthe tendons of the er eaplunens 1 Teo he fs datonm gril hen foe 4 Trlonst ne nro 149 5 Tendon Transfers Sosa anette enna tet diana Talend won pss eet dol eee [eels ofthe sng tnger to replace the oppanens pls Crp sas Shemale gram aera deere forum pees the rng ngeorepocete opanenspom 1 Teck ote en ci us 2 Tan athe we tum spat en ner oe tx eg he eon 2 ossstomecusing mallet dtl parton ths eagonak peeled window is pene it the ona etna 2 Ten he er pam pert hci ger_ 150 ee _::. _QSeeS_ ae Median Nerve Palsy Figs 55a andb The tendon ofthe flexor digitorum spes- bal pect (his of the ing finger incensed a the. Meta Sophalnge jo of he tam 1 eof er Son pao ng ge Eis mete 2 iicicor pee eo Grip denon fhe agen pac hne 3 Swe an fing figs pase tough he tendon of the sac paca £ AEGIS: pace (tir tnd end the tncon ft emenar pac ons and 5 Tendon afte cenn lke nc ey 4 Tendon ae enol ws The second sp swapped around the sur posal to the intacrpstligea abt deci ancored tothe te ‘deus rerion ee attr plesand the este a the Ist f the prnmal pao fe thd 2 ar pec eee Ee aces See tte a am neton ie Sooe ieee 151 5 Tendon Transfers 58a and B_the tondon ofthe flare dgtorum super fale of the tig finger rinsed atthe metacapo- Phslngel en ofthe thu ane nd foeTuoresors method Dar lp of the ene irom sper tendon passed ‘rough esd he et mtacag nd wtre eed Sp dal to the metcpophaanged Jon oer the dtl ponerse. 2 rapt “et eto te pti noe SS (vr te Seon En 152 . ada sree lent Sr term ser fhe tne Tenn cepts brs Median Nerve Palsy Figs 572 and ® the tendon ofthe les cgtorum supe fils of the rng finger rserted at the meta Drange! ofthe thu Redan mecod| ‘Gres sucha the feo Sonam supercleedon i pased ‘tough tne tan ofthe actor polis ren an he ein 3 the ese oles ones 1 elon har dun ipa he iy gs 2 Fl pt te 3 Tether ae 5 Sxprent pace 5 nn he bcp rg b 1 enn ft Sn atari perc oe 2 Ooo peer 3 fdr es ous 4 acral 5 Neon he amr ote gue i eon the amor gta bee 153 5 Tendon Transfers Ulnar Nerve Palsy Function (see Fig 5268) Clinical Picture ‘+ treme hyperextension of the metacarpophalangeat joints in he ing finger and smal finger wit ass of fusetion inthe interest and the hrc of the middle and ting fingers Moderate typerestension of the _metacar- Dophalangeal Joints in the index finger and middle finger with fss of function in the Interoseous smucles. The lumbrcals of the index and mide in {ets remain functional (supplied by the median nerve ‘6 Abduction of the ing fnger and small finger Loss of function in the iterose results in ulnar devietion de to the action of the extensor digitorum. ‘+ Hyperextension ofthe metacarpophalangeal joint of ‘he thumb with los of function inthe deep ead of the Mexor pallies brevis ‘© The ingers cannot be spayed Theres lss of func- tenia the palmar and dora interosse, ‘+ The thumb to index tip pinch s weak with toss of function inthe adductor pollicis and visible attphy inthe fist interdigital space. Replacement: flexor Dalles longus (supplied by the median nerve. Fro- ments sgn is poste; there i strong Mexion inthe Inerphaangeal joint during exercise. ‘The patent is unable to fex oly the distal phalanx of the itl finger due t loss of function in the Mexor igiterum profundus of che cng and ive fingers. ‘This only occurs in proximal ulnar nerve palsy Proximal Ulnar Nerve Palsy ‘An una caw hand deformity of the cing finger and sinll finger is present (this sa mild frm because the flexor aigtorum profundus of the ving a lle fingers are also paralyzed). The pinch mechanism is also ‘weakened, Distal Ulnar Nerve Palsy A severe ulnar caw hand deformity ofthe ting flager and smal finger i present, and the pinch mechanisi is weakened, Surgical Principle ‘+The claw hand ard the hyperextension inthe meta gh. 650, & Altachinent of am anusion of the extensor Sponearose wih» sll exsocrtoginous agin hlved wth a pull vie ‘tm tee le eng the dtl phan, nthe wes {chord pehery ora aston ard sea wher by presig aiieteler ney ater nrwanyovane 2 Pec reaped son tar Extensor Tendon Injuries .6260-¢ Aachment of an avon of the extensor energies rage th © alone Fracture Dislocation of the Distal Interphalangeat Join, ype W (eis.027 and 6.28) «Pin stabilization with retrograde drilling technique rn Stblzoion with Retrograde Dlling Tecgue (ig.628) Ingication: Palmar facture dsication with instability (ofthe dtl otephalanges joint cue to avulsion of & lige dor per aly retest le ticular surface Approach: Z-shaped incision over the distal iter Phalangea joint. Surgical technique: & double-ended pin Is inserted through the surface ofthe acture atthe Cener. The dil \ \\ WN 0,627. almar facts action with tality of the (tl interphalangeal one due To lion Of age Beat Fregment (ype 1 en te te datum ond 3 hte eras igiest ‘en range bole cid rou te base of he da Dain andthe auhed aga een Be wre es En ln acre or moos. The deal iteraage oe ‘iy Sue be eased steon depending on ve sbiy hired ith the Sut fs moved and the end ofthe pin is driven into the distal ‘Phalanx. The cstalIntephalargea join and fragment Se reduced by applying palmar and dorsal compression ‘with the joie etendee- Te pin s driven Back tough the fxgment and the dal phalans Pin: Double-ended pin 1-12 mmin diameter depending ‘onthe sizeof the faaent Postoperative management: The stm is immobilized for four weeks ina palat ast and Mager split. after ‘which the pin Is removed. radiographic exemination {ssi con bone ge pin Stemored and she finger is further immobilized na eustom finger spe 2s In gonservative treatment for another week or two (see pri94 and Fig, 622, yi Fie.62%a-t Retrograde ling techni suse npn stab Toton af patrar acre location with sabi ofthe ‘Seal ieerpalongeal jot due to lion of ge oral 1 'Uoubie ended inetd rough he ace of the fa Surat the bn of te ota pane 197 6 Tendon Injuries 1 Adasen inserted trough the race acs € The dills moved ture a the are the dtl phan Der ape 1 Artes agren wh el pmas 2 Met be mate shoe 4 The ctr eed by ppg pana and sal campres- shen tothe aan th tet tended Te in hen the hog he actre agment 198 ‘and the bony agra pace wth 2 pn et ae Stee da mephsangstion Extensor Tendon Injuries Fig.629_ tary tothe etenarsponeureisin zone D4 {ines pete’ Henn nthe dtl terpalanges Js more Dronutced than eee Insane Da. The poate Silage nt often be Myerecendes Closed uptre ofthe Extensor Aponeuross Type) (fig 622 nd 829-63) ‘= Conservative treatment. fe Tendon suture (5c Fig.631) conservative Testment (se also p94 and Fig. 6.22) ‘hosed injures canbe successfully eated by immobil- {ation fret weeks [ya costom spline Injures ths ane take Tonger to heal than In zone Da ‘Open njrtes othe EatersorAponeuross (Typ (igs 620-631) ‘+ Tendon suture Tendon Suture (Fie 631 Indications: Open injuries and chronic subcutaneous ruptres ofthe extensraponeursis: les frequently in bere closed ruptures. r ‘Approach: Angled incision ver the dle phalanx and ‘stat iterphalangeal nt ‘Suture technique: Cox stures ate placed (seep. 180, Snd Fig 61), and the distal interphalangeal jont is tranefixed in extension ‘Suture material Braided 4-0 suture material Pin: 1 mm, Postoperative management: The hands immobil fora total oss weeks ma volar cast a in anger split. The pin i emoved afer four weeks. The hand is hen iodized Ina custon spline asin consenativeteat= ‘ment Tor another two Weeks (seep. 194 and Fig. 622), ig.630_ Rupture ofthe extersoraponcuossproinalt the Insertion of te blue renal igorents pe) 4 pial tor ae ets 32 Senta aan 1ig.631_ Rupture the exteror apenas proxinato the Inert ofthe oblige retinal garment treated ith ore Sutures end rans the distal nterpalangel ont ‘terion 13 eon Bod 199 6 Tendon injuries Zones Dd 3 and Dd 4 5.652. Rupture of he intrest band {el petue: The prc! nepal ot i lesen "he dita intapalagel ore etre 10.633. closed eaprce ofthe mil part ofthe interme: ‘Sat band nse B02 Thee Toss of ace extension i the pron nepanges 1 Soothe ty tnd 22 tat pato et and 5 Tat or ium setae ‘slated avulsion, Bory Alin, or Cased Rupture ofthe "Medi Part of the imermedlate Sand (55.6532-638), © Conservative testment ‘Aachen with plo suture, ‘¢ Tendon suture. ‘© Atachment with pullout wive (as on 9.196 and Figs 625 and 6.29, amservotveTeotmert (Fig, 6:34) An isolated closed rupture ofthe medial part ofthe in termediate band 20% Dd 3} can be successfully treated conservatively However, the lateral part of te Interme= Giateband and lateral band mus be tact Acinic ign olthisisthat the patent ean actively maintain extension Iindhe finger ates passively extended atthe promi Incerphatangeal jin. “Treatment: The fingers immobilize for six weeks in a ‘custom spline that cludes the metacarpophalangeal nd proximal intepaalangel joints and maintains the proximal interphalangeal oi in extension. A padded Welero strap enclosesthe proximal interphalangeal ot, ‘Motion exercises forthe metacapophalangeal ad distal Incerphalangeal joins ar performed with te splint in pee ‘Atachmet with Plt Suture Indications: Closed and open injuries tthe extensor tendons. Approach: & curved incision is made around the proxl= mal interphalangeal joint in elsed injuries. In open injuries, the primarj wound 1s extended to form 2 Zshaped inclsion. Suture technique: Pullout suture (see p.18) and Figs.62ac) is inserted through holes dried obliquely at the base of the mide phalanx {medication ofthe fechnique shown In Figs. 60a). The proximal inter- Dhalengea joint is tasted in extension ‘Suture material raed 4-0 suture materia, Pin: tem, Postoperative management: The hand is immobilized for a total of six weet, niall in 3 palmar cast o in custom finger splint ‘The pin is removed after four ‘weeks. The proximal incerphalangeal joint isthe mobilized in 2 custom spline atin conzervative teat- ment fr another twoweeks (se Fig 6.34) Motion exer. ‘ses for the metacstpophalangeal and. distal iner- Dhalangeal joints ae performed: The pullut suture is femoved a¢ the end 3 the Mth week postoperatively ‘The knots divided above ze pas utton an the ‘ure is wcharawn su he pllou loop, 200 figs 62348 and Splint for conservative treatment ‘oved ruptre of the medal orto the nteredite Band Sone a5 Tendon suture (i,6.36) Indications: Closed and open injuries to the extensor tendons. ‘Approach: A curved incsion is maée around the prox- Inet interphalangeal Joint in closed injuries. In open Injuries the primary wound is extended to form a shaped incision, ‘suture technique: Core sutures (seep. 180 and Fig. 62) fre used; separate sutures are placed fr the indvidvat tendon segavent. The proximal interphalangeal joint i ‘Wansfxed in extension. Note: Selective sutures inthe individual tendon seg ments ae necessary to aod impsiting the diflering mo- ‘om ofthe tendons The Tength af she individual tenon segments mus be festored othe exact orignal tate C0 ‘inn te sk of impaired motion athe discal inter+ shalangeal joie. ‘Suture material Braided 4-0 suture materia, Extensor Tendon Injuries Postoperative management: The hand is immobilized fora total of 3x weet in3 palmar east or ina finger pli The pins removed afer fou: week. The proximal interoalangeat joint then immobilized ina custom spline an eoaseratve trent for another two ‘eeks (Se Fig 634). Wotion exercises forthe metaca= ophalangeal nd dist interpnalangeal joins are p= Formed, ets not necessary fo remove the tendon Suture. Avalon, Bony Asin, loved Raptr, or Laceration of ‘he Medal and Lateral arts ofthe Intermediate Sond lana the Lateral Band (see Figs.626, 6.38, 036. and 60, ‘© tachment with pullout wire (2s on p.218 and in F660), ‘+ Atachment sith wie suture (as on p.196 and in F626), ‘+ Tendon suture (see » 201 and Fig. 636). 201 6 Tendon Injuries 14.635 Laceration of the intermediate ban, lateral band, ‘nd oblige etic ‘Theres sof ave evens the rosa apd alte loge ns of th ger 2 raat in omen 32 lool a ap at 35 awa pat a he mete ine { j Figs $362 and Lacaration fhe intermediate bandera} enon band, and eblque reinaclr igrent weated by repaing Lasalle eran {he tendon wit ore sures and Waning te provimal ins 2 esl the eo {rphaangeal jot 15 Les et he reese rd Tein cn sgrens a lect steed 1 Glu neem 202 Extensor Tendon Injuries Dorsum of the Hand Zone Dd5 4.637 Lneraton of the extensor tenden at the eve the Imetcapophaanged ent Cine ptt: the metaapoptlngel ot i led andthe Ppownal nd asta! meron os ate extended du the Elon othe ki 638. aeration ofthe extensor tendon at the evel ofthe retacarpophalanget ont 1 enon te sarc dean ie fer Laceraion of the Extenser Tendon a the Level of the ‘Metacarpophalangel fre (Figs 67-640) ‘¢ Tendon separ with ore sutures Tendon suture wit pullout suture, Tendon opal with Core atures (Fi 6.39) Indications: Closed and open injries to he extensor tendons ‘Approach: A curved incision is made around the proxi- tal intesphalangeal Jon in closed Injuries. In open Injuries, the. primary wound is extended to form 2 ‘2 shaped incision. ‘Suture technique: Core sutures eee 9.180 ane Fig 6.2) reused ‘Suture material raed 4-0 suture materia. Rynning sure is placed using 6-0 monofilament suture mate Hl Postoperative management: The hand is immobilized for five weeks [oa vols cast of anger spline. cis not necessary eo remove te tendon suture. 203 6 Tendon injuries £9,639 Laeaton te exteror tendon a the vl oF he maeepng nt tested by vp the odon Tendon sure ith Pullout Site (Fig. 640) Indications: Closed! and open injuries tothe extensor tendons. ‘Approach: curved incision is made aund the praxi- Imatinterohalangeal joint in closed imures. z-open Injuries, the primary wound i extended to form a shaped incision 3 Fett enon dtc ete ‘Suture technique: Pullout suture (See p.181 and Fig. 6.24) used Suture material: Fullout suture consist of braided 4-0 Suture material daly armed with staight needles A pullout oop is used. Rung sutures paced using 6-0 ‘monolilamene suture materia Postoperative management: The hand is immobilized forfour weeks ina palmar castor finger slit Mobi Zatdon begins witheuturesin lace. The pulloue sures emoved at the end ofthe Ath wee postoperatively ‘The knots divide above te plastieburtor, and te t= ‘ue is withawn with the pou op. F640 aeration ofthe extensor ten ‘dn atthe oes of he mace ‘pralangsi jie treated with tendons fee wth pslout wire 3 nach ne ol eee Zone D4 6. Fig 41. Lacrton fan extensor tendon in one Dd 6 prox ‘iid peur berson dei nthe meaexpootloge ont ‘ith real censon in the oa bed da neplged Jans deo te ston of te umbree The endineSn- Frecton part acrtan Jere of exten rom he atin ck Theater tng. Tele ge dosnt hac atch si ‘Teast dt the ntertenhaur connection one O48. Fig 642, Lacration fan extensor tendon in one 6 pron ‘rl to the inertendoots conmocton Extensor Tendon Injuries Laceration of an Extensor Tendon Proxima othe nts tenalnous Connection (Fes 61-643) 4+ Tendon suture using modified Kirchmayrsechnique Tendon Sure Using Mode Kicker Technique ig6a3) Indications: Closed ané open injuries tothe extensor tenons ‘Approach: Acurvd incon i mage proximal tthe In- {erphalangea! Joint in dased injuries. In open injuries ‘the primary wound is extended oforraaZshaped in\- ‘Suture technique: A modified Kirchmayr suture (see iB and Figs 64-66) s used Suture material: Braided 4-0 suture material armed ‘with venous needles is sed. Running suture ts laced {sing 6-0 monoflamen: suture material Postoperative management: The hand is immobilized forfour eeks ina vol cast ofa finger splint. isnot necessary to remove the tendon sue Note: Other suture tectniques such as core or pullout sutures may also be used tea injures Is his zone 205 6 Tendon Injuries 9.643. Lacration of an etensor enon in ne 4 6 prox ‘halt the iertennau connection ested wth 3 tendon ‘ture ug the moted Kray techni 206 Extensor Tendon Injuries ‘Extensor Tendon juris with Defects Proximal tothe ln tertendinous Connection {Fifs. 644-647) + The defect is bridged with the extensor indicisten- don. The defects bridged with the extensor digit minim tendon, 1+ Tre defects bridged with stand from the extensor inicstendon. 1+ The defect is bridged with a fee graft Fig... fect in the tendon of the extensor diovan of ‘he mid nger prima to the inerterdinauncomection 4 plone eer gr fh mi fee lading Extetae Tendon Defects (Figs. 645-6.47) Indications: Extensor zenon defects and tendon retrac- tions in ehtonie injures ‘Approach: The wound is excended to form a Zshaped inetsion ‘Surgical technique: The delet is bridged by trnspos- Inga substiste tendon (he tendon of the extensor ink CGeorextensor digi nimi muscle) astrand ofan adjs- ent tendon, of a fee ton gran (the tendon of the Palmar longus or plantaris muscle). The substitute en- ‘Sons then sutured inthe ends ofthe interrupted fn on, ‘Suture materi: Braided 4-0 suture material i used Running sutures placed using 6-0 monoflament suture materia, Postoperative management: The hands immobilized forfive weeks ina volar paster cast Ils pat necesr2ry to remove the tendon suture sas mec nnn nee git masse ii whens mente 1 enon weer ins scant) 5 donot anor acs 4 emt sno ponte ri ne 207 6 Tendon Injuries 208 Extensor Tendon Injuries ‘Wrist and Forearm Zone Dd7 4.649 Lacratin ofall extencor tendons excep the exten {or polis breve and extensor carp nr tendons tthe ‘wit in sone B42 Fes tenting the wrist atts ideation of heb (he ruc Laceration of the Extensor Tendon inthe Wrist (igs 648-550) Tendon suture using modified Kirehmayr technique ‘or Bunnell suture Fig.648_ laceration ofl xtenrr tendons excep he eten- Sor poles tres reap las tendons tthe inet pre he metacapoplangel jos of he ges and She merpanga! onto he tam afe Reed, tein poshetn the rnc ond stnephngen as et reduc tothe ston of theme an amber inthermtacpoohlnges foto tha ub dot the tion the exersr pales ters muscle, Vst een sl ‘Sent te undo the temor car urs scl pe ‘ewes igen Saat. : Seer sgoaes “Stn te naa igor “font he ce hes Tenor eee nr 209 6 Tendon Injuries Tendon Suture (Fg 6.50) Indications: All injuries to extensor tendons In this ‘Approach: The primary wound is extended 0 form 2 Shaped incision. The extensor resnaculum s opened {rom the ular sie. Aer the tendon sutures have been placed, the tendon compartments are clase by suturing the extensor retinaculum, ‘Suture technique: Mesified Kircnayr technique (see . 183and Figs.64-66) or Bunnell echaque (seep 186, and Fig. 638), ‘Suture material raed 3-0 oF 4-0 suture material is used: Running suture is placed using 6-0 monofilament suture materia Zone 048 i651 aeration of the extensor tendons nZone Da 8 "hcetenor gtr edo oe ghee Hess Inv compltey seared Te tad fe exten cay 58 tongs extensor cs ada tren etersr a Ua, ee Sor pales nai, reso poesbrev. entero. rw ener dg mi tact 210 Postoperative management: The hand is immobilized forfive weeks ina volt plaster cist, tis not necessary remove the tendon sre ote: During. immobilization inthe plaster cast (with ‘hehand ina functional pesiton), the suture ites inthe Fetinaulum should nee drety above those inthe tendons a this could result in adhesions. Care must be fake to assess and aid Uns isk intraoperatively. 1 ‘ecessay 8 partial section should be performed, of the retinaculum should be advanced by extending the Ineision inthe shape 22 Fie.650 A leeation ofthe extensor tndons nthe wes ane 047s vepaed wth tenéon sutures using mocted ‘ctnaye techriqu otouace sure ong he extensor "etna ‘spk he dere Tendon ofthe soma nfs ee ra rte ec ego Lacetaion ofthe Extensa Tendons in the Forearm (igs 631-633) Tendon suture usig modified Kirchmayr technique ‘or Bunnell suture. \—— ec pcre: Exenson reduced in the metcarppbsanget Jos mud gor an ing ger (ers degen ected by the seen conection) al eto pee tinh des Eger ed ite ge othe tenors he Extensor Tendon Injuries 9,652 _Laceration of he extensor tendons in Zone Dd 8 Pyeng ge dw cas eon Tendea suture (Fi. 5.53) Indications: All injuries to extensor tendons in chis ‘Approach: The primary wound Is extenéed to forma 2 ‘haped incision. ‘Suture technique: Modified Klrchmay technique (see Drl83.and Figs 5-66) or Bunnell fecigue (Seep. 185 bint Fig 68). ‘Suture materia: Braided 3-0 (4-0) suture material is sed, Running suture s placed using 6-0 monofilament suture mata Postoperative management Tse hand is immobilized fos weeks ina volar plaster eas Tis not necessary 19 remove the tendon suture, ‘Note: The tendon excursion inthis zone is at its maxi- Thum The sutures must withstand extverse axa leads This requires the use of srongee suture material 2nd 3 longer period af immobilization. Wherever possibe, the sue ales should be wrapped with adjacent tissue {muscle oft) to minimize the risk of adhesions. 1 reno ten dam 3 Tenn ef ie se pir ge 4 Tena af enema agtimcn ig,652 Laceration ofthe extensor tendons in 20ne 04 8 it ‘epee ih hota sutures or ith a mode Krchayt ‘eague and ruing sare, 1 Toot oa as 3 enol one ag orun “Tenino te ensue 2 6 Tendon Injuries Thumb Fg. 654. Lactation a the eens sponeuron none Pd? Clea pict: The meron ont of he hub er, a the meacrpophaunge ant ends The cok pe {e's th soneasinan Soest ote tenn he een ‘ot poles ngs mule 20s #8 1-5 Fig.655_A tcration ofthe estntor aponcurol In zoe a2 is repaed by placing cote sutures nthe tendons ‘The terphngel i may 250 be Carsacd stmin pening on the abit ace We fe sue 212 Closed Tendon upturs in Zones Pd 1 and Pd 2 (Pigs-622 and 623,625 and 525, 654 and 655) © Conservative treatment. ‘+ Auachment (see pr 195,196 and Figs. 623, 625 and 626). Tendon suture Note: Conservative a! surgical treatment of extensor tendon injuries inte thumb is essentially identical £0 (weatment of finger iris. onserotne Treatment (seep, 194 and Fig. 622) ‘lose extensor tendon injuries in zones Pa and P42 ‘canbe successful eat coservatvey ike juries in zones Dd and Od. The immebilacion petiods are ‘dential (a modified version ofthe spine shown in Fig 622s used), All other injuries are weated surgically Tendon sure (Fi, 658) Indications: Closed and open injuries 1 the extensor tendons in zones Pa T-Pa, ‘Approach: The primary wound is extended to frm a ‘Shaped incision Suture techaique: Follost suture (see p.181 and Fig.62), core sutures [sce p. 180 snd Fig. 61), or mod ied Kirchmayetectnigue (Sep, 183 and Figs 64-0.) ‘The interphalangeal jan may also be tansfeed In ex tension depending on the stably achieved with the t= Suture material: Braided 4-0 suture matval is used Runsing sutures placed usng6-0 monofilament suture materi Pin: 1 mam, Postoperative management: The hand is immobilized Ina thumb splint for atta of si weeks, The pin i = ‘moved after fear weeks he thumb I then inmobiized ‘na modified finger salin asin conservative treatment for anaer two week (using 2 modified version of the spin Fg 622} is ecesary eo emovetse te Treatment of Poorly Healed Injuries All Fingers ‘ones Del 1, Pd 1, and Dd 2 Invufcency ofthe Extensor Aponeurasls Due to Scaring Inthe Region of (asta tnterphatengeat ot (figs 656 and 557), ‘+ Sear shortening aponeutoss. to reconstruct the extensor Preliminary remarks Civen the short excursion ofthe extensor aponeurossin the distal phalanges, even a slight increase inthe lengths tthe teninous tissue from searing can result ina ig- fifieant extension deficit hat resembles a male finger Injury. Correcting this exclusively lca distal deformity Fequiesunimpalted passive motion othe (stl inter= Phalangeal joint and continuity of the extensor Sponeross despite searcing. ‘Scar shortening to Rconstrac the Extensor Aponeuass (rig 657) Indication: Active extension deficit inthe intor- ‘halangeat joint ofthe thumb of alsa interphalangeal Jus of the fingers as a resule of an increase inthe length ofthe extensor aponeurosis fom scaring this region. Correction requires unimpaied passive motion ‘ofthe distal imerphalargeal joint ‘Surgical principle: The seri entaly excised, ana for the purpose of shortening a secondary suture placed inthe extensor aponeurosi. The distal lnterphalangcal Joints temporally transfixed with api. ‘Approach: A shaped incision is made over the distal feterphalangeal jae Surgical technique: See lg 657. Suture technique Core sutures (se p 180 and Fig. 6.1). Suture material: Sraided 4-0 suture material i wed Pin: 1 mn. Postoperative management: The hand is immobilized {na volar plaster east o a inger splint for atta of sx ‘weeks. The pints removed after four weeks. The nse is then immobilize ina modified fnger spit as 3 con- servatve treatment for another two weeks (using. & modified version of che splint in Fg 622). Its noc ec ‘sary to remove the tendon suture. Complications: Adhesions frequently occur when the Ssutue site does note directly above the jin Le the Srila earlage, Extessve sea excision makes i a= {ult to adapt the tendons and achieve a stable suture. ‘Tanstang the (ist! interphalangeal jintinhyperex- tension can lead to a secondary flexion impalimient, £4,6369,0_Delormty cesemating a mal Hager ur r= ‘ng tom inetidony othe eterorapeneross dc to esrng Following am tnry =the eel a te distal er Dalanges! joe na fing Combe scarica eur asubatnebus rupture oF op loam he tend f te exo pbc on 20h Pov eeha lateral asgect node apse ee 3° toute sats! dal pono 213 6 Tendon injuries Figs 6572re The extensor spon i reconstructed by ‘neal excising te sca . The tal uepalngetioon gate dling ecg sed inertenson Retr ¢ Core sutures av pie to approcmae the tendon te eens alin 214 Exiensor Tendon Injuries Zone D43 Insufcency ofthe Meal Part ofthe Intermediate Band Duet Searing (igs 958-560) ‘+ Reconstruction of the intermediate band by electing, 2 tendinos Nap to restore continu. Reconstruction ofthe intermediate band with aten- on graft Preliminary Remarks Reconstrcting the medial part ofthe intermediate band fo treat traumatic isuticeney wil only be successtl the absence of ineversble damage to other extensor -troctes (lateral part ofthe inermedte ban, lateral bund. and cbiqu retinacular gament) oF the capsular Iigaments ofthe preximal andjor cist interphalangeal jonts (Boutonnire deformity with contracture) Pathoanatomy “Tne length ofthe meciatpart of the intermediate band is inceased due t searing. The resulting insufficiency of the transverse retinacul iament ane volar slipping of the Intra patt of the intermediate band and lateral band beneath the axis af the proximal interphalangeal Joint produce an extension defi in the proximal itet- Dhslangeal jane. Tiss accompanied by hyperextension {nthe stl ineyphalangeal Joint to prodce what is nawn ea “boutonnite deformity” ten the metacar- ‘pophalangel joint wil aso be hyerextended Figs 63a and & Boutonire deformity rexuing Irom he Eifieny ofthe medial pat ofthe termediate band due to al nt of ne vane tise ganests shown 1, SE come 1 ie pt the spec rt 2 fafa oe othe mal par ote eos and ) Eerie, 215 6 Tendon Injuries ‘econstcton ofthe Intrmedite Band by Reflecting @ Ten ‘dinousFop to Restore Catt (Fg 6.59) Indication: insufficiency de to scarsing ofa defect in ‘the intermediate band with the lateral band inact and unimpaired. passive motion In. the interphalangeal joints. The procegue s well suited for correcting small sears or fects Surgical principle: The continuity ofthe medial part of the itermedite band is restored by yefecting 3 Cental strip of tendon of the appropriate length Approach curved incision Is made around the proxi- imal interphalangeal joine extending to the proximal third of the proximal phalanx. special care should be taken in dissecting the ging layers. ‘Surgeal technique: See Fig. 658 ‘Suture material Braided 4-0 sueure materia is used, Pin: 1 mi, Fign6802-¢ The ntrmedite band reconstructed by ‘ecting a tencnovs fp to restore contnly 4 Asp of tendon wha dita pects narnia {o preitl sae ron the dal prt oe terme ind The se fhe eect crooning fest 216 Postoperative management: The hand is immobilized Ina volar plaster east ora finger slit fo a otal of si wecks Te pinis removed after four weeks. The figs then sinmobilized i a modified finger splint sein con~ servative treatment far ancther two weeks. (see iz 634, Motion exercises forthe metacarpophalanges! and distal interphalangeal joints are performed, Its not necessary to remove the tendon sutare Complications: The sutures atthe insertion and the re- feted portion ofthe tendinous strip shovle be very {ighE Aap wil result man extension deck Extensor Tendon Injuries in) 1 the teins sts eesti the dees. The egied —¢ The praia mpl nts arsed teson lent dtd th Be real erp en ‘Stenson. Seong sutures are lee the eflced portion Std the nerion (he ave ofthe mide plo). The scr the pst gantnfnczte tendon ghdng Teese nthe Interest band hen sed Net The scr tue onthe prstalnpalnge! nt ovbeendaktednthe hureto beter epoca ‘hcl be reserved to alt tendon ang, 12 fda Bratt meet an 217 6 Tendon Injuries ‘Recostroction ofthe Intrmedte Band with Tendon (rot (P60, Indication: Insufficiency du to scarsing oF a defect in the intermediate band with the lateral band intact and ‘unimpatred passive motion inthe intepalangeat Joints The procedures well suited Tor correcting exten Sve scars or defers. Surgical principle: The insufficient scar tisue o defect inthe intermediate band i bridged with 4 stand of te ‘enon of che palmars longus. Approach curved incision is made aound the prox: mal tnterphalangeal Joint extending to the proximal third of the proximal phalanx. Special care should be taken in cssecting te ging layer. Surgical technique: Se Fig. 6.60. as 6402~d The imermedate band is raconstructed with » tendon grat and Tebaseof the mie pis expr, nero eco hoes are ed by hand tt 4 anal ech tee The eles ae hen succes wide whe robe soe ets Samet ol but 3 om tad 4 Beste mt po 22 dal pe othe eer bad 218 Postoperative management: The band is immobilized Ina valar plaster castor a splint for 3 total of six weeks. “The pin removed eer four weeks. The fnge Is then Immobilized inva matted finger splint asin conservas tie reatment fr anther two weeks 220 Fg 624). Mo. tion exercises for themetacapophalangeal and distal in texphalangel joins ae performed. eis not necessary to remove the tendon satue Complications: Dring the holes in the base ofthe middie phalanx too close togeter or too large wll ‘weaken the bony brcgeandresultininsulicency ofthe distal ration, ‘The graft may impai motion ifthe adjustment ofthe lateral band Is too ght oto loose. ‘Adhesion can ccurat the proximal phalanx Extensor Tendon injuries (€tenden strand aut gus: ep 255 a 6.109 for haves) i ao vousn the hae ag 2 oe ‘lee ele oa we op 4 Thetondon gts cred athe ofthe. Thee tanned. The regu eg demand we Pra neratlaael jr i xenon. The pr {pone ith aed a extern. Seong sare ‘Sika contol gat Nether tsue oe th psi tephaangea on. Fs ban eke in he Ngure ta beter ste the po- fede Isto be preserved tof tender gig. 1 odo ot 219 6 Tendon injuries Zone Dd Fig 61 Rupture ofthe extensor polis ens tendon inthe third extn tenon compartment Tendon of he abc ales rae GES Spr bee TEsena cers coos 220 ‘Rupture of he Extensa Poll ongus Tendon (fits 661 ana 662) + Tonsier ofthe exensor pollicis longus tendon Preliminary Remarks Direct suture repair as not proven effective in treating 2 Subcutaneous ruptute of the extensor pollicis fongus fencon In the (ire censor tendon compartment. The ‘Stumps of the tendon are usualy retracted and exhibit Significant éageneratve changes. The same applies to chron as In contrast transfering the tendon of the extensor indi sto restore function produces good results. We donot feels necesaty to econnect he extensor polis on- ss tendon to inereae stengt athoanatomy Subcutaneous ruprue ofthe extensor polis longus tendon a the level of Liste’ tubercle frequently occurs In asrocaton with sighly displaced radalfactures, This may be due co bieeding int the third extensor te don compartment. The tendon stumps afe usually thier and. fayee with signieant. degenerative changes. Flexor Tendon Injuries ‘Transfer ofthe Extensor Ind Tendo (Fg. 662) Indication: Subcutaneous rupture ofthe extensor poli- {is longus tendon in zone Dd ® or chronic injuries to his {envdn proximal to zone Pad “Te extensor indcis tendon can alsa be used to replace ‘other extensor tendons in the hand ‘Surgical principle: he zendon ofthe extensor polls Tongus. muscle is divided proximal to the metacar~ pophalangel joint of the index finger Suacitansous issection is Catied proximally (0 the extensor ret- ‘culm. The tendon fs transerted radially an sured {2 te dtl stump of he eens plies longs te Fis.6.622-d_ansfrof the extensor indicstendon 2 the sproach requres tee seposte rosie’ 1, "Riess innen made oer est metacpal {aac the mo teen 1, Reece nen ae posal abd war to the ‘etearoplagent ant a eden ger de he ‘Stes no core yma bansere ncn made on th eta of be fuera edn campo oe ee Approach: Fi.562a ‘Surgical technique: Fis, 6020-< ‘Suture material: Braided 4-0 suture matril is used 1 the exes tendons blquely vie approximately {Som pra tothe mtacapephaargel ote inde Tg Subewancue deseo te enon cared pos tly oyna te nen rete in a Bn tendon {irppe) the tnden en pused palma othe tendon of tibtensortgtrum use fedex ge Bt dra to {hearer ofthe ele copra orgs ant enor ‘heals rev the st tac, 1 endanger the ner 2 endothe ese aw ve 3 Teflon he sence ons [Sr meas 221 6 Tendon injuries An nla ste sed ta comet thet tendons at the tee the fat etapa ee Fg 8). Te Dumb b 2b ‘lcd ats ened ttre the ried tenet nts postion, teace tures made undo ‘ae tron, Tur Tuneton cn be coped to fe com tral ie paige wren maximum fer ard terion fhe compare tothe neod wed p Seserine tholengt tendon gar reonectg ew ence the igers: ep 297 a Fit THe and The prin Sonat he etouor ples ange tsdan ot expo eet erent Se Postoperative management: Tie hand is immobilized Ina thumb and forearm plaster castor a humb spin for four weeks, Complications: Suturing the tendon too close c the retacarpopnalangeal jist ofthe thumb can restrict ‘motion (note the direction of pul). The two tendons Soule be connected as fr prosimally as possible Insoffiiet approximation of che distal stump ofthe ex- feasorincis tendon and the tendon ofthe extensor igitorum muscle ofthe index finger can result instar bly ofthe extensor tendon and an extension dete in the Index tinge ‘The tendon of the extensor digitorum muscle of the Inde finger snot suable for sci a transfer. 222 The sump ofthe oxeso nds tendon sutured atthe ‘meacnpapaingea ant A song sie hare preves Say fe Rar. 1 Tendon te xan Su ote ge 2 Tedon oh ea rg) Osc the esos Tedonal eer dtm pod Teonat Be fe gtoum siecle cord mie ete 3 Sete nemettaene 1M fate then 12 Rewory na rs ene) 17 Ghent afte Rw endo shea fe tu , ae A ocyeeer de te mmm rect os EEE atemeanmaten, Flexor Tendon Injuries Flexor Tendon Injuries Preliminary Remarks Reconstructing injured flexor tendons requires great SIL The peritenon and synovial sheathes are easily In- jure, Incaoperatve damage to synovial tissue caused by instruments of unsitabe size or Cssue drying pro- ‘motes scaring. Operations should be only performed Linde loupe magnification in a elatively bloodless fel “Tissue spating suture technique i important; the two {nds ofthe tendon should be reunited with stony si- {ures that donot eave any gap. Thickening atthe suture site will impair tendon ging Inthe narrow seat ‘Anatomy and Tendon Zones ‘The pulley shoul als be reconstructed. Instability o¢ absence ofthese structures result in impaired motion pd loss of strength ‘Where both flexor tenon have been severed, both Should be reconstructed. This essential to ensure ‘vascular supp to the te don and fer good functional re flts (fine motor conto and strength) Postoperative management 1 enhance functional reba baltaton hs Become an important part ofthe manage ment of flexor tendon injures. fig. leno tendon zones sie omen terones ofthe le nda a th (gensedeigunedsrOp Op andthe al he um 237 = me ‘a gers cn ough tt) te 223 6 Tendon Injuries 2 9.665. Fes tendon sheath ofa fngee g.666 lvoe tendons nd neurovsicu suppy the {ier aspet irate spect A pot ay Fa il) Sito, 224 Flexor Tendon Injuries F668 Palmela dep narns yer tte ae eth we an ee Set me evant ne eve 1) rate rr tone te 1 bepodnar ach 2 ee fi i i 225 6 Tendon Injuries ‘Treatment of Acute Injuries Forms of ijres Fingers ‘+ Avulson ofthe tendon from the distal phalanx. ‘+ Bony avulsion of the tendon from the distal phalanx. Zone Dp ‘Bony avulsion ofthe tendon fom the distal pha + Laeeration ofthe tendon Preliminary Remarks Avulsion ofthe tendon ofthe Nexor dightorum profundus musele and bony avulsion ofthis tendon from the distal phalanx usually occur as closed Injtes In contrat to Closed peripheral injuries of the extensor endons ofthe hand, surgical treatment Is always necessary In avulsion injuries, itis imporant co note that aside ftom the bone injury (which may or may not involve in "ality ofthe distal interphalangeal Jind he tendon ‘ofthe let digorum muscle may aso beavulsed from the bone fragment ‘vision ofthe Tendon of he Flexor Digitorum Profundus ‘Meee am the let! Plone (Fis-670-8.72) } 6 aachmene with llout sua, Attachment wit Pot Suture (Fi, 672) £5,570 lated nur to the tendon of the exer dgerum — indications: Closed nd open jus ‘fundus of the msi igri one Dp 1 or Dp 2 Indeations: Closed and open in Enel pcre Tose ae tate Fonon i te dt er Approach: AZ-shaped Incision is made over the prox Polagel ose Ave feson spss in te Mesear— maland sal interpbalangea joints, It may be neces Paoboange! and paca merle jo fry to extend the Incision proximally If the tendon i severely retracted 6.671 Alon of the tendon ofthe flee digitorum pro Fi. 6.72. The tndon fhe flexor gto profundus t- wear" ‘eked ithe plo satire 1 en ote er drum go 1 Tendon esr don ponds 2 Snel tou seis 2 atop fa sy 3 ett 226 Flexor Tendon Injuries Suture technique: Pullout suture (see p.181 and Fig. 62a), Suture materia: Bralded 4-0 suture material éoubly armed with 3 svaight needle and aplastic bution over 2 Soft washer ae usec A pullout loops use. Running su- {ures placed using 6-0 monoflament suture material. Postoperative management: Postoperative manage- ment to enhance funetioalfehablfation ofthe ges Is indicated (sep. 239 and Figs §88-680). The pullout futures emved atthe end ofthe th week postopeta- tively. The kno divided above the plastic button and the suture is withdrawn with the pullout loop. Bony Avion ofthe Tendon ofthe Flexor Diora Pro- Fad ror the Distal Phtane with Aaetonal Avion tthe tendon from the Bone Fragment (Figs 673-6: Interna sation ofthe avulsed bone fragment anéat- tBehment ofthe tendon. Internal Fsatio ofthe used Bone Fogment and itchy ‘mont ofthe Tendon onthe Distal Plant (Ff, 6.7) Preliminary remarks: Sil avulsed fragments are usu~ fly proximally displaced sith the tendon ofthe Mexor ‘igor profundus muscle Lager agments usually become lndged in the A‘ snd AS pulleys. Where the force ofthe injury i sficlent, the tendon can avulse from the fagment and retract farther proximally. Frag= ments large than one-hir of the articular surface will result in insiablty in the sta interphalangeal joint {eorsalfacuredisloeation) Indication: Hory avulsion of the tendon fom the distal Dhtank with avulsion of te tendon fem the bone rag Approach: A Z-shaped incision fs made over he prox- ‘mal and distal interphalangeal joints. 1f the tendon is Severely retracted, emay be necessary 1 extend the In- ‘sion proximally, yee rarely as far asthe palm of the hand Internal fixation: Open reduction and stabilzation of the tagment vat: screw (15-2mm in diameter = in (1-12 mm, + pullout wice (Fi. 63. ‘+ ite suture (compare Fig.6.25). ‘Suture technique: Fulloat suture (see p.181_ and Figs G2a-c)is ued, The pullout wireis used trefixthe tendon together witha small base fragment (i. 6:3). ‘Suture materia: The pullout wire consists of braided 40 (4-0) suture material doubly armed with strakght heedies, pullout loop, and plesue bution over sot ‘washer The pullout wit consists of multflament see! ‘wire with 2 shaped anchor armed wich a staght eedle on che peripheral end and a carved cutaneous ‘eed on the oer end, a paste button over soft ‘washer and two lead shot pellets. Figs 6738 and b Bony awison of the tendon ofthe tee {igtocu poland nh he tendon ta Sted om thebone Hagment “he dared Fragmented ithe ply The danse tracted a aro the rsa niephalngel it Se ae Note: Tansfixing the distal interphalangeal joint witha pins ony indicated when theyoin¢ cannot be stabilized by inert Mxaton. Postoperative management: Were a pallou sutures Used Gee, with an ave tendon and stable it), post= ‘operative management enhance functional ehablita- tonisthe same s after flexor tendon suture inthe fi gers (seep, 239 and Fis. 689 and 680) The pullout s- Ture Is removed atthe ead ofthe fith week postopera. tively. The kao is cvide! above the plas button and the suture is withdrawn with te pllout loop. Where a pullout wite sued (ie. with bony avulsion of the tendon) postoperative management 10 enhance Fonction rehabieaon is containdeated fr the Mist four wesks gusta the rk of we fracture ander local tissue damage, The hand shouldbe immobilized forfour ‘weeks in 2 vost plster cast and spin. The wie Is re= ‘moved atthe end of the ith week postoperatively. The wre vided betwees the led Shot pallet and the plastic button and then sithdtaw wth the anchor on the other end 227 6 Tendon Injuries Figs 676¢ ony aon of th tendon ofthe foe da ram profane om te ial phan th srltan fhe {endon ram the bone Faget rested yrefing the e- th ig shows the posting oe pub sate and ‘le fr nr fast wih bone ew laceration ofthe Tendon ofthe Flexor Digtonum Profun- fis Muscle in Zone Opt wth’ s Shot Distal Sure. (Figs 675, 676 snd 678) + Advancement. “+ Tendon suture (see Fg. 678), ‘Advancement i Zne Dp (5,876) reliminary remarks: Wht there laceration of the tendon of te exor agri prfunus leaving 2 shore distal stump the preximal stump canbe inserted 3 the ‘istal phalanx instead of suucing the tendon. The ten= on should not be shortened more than Samm fm mize the risk of eeatng excessive flexion in the dis Interphalangeal ine. This could compromise the Fune= tion ofthe adjacent fingers as the Nexo digitorum pro- fundus tendons originate fam 2 common muscle belly, Indication: Closed! and open injures tothe Nexor ten= dns witha short asta sump. 228 tial ation othe sed Fragment. The tenn 2 ny agen 3 Neen hr tum pis 5 Nec he oer dtm apart ‘Approach: 2235 clon is made inthe mile and distal phalanges in closed injries. The incision may De ‘extended proximally to teat 3 severely retracted t= don. 1a open injuries, the wounds extended with id Tateilinislons ta erm a zigzag inion ‘Suture technique: Pullout suture (see p.181 and Figs 62a-¢) is used ‘Suture material Toe suture consist of bralded 4-0 su- ture material doubly armed with staighe needles, 3 Pullout loop, anda plastic button over aso washer Postoperative management: Postoperative. manage ‘ment tenance functional habitation isthe same = tera ezor tenon suture nthe ingers (ste p.239 and Figs 689 and £90) The pullout suture Is removed athe end ofthe ith weck postoperatively. The knots divided above the plastic bation andthe Suture Is withdrawn, ‘with the paiout oop. Flexor Tendon Injuries Tendon Sturn Zones Dp 1 and Op 2 (Fas. 6.77 and ons) Indication: Tendon laceration with along distal stump {over 5 mi Approach: The wound i extended with midlateralinci- Sons to form 3 2g2ag incision. Suture technique: Modified Kichmayr suture (see 183 and Figs.64-66). Suture materia: Braided 4-0 suture material is wsed Running sucreis placed using 6-0 monoflament suture mater Postoperative management: Postoperative manage ment to enhance functional rehabilitation is Indicated fer flexor tendon suture inthe fingers (se p.239 and Figs 689 and 690) Irs pot necessary to remove the tendon suture fig, 760" Laceatino theron ofthe sor garam (rfundor in zone Dp with Shert dtl sup teste y fend svancement he proximal enon sup inserted ‘it sare tough the bone sue on otetng Be tendon wing pleut tire ped troah the Dow 0.625. saceraton of etendan ofthe exe dora re [tnduc insane Dp ithe shor el tmp 1 done ne dtr pints a( band the tl stung ole tenon sun the prom ‘toro ater remeron apoio stent ‘ote Storeng te Reo tora offs teen fro: dn Sr cancateente Fon the Tcrhsange! ot ean moa incon 229 6 Tendon Injuries Zone Dp2 Isolated Laceraton ofthe Tendon ofthe Flexor Diora Profndas (Fas 6.77 and 6.78), figs 6772 and bated laceration ofthe tendon of the fw itor preunds wthnuryt the A ply 1 endnote tour deem pote 2 ni tn ren sigs. 678are_tolted lecation of the tendon af the fluor and ¢ The At pully is opened rough he inary Wound So ‘Aaionnpofondswthiny tothe spl eat 0 {ue the tena Then the ply close, ‘ang the endon wing mode Krehmay Techni fa ay eee 70 Flexor Tendon Injuries acration of th Flexor Tendons (Figs 679-682) ‘+ Tendon suture. Fp 699. Lactation of oth ator tendons in zan8 Dp2 {ned petre There of ce eso sn he pon apd ‘ital erphlongel os a ace Fowan sts pose n the metacupophsgel jin uc othe ation of ean gh. 6808 and &_Laceatin of both Hor tendons nZone ‘Op 2 wi he fg extended endo snot be na thee hen the Fe ‘ers enended red the jury ees forthe tendon ep 1 eal er ton supra 2 Teron er nm pans Tendon Satur (Fi, 682) Indication: Laceration 0° both flexor tenons Approach: The wound isextended wit miter inci- Sons to farm 38208 inesion. The synovial sheath Should only be opened a fa as is absolutely necessary. ‘Aalitioal ines in he palm ote hand may bere Aired to reat severly retracted tendons. Suture technique: Modified Kirchmayr suture (see prI83 and Figs 64-66) Core sutures (see p. 180 and Fig.61) or crossover sttures are indicated {0 creat 3 laceration ofthe flexor digitorum supeficiais cose co the Insertion. Suture material: Braided 4-0 suture maceral is used. Running sutures placeéusing 6-0 monoflament sure rmsteria, Postoperative management: Postoperative manage tent to enance functional rehabltation Is indleatee fer a exr tendon suture inthe fingers (se 232 an Fis 89 and 690) rar necessary remove the Fig.68a and b Lactation ot bot eto endons in 20r8 Dp wth the ger feed ‘hetendon sips il befcanda dere iv whan ie Fae Inetended sath uy pest fr the tenon ropa 231 6 Tendon injuries 1 imoroper ooo ofthe tendon ley. Theforceps inthe Moston sre te base ofthe poral plane Beene they ate net hed pal othe dren of ete dosha The mon tp sme be aod fies 5820-8 Surgical tedigue fr suturing a aeration of flexor endo in zone Op2 1 ne ted fresare sed aga the psnatends tthe Senda thot akg anna nan te pl of ‘han The wit ea rth proce, fn arate proce to gasp the proximal tendon Steps tug an neon nthe palma he ane Te {eed pao be en seh ‘Steer a rout the tendon whch teh puted dats» Bt oe Tendeloo ste Flexor Tendon Injuries paar ©The tendonfhe tr sper srepated wth issover 6 Tendon Injuries Palm Zones Dp 3 and Dp 4 laceration of Both Fexor Tendon (Figs. 683-6 85) Tendon suture, F.683 aeration of both err tendans in the mid i ‘se nd ng finger n zane Dp 3 act ptr: ere oo ci eon inthe roxio stalinephlngel js Weak sce Reson illu ‘he metcapoptinges ts de tothe actn of the 234 Tendon Suture (Figs. 644 ane 685) Indication: Laceration of one o* more exor tendons. Approach: The primary wound is extended. An addi tional incision im the wrist reson may be required to (rea severely retracted tendons. ‘Suture technique: Modified Kirehmayr suture (see 183 and Figs 64-65), Suture material: Balled 4-0 sutuie material is wed Running sutures placed using6-0 nonoflament suture mater Postoperative management: Postoperative manag ment t enhance fundional rein Is inclested ter aMexr tendon suture inthe fingers (se 239 6 Figs 689 and 690) Icis not necessary to remove the tendon sure Note: Associated Injuries to neurovascalar structures should be treated primarily whenever possible, Post- operative management enhance funcional ehabiits- ‘on will wally be pessible in spite of tis 155,688 Complex rua eeation in the pl “enon repeated enn the west andthe js othe Inwoked ngewe cent aoce ngs tendons ‘ignate fmm 2 conan ral bly) 1 cam pana gt ate 2 Tenia Roar aun pera 2 Ser arr hed cre 3 ena fe how eto plo Flexor Tendon Injuries 235 6 Tendon Injuries Fs.688ard_ Management of laceration of oth Neortn- 1 oun fh ea dtu psn ‘dang in the ide ng andring finger ze Dp 3inohes 2 “amie, tendon suture and treatment of museaarnarsand otheras- 3 Tsuba he ess datum pes Seed ines ee tendon fe sted ung 2 edie Keehn tach ne Graff trac micltisie fom the samba se rpsed between the wed tendons to pee ade 4 a ectrn of te eons es en “how heparan neve. Te ese rec one ttc Tern fu ghana a tee fm a Fara he mec rene uy pity on ge Wrist and Forearm Zone Dp Laceration of Both Flexor Tendon (Figs. 686-5 8) + Tendon suture F685. Lacrton of both flexor tendons ia the inde. ‘ne nding gers in zone Dp ine pte on of ce eo he posal and ‘itl erpsianea fone Wea Nexon Sa posse nthe ‘netacarpoptalagenl ont du othe acto fe amb, F687, complex traumatic tration ronimal othe exor ing ene tenons ae yng hw athe Flexor Tendon Injuries Tendon Suture (Figs. 687 and 688) Indication: Laceration of one or more Nexor tendons. ‘Approach: The primary wound is extended Suture technique: Vocifed Kirchmayr sucure (see pid ond Figs 84-66) Suture material: Braided 4-0 suru materials used Running sutures place using 6- monofilament suture smateria, Postoperative management: Postoperative manage rent to enance funcional rehabilitation #6 indleated ter lear tendon stein te fingers (Se 239.6 Fes. 689 and 680). Itis noc necessary to remove the tendon suture, Note: Associated Injuries co neurovascular stuctures Should be treated primarily whenever possible. Post- ‘operative managementto enhance rnctionalehabilta- ton wil usualy be possible in spice ofthis. “The same suture technique is wsed in treating injuries to te tendon of te exo: carp radials angus, Nexor carpi radials brevis, exo erp lnais, and pelrars Ins Postoperative managerent (oenfiancefuncloalreha- bitation not necessary in slated lacerations ofthese tendons, Te arm's imnobilized for five weeks in aore 2 Pa bon ote med nae 237 6 Tendon Injuries Te sue wea to cone wane proximal to the exo retinaculum napintas sects ae ste ayes. Trdon stares ae paced (hing oetes Kren techie. «Alena ccs epee fray suture, Where posite, muscle Is exposed be ‘hota the std de Flexor Tendon Injuries Zones Dd 1 Through Dd 5 Posopertve {0 Enhance Fanconi. {ation flat} ofr Fox Tendon Sure nthe gers (Figs 689 and 680) “The forearm and hand are immobilized ina dorsal splint that limits extension inthe wrist and in the metacar- popbalangeal joins ofthe fingers. This by ise is su ‘ent to prevent the exors frm exeiag any pull on thelr tenons: Actively extending the fingers also t= ges a reflexve reduction in the tne of te Nexors. This Bandage configuration permits the flexor tendons (0 lide without placing signifcant stresses on te sures, ‘A metal lop with an elastic band is sled co the ail of ‘each injured Ringer. The band i fed through a series of pulleys close othe bandage The tension on the band is ‘only sufcient to maintain passive lexion in the finges ‘he patient ean actively flex them afar asthe splint wl slow Motion exercises are begun on postoperative day one ‘he wound dressings reduced. The splints leftin pace for four weeks, and the elastic bands for anther wel. Mle that. 0.699 Farina ebaataton rear tendon stein thee ‘Etim exo he wrt edced by pons 20-3 Themetaaopbainge fins of he bese Rene 2p rey 33° The pone and dal ntepalnggl mse ‘de Fig. 890¢-¢ Splint eames factor ohana ‘flexor tenon suture Inthe ners 3X no oud nt nal the je Fig ad Sante bane fed hee op a 239 6 Tendon Injuries bande thease bang pase ses the ng ints Ful 1 eal ep {he etersins ossble ine prowratand cal 2 Plea he bndne dt he ore Pholngclants te spinelmaeaurson ntermecs > Hand ‘Seppe an ‘Thumb Zone Pp 1 gat Lartn fhe tendon tte opt ants ‘Ca itr: There eon in te epg je Ste thumb. Weak fexor is sti pss m tees" ‘ooh ait du othe con of the Reso po bret, ‘islet fontun the exo aceon ofthe pie lars tendon zanes Pp 1-293 orp 5 240 loved Inries to the Tendon ofthe Flexor Pols Longus ‘The rare subcutaneous avulsion, bony avulsion of the {ndon fom the base of the distal patans, and dorsal fracture distcaton ofthe distal phalanx with bony avul sion of the tendon are Ueated surgically. Suc tech- flgue is idential to that used In the fingers (see p. 26 and Figs. 671-64). Lceration of the Tendon ofthe Flexor Poles Longus ‘sith Short Osta stump (Fs. 691-683) ‘= Advancement, 1,692, Frequent tes of ijry tthe thumb ine ones ‘atthe lef the distal terpolanea! jis one PP? uhelevla the abut gament and thereon pox Tendon atthe aus loess ares rey ae requ y the Specter 1 rma opt Flexor Tendon Injuries ‘Advancement (Fi.6.83) Pretiminary remarks: Whore there is alaceation ofthe tendon leans shor dal timp, the proximal tum an be inserted atte distal phalan instead of suturing the tendon. The tendon in ie Chum ma’ De shortened ‘more generously than in the Minger. However, this Shortening should net exceed 10mm to minimize the "sof cresting excessive levion inthe iterpalangeal Joint and possibly inthe metacarpaphalangeal joint Indication: Laceration or rupture of tendons with 3 short distal stump (apt 10mm). ‘Approach: In open injtes, the wounds extended with ‘mldlateral incisions t fora zigzag incision. A zigzag, Incision fs made in closed injures. Suture technigue: Pullout suture (See p.181 and Fi G2a-c) is sed, Suture material: Teste consists of braided 40 5u- ture materal doubly med with straight needles, 2 Dillout lop, and spas buon aver a soft washer Postoperative management: Postoperative. manage ‘ment fo enfancefunticna habitation Is the same as iter Tepaltof the Nes polls longus tendon (see .247 and Figs 6100 and G01). Te pullout suture Femoved atthe end ofthe fith week postoperative ‘The knots divided above the plas ution an the = tare i tha with the pullout Loop. 9,693. aeration ofthe tendon of the fee pols longus Inuit short dtl tet by tendon advance Iron the posal tendo stumps inserted witha pullout se 241 6 Tendon Injuries Zone Pp 2 Laceration fhe Tendon ofthe Feo Pls ong a Shetowtotthe owns Mn (Fee 654-698) «Splice advancement ofthe tendon Tendon suture Spice Advancement ofthe Tendon (Fig 694) Preliminary remarks: Unfortunately, adhesions easily ‘cea aceravons ofthe flexor polis longus in 20ne 2, especially where cere extensive craumadc dar ape fo the tendon andfor tendon sheath. One way to minimize the risk of adhesion is to perionm a Z-shaped Splice advancement of the tendon inthe distal forearm, tb replace the vistal tendon stump. This eliminates the heed or tendon sutures inthe injured area, Indieation: Laceration ofthe cendon a the lve of the proximal phalans with estensive waumatie damage fhe tendon andr tendon sheath Fig 594are Splice advancement ofthe tendon ofthe Noxor pic nau he etn fe tendon a he dtl pan expose The dial lear is ofepred to facbate he Eshped 9 vance of the sped tendon at te muscles joion 242 Approach: The wound i extended as fra theinserion of ie flexor tendon atthe eistal plans. The Mexor polis longus enon is exposed it the distal forearm tsing the tendon of te flexor carp adais as an ana mi landmark forse ineston, 3 entorgaaue 1 Moen ee pa nga § Pama bana fe rc 1 Se Ah aenen Flexor Tendon Injuries eee nc NaNO ‘Surgical technique: A Z-shaped splice advancement of the flexor poles longus tendon at the musculoten- ‘nous Junetion is performed in the asta forearm (ig s98m), The distal tendon stump is resected to approximately Sm, This stump use co strengthen te nserlon of the proximal tendon stump. “Te proximal sump is inserted athe distal phalanx and {iked wit + pullout suture throug the bone, Muscie is tarapped over the sure stein te disal forearm to pre= vent adhesions. ‘fer the proximal tendon stump hasbeen permanent Feineerted at he base ofthe cistl phalanx the two ten= dn strips at the splice site in the distal forearm ae ap- roxiated with a etining suture. Thumb function can fhen be evaluated In comparison to the conalate Sd withthe wisn maximums extension and Nexon, [nis done wien determining the lent of tenon grafts to reeonstuct the flexor tendons in the fingers (ste p.257, 256, and Figs. COM e-4, and S112E-d), Suture technique: 4 pulloat sutore (see p.181 and Figs 6 ace) is sed inthe dtl phat wi coe i= {ures between the distal tendon stump and the re Inserted tendon (seep. 180 and Fig 6.1. Core sutures in the distal forearm fix the spliced tidon and are used 9 proximate the muscle (seep. 186 and Fig 67), ‘Suture materia: 4 suture consisting of brad 4-0 su- ture material coubly armed with straight needles. a pullout loop, and a plasic button over a sort washer is Used for rensertng the tendon atthe distal phalanx Braided 4-0 sure materials used the dst forearm, nd absorbeble 4-0 sutare materials used in approx ‘mating the muscle Postoperative management: The same after epaitof the foxr polis longus tendon (sce 9.247 and Fgs.6100 and 6.101) The pullout suture is removed at the end of the filth week postoperatively. The knot is ‘divided above the past button, andthe suture i wit ‘awn with she pullout lop, Ils 80t necessary Wr move the tendon sutures inthe distal forearm. Technique of Zope spice afvarcement of the tendon a Serer in tan eaeed 1 enon ee pais rs 2 plo «The tendons in stay thr he bane wt put Ue: he fs then rapped ver the sree of he ett pt ata nl satin 4 1 Fergie nas 243 6 Tendon Injuries Tendon Suture (Figs. 695 and 696) Indication: Lacertion ofthe tendon in zone Pp 2 atthe level ofthe metacarpophalageal jin or proximal tt ‘Approach: The primary wound is extended, An ad- ional incision inthe eistl forearm may be required to ‘eat a Severely retracted proximal stump, Suture technique: Modified Kirchmayt suture (see 183 and Figs 84-66). ‘Suture material: Braided 4-0 (3-0) suture maesat armed with various needles is used, Running suture i Placed using 6-0 monofilament sutuee materia, Postoperative management: Postoperative. manage ‘ment f0 enhance functional rehabilitation f= insisted after a flexor polis longus tendon suture (cee p. 247 8nd Figs. 6.100 ané 6.101), 0.695. taceration a he xr plillongutondon tthe lee! ofthe metacarsnphalangeat jt. Te erston ie ices head rewonsclr bun 2 ope par tit 5 Meroe dc pals 4 ge nnd a rp 5 Tendon ih te: peau 6 Papereinar ene in. 96. the Neos plc longus tendon sutured (ich- ‘may technique) a the evel te metcapophalngel jot and the ada neurortclsbande roped 1 anes afters 2 Obie a of est pe 5 Teal Rr pet ge 4 Hihoce partes 5 peat ead tur pot bese 244 Zone Pp3 acraion ofthe Flexor Pals Longu Tendon in the Sense Ragin (gs 697-699), 1+ Tendon suture Tendon Suture (Fas 698 and 699) Indication: Laceration ofthe flexor tendon Inthe thenat region Approach; The primary wound is extended to form a Zahaped incision. An additonal incision in che distal forearm may be request teat a severoly retracted prosinal stu. ‘suture technique: Modified Kichinayr suture (see ribs ane Figs 84-66). Suture material; Brakded 4-0 (3-0) sure materia fred with various needles i used. Running suture is placed ving 6-0 monofilament suture material, Postoperative management: Postoperative manage- iment fo enhance funetonal rehabilitation i indicated ‘era Mexor pollicis longus tendon suture (see 9.247 4nd Figs, 6100 ad 6101) Note: A primary tendon suture is prefered, and as- sociated jules should also be treated primarily. Despite postoperative management to enhance functional vehabiitation, adhesions equenty occur in this repon following severe trauma, One should con- ‘ler @ primary tendon graft (35 on p.254 and in Figs 6109-6112) or secondary treatment ina owo-sage tendon aft procedure asin the fingers (se p248 and Figs 606-6.12) in severe lacerations or wounds re- firing extensive debrigement Flexor Tendon Injur Fig.637_Peaon of the tndon of the exo poles ongusin {he tora region Dahenons eqn ext Fong eran bts 1 Tone 245 6 Tendon Injuries a,698 A mote Krchmaye tcigue i used to stare ‘he lec police tendon mth tena eon protest eee Fig.690. Peary autre ofthe exo polis longus tendon tnd uss Shenae ‘Soest nis ore and ners strates should ho be teatee pronesy oe ere 246 Flexor Tendon Injuries So oregon tS Zones Pp 1 through Pp3 Pesoperativ anogerent to Enhance ncn Rehobi {acon diet afer a Flexor Pall Longs Tendon Sure (Gigs 6100 ad 6.101), “The forearm, hand, an thumb ae immobilized ina dot- Sal splint that limits extension in (he wrist and inthe joints of the thum Bue does not include the Finger joins. ‘Te bandage technique and the treatment principle are Identical to ceatment of the fingers (See p.239 and Figs S89 and 690, tan toon nurse 9.6100. Postoperative management to enhance fonctions ‘habitation afters exer pl longi tendon sire otion af he nthe se Ie nxtyenacd Mi, Seater ‘Dace epson g.6201_ Postoperative nanagement to enhanc uncon ‘ehatation ae exer ols longs tendon tre “he asic band pare Fees the fons os. The spt ks ive exes, 247 6 Tendon Injuries 2 tendon Wnjuries ‘Treatment of Poorly Healed Injuries ‘Chronic Hexor Tendon Lacrations 4 Immediate tendon grat 1 Two-stage tendon recanstruton "Short gra = Tong ga + Tenodess ‘+ Arthrodess (see pp. 294,296, and Figs. 761 and 7.67). Prcliinary Remarks Whether exon inthe fngers can be succesfully e stored ater a chronic exor tendon lsceration will de- pend on how recent the injury isand on local conditions, Flexor tendons can usually Be rectly replied. itn {three ive weeks ofthe injury Gependingon thesever- Ity of adhesions and searing in the tendon and tendon sheath Local changes inthe tendon sheath (uch 2 cating oF Infection). compromised skin or vascular supaly. 2nd joine contractures worsen the chances of achieving Complete restoration of function Essential prereuisices fora succesful tendon grat in- clude: ‘Soft issue release and debridement, ‘© Invact tendon sheath, Functioning muscle * Unimpaired passive motion inthe joint. Rehabilitation therapy is indicated where these conti- sonar not met ani some ses rey mig have to ereate these concitlons An altemnative st improve hand and finger function by Surgical fusion of the finger joints (Cenedess ot ar- trodes) mmect Tendon Graft (gs. 6109-6.112) Indications: Chronic Rexorcenon lacerations without accompanying injures tothe tendon sheaths whee & ect tendon sutures not easibe and flexor tendon i Juries inthe thenar ceo Surgical principle: Replacement of one or both flexor tendons ofa finger witha rae rom the palmari longus or plantaris muscles, Surgical and suture technique: This i essentially iden- {ial othe technique used i te second stage oft. Stage tendon reconstruction (se p.254 and Figs. 6108 S412). a blune probe is used. pull the erat nto the tendon sheath Postoperative management: Postoperative manage- ‘ment to enhance fictional ebabitation Is the same as after a exr tendon suture in the fngers(see .239 ond Figs. 689 and 690) or Nexo pollicis longus tendon so- ture (Seep. 247 and Figs 6100 and 6.101), 248 ‘wo Stage Tendon Reconstruction, Fst and Second Sage (Figs 802-6-72) Indications: Chronic Nesor tendon laceratons with scarring ofthe tendan shexths andor local soe ssue amage Short graft (fingerto palm) to bridge a defect inthe Finger: ~ Long pat (finger istal forearm) ta bridge a dect Inthe finger, palm and wrist. ‘Surgeal principle: Fst suge: The saris resected and the tendon sheath rennstrucred with of zsue et elope plastic spacer (a Silastic od) is inserted nto the tendon sheath. Pstoperative management icles Passive motion exerces that use te ging motion of ‘he Sis rod w form a new fencon Seah, ‘Second stage: The Silastic dis replaced with a tendon ‘raft fom the palmar tongs of plantaris. = Postoperative management: Postoperative manage- ‘ment to enhance functional habitation isthe same 3s after aexor tendon suture inhe gers (ste p.239 nd Figs. 689 and 6.80} ora lexor polis longus tenon su Cure (Seep. 247 and Fis. 6100 snd 6101, Flexor Tendon Injuries oor itor ‘rst stage short an ong rat) ‘Avproach: A 2ig2 incision is made inthe finger and Palm, Long grafts may require an addtional angled inc\- Sion in the distal forearm (Fg, 6103). Surgical technique: Figs. 6 102-6108. Suture technique: Core sutures (seep. 180 and Fig, 64) Se placed tof the Silastic fod and reconstruct the flexor tendon ples ‘Suture materia Braided 4-0 suture materia is used Postoperative management: The hand is immobilized ina palma plaster cast fo thee weeks Motion therapy forthe whole hana is chen begun. This involves passive ‘motion exereises or te involved finger joints. These ex- ffelses ae continued for two to thee montis until a tendon sheath develops Fo.6102 Extensive seing in the tendon sheath in hone Mexor tendon nies rect enon steer recnstction in 3 Sng operation sno Tonge eae 1 sexing al ao sth 4 Nd se dato superie 5 renee Som digtnan pron ‘Complications: Early, cessive motion exercises with fhe silastic rod in place can Tea to nlammation ofthe tendon sheath Note: The rounded end of the Slate rod should le ‘proximal ie, inthe pam or wrist 1 te Silastic ro is too inthe tendon sheath wil be too narow forthe grat This will sult impaired mo- tion aad loss of strength I che Silas rods 10 thie, the vendon sheath wil be too wie forthe graft This ls increases the risk of in- flammation during passive melon exercises. [An overly wide (endon sheath and inadequate secon- ‘Stuctonof the lgartandon pulleys wil esultin “bow Stinging: of the flexor tendon wth fossof strength and ful Nexon. Fe,6103- nos dice for lua tendon reconstucion 249 6 Tendon Injuries Flexor Tendon Injuries fpss0ged Tao stge xrtendonrecntionwth® Tonle en dg on stot ra a ose) eto apenas so sated ote recnstd ton hath, 3 bed eee ‘Grn sgt ger than 3 3 tne plamed 251 6 Tendon Injuries The Sas ro ad he dal pan _Flexor Tendon Injuries 4 253 6 Tendon Injuries fo,6108 Twostage flexor tendon reconstction with ong rat rt stop) The tases pled hough the carpal wine sound nt [evi the Stal ftear. The pina en te tenon of te wr cre supers and exo igor pron are ‘ited th enor sethaelom one motets. The fete of hero (oa Orme) sgn age tha Ce Famed gra 1 ena te ar datum pd § endnote es dgoum iptesle Somber Sacra ‘Second stage (shor: an fon graft) Approach: Ax oblique incsion is made in the distal phalanx ofthe fnge. A second incision ts made inthe pall fora shore rato nthe distal forearm for along. raf Tae incisions follow the respective sears fom the fist operation. ‘Surgeal principle: A shor graft is obtained fom the palmar longus tendon or along raf rom the plantaris fendon. The Slstc od is replaced with the graft Surgical technique: Fs. 6108-612 ‘Suture technique: pullout sutures used on the distal end (se p. 18 and Hgs-62a-c).A modified Krchmaye ‘Suture (ste. 183 and Figs.64-66) or shoelace suture (Gee p.186 and Fig.68) is used inthe palm with short, rafts Long grafts we woven into the endon(eep. 188 Sd ig. 6) nthe distal forearm (Jong gra) ‘Suture material: Braided 4-0 (3-0) suture material is Used uring sutures placed using 6-0 monotlament Postoperative management: Postoperative manage ‘ment to eahance funcional rehabilitation ithe same as fier fexortendor suture inthe fingers (Seep. 239 aad Figs 689 nd 690)» 3 lear poles longus tendon si ‘ure (Se page 247 and Figs. 6.100 and G01), Complications: Grft length is important. Too short a raft wil result in a flexion contracture of the finger Joints! too ong a raft or gap inthe suture wil esultin "patted exon aa loss of strength Note: The fina eng of the graft should only be deter ‘mined after moving the finger through its range of mo= tion several times Injury to the peritenon of the graft increases the risk of saesions, ‘The tendons ofthe second through ith extensors ofthe toes may be consicered 25 donar sites Ifthe palmar Tongus ahd plantas re not avalale 254

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