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Techniques in Hand and Upper Extremity Surgery 10(4):200Y205, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| R E V I E W |
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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis
measurement using laser diffraction, 9.1 mm of ECRB over the radial tunnel, but not at the elbow joint. Specific
tendon lengthening was predicted to result in a 25% tests used in the workup of lateral tendinosis and radial
reduction of insertional loading while providing a 25% tunnel include pain with passive pronation, passive elbow
increase in muscle active force generation.21 The best extension, active supination against resistance, wrist
clinical results reported in the literature were for 22 extension against resistance, and long finger extension
patients treated with a VYY slide lengthening that gave against resistance. Although conventional wisdom has
100% good to excellent results and 95% of patients held that some of these tests are uniquely capable of
reporting no limitations in daily activities.22 differentiating lateral tendinosis from radial tunnel in
Typically, patients with lateral elbow pain that does isolation, clear and convincing data have never been
not appear to originate from the radiocapitellar articulation brought forth to support that contention.
have been assigned a diagnosis of either lateral tendinosis
or radial tunnel syndrome, but not both. In fact, 1 Additional Testing
randomized prospective study approached the problem of One article describes an attempt to distinguish radial
lateral elbow pain by either performing PIN decompres- tunnel syndrome electrodiagnostically by a differ-
sion (50% success) or lengthening the ECRB in the ential latency obtained in 3 different positions of
proximal forearm (43% success).23 Little attention has forearm rotation, but clinical practice standards still
been given to the possibility that these 2 clinical entities hold that electrodiagnostic testing is not useful as
may actually represent an integrated pathology despite part of the evaluation of a patient suspected to have
anatomic and biomechanical findings that demonstrate radial tunnel syndrome.1,7,25 One adjunct that has been
the relationships between the supinator and ECRB with used to supplement the physical examination by some
respect to tensile force in the common extensor origin and authors has been the ability to block positive provoca-
radial tunnel pressure.24 Improved clinical results rather tive physical examination tests for radial tunnel with the
than the characteristically unpredictable outcomes with a instillation of local anesthetic.26 If a block using 3 to
third of patients having substantial residual pain may be 5 mL of 1% lidocaine is done at the radial tunnel and
realized if both pathologies are treated together, rather PIN more distally, incomplete relief is an expected
than leaving one or the other untreated to act as a source finding in the usual clinical scenario of concomitant
of continued pain and poor functional performance. lateral tendinosis. If complete relief is achieved with a
distal block of the PIN, the patient likely has a pure radial
tunnel syndrome. If complete relief is achieved with a
| INDICATIONS/CONTRAINDICATIONS whole radial nerve block above the elbow, this only
The indication for surgery is based on making the clinical demonstrates that pain emanating from the lateral elbow
diagnosis of the 2 conditions, lateral tendinosis and radial region is being transmitted through the radial nerve, but it
tunnel syndrome, determining that other differential does not identify the specific source or etiology of the pain.
diagnoses are not responsible for the patient’s pain and
ensuring that the patient has none of the other contra- Differential Diagnoses
indications discussed below. A high degree of proximally based radicular pain in the
upper arm, shoulder, or neck region should call attention to
History one of the major differential diagnoses that must always be
This begins by identifying those patients who complain considered, primarily cervical radiculopathy (specifically
of pain in the lateral elbow and/or the proximal forearm. at the C5YC6 level that maps out the dermatome passing
In mild cases, the pain is usually absent at rest, over the lateral elbow). Other differential diagnoses that
provoked by powerful grasping and lifting activities, must be considered include elbow arthritis, intra-articular
and worse at the end of the work day. As the condition loose bodies, plica, avascular necrosis of the capitellum,
becomes worse and more chronic, a baseline pain is posterolateral rotatory instability of the elbow, lateral
usually present at all times but is still augmented by overload from medial collateral ligament instability, and
activation of the extensor-supinator muscle group. The compression of the lateral antebrachial cutaneous nerve.
pain may radiate distally or proximally with radiation
implying a greater degree of nerve involvement as Other Contraindications
opposed to a pure lateral tendinosis. The pain associated The major contraindication for surgical care of a patient
with radial tunnel syndrome typically radiates distally. suspected of radial tunnel and lateral tendinosis is for a
patient whose pain does not appear to be specifically
Physical Examination attributable to these clinical conditions. On history, the
On physical examination, patients should feel relatively patients should be able to clearly localize the anatomic
nontender in surrounding areas and specifically tender to location of the pain by pointing with the index finger of
pressure application at the common extensor origin and the opposite hand. Broad, generalized, and nonspecific
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Henry and Stutz
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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis
| REHABILITATION
The prime activity of the postoperative rehabilitation
process mirrors closely the preoperative therapy tech-
FIGURE 4. The arcade of Frohse and additional fascial nique with the main emphasis on composite stretch of
bands within the supinator that cross the PIN are fully the muscle fibers in ECRB and EDC. The combined
divided. The PIN, encased in perineural fat, (black arrow) position of elbow extension, forearm pronation, and
courses obliquely from upper left to lower right, perpen-
dicular to the fascial fibers of the supinator (a thick band wrist flexion stretch of the ECRB and EDC muscle
pointed to by the scissors is seen proximally crossing the fibers is performed hourly for at least 10 repetitions per
nerve and has not yet been divided). session (Fig. 6). Mobilization of the skin layer to glide
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Henry and Stutz
| CONCLUSIONS
The issue surrounding radial tunnel syndrome tradition-
FIGURE 6. The main exercise in postoperative rehabil- ally has been properly identifying it clinically. When
itation is the composite stretch of elbow extension,
forearm pronation, and wrist flexion. treated surgically as an isolated entity, a third of patients
are left with substantial residual pain that limits activi-
ties. In contrast, lateral tendinosis seems to be easy for
rather than adhere to the antebrachial fascial layer is clinicians to identify but has a great number of different
performed manually, and a silicone patch is worn over techniques proposed for its treatment, all of which share
the scar while it matures. Strength development in the the common theme of interrupting the linear tension
forearm muscles is not begun until a full composite applied to the common extensor origin. The results
stretch can be comfortably performed which occurs appear to be quite similar to those of radial tunnel and
anywhere from 3 to 6 weeks postoperatively. Progres- relatively independent of the technique selected. Perplex-
sive strengthening is then carried out during the next 4 ing in the literature is the apparent concept that a given
to 6 weeks while the patients resume their more patient must have either lateral tendinosis or radial tunnel
challenging personal activities of work or sport. Patients syndrome, with little or no allowance for the possibility
are not told that they must avoid anything in particular that both pathologies may coexist. Review of the relevant
in the first 2 weeks after surgery. However, the wound anatomy indicates that a combined pathology of com-
must be kept free of infection. The patients are advised pression of the PIN and excessive tension at the common
that continued pain and local inflammation are warning extensor origin should, in fact, be more common than not.
signs of overactivity. A standard progression of first This technique addresses the possibility of coexistence of
achieving full range of motion and composite stretch, radial tunnel syndrome and lateral tendinosis and treats
then adding controlled strengthening exercises, then both with a unified approach.
job- or sport-specific strength development, and finally
full return to work or sport is followed. The longest a
patient should take to return to full activity is 4 months. | REFERENCES
1. Barnum M, Mastey RD, Weiss AP, et al. Radial tunnel
| RESULTS syndrome. Hand Clin. 1996;12:679Y689.
The authors have used this combined treatment 2. Atroshi I, Johnsson R, Ornstein E. Radial tunnel release.
approach on 44 previously unoperated patients (26 Unpredictable outcome in 37 consecutive cases with a 1Y5
year follow-up. Acta Orthop Scand. 1995;66:255Y257.
men and 18 women) with a mean age of 45 years
(range, 27Y63 years). All patients had participated in a 3. De Smet L, Van Raebroeckx T, Van Ransbeeck H. Radial
nonsurgical treatment program for a mean of 16 months tunnel release and tennis elbow: disappointing results?
(range, 4Y48 months) before surgery. Patients were Acta Orthop Belg. 1999;65:510Y513.
followed up until their discharge from clinic at a mean 4. Jebson PJ, Engber WD. Radial tunnel syndrome: long-
of 4.5 months (range, 3Y7 months). At this point, formal term results of surgical decompression. J Hand Surg.
therapy was discontinued, and the patients were released 1997;22A:889Y896.
back to full duty work at a mean of 8 weeks (range, 5. Lawrence T, Mobbs P, Fortems Y, et al. Radial tunnel
2Y12 weeks). Preoperative grip strengths of a mean syndrome. A retrospective review of 30 decompressions
22 kg (65% of contralateral) were increased to a of the radial nerve. J Hand Surg. 1995;20B:454Y459.
postoperative mean of 34 kg (97% of contralateral). 6. Plate AM, Green SM. Compressive radial neuropathies.
All but 2 patients declared complete relief of the Instr Course Lect. 2000;49:295Y304.
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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis
7. Ritts GD, Wood MB, Linscheid RL. Radial tunnel and complications. Tech Hand Up Extrem Surg. 2005;
syndrome. A ten-year surgical experience. Clin Orthop 9:105Y112.
Relat Res. 1987;219:201Y205. 17. Grundberg AB, Dobson JF. Percutaneous release of the
8. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, et al. common extensor origin for tennis elbow. Clin Orthop
Results of surgical treatment for radial tunnel syndrome. Relat Res. 2000;376:137Y140.
J Hand Surg. 1999;24A:566Y570. 18. Nirschl RP. Lateral extensor release for tennis elbow.
9. Regan W, Wold LE, Coonrad R, et al. Microscopic J Bone Joint Surg. 1994;76A:951.
histopathology of chronic refractory lateral epicondylitis. 19. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release
Am J Sports Med. 1992;20:746Y749. for lateral epicondylitis. Arthroscopy. 2001;17:582Y587.
10. Verhaar J, Walenkamp G, Kester A, et al. Lateral 20. Tasto JP, Cummings J, Medlock V, et al. Microtenotomy
extensor release for tennis elbow. A prospective long- using a radiofrequency probe to treat lateral epicondylitis.
term follow-up study. J Bone Joint Surg. 1993;75A: Arthroscopy. 2005;21:851Y860.
1034Y1043.
21. Friden J, Lieber RL. Physiologic consequences of surgical
11. Bisset L, Paungmali A, Vicenzino B, et al. A systematic lengthening of extensor carpi radialis brevis muscle-tendon
review and meta-analysis of clinical trials of physical junction for tennis elbow. J Hand Surg. 1994;19A:269Y274.
interventions for lateral epicondylalgia. Br J Sports Med.
22. Rayan GM, Coray SA. VYY slide of the common extensor
2005;39:411Y422.
origin for lateral elbow tendonopathy. J Hand Surg.
12. Chung B, Wiley JP. Effectiveness of extracorporeal shock 2001;26A:1138Y1145.
wave therapy in the treatment of previously untreated
23. Leppilahti J, Raatikainen T, Pienimaki T, et al. Surgical
lateral epicondylitis: a randomized controlled trial. Am J
treatment of resistant tennis elbow. A prospective, random-
Sports Med. 2004;32:1660Y1667.
ized study comparing decompression of the posterior
13. Peart RE, Strickler SS, Schweitzer KM. Lateral epicon- interosseous nerve and lengthening of the tendon of the
dylitis: a comparative study of open and arthroscopic extensor carpi radialis brevis muscle. Arch Orthop Trauma
lateral release. Am J Orthop. 2004;33:565Y567. Surg. 2001;121:329Y332.
14. Almquist EE, Necking L, Bach AW. Epicondylar resec- 24. Erak S, Day R, Wang A. The role of supinator in the
tion with anconeus muscle transfer for chronic lateral pathogenesis of chronic lateral elbow pain: a biomechani-
epicondylitis. J Hand Surg. 1998;23A:723Y731. cal study. J Hand Surg. 2004;29B:461Y464.
15. Dunkow PD, Jatti M, Muddu BN. A comparison of 25. Kupfer DM, Bronson J, Lee GW, et al. Differential
open and percutaneous techniques in the surgical treat- latency testing: a more sensitive test for radial tunnel
ment of tennis elbow. J Bone Joint Surg. 2004;86: syndrome. J Hand Surg. 1999;23A:859Y864.
701Y704. 26. Sarhadi NS, Korday SN, Bainbridge LC. Radial tunnel
16. Luchetti R, Atzei A, Brunelli F, et al. Anconeus muscle syndrome: diagnosis and management. J Hand Surg.
transposition for chronic lateral epicondylitis, recurrences 1998;23B:617Y619.
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Techniques in Hand and Upper Extremity Surgery 10(4):206–211, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| R E V I E W |
| ABSTRACT head, and the palmar plate and enable effective extension
of the MCP joints. Rheumatoid arthritis can cause nu-
The extensor mechanism of the hand is complex,
merous deformities in individuals due to ligamentous
requiring effective functioning of all involved struc-
laxity, tendon ruptures, and sagittal band attenuation or
tures, including the sagittal bands. The sagittal bands
rupture. In particular, sagittal band disruption produces a
function to maintain the extensor tendons in midline
loss of active finger extension at the MCP joints (Fig. 1),
and to limit their distal excursion. Injury to the sagittal
which can lead to instability of the extensor tendons,
bands or sagittal band attenuation can cause instability
swan-neck deformities, and ultimately volar subluxation
and ulnar displacement/subluxation of the extensor
of the MCP joints. Sagittal band attenuation or rupture
tendons into the valleys between the digits and lead to
is evident if a patient can actively hold the fingers in
a subsequent loss of active finger extension at the meta-
extension when placed. However, after active flexion,
carpophalangeal joints. Secondary conditions may also
they are unable to actively extend the digits (Fig. 2).
develop, such as swan-neck deformity, as is frequently
The dynamic MCP extension assist splint is de-
observed in the rheumatoid arthritis population. To pre-
signed to allow active MCP flexion and assist with MCP
vent or reduce an extension lag and secondary changes
extension. The splint stabilizes the extensor tendons and
and to maintain the functional use of the hand, a dy-
assist in tendon gliding to allow extension at the MCP
namic metacarpophalangeal extension assist splint is
joints. The splint also helps prevent secondary compli-
necessary. This splint enables extension at the meta-
cations such as extensor quadriga, swan-neck deform-
carpophalangeal joints, thus enabling the functional use
ities, intrinsic contractures, and subsequently volar
of the hand. This article reviews the biomechanics of the
subluxation of the MCP joints.
sagittal bands and the corrections that enable finger
extension at the metacarpophalangeal joints, thus pre-
venting secondary conditions.
Keywords: extensor tendon complications, sagittal bands, | PERTINENT ANATOMY AND
rheumatoid arthritis
BIOMECHANICS OF NORMAL
DIGITAL EXTENSION
Sagittal bands have been described as a girdles surrounding
S agittal bands play an important role in stabilizing
extensor tendons in midline. They encircle the meta-
carpophalangeal (MCP) joint capsule, the metacarpal
the lateral and dorsal MCP joints, stabilizing the extensor
digitorum communis (EDC) tendons over the dorsum of
the joint during digital flexion and extension and limiting
longitudinal gliding.1,2 The extensor anatomy proximal to
Address correspondence and reprint requests to Shrikant J. Chinchalkar, the sagittal bands is relatively simple, when compared
OTR, CHT, Department of Hand Therapy and Hand & Upper Limb
Centre, St. Joseph’s Health Care London, 268 Grosvenor Street, London, with the distal extensor system.2,3 The EDC tendons that
Ontario, Canada. E-mail: shrikant.chinchalkar@sjhc.london.ca. run to the index, long, ring, and small fingers emerge
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Dynamic Assist Splinting
FIGURE 1. A, Sagittal band disruption produces a loss of active finger extension at the MCP joints. (Reproduced with
permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.) B, Sagittal band rupture in the long finger of
this patient results in an extension deficit of this digit, subsequently affecting all adjacent digits.
from the fourth extensor compartment at the wrist and tions of the EDC tendons in index and small fingers have
diverge as they advance toward their insertions at the base been reported.6,7 The juncturae tendinum and intertendi-
of the middle and distal phalanges. Historically, it had nous fascia interconnect the EDC tendons, maintaining the
been reported that the EDC also inserted on the base of divergent angle of the extensor tendons and supplementing
the proximal phalanx; however, the presence of this in-
sertion has been questioned.4,5 Some anatomical varia-
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Pitts and Chinchalkar
FIGURE 4. Rupture of the sagittal bands decreased effective amplitude of EDC tendon. Rupture of the sagittal band
mechanism around the MCP joint occurs most commonly on the radial side. A, This results in subluxation of the EDC tendon
into the valleys between the heads of the metacarpals (as shown above in the long finger). This leads to a decreased
effective excursion of the EDC tendon and an extensor lag, mostly at the MCP joint. B, The normal tract of the EDC tendon is
shown subluxed. Reprinted with permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.
extensor force during digital extension.8,9 These structures With hand motion, from a fully flexed position, the
are also thought to provide some stability to the sagittal central slip of the EDC tendon first initiates extension of/at
bands.10 The sagittal bands, which lie distal to the the proximal interphalangeal (PIP) joint. As the PIP joint
juncturae tendinum and stabilize the extensor tendons achieves some extension, the lateral bands gradually
over the MCP joint, are dynamic structures that move with migrate dorsally causing tension at the distal interphalan-
the extensor tendon during MCP joint motion. Along with geal (DIP) joint producing extension.1,4 The dorsal
the volar plate, the sagittal bands act like a sling around the aponeuroses of the digital extensors play an important
base of the proximal phalanx and assist the EDC tendon in role in the extension of the middle and distal phalanges.12
MCP joint extension.1,4,10,11 The intrinsic muscles continue to extend the PIP and DIP
FIGURE 5. Swan-neck deformity, ulnar drift, and MCP joint volar subluxation. Sagittal band rupture results in an
extension deficit of the MCP joints, often starting in one digit and progressing to adjacent digits. A and B, The swan-neck
deformity and ulnar drift in fingers are results of sagittal band attenuation or rupture causing volar subluxation of the MCP
joints. C, Volar subluxation of the MCP joint is as a result of continuous intrinsic load at the proximal phalanx. Figure 5A
was reproduced with permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dynamic Assist Splinting
joints simultaneously, acting through the medial and the | SECONDARY COMPLICATIONS
conjoined lateral bands. As the PIP and DIP joints
Sagittal band attenuation results in the intrinsic muscles of
extend, the EDC pulls the sagittal bands proximally over
the hand being placed in a shortened position, which over
the metacarpal head acting as a sling over the proximal
time may develop intrinsic muscle tightness. The intrinsic
phalanx, which simultaneously extend the MCP joint.1,13
muscles help compensate for a loss of MCP joint
The juncturae tendinum, with the assistance of the
extension, by contributing an excessive extensor load at
sagittal bands, maintains the extensor force while
stabilizing the extensor tendons over the dorsum of the
MCP joints. The combined force of the intrinsics and the
EDC maintain full digital extension (Fig. 3).3,11
| BIOMECHANICS OF EXTENSOR
DEFICIT CAUSED BY SAGITTAL
BAND RUPTURE OR ATTENUATION
The sagittal bands and juncturae tendinum transmit precise
forces during digital flexion and extension. The sagittal
bands and the EDC tendons collaborate to extend the MCP
joint.14 The sagittal bands, however, can be vulnerable to
stress and attenuation, particularly on the radial side, and
can result in ulnar subluxation of the extensor tendons, as
seen in rheumatoid arthritis.10,15 This creates instability
of extensor tendons over the MCP joint, and results in
inadequate forces to extend the MCP joint due to length
tension deficiency. Thus, with EDC activation of digital
extension, the sagittal bands fail in maintaining the EDC
in midline and extending the MCP joint (Fig. 4). The lack
of extension of the involved digit subsequently results in
a decreased excursion of the adjacent EDC tendons
through distal tension on the juncturae tendinae. A lack FIGURE 7. A and B, dynamic MCP extension assist splint.
This splint allows for active finger flexion and assists with
of MCP extension in persons with rheumatoid arthritis is MCP extension. If greater pull is required to draw the MCPs
often multifactorial, compounded by ulnar subluxation of into extension, a rubber band and rubber band posts can be
the EDC at the MCP. applied to the palmar and finger components.
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Pitts and Chinchalkar
the PIP joint. With the occurrence of a myostatic aspect of the finger component. Ensure that the coils are
contracture of the intrinsic structures, a secondary swan- aligned with metacarpal heads of the index and the small
neck deformity gradually develops. Over time, all the finger and that the pull of the coils is into extension. If
digits will demonstrate intrinsic tightness, a secondary greater pull is required to draw the MCP joints into
swan-neck tendency, and ultimately extensor quadriga, if extension, attach the rubber band posts to the dorsum of
the pathomechanics are not addressed early (Fig. 5).2 This the palmar and finger components of the splint, over the
complication is particularly evident in the rheumatoid fifth metacarpal and proximal phalanx. Place a rubber
affected hand, where attenuation of the sagittal bands of band, with appropriate tension on the 2 posts to enhance
1 digit may lead to the development of swan-neck the pull into extension (Fig. 7). Note that the rubber band
deformities of all digits (Figs. 5A, B).15 In addition, in should not restrict the active flexion of the MCPs.
rheumatoid swan-neck deformities, continuous load of
the intrinsics at the proximal phalanx may be one of the
main causes of volar subluxation and ulnar deviation of | DISCUSSION
the MCP joint (Fig. 5C).2
In our clinical experience, this splint has been effective in
treating patients with attenuation or rupture of the sagittal
bands in rheumatoid arthritis. It has helped minimize the
| PREVENTION OF COMPLICATIONS complications described previously, and most impor-
WITH SPLINTING tantly, it has facilitated functional use of the affected
The dynamic MCP extension assist splint is designed to hand. The dynamic MCP extension assist splint is a new
allow active MCP flexion and assist with MCP extension. splint design, developed for individuals with difficulty or
The splint assists in relocating and stabilizing the extensor an inability to extend their MCP joints, primarily seen in
tendons on the dorsum of the MCP joints by decreasing the persons with rheumatoid arthritis. As such, no clinical
tension on the extensor system during active MCP data are currently available on its use, and further study is
extension. Thus, it assists with tendon gliding and enables needed. However, this splint offers a temporary solution
MCP joint extension. Upon attaining extension of the to enable assisted MCP extension for daily hand
MCP joints, the splint also helps prevent intrinsic functioning and to prevent progressive complications.
contractures and ultimately the secondary complications
such as extensor quadriga, swan-neck deformities, and
subsequent volar subluxation of the MCP joints. A | REFERENCES
similar design for can be used for MCP flexion.2,16
1. Zancolli E. Anatomy and mechanics of the extensor appa-
ratus of the fingers. In: Structural and dynamic bases of hand
surgery. 2nd ed. Philadelphia: JB Lippincott, 1979:3Y63.
| INDICATIONS
2. Chinchalkar SJ, Gan BS, McFarlane RM, et al. Extensor
This splint can provide a temporary solution to enable quadriga: pathomechanics and treatment. Canadian Jour-
hand function before MCP sagittal band reconstruction nal of Plastic Surgery. 2004;12:174Y177.
surgery if indicated, or a permanent solution if not.
3. von Schroeder HP, Botte MJ. Anatomy of the extensor
Primarily, it can minimize the secondary complications
tendons of the fingers: variations and multiplicity. J Hand
described previously. Surg [Am]. 1995;20:27Y34.
Technique of Splint Fabrication 4. Harris C. The functional anatomy of the extensor mecha-
Materials. (a) Aquaplast, 1/8 in thickness, two 1-in- nism of the finger. JBJS. 1972;54A:713Y726.
wide strips; (b) two coil springs; (c) two rubber band 5. Jan SVS, Rooze M, Audekerke JV, et al. The insertion of
posts made up of piano wire, optional, depending on the the extensor digitorum tendon on the proximal phalanx.
required strength of pull; and (d) elastic bands (Fig. 6). J Hand Surg [Am]. 1996;21A:69Y76.
Fabrication. Palmar-based component: using a 1-in 6. Gonzalez MH, Weinzweig N, Kay T, et al. Anatomy of
strip of Aquaplast, encircle the hand, molding the Aqua- the extensor tendons to the index finger. J Hand Surg
plast just proximal to the distal palmar crease volarly [Am]. 1996;21A:991Y998.
and the metacarpal heads dorsally. 7. Gonzalez MH, Gray T, Ortinau E, et al. The extensor
Finger component: mold the second 1-in strip tendons to the little finger: an anatomic study. J Hand
circumferentially around the proximal phalanges. Surg [Am]. 1995;20A:844Y847.
Attach the finger and palmar components using the 8. von Schroeder HP, Botte MJ, Gellman H. Anatomy of the
2 coil springs. Attach each coil spring to the dorsal lateral juncturae tendinum of the hand. J Hand Surg [Am]. 1990;
aspect of the palmar component and to the volar lateral 15:595Y602.
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9. Wehbe MA. Junctura anatomy. J Hand Surg [Am]. 1992; 13. Valentin P. Physiology of extension of fingers. In:
17A:1124Y1129. Tubiana R, ed. The Hand. Philadelphia: WB Saunders,
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biomechanical study. J Hand Surg [Am]. 2000;25: 14. Rayan GM, Murray D, Chung KW, et al. The extensor
1107Y1113. retinacular system at the metacarpophalangeal joint.
11. Gausepohl T, Koebke J, Pennig D, et al. Changes in the Anatomical and histological study. J Hand Surg [Br].
form of the interosseous hood during extension and 1997;22:585Y590.
flexion of the metacarpophalangeal joint. Handchir 15. Wilkes LL. Ulnar drift and metacarpophalangeal joint
Mikrochir Plast Chir. 1998;30:220Y225. subluxation in the rheumatoid hand: review of the patho-
12. Landsmeer JMF. The anatomy of the dorsal aponeurosis genesis. J South Med. 1977;70:963Y967.
of the human finger and its functional significance. Anat 16. McKee P, Morgan L. Orthotics in Rehabilitation: Splint-
Rec. 1949;104:31Y44. ing the Hand and Body. Philadelphia: FA Davis.
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Techniques in Hand and Upper Extremity Surgery 10(4):212–223, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
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Larson et al
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
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Larson et al
the 1,2-ICSRA (Fig. 4). The course of this vessel and the
vascular anatomy of the distal radius and ulna have been
previously described.20 The vascularized bone graft
should be centered 15 mm proximal to the radiocarpal
joint over the vessels to ensure the nutrient vessels are
included in the graft. Dissection is straightforward given
the superficial location of the vessels. The patient is
positioned supine, with the affected extremity extended
on a hand table. A nonsterile tourniquet is placed. After
prepping and sterile draping, the extremity is either
exsanguinated with an Esmarch wrap from the wrist
proximal, or elevated to ensure some blood remains in
the upper extremity to allow identification of the
vessels. We previously described an S shaped incision
over the first and second extensor compartments as
illustrated in Figure 4.36 This incision made fixation of
the scaphoid with a screw difficult; and as such, we
have modified the incision to follow the course of the
extensor pollicis longus (Fig. 5A). This incision allows
easier access to the proximal pole and to the entry site
for cannulated screw placement. The skin and the
areolar tissue above the extensor retinaculum are carefully
dissected off the retinaculum (Fig. 5B). The superficial
radial nerve and its branches should be identified and
protected. The 1,2-ICSRA and venae comitantes are
located between the first and second extensor compart-
ments and lie directly on top of the extensor retinaculum
(Fig. 6). These vessels can be dissected distally to its
origin off the radial artery. Proximally, the bone graft site
is centered 15 mm proximal to the radiocarpal joint. The
first and second dorsal compartments are opened, leaving
a cuff of retinaculum on either side of the vessels; and
the tendons are retracted radially and ulnarly (Fig. 7).
Once the vessels are identified, attention is directed to the
scaphoid to identify the nonunion, fracture site prepara-
tion, and fixation. The extensor pollicis longus tendon is
identified; and the retinaculum is elevated through the
second compartment, releasing the extensor pollicis
longus and retaining the ulnarly based retinacular flap.
If visualization of the dorsal wrist capsule is still not
achieved, an ulnar-based capsular flap can be created by
FIGURE 7. A, The extensor compartments are opened to dividing the septum between the third and fourth
maintain a cuff of retinaculum enclosing the 1,2-ICSRA extensor compartments; and the fourth compartment
and the entry of its nutrient artery into the bone at the extensor tendons are retracted ulnarly. A transverse
bone graft donor site. B, The retinaculum on the ulnar dorsal-radial capsulotomy is made just ulnar to the 1,2-
border of 1,2-ICSRA is cut from the second dorsal ICRSA vessels to the fibers of the radiotriquetral
compartment. The radial border of the retinaculum has
already been released. C, With the first 2 compartments ligaments (dorsal intercarpal ligament). Up to half of
released, the abductor pollicis longus and extensor the radiotriquetral ligament can be divided if needed to
pollicis brevis can be retracted radially, and the extensor expose the scapholunate joint to facilitate the placement
carpi radialis longus and brevis retracted ulnarly, expos- of a cannulated screw if possible. The scaphoid nonunion
ing the graft site. The probe points to the 1,2-ICSRA site is identified and is typically transverse in orientation
rejoining the radial artery distally. The dorsal distal radius
is immediately to the right, with a cuff of retinaculum (Fig. 8). The wrist often needs to be flexed to expose a
surrounding the bone graft donor site. (Reproduced with proximal pole fracture nonunion that may be under the
permission of the Mayo FoundationÓ.) dorsal lip of the radius.34 Care should be taken to prevent
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
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Larson et al
FIGURE 10. A and B, Anterior-posterior, lateral, and oblique radiographs of the right wrist in casting material shows a
minimally displaced proximal pole fracture of the scaphoid. No humpback deformity or carpal instability is evident. C and D,
Coronal and sagittal views of the right wrist on CT imaging. The fracture line is minimally displaced, but quite proximal. E and
F, T1 and T2 coronal views of the right wrist on MRI. The increased signal over the scaphoid on the T2 image is consistent
with marrow edema. (Reproduced with permission of the Mayo FoundationÓ.)
bone. The fracture margins are identified, and a slot for the ulnar margins of the selected graft site. For the distal cut,
vascularized bone graft is created using fine and sharp the 1,2-ICSRA and veins are retracted radially and then
osteotomes to accept an appropriately sized dorsal inlay ulnarly to protect the vessels; and 2-mm osteotomes are
graft (Fig. 13). The slot is placed parallel to the midcarpal used to make the distal cuts underneath the vessels. The
joint, which needs to be exposed to prevent damage to the graft is carefully lifted from the radius, taking care not to
midcarpal articulation of the scaphoid. The size of the slot fragment the graft (Fig. 14). If desired, the tourniquet can
is dependent on the fracture configuration and size of the be deflated to check for arterial perfusion of the graft
proximal fragment, but is typically 4 to 6 mm wide and 6 through the distally based pedicle. We have found the
to 8 mm long. The proximal fracture fragment should be graft to bleed in all cases, and no longer perform this step
closely examined to determine vascularity (Fig. 13C). because the blood often obscures the surgical field
When the proximal pole fragment is too small to despite reelevation of the tourniquet. Additional cancel-
accommodate a slot, it is possible to position the graft in lous bone graft is harvested from the distal radius site,
the excavated cavity of the proximal fragment. placed into the nonunion site, and packed at the periphery
Afterward, attention is turned to the graft donor site. of the cavity created. Rongeurs or bone cutters may be
The center of the graft donor site is identified 15 mm used to shape the final graft, which should be slightly
proximal to the radiocarpal joint to include the nutrient larger than the recipient slot. The bone graft may be
vessels penetrating into the bone. The 1,2-ICSRA and slightly compressed using the proximal, flat part of the
venae comitantes are dissected toward their distal anasto- Adson forceps. This allows the graft to be inset more
moses to the radial artery and gently elevated from the easily and to expand after insertion. The graft is then
radius and joint capsule. The 1,2-ICSRA and veins are left passed beneath the radial wrist extensors and press-fit
adherent to the bone at the graft site, then ligated proximal into the prepared fracture site (Fig. 15). When tamping in
to the graft site. The graft should be measured slightly the graft, it is imperative that direct trauma not be applied
bigger than the defect at the fracture site. Small osteo- to the vessels. One technique is to use a toothless Adson
tomes are used to make cuts on the proximal, radial, and forceps to straddle the vessels and gently tap the forceps
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
with a small mallet. Hemostasis is obtained, the wound bone grafting for scaphoid nonunion, failed conven-
irrigated, and the incision closed with nonabsorbable tional bone grafting, or an avascular proximal fragment,
sutures. It is not necessary to suture the capsule back in all progressed to union at a mean of 11.1 weeks. Of the
place. The patient is placed in a well-padded long-arm 4 patients with preoperative radioscaphoid arthritis, 3
thumb spica with the wrist in neutral position. had a poor or fair result.21
Representative postoperative imaging studies of a
scaphoid nonunion treated with pedicled vascularized
bone grafting and screw fixation are shown in Figure 16.
| COMPLICATIONS
Worse outcomes are to be expected in the setting of
scaphoid nonunions with radioscaphoid arthritis.21 In a
series of 14 patients undergoing vascularized pedicle
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Larson et al
FIGURE 13. A, Fibrous tissue is debrided from the FIGURE 14. A, The 1,2-ICSRA is ligated proximal to the
scaphoid nonunion site. An anatomical slot parallel to graft, which is then lifted from its site. B, A small
the midcarpal joint is created with osteotomes and burr. osteotome is first used to free the graft, with cuts made
The slot is sized to accommodate an appropriately sized radially, ulnarly, and proximally. For the distal cut, the 1,2-
dorsal inlay draft, typically 4 to 6 mm wide and 6 to 8 mm ICSRA is retracted first radially and then ulnarly as 2
long. The midcarpal joint should be exposed to avoid separate cuts are made. C, The graft can then be gently
damaging the midcarpal articulation of the scaphoid. B, elevated from the donor site with the osteotome blade
The prepared slot is seen at the upper left, and the donor and a toothless Adson forceps. (Reproduced with per-
site at lower right surrounded by the cuff of retinaculum. mission of the Mayo FoundationÓ.)
C, This prepared slot on another patient shows a lack of
proximal bleeding bone, indicating avascular necrosis.
(Reproduced with permission of the Mayo FoundationÓ.) were more smokers and female subjects in the nonunion
group compared with the union group. Additionally, the
In the largest series to date, we reported the outcome odds ratio for going on to nonunion was greater for
of 48 nonunions treated with this technique. Fourteen of patients with proximal pole avascular necrosis and
48 patients had persistent nonunions after vascularized preoperative humpback deformity.11 With regard to
pedicled bone grafting.11 As discussed previously, there fixation technique, screw fixation of the fracture had a
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
favorable effect on scaphoid union. 11 Of those avascular necrosis, screw fixation resulted in 100%
nonunions fixed with screws, 88% went on to union union rate versus 67% with Kirschner wire fixation. In
(23 of 26), compared with 53% fractures fixed with the presence of proximal pole avascular necrosis, 62%
Kirschner wires (8 of 15). Without evidence of of scaphoids fixed with screw fixation went on to union,
compared with 44% of those with Kirschner wire
fixation.11 From retrospective chart review, we con-
cluded that up to 3 of the scaphoids went on to nonunion
as a result of inadequate fixation after vascularized bone
grafting.
In this series, we also reported a 4% incidence of
superficial infection (2 patients) and 2% incidence of
deep infection (1 patient).11 The superficial infections
were successfully treated with oral antibiotics, although
one superficial infection went on to nonunion, as did the
deep infection.11 Graft extrusion occurred in 4 of
48 wrists, although in 2 of the cases, the fracture went
on to union with the graft in a displaced position.
| REHABILITATION
A compressive postoperative dressing is placed for
edema control. Range of motion exercises of the fingers
and shoulder are encouraged immediately. At 2 weeks
postoperatively, sutures are removed. The arm is kept
immobilized for 6 to 8 weeks in neutral wrist position in a
long-arm thumb spica. After this, radiographs are
obtained to assess for fracture healing. If indicated,
additional immobilization is continued with a short-arm
thumb spica. Wrist range of motion and strengthening
exercises are started after the fracture is healed.
| CONCLUSION
Vascularized bone grafting to scaphoid nonunions pro-
vides a promising option for treatment. In the case of
proximal pole avascular necrosis, results are more
guarded; but vascularized pedicled bone grafting remains
a viable alternative to conventional methods. Should the
pedicled graft fail, the option for free vascularized bone
grafting remains. Pedicled vascularized bone grafting
requires only one incision with little donor site morbidity.
The dissection is relatively straightforward, requiring no
vascular anastomoses. Fixation with screws has shown
improved results compared with Kirschner wire fixation,
although internal fixation must be chosen on an individual
FIGURE 15. A, The graft is then press-fit into the basis given the fracture type. We have found improved
prepared slot. B, The vessels should be carefully pro-
tected as the graft is passed under the extensor tendons. exposure for adequate fixation of the scaphoid with the
C, The graft should be slightly larger than the prepared incision following the course of the extensor pollicis
slot to prevent extrusion of the graft. A toothless Adson longus. Vascularized bone grafting based on the 1,2-
forceps may be used to compress the graft slightly to ICSRA is a viable treatment choice for the difficult and
allow it to reexpand after being press-fit into the slot. To disabling condition of proximal pole nonunion. For
avoid trauma to the vessels, the Adson forceps may be
used to straddle the vessels and gently tapped to impact scaphoid nonunions with both carpal collapse and avas-
the graft into place. (Reproduced with permission of the cular changes, alternative methods of vascularized bone
Mayo FoundationÓ.) grafts should be performed.
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Larson et al
FIGURE 16. Radiographs of the wrist joint at 16 months postoperatively show healing at the proximal pole scaphoid
nonunion. Hardware is in appropriate alignment (Reproduced with permission of the Mayo FoundationÓ).
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Dorsal Distal Radius Vascularized Pedicled Bone Grafts
In: Saffar P, Amadio PC, Roucher G, eds. Current Practice in 30. Harpf C, Gabl M, Reinhart C, et al. Small free
Hand Surgery. London: Martin Dunitz, 1997:307Y313. vascularized iliac crest bone grafts in reconstruction of
24. Moran SL, Cooney WP, Berger RA, et al. The use of the the scaphoid bone: a retrospective study in 60 cases. Plast
4 + 5 extensor compartmental vascularized bone graft for Reconstr Surg. 2001;108:664Y674.
the treatment of Kienbock`s disease. J Hand Surg. 2005; 31. Doi K, Sakai K. Vascularized periosteal bone graft from
30:50Y58. the supracondylar region of the femur. Microsurgery.
25. Chacha PB. Vascularized pedicular bone grafts. Int Orthop. 1994;15:305Y315.
1984;8:117Y138. 32. Fuchs B, Steinmann SP, Bishop AT. Free vascularized
26. Robbins RR, Ridge O, Carter PR. Iliac crest bone grafting corticoperiosteal bone graft for the treatment of persistent
of Herbert screw fixation of nonunions of the scaphoid with nonunion of the clavicle. J Shoulder Elbow Surg.
avascular proximal poles. J Hand Surg. 1995;20A:818Y831. 2005;14:264Y268.
27. Boyer MI, VonSchroeder HP, Axelrod TS. Scaphoid 33. Doi K, Oda T, Soo-Heong T, et al. Free vascularized bone
nonunion with avascular necrosis of the proximal pole. graft for nonunion of the scaphoid. J Hand Surg.
J Hand Surg. 1998;23B:686Y690. 2000;25A:507Y519.
28. Straw RG, Davis TRC, Dias JJ. Scaphoid nonunion: 34. Markiewitz AD, Stern PJ. Current perspectives in the
treatment with a pedicled vascularized bone graft based management of scaphoid nonunions. Instr Course Lect.
on the 1,2 intercompartmental supraretinacular branch of 2005;54:99Y113.
the radial artery. J Hand Surg. 2002;27B:413Y416. 35. Mack GR, Bosse MJ, Gelberman RH, et al. The natural
29. Gabl M, Reinhart C, Lutz M, et al. Vascularized bone history of scaphoid non-union. J Bone Joint Surg.
graft from the iliac crest for the treatment of 1984;66A:504Y509.
nonunion of the proximal part of the scaphoid with 36. Shin AY, Bishop AT, Berger RA. Vascularized pedicled
an avascular fragment. J Bone Joint Surg. 1999;81A: bone grafts for disorders of the carpus. Tech Hand Up
1414Y1428. Extrem Surg. 1998;2:94Y109.
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Techniques in Hand and Upper Extremity Surgery 10(4):224–230, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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Corrective Osteotomy for Distal Radius Malunion
Loss of Radial Inclination minimally invasive distal radius osteotomy for treatment
Jenkins and Mintowt-Czyz13 found a statistical correla- of distal radius fracture malunion has been described
tion between loss of radial inclination and decreased previously,16 the new implants for volar fixation of distal
grip strength in patients with distal radius malunions. radius fractures offer another alternative.
Previous biomechanical studies by Pogue et al3 showed The author has developed and used a technique for
that significant loss of radial inclination resulting in less corrective osteotomy and fixation of a distal radius
than 10 degrees of radial inclination results in signifi- malunion which restores angulation and length, releases
cant changes in the load mechanics across the proximal radius-based extensor retinacula, and eliminates or re-
wrist joint. duces the need for remote bone graft, allograft, or bone
graft substitutes. The technique described in this
manuscript uses the recent advancements in and various
Treatment implants for volar plate fixation combined with an open-
Treatment for correction of distal radius malunions has ing wedge osteotomy of the distal radius. However, the
included a closing wedge osteotomy with distal ulnar opening wedge osteotomy is a biplanar osteotomy that
resections14 and an open wedge osteotomy and bone incorporates the dorsally extruded fracture fragments
grafting with or without distal ulnar resection.9,15 There from the distal, dorsal compression fracture component
was also a previous description of a minimally invasive of the distal radius fracture (Figs. 1AYC) to act as an
distal radial osteotomy for treatment of distal radius intact strut graft, while additionally addressing the
fracture malunion in 1997.16 Corrective osteotomy of often contracted and thickened dorsal extensor retinac-
the distal radius to treat symptomatic malunion and/or ulum and periosteum which can limit or even prevent
significant deformity was reported as early as 1937 by reduction of the malunion.19
Campbell.17 Fernandez9 reported on a series of patients
with distal radius malunions that he treated with an | INDICATIONS AND
opening wedge osteotomy, iliac crest bone grafting, and CONTRAINDICATIONS
a dorsal T plate. This approach has essentially remained
the standard of care for almost 2 decades. In 1988, This technique is appropriate in the same circumstances
Watson and Castle15 suggested using a trapezoidal and follows the same patient selection criteria as any
osteotomy with a distal radial bone graft and Kirschner alternative technique for a corrective distal radius
wire (K-wire) fixation. Fixation with a percutaneous osteotomy. These criteria include cosmetic deformity,
K-wire is recommended by Watson and Castle, and had pain secondary to malalignment, and/or significant
the benefit of avoiding problems of the subcutaneous deformity expected to increase the likelihood of devel-
dorsal plate. Other alternatives, such as a closing wedge opment of posttraumatic degenerative changes. Com-
osteotomy and distal ulnar resection, were advocated by plete remodeling of the fracture malunion is a relative
Pausner and Ambrose14 as an alternative treatment. contraindication for this technique because the dis-
With regard to the timing of a corrective osteotomy, placed, comminuted, dorsal compression component of
Fernandez9 generally waited 5 to 6 months after the the fracture would have resorbed and remodeled, and
injury before performing an osteotomy of the distal not be as large of a dorsal strut graft. Therefore, earlier
radius. Jupiter,18 however, reported slightly improved treatment, once fracture malunion is recognized, is
results and a decrease in the duration of disability in pa- preferred by this author. Abnormal load mechanics
tients treated with a corrective osteotomy 6 to 14 weeks may be expected to develop if proximal wrist joint
after the fracture malunion when compared with patients alignment is altered to result in radial shortening of
with a distal radius malunion who waited over eight 2 mm or more, angulation of the distal radius of greater
months for a corrective osteotomy. than 20 degrees in either the palmar or dorsal direction,
It has been the author’s observation that wrists with a or radial inclination of less than 10 degrees.
prefracture ulnar negative variance can tolerate a limited
degree of radial shortening better than wrists with | SURGICAL TECHNIQUE
prefracture ulnar positive variance.16 Also, in earlier me- A longitudinal skin incision is made over the course of
chanical studies, it was found that 4 mm or more of ra- the flexor carpi radialis tendon, starting at the level of
dial shortening in an acute fracture was associated with the radial styloid and extending proximal 6 to 8 cm.
disruption of the triangular fibrocartilage complex.3 Subcutaneous tissue is carefully dissected down to the
Therefore, even if the ulnar styloid is not fractured, but level of the flexor carpi radialis tendon sheath. The
there is radial shortening resulting from a distal radius tendon sheath is incised longitudinally. The tendon
fracture of 4 mm or more, disruption of the triangular sheath of the flexor carpi radialis tendon should be
fibrocartilage complex should be expected. Whereas a released from a distal point at the level of the scaphoid
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Viegas
FIGURE 1. A series of diagrams illustrating (A) the dorsally extruded fracture fragments from the distal, dorsal
compression fracture component of the typical distal radius fracture, (B) the early consolidation and callus formation of the
fracture, and (C) the subsequent healing.
tubercle to the musculotendinous junction of the flexor cauterized before or during release of the lateral margin
carpi radialis proximally. The tendon is retracted and of the pronator quadratus. The release is extended trans-
the deep layer of the flexor carpi radialis tendon sheath versely at its distal margin and, using a periosteal elevator,
is also incised longitudinally. The flexor carpi radialis the pronator quadratus can be reflected off the underlying
tendon is retracted radially and the median nerve and radius and periosteum. The fracture line, particularly of
the superficial and deep flexor tendons are retracted early distal radius malunions, should be quite easily
ulnarly, with blunt dissection carried out superficial to identified once the pronator quadratus is reflected.
the pronator quadratus muscle. Once the pronator Next, the first dorsal compartment should be entered
quadratus muscle has been identified, it is released just lateral to the lateral margin of the radius. Within this
sharply at its lateral margin. Careful attention should be compartment, the extensor pollicis brevis tendon and,
given to the perforator vessels, which should be quite often, multiple slips of the abductor pollicis longus
FIGURE 2. A series of diagrams illustrating (A) the initial approach of the 0.045-inch-diameter K-wire (B) that should be
drilled only to the depth of the dorsal cortex of the radial shaft (C) in a series of perforations along the volar fracture line
(D) to prestress the fracture line for subsequent osteotomy.
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Corrective Osteotomy for Distal Radius Malunion
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Viegas
FIGURE 6. A series of diagrams illustrating the (AYC) progression of flexion and volar translation of the osteotomized distal radial
fragment and (D) the release of the retinaculum of the dorsal compartments.
osteotomes and displacing the soft tissue will facilitate fixation is completed, the brachioradialis, which was
positioning the osteotome at the acute angle to the radius released in a z lengthening fashion, is repaired using
to make the dorsal osteotomy. This osteotomy should horizontal mattress stitches of 4Y0 Vicryl suture
extend distal to the level of and meet with the other (Ethicon, Somerville, NJ). The pronator quadratus
osteotomy cut along the line of the predrilled K-wire muscle is placed over the fixation plate and repaired to
perforations from the volar aspect of the distal radius the brachioradialis, again with 4Y0 Vicryl sutures. Once
fracture malunion. Fluoroscopy can be used to help target fixation has been achieved, the range of motion of the
and connect the 2 osteotomies (Fig. 5). It is important to wrist and forearm is assessed under fluoroscopic control
release the extensor retinaculum of the dorsal compart- and direct visualization to determine stability of the
ments 1 through 5 and their septal attachments to the
radius and the periosteum, as they can impair and even
prevent subsequent reduction of the distal fragment.19
Once the osteotomy is completed, the distal frag-
ment is flexed, volarly translated, and, if necessary,
slightly ulnarly deviated to restore the normal alignment
and length of the distal radius (Figs. 6AYD). When
reduced, the dorsal prominence of bone, which has been
osteotomized and mobilized with the distal radial
fragment, should line up with the distal margin of the
proximal radial shaft and act as a strut graft, partially
filling the subsequent defect caused by this opening
wedge osteotomy. Additional bone graft, or a bone graft
substitute, can be added to the remaining defect.
However, this author has found that, often, the dorsal
component of this complex osteotomy is itself adequate
and additional bone grafting is not necessary.
Once the corrective osteotomy is completed and
alignment of the distal fragment is confirmed to be
adequate both by visual inspection and radiographic
imaging, distal radius fixation is accomplished by volar
plating (Fig. 7). This author’s preference has been the
DVR Plating System of Hand Innovations (Miami, FL). FIGURE 7. A diagram illustrating the 2-plane osteotomy
However, any fixed angle device for volar fixation of of the distal radius malunion reduced and fixed with a
distal radius fractures should be acceptable. Once volar fixation plate.
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Corrective Osteotomy for Distal Radius Malunion
FIGURE 8. Preoperative (A) anteroposterior and (B) lateral radiographs of a patient with a distal radius malunion, (C) the
path of the osteotomies is indicated by the dark arrows; the lighter arrow demonstrates the dorsal approach to release the
extensor retinaculum and place the dorsal osteotome, (D) and the subsequent direction of flexion and volar translation of
the distal fragment to (E) result in the reduction of the distal radius and the postoperative (F) anteroposterior and (G)
lateral radiographs after reduction and volar DVR plate fixation of the radius.
fixation. This will help subsequently determine the difficulty regaining full digital or wrist range of motion,
appropriate postoperative rehabilitation program. Dorsal formal therapy is arranged.
and volar skin incisions are closed in an interrupted
fashion. A sugar tong splint and Ace wrap (Novaplus, | COMPLICATIONS
Rockhill, SC) are used to immobilize the fracture.
Possible complications with this technique include tendon
| REHABILITATION irritation, both at the volar distal aspect of the volar
fixation system and/or dorsally, particularly if peg, tine, or
The motion of the digits of the operative hand is begun screw fixation is excessively long. Arthrofibrosis and
immediately after surgery. The intraoperative sugar tong stiffness of the digits are possible and can be minimized by
splint and dressing is removed at 2 weeks in the clinic. early mobilization and encouragement of both active and
Sutures are also removed at that time. Unless fixation is passive range of motion. Infection, loss of fixation, and/or
considered tenuous during the intraoperative assessment, malunion are other possible complications.
the patient is progressed to a volar wrist splint at 2 weeks
and allowed to begin gentle, active only range-of-motion
exercises when out of the splint over the next month. | SUMMARY
Splinting is continued on an as-needed basis until The new designs of volar radius fixation plates with
radiographic union is identified. If the patient has locking screws, pegs, or fixed tines offer not only a new
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Viegas
means to fix acute, distal radius fractures, but also to fix 7. Milch H. Treatment of disabilities following fracture of the
the distal radius after corrective osteotomies for treat- lower end of the radius. Clin Orthop. 1963;29:157Y163.
ment of distal radius malunions. Furthermore, the 8. Taleisnik J, Watson HK. Midcarpal instability caused by
technique described herein offers the separate dorsal malunited fractures of the distal radius. J Hand Surg [Am].
approach to formally release the extensor retinaculum of 1984;9A:350Y357.
the dorsal compartments and periosteum to facilitate the 9. Fernandez DL. Correction of post-traumatic deformity in
reduction. It also offers a complex combination of adults by osteotomy bone grafting and internal fixation. J
osteotomies to improve the subsequent alignment and Bone Joint Surg. 1982;64A:1164Y1178.
reduction and offer a portion of the corrective osteo- 10. Altissimi M, Antennia R, Fracia C. Long-term results of
tomy to act as a dorsal strut graft for better stability, conservative treatment of fractures of the distal radius.
while also allowing one to minimize or completely elim- Clin Orthop. 1986;206:202Y210.
inate the need for additional bone grafting (Figs. 8AYG). 11. Dias JJ, McMohan A. Effect of Colles’ fracture malunion on
The Z lengthening of the brachioradialis offers ease of carpal alignment. J R Coll Surg Edinb. 1988;33:303Y305.
reduction of the distal radius malunion and also affords
12. Porter M, Stockley I. Fractures of the distal radius:
a facilitated means to repair the pronator quadratus intermediate end results in relation to radiologic param-
muscle. This approach offers a viable alternative for eters. Clin Orthop. 1987;220:241Y252.
correction of distal radius fracture malunions.
13. Jenkins NH, Mintowt-Czyz CW. Malunion and dysfunc-
tion in Colles’ fracture. J Hand Surg [Br]. 1988;13B:
| ACKNOWLEDGMENTS 291Y293.
The author thanks Randal Morris for assistance and 14. Pausner MA, Ambrose L. Malunited Colles’ fractures:
collaboration in the illustrations used in this manuscript correction with a biplanar closing wedge osteotomy. J
and Kristi Overgaard for editorial assistance. Hand Surg [Am]. 1991;16A:1017Y1026.
15. Watson HK, Castle TH Jr. Trapezoidal osteotomy of the
distal radius for unacceptable articular angulation after
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4. Palmar AK, Werner FW. Biomechanics of the distal radial 19. Iwamoto A, Morris RP, Andersen C, et al. An
ulnar joint. Clin Orthop. 1984;187:26Y35. anatomical and biomechanical study of the wrist exten-
5. Adams BD. Effects of radial deformity on distal radioulnar sor retinaculum septa and tendon compartments. J Hand
joint mechanics. J Hand Surg [Am]. 1993;18A:492Y497. Surg. 2006;31A:896Y903.
6. Lidstrom A. Fractures of the distal end of the radius: a 20. Ko S, Andersen CR, Buford WL, et al. Anatomy of the
clinical and statistical study of end results. Acta Orthop distal brachioradialis and its potential relationship to distal
Scand. 1959(suppl 41):58Y118. radius fracture. J Hand Surg [Am]. 2006;31A:2Y8.
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Techniques in Hand and Upper Extremity Surgery 10(4):231–234, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
Steven M. Topper, MD
Colorado Hand Center
Colorado Springs, CO
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Ronchetti and Topper
| INDICATIONS/CONTRAINDICATIONS
The patient who presents with painful wrist arthritis
secondary to SLAC or SNAC are ideal candidates for
partial wrist fusion with the OSStaplei (Fig. 1). Isolated FIGURE 2. Intraoperative example of staple placement.
midcarpal arthritis is also an excellent indication. The
technique can be used in Kienbock disease for scapho-
capitate fusion as well. Severely osteoporotic bone is Provisional reduction of the capitolunate joint is
also a relative contraindication. Patients should be performed, and the reduction pinned with a K-wire. This
informed preoperatively that the procedure will not restore is checked under fluoroscopy. It is preferable to have the
normal motion. It is intended to relieve pain and preserve lunate in neutral to slight flexion; this is aided by placing
grip strength. a K-wire in the lunate and rotating it into flexion.5 Also
try to ensure that the capitate is centered over the lunate
to obtain the largest area for fusion.
The guide for drilling the OSStaplei is then placed
on the capitate and lunate on 1 side of the bone so that 2
| TECHNIQUE staples can be placed across the capitolunate articulation.
This technique describes a capitolunate fusion with The 1.8-mm drill bit is then drilled first through the
scaphoid excision; a full 4-bone fusion can be performed lunate. The drill will go through the cartilage on the
by adding the triquetrohamate joint to the fusion mass. dorsal surface of the lunate; be careful not to drill too
A standard dorsal wrist approach is used between the distally on the lunate or the staple will protrude into the
third and fourth extensor compartments. Capsulotomy is fusion site. The pin is placed in the drill hole through the
performed, and the proximal and distal carpal rows are guide to maintain the selected length of the staple chosen.
identified. The scaphoid is excised and placed on the back The second hole is then drilled in the capitate. Depth
table to be used for supplemental bone graft. The cartilage measurement is then made with the depth gauge.
surface of the capitolunate joint is inspected and denuded A small rongeur is used to create a trough in the lu-
of cartilage. This can be accomplished by the use of a nate, so the staple will seat at or below the level of the
high-speed burr or a rongeur. The surfaces should have cartilage. Place the appropriately sized OSStaplei into
visible cancellous bone. It is important to maintain carpal the predrilled holes; use the seating device to completely
height and the overall shape of the carpus. For this reason, seat the staple (Fig. 2). Check the position under
the arthrodesis site is packed with cancellous bone graft fluoroscopy to ensure proper placement (Figs. 3, 4).
which is harvested from the excised scaphoid and/or from Remove the provisional K-wire.
the distal radius. Next, the OSS Forcei Activator (BioMedical Enter-
prises Inc) is used to compress the prongs of the
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Lunocapitate Fusion Using the OSStaple Compression Staple
| COMPLICATIONS
Seven patients have undergone capitolunate fusion with the | REHABILITATION
OSStaplei with an average follow-up of 6 months that Postoperatively, patients are placed in a short-arm volar
have resulted in no nonunions, no occupational changes, splint. Sutures are removed at 10 to 14 days, and a
and complete pain relief in 6 of 7 patients. Five of the short-arm cast is placed. Repeat X-rays are checked at
6 weeks postoperation, and if fusion is apparent and the
patient has little or no pain, they are transitioned to a
removable orthoplast splint (Figs. 5, 6). Occupational
therapy begins when the fusion appears solid.
| ACKNOWLEDGMENT
Supported by BioMedical Enterprises Inc., San Anto-
nio, TX.
| REFERENCES
1. Burgess RC. The effect of rotatory subluxation of the
FIGURE 5. Postoperative anteroposterior radiograph at scaphoid on radioscaphoid contact. J Hand Surg [Am].
6 weeks. 1987;12:771Y774.
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Ronchetti and Topper
2. Watson HK, Ballet FL. The SLAC wrist: scapholunate collapse wrist: proximal row carpectomy versus four corner
advanced collapse pattern of degenerative arthritis. J Hand arthrodesis. J Hand Surg [Am]. 1995;20:965Y970.
Surg [Am]. 1984;9:358Y365. 6. Cohen MS, Kozin SH. Degenerative arthritis of the wrist:
3. Chen C, Chandnani VP, Kang HS, et al. Scapholunate proximal row carpectomy versus scaphoid excision and
advanced collapse: a common wrist abnormality in calcium four-corner fusion. J Hand Surg [Am]. 2001;26:94Y104.
pyrophosphate deposition disease. Radiology. 1990;177: 7. Tomaino MM, Miller RJ, Cole I, et al. Scapholunate
459Y461. advanced collapse wrist: proximal row carpectomy versus
4. Krakauer JD, Bishop AT, Cooney WP. Surgical treatment four corner arthrodesis. J Hand Surg [Am]. 1994;19A:
of scapholunate advanced collapse. J Hand Surg [Am]. 134Y142.
1994;19:751Y759. 8. Watson HK, Goodman ML, Johnson TR. Limited wrist
5. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving arthrodesis. Part II: Intercarpal and radiocarpal combina-
procedures in the treatment of scapholunate advanced tions. J Hand Surg [Am]. 1981;6:223Y233.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand and Upper Extremity Surgery 10(4):235–238, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
| ABSTRACT | TECHNIQUE
The authors report a technique of the anterior cubital The procedure is carried out under general anesthesia in
approach that is an exposure for displaced pediatric a supine position with a tourniquet control. The
supracondylar fractures. Reduction is very safe and easy fractured arm is placed on the hand table. If the right
with this approach. Anatomical structures that hinder arm is fractured, the surgeon sits between the arm and
reduction such as the brachialis muscle or joint capsule the head; thus, if the left arm is fractured, the surgeon
and neurovascular tissues can be identified easily. This sits between the arm and the body. About a 3 cm
technique has not been a popular form of treatment in transverse incision is made following the flexor crease
many countries, particularly in the United States. (Fig. 1). The subcutaneous tissue is traversed with a
Keywords: type III displaced supracondylar humeral blunt dissection to reach the brachialis muscle. The
fracture, anterior cubital approach radial nerve, brachial artery, and median nerve can be
explored and freed through this incision if there is a
| HISTORICAL PERSPECTIVE neurovascular insufficiency before the reduction. In
displaced fractures, the brachialis muscle is commonly
According to LaGrange, anterior cubital approach was
originally defined first by Hagenbeck in 1894.1 Sorrel torn by the proximal fragment (Fig. 1). The fracture site
is approached through this penetration using blunt
and Longuet published the first clinical results and
dissections. After decompressing the fracture hema-
recommended this technique for the treatment of
toma, any soft tissue interposition is stripped with a
pediatric supracondylar humerus fractures in 1946.1
periosteal elevator (Fig. 2). The surgeon then holds his
Carcassonne et al1 popularized the technique as the
thumb on the proximal fragment and presses downward,
anterior and internal reduction for pediatric supra-
with his fingers holding the distal fragment posteriorly
condylar fractures in 1974. Kekomaki et al2 treated 32
while the assistant applies traction to the forearm, with
cases with anterior approach and with eleven successful
outcomes in a detailed study in 1984. Aronson et al3 the elbow flexed at an angle of 90 degrees and with
forearm pronation (Figs. 3A, B). In cases where the
suggested the anterior transverse exposure for reduction
of supracondylar humeral fractures in children as a
forgotten approach, reporting no unsatisfactory results
of 11 cases. Koudstaal et al4 showed that the anterior
approach is safe, simple, and easy to perform. Ay et al5
reported the advantages and the drawbacks of the
anterior cubital approach.
| INDICATIONS AND
CONTRAINDICATIONS
All pediatric supracondylar fractures that are displaced
and of extension type are indicated with or without
neurovascular insufficiency.
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Ay et al
| COMPLICATIONS
There are no major complications about the presence of
a scar tissue, deformity, or contracture.
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Displaced Pediatric Supracondylar Humeral Fractures
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Ay et al
| REFERENCES
1. Carcassonne M, Bergoin M, Hornung H. Results of
operative treatment of severe supracondylar fractures of
the elbow in children. J Pediatr Surg. 1972;7:676Y679.
2. Kekomaki M, Luoma R, Rikalainen H, et al. Operative
reduction and fixation of a difficult supracondylar extension
fracture of the humerus. J Pediatr Orthop. 1984;4:13Y15.
3. Aronson DC, Meeuwis D. Anterior exposure for reduction
of supracondylar humeral fractures in children: a forgotten
approach. Eur J Surg. 1994;160:263Y266.
4. Koudstaal MJ, De Ridder VA, De Lange S, et al. Pediatric
supracondylar humerus fractures. The anterior approach.
J Orthop Trauma. 2002;16:409Y412.
5. Ay S, Akinci M, Kamiloglu S, et al. Open reduction of
displaced pediatric supracondylar humeral fractures through
the anterior cubital approach. J Pediatr Orthop. 2005;25:
149Y153.
6. Boyd DW, Aronson DD. Supracondylar fractures of the
humerus: a prospective study of percutaneous pinning.
J Pediatr Surg. 1992;12:789Y794.
7. Mulhall KJ, Abuzakuk T, Curtin W, et al. Displaced
supracondylar fractures of the humerus in children. Int
Orthop. 2000;24:221Y223.
8. Kurer MHJ, Regan MW. Completely displaced supra-
condylar fracture of the humerus in children. A review of
1708 cases. Clin Orthop. 1990;256:205Y214.
FIGURE 6. A and B, Anteroposterior and lateral radio-
graphs demonstrating perfect alignment of fragments after 9. Rasool MN, Naidoo KS. Supracondylar fractures: postero-
open reduction and internal fixation with anterior cubital lateral type with brachialis muscle penetration and neuro-
approach and crossed Kirschner wires. vascular injury. J Pediatr Orthop. 1999;19:518Y522.
10. Sabharwal S, Tredwell SJ, Beauchamp RD, et al. Manage-
We have not seen any poor or unsatisfactory results ment of pulseless pink hand in pediatric supracondylar frac-
with primary reduction using anterior cubital approach tures of humerus. J Pediatr Orthop. 1997;17:303Y310.
in the early or late follow-ups.4 11. Lyons ST, Quinn M, Stanistki CL. Neurovascular injuries
Open reduction through the anterior cubital approach in type III humeral supracondylar fractures in children.
is an option for the surgical treatment of the pediatric Clin Orthop Relat Res. 2000;376:62Y67.
displaced supracondylar humeral fractures. The drawbacks 12. Archibeck MJ, Scott SM, Peters CL. Brachialis muscle
of the approach are that the surgeon must be aware of the entrapment in displaced supracondylar humerus fractures:
anatomy and exposure of neurovascular structures, that the a technique of closed reduction and report of initial
transverse incision does not allow full exposure and results. J Pediatr Orthop. 1997;17:298Y302.
visualization of the fracture fragments, and that the 13. Erdemli B, Bektas U, Ay S, et al. Surgical treatment of
reduction is achieved directly with feedback from the displaced supracondylar fractures of the humerus in
thumb. However, the technique has certain advantages.1Y5 children. Turk J Med Sci. 1995;2:91Y94.
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Techniques in Hand and Upper Extremity Surgery 10(4):239–244, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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van Riet et al
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Elbow Reconstruction Using a Circumferential Graft
both the radial head and the coronoid process. The cir-
cumferential ligament reconstruction may be indicated
after skeletal fixation and ligament repair in which
stability is not adequate. A dynamic external fixator may
be indicated or used as an alternative in these cases. A rare
cause of instability can sometimes be found after con-
tracture release or removal of heterotopic ossification.
Clinical assessment, including history, physical
examination supplemented by an examination under
general anesthesia, and fluoroscopic and arthroscopic
assessments, are used to identify the pattern of instability.
FIGURE 3. Single-loop technique of the lateral and In most cases, only 1 ligament would require reconstruc-
medial ligamentous complexes. 1) The graft is passed
from lateral to medial through the ulna. 2) The graft is
tion. However, in more complex instabilities, such as
tensioned and passed through the humeral tunnel. This combined or global instabilities, a circumferential graft
reconstructs the anterior bundle of the MCL. 3) The LUCL may be used to provide stability. We have performed a
is reconstructed by passing the graft through the ulna, single-loop technique to provide a reconstruction of the
completing the single loop circumferential reconstruction. anterior band of the MCL and the LUCL (Fig. 3). In more
complex cases such as those of global instability, there
may be injury to all 4 ligamentous units. In these cases,
we recommend that all be reconstructed using a double-
failing between the tendon-screw interface. The authors
loop technique (Fig. 4).
commented that insufficient tension in the graft could be
Contraindications include patients in whom their
another factor that attributed to failure of the construct.19
general health status does not allow a prolonged surgical
Although bilateral ligament injuries are not
procedure, active infection in the operative area, or if their
uncommon, lateral and medial techniques have evolved
mental status does not allow a coordinated postoperative
separately. To our knowledge, no reports have been
rehabilitation period. Elbow stiffness could be a relative
published on a reconstruction of the medial and lateral
contraindication. This grafting technique should not be
ligament complexes with a single procedure using a
considered as a single procedure to overcome instability
single graft.
produced by skeletal insufficiency, such as complex
coronoid process fractures. These conditions should be
addressed first before considering the circumferential
| INDICATIONS/CONTRAINDICATIONS ligamentous reconstruction described below. An external
The technique described in the following section is
indicated in patients with symptomatic chronic global
instability of the elbow. Patients typically present
complaining of recurrent, painful clicking, snapping,
clunking, or locking of the elbow.20 They experience
varying disability ranging from mild instability, which
ultimately may contribute to ulnohumeral arthritis,7 to
instability that limits the ability to exert force with the
upper limb, to recurrent subluxation or dislocation, and
to fixed subluxation or dislocation at the other end of
the spectrum.21
From a clinical evaluation of the elbow, instability
can sometimes be difficult to appreciate and does not
always show the extent of laxity present. Arthroscopic
FIGURE 4. Double-loop technique of the lateral and
evaluation can also be used to evaluate medial and lateral medial ligamentous complexes. 1) The graft is passed
gapping of the ulnohumeral joint during rotational, varus, from lateral to medial through the ulna. 2) The graft is
and valgus stresses to the elbow.22 Symptomatic patients tensioned and passed through the humeral tunnel. This
with documented instability of the elbow are candidates reconstructs the anterior bundle of the MCL. 3) The LUCL
for the technique described. is reconstructed by passing the graft through the ulna. 4) A
second pass is made through the humerus, reconstructing
Other indications include residual elbow instability in the posterior bundle of the MCL. 5) The graft is then
the so-called terrible triad injuries after a fracture dis- brought down to the ulna again, and this reconstructs the
location, after adequate reconstruction and fixation of posterior part of the lateral ligamentous complex.
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van Riet et al
Single-loop Technique
FIGURE 6. Medial intraoperative view of a double-loop
A 4.5-mm hole is drilled through the axis of rotation on technique. The ulnar nerve is released and protected.
the humerus, from the center of the capitellum on the The 2 limbs of the ligament graft are seen to reconstruct
lateral side to the anteroinferior surface of the medial both the anterior and posterior bundles of the MCL.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Elbow Reconstruction Using a Circumferential Graft
into the lateral and/or medial graft exit holes in the knee. We have not encountered any donor-site morbidity
humeral epicondyles. This will effectively stabilize or other complications related to this technique.
tension in each limb of the graft.
| REHABILITATION
Double-loop Technique
Postoperatively, the patient is placed in an above-elbow
If preoperatively, it was decided to also reconstruct the
plaster slab with the elbow in 90-degree flexion and
posterior band of the MCL and the posterolateral capsule,
neutral forearm rotation for 1 week. Because of the initial
the technique is tailored for this pattern (Fig. 4). This is
stability, we have enabled patients to commence active
similar to the single-loop technique but also includes the
mobilization and to not use a brace postoperatively.
posterior bundle of the MCL and the posterior aspect of
the lateral ligament complex. The first ulnar tunnel from
the sublime tubercle to the medial proximal ulna | ACKNOWLEDGMENT
remains the same. A second ulnar tunnel in the proximal The authors thank Ron Heptinstall for his contribution
ulna is drilled from the supinator crest directed to the in creating the artwork and preparing the manuscript.
olecranon, exiting at the level of the center of the
greater sigmoid notch. An additional tunnel needs to be
drilled through the proximal ulna. This will be drilled | REFERENCES
straight laterally from the medial aspect of the olecranon 1. Morrey BF, An KN. Functional anatomy of the ligaments
at the level of the center of the greater sigmoid notch. of the elbow. Clin Orthop. 1985;201:84Y90.
The humeral tunnel is 6 mm to accommodate the
2. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory
graft passage twice. A trailing suture is again preloaded
instability of the elbow. J Bone Joint Surg Am. 1991;
in the circuit. The graft follows the suture through the 73:440Y446.
entire circuit, starting again from the lateral side of the
3. Olsen BS, Sojbjerg JO, Nielsen KK, et al. Posterolateral
ulna through the sublime tubercle on the medial side.
elbow joint instability: the basic kinematics. J Shoulder
The reconstruction of the anterior band of the MCL and
Elbow Surg. 1998;7:19Y29.
the LUCL is again performed. The graft is now passed
through the supinator crest to the posteromedial side of 4. Mehta JA, Bain GI. Posterolateral rotatory instability of
the elbow. J Am Acad Orthop Surg. 2004;12:405Y415.
the proximal ulna and pulled up through the humeral
tunnel for the second pass. This reconstructs the 5. O’Driscoll SW, Hori E, Morrey BF, et al. Anatomy of the
posterior band of the MCL. Finally, the graft is pulled ulnar part of the lateral collateral ligament of the elbow.
down to the lateral side of the greater sigmoid notch, Clin Anat. 1992;5:296Y303.
where it is fixed with an interference fit screw (Fig. 6). 6. van Riet RP, Morrey BF, O’Driscoll SW, et al. Associated
The graft is again tensioned before each pass through the injuries complicating radial head fractures: a demographic
bone, and the double tendon graft can be fixated into the study. Clin Orthop Relat Res. 2005;441:351Y355.
humeral tunnel using an interference fit screw. It is 7. Eygendaal D, Verdegaal SH, Obermann WR, et al.
important to make sure that the elbow is fully reduced Posterolateral dislocation of the elbow joint. Relationship
throughout this procedure and, especially, before the to medial instability. J Bone Joint Surg Am. 2000;82:
graft is secured. 555Y560.
The flexor-pronator mass is repaired back to the 8. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous
medial epicondyle, and the Kocher interval is closed reconstruction for posterolateral rotatory instability of
using nonabsorbable sutures. The skin is closed in layers. the elbow. J Bone Joint Surg Am. 1992;74:1235Y1241.
9. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamen-
tous repair and reconstruction for posterolateral rotatory
| COMPLICATIONS instability of the elbow. J Bone Joint Surg Br. 2005;87:
Potential complications include ulnar nerve damage 54Y61.
caused by tunnel placement and the medial approach, 10. Eygendaal D. Ligamentous reconstruction around the
and posterior interosseus nerve damage on the lateral side elbow using triceps tendon. Acta Orthop Scand. 2004;
of the elbow. The ulnar nerve is therefore transposed 75:516Y523.
routinely. Recurrent instability, elbow stiffness, and 11. O’Driscoll SW, Jupiter JB, King GJW, et al. The unstable
wound breakdown from the posterior incision have all elbow. J Bone Joint Surg Am. 2000;82-A:724Y738.
been reported in reconstructive elbow procedures. Com- 12. Ashwood N, Bain GI, Unni R. Management of mason
plications related to the potential use of a hinged external type-III radial head fractures with a titanium prosthesis,
fixator can also occur. Potential complications also ligament repair, and early mobilization. J Bone Joint Surg
include donor-site morbidity on the medial side of the Am. 2004;86-A:274Y280.
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van Riet et al
13. Bain GI, Ashwood N, Baird R, et al. Management of 18. Armstrong AD, Dunning CE, Faber KJ, et al. Single-
mason type-III radial head fractures with a titanium strand ligament reconstruction of the medial collateral
prosthesis, ligament repair, and early mobilization. Surgical ligament restores valgus elbow stability. J Shoulder Elbow
technique. J Bone Joint Surg Am. 2005;87(suppl 1): Surg. 2002;11:65Y71.
136Y147. 19. Armstrong AD, Dunning CE, Ferreira LM, et al. A
14. Conway JE, Jobe FW, Glousman RE, et al. Medial biomechanical comparison of four reconstruction tech-
instability of the elbow in throwing athletes. Treatment niques for the medial collateral ligament-deficient elbow.
by repair or reconstruction of the ulnar collateral ligament. J Shoulder Elbow Surg. 2005;14:207Y215.
J Bone Joint Surg Am. 1992;74:67Y83. 20. Ruch DS, Kuzma GR. Elbow and forearm instability and
15. Azar FM, Andrews JR, Wilk KE, et al. Operative arthroscopy. In: Trumble TE, ed. Hand, Elbow and
treatment of ulnar collateral ligament injuries of the Shoulder. Rosemount, IL: ASSH; 2003.
elbow in athletes. Am J Sports Med. 2000;28:16Y23. 21. Morrey BF. Chronic unreduced elbow dislocation. In:
16. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the Morrey BF, ed. The Elbow and Its Disorders. Philadelphia,
ulnar collateral ligament in athletes. J Bone Joint Surg Am. PA: WB Saunders, 2000:431Y436.
1986;68:1158Y1163. 22. Field LD, Altchek DW. Evaluation of the arthroscopic
17. Thompson WH, Jobe FW, Yocum LA, et al. Ulnar valgus instability test of the elbow. Am J Sports Med.
collateral ligament reconstruction in athletes: muscle- 1996;24:177Y181.
splitting approach without transposition of the ulnar nerve. 23. Patterson SD, Bain GI, Mehta JA. Surgical approaches to
J Shoulder Elbow Surg. 2001;10:152Y157. the elbow. Clin Orthop Relat Res. 2000:19Y33.
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Techniques in Hand and Upper Extremity Surgery 10(4):245–251, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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Addosooki et al
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Gracilis Harvesting Technique
receives mainly transversely oriented fasciocutaneous adductor longus became prominent and was easily felt.
perforators from the main gracilis muscular perforating A line drawn from the pubic tubercle along the adductor
arteries, which usually pass anterior to the gracilis, longus prominence demarcated the anterior border of
along the septum between the gracilis and the adductor the gracilis. An elliptical skin paddle was designed just
longus. Direct musculocutaneous perforators are few behind this line, 6 to 10 cm distal to pubic tubercle, with
and inconstant.19,20 The skin overlying the middle third a diameter of about 6 10 cm (Fig. 3).
of the gracilis is primarily dependent on fasciocutaneous
perforators from the superficial femoral artery. These Incisions
perforators communicate with the vascular pedicle of We approached the gracilis through 3 incisions. The
the gracilis through longitudinally oriented vessels first was the incision that outlined the skin paddle,
running through the fascia over the gracilis.20,21 The which may be extended proximally or distally for few
skin over the distal third is supplied by smaller centimeters as needed. The second incision was a short
fasciocutaneous perforators from the superficial femoral incision (4Y6 cm) located at the posteromedial side of
artery and the descending genicular artery. Depending the distal thigh, just proximal to the knee joint, over the
on the previous description, the skin paddle of gracilis distal tendon of the gracilis muscle. The third incision
myofasciocutaneous free flap should be centered over was a transverse incision (6Y8 cm) located on the
the proximal third of the gracilis and slightly anterior to anteromedial side of the proximal tibial, just distal to
the anterior border of the gracilis, with inclusion of the the level of the tibial tuberosity (Fig. 3). The third
all fascia around the gracilis to ensure its vascularity.20 incision is needed when the gracilis will be placed
The motor nerve of the gracilis is a branch of the proximal to the shoulder to restore fingers flexion or
anterior division of the obturator nerve. The obturator extension because the free gracilis needs to be long
nerve emerges from the obturator foramen under the enough to span the distance from the clavicle or
pectineus muscle and divides into anterior and posterior proximal ribs to the distal forearm to be sutured to the
divisions. The anterior division passes between the fingers flexor or extensor tendons. In other indications,
adductor longus and brevis, giving motor branches to the first and second incisions will be enough.
both muscles before giving the motor branch to the Dissection
gracilis muscle. The medial cutaneous nerve of the We incised first the anterior border of skin paddle. The
thigh, a branch of the obturator nerve, courses just subcutaneous tissues were cut obliquely to obtain a wide
lateral to the motor nerve of the gracilis on the base of subcutaneous tissues for the skin paddle to
undersurface of the adductor longus muscle (Fig. 2). ensure the vascularity of the skin paddle. The great
Planning saphenous vein was identified and dissected free. It is an
The patient was placed in supine position. The knee was important landmark because it is located about 2 cm
anterior to the intermuscular septum between the
flexed, and the hip was flexed, abducted, and externally
gracilis and the adductor longus. The deep fascia was
rotated. In this position, the tendon of origin of the
incised along the course of the great saphenous vein to
include the intermuscular septum between the gracilis
and adductor longus, along which skin paddle fasciocu-
taneous perforators usually pass, opposite the dominant
vascular pedicle (Fig. 4). We reflected the deep fascia
posteriorly and continued dissection between the graci-
lis and the adductor longus muscle until the main
vascular pedicle of the gracilis was confirmed (Fig. 2).
Then, we incised the posterior border of the skin paddle.
The subcutaneous tissues were also cut obliquely to
obtain a wide base for the skin paddle. The skin paddle
and subcutaneous tissue should be trapezoid-like in
transverse section (Fig. 1). We continued dissection
posteriorly, avoiding cutting the deep fascia, until the
FIGURE 2. The adductor longus was retracted anteriorly. posterior border of the gracilis was reached. The deep
The gracilis vascular pedicle runs over the adductor fascia was cut 1 to 2 cm posterior to this border, and the
magnus and brevis (black transverse arrow). The motor gracilis, completely invested in fascia, was dissected
branch of the gracilis runs proximal to the pedicle (black
vertical arrow), and the sensory branch of the obturator (Fig. 1). Inclusion of the fascia around the gracilis
nerve runs parallel to the motor nerve on its lateral side ensures the blood supply of the skin paddle, as we
(white vertical arrow). described in the ‘‘Anatomy^ section, and enhances
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Addosooki et al
FIGURE 3. The patient was positioned with the hip FIGURE 5. The dissection was continued anteriorly and
flexed, abducted, and externally rotated. The upper dotted distally between the gracilis and adductor longus (black
line was drawn along the adductor longus muscle, and it arrow) until the adductor magnus comes anterior to the
demarcated the anterior border of the gracilis. An elliptical gracilis (white arrow). At this point, we dissected circum-
skin paddle was designed just behind this line, 6 to 10 cm ferentially around the gracilis (gray retractor).
distal to the pubic tubercle, with a diameter of about 6
10 cm. The second incision was designed on the poster-
omedial distal thigh just proximal to the knee. The third to an extension chain that attached to a lifting apparatus.
incision was a transverse incision on the anteromedial The endoscope was fixed to a scope holder and adjusted
border of the leg just distal to the tibial tuberosity.
to allow a good field of view. A second endoretractor,
also attached to the lifting apparatus, may help to make
gliding of the gracilis in the new bed. Then, we the optical cavity wider (Fig. 7). Under endoscopic
continued the dissection anteriorly and distally until guidance, the surgeon proceeded to dissect distally from
the adductor magnus muscle was anterior to the anterior the second incision using a long-limb tooth forceps, a
border of the gracilis (Fig. 5). At this point, we dissected pair of long dissecting scissors, and electrocautery
circumferentially around the gracilis and retracted it by instruments. The gracilis minor vascular pedicles were
a rubber drain. meticulously dissected, ligated with vascular clips, and
When the limits of open dissection were reached, cut, because it is very difficult to stop any bleeding
dissection was continued endoscopically. The gracilis under endoscopy. The interseptal fascia was cut to
tendon was approached through the second incision just include the overlying fascia of the gracilis so as to
behind the sartorius muscle fleshy tendon (Fig. 6). A provide a gliding surface for the muscle after transfer
subcutaneous tunnel between the first and second into an unhealthy recipient bed. After the dissection of
incision was developed above the deep fascia over the the proximal two-thirds of the subcutaneous tunnel was
gracilis. A large endoretractor was inserted through the completed, the endoscope was removed and inserted
proximal incision and secured to the skin edges to through the second incision. Dissection from this end is
prevent it from slipping out. It was lifted by hooking it
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Gracilis Harvesting Technique
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Addosooki et al
the knee and the hip after delivery of the gracilis to the
first incision and close the second and third incision in
this position to relief sciatic nerve compression.
| REFERENCES
1. Tamai S, Komatsu S, Sakamoto H, et al. Free muscle
transplants in dogs, with microsurgical neurovascular
FIGURE 11. The gracilis muscle was harvested com- anastomoses. Plast Reconstr Surg. 1970;46:219Y225.
pletely. The black arrow points to the vascular pedicle,
2. Harii K, Ohmori K, Torii S. Free gracilis muscle
and the white arrow points to the motor nerve of the
gracilis. transplantation, with microneurovascular anastomoses for
the treatment of facial paralysis. A preliminary report.
Plast Reconstr Surg. 1976;57:133Y143.
proximal as possible to the obturator foramen. The 3. Manktelow RT, McKee NH. Free muscle transplantation
dissection should be cautious to avoid injury of the to provide active finger flexion. J Hand Surg [Am].
adductor longus and brevis motor branches. The nerve 1978;3:416Y426.
was then cut, and the gracilis muscle dissection was
4. Chung DC, Carver N, Wei FC. Results of functioning free
completed posteriorly without tension on the vascular muscle transplantation for elbow flexion. J Hand Surg
pedicle. The vascular pedicle was then ligated, and the [Am]. 1996;21:1071Y1077.
dissection of the gracilis was completed proximally up
5. Manktelow RT. Functioning microsurgical muscle trans-
to its aponeurotic origin from the pubic arch. The
fer. Hand Clin. 1988;4:289Y296.
muscle origin was cut from the pubic arch, and the
bleeding was stopped using electrocautery (Fig. 11). 6. Egerszegi EP, Zuker RM, Caouette-Laberge L, et al.
The adductor magnus and adductor longus muscles Neurovascular transfer of the m. gracilis for the treatment
of Volkmann’s contracture following supracondylar frac-
were approximated using absorbable sutures to avoid
ture in childhood. Ann Chir. 1991;45:803Y810.
dead space formation. The wound was closed over a
suction drain and covered by compressive dressings. 7. Doi K, Hattori Y, Kuwata N, et al. Free muscle
The procedure took about 2 hours to be completed, transfer can restore hand function after injuries of the
lower brachial plexus. J Bone Joint Surg Br. 1998;80:
including the wound closure.
117Y120.
8. Doi K, Kuwata N, Muramatsu K, et al. Double muscle
| COMPLICATIONS transfer for upper extremity reconstruction following
Carr et al22 reported donor-site complications in 104 complete avulsion of the brachial plexus. Hand Clin.
cases of free gracilis transfer. These complications 1999;15:757Y767.
included excessive pain at the incision site, minor 9. Doi K, Muramatsu K, Hattori Y, et al. Restoration of
wound infection, temporary sciatic nerve palsy, and prehension with the double free muscle technique follow-
scar-related problems. They reported functional diffi- ing complete avulsion of the brachial plexus. Indications
culties in 26% of their patients, but most patients and long-term results. J Bone Joint Surg Am. 2000;82:
reported no noticeable functional deficits from gracilis 652Y666.
loss. Deutinger et al23 reported 11% reduction of 10. Doi K, Hattori Y, Soo-Heong T, et al. Endoscopic
adduction strength after gracilis harvest, but this harvesting of the gracilis muscle for reinnervated
reduction was not noticed by the patients. He also free-muscle transfer. Plast Reconstr Surg. 1997;100:
reported an area of hypesthesia corresponding to the 1817Y1823.
cutaneous territory of the obturator nerve and aesthetic 11. Hallock GG. Minimally invasive harvest of the gracilis
problems of the donor site. The most common compli- muscle. Plast Reconstr Surg. 1999;104:801Y805.
cations in our experience, with more than 200 free 12. Jeng SF, Kuo YR, Wei FC. Minimally invasive harvest of
gracilis transplantation, and also in other reports11,22,23 the gracilis muscle without endoscopic assistance. Plast
had been wound-related problems. These included Reconstr Surg. 2001;108:2061Y2065.
wound infection, delayed healing, and unsightly scar at 13. Hattori Y, Doi K, Abe Y, et al. Surgical approach to the
donor site. Although the scar was obvious in most of our vascular pedicle of the gracilis muscle flap. J Hand Surg
patients, most did not complain about the scar. None of [Am]. 2002;27:534Y536.
our patients had functional deficit after gracilis harvest. 14. O’Ceallaigh S, Mehboob Ali KS, O’Connor TP. Func-
We had an experience of temporary sciatic nerve palsy tional latissimus dorsi muscle transfer to restore elbow
after gracilis harvest, most probably due to long- flexion in extensive electrical burns. Burns. 2005;31:
standing compression. Since then, we always extend 113Y115.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gracilis Harvesting Technique
15. Doi K, Sakai K, Ihara K, et al. Reinnervated free muscle 19. Yousif NJ, Matloub HS, Kolachalam R, et al. The
transplantation for extremity reconstruction. Plast transverse gracilis musculocutaneous flap. Ann Plast Surg.
Reconstr Surg. 1993;91:872Y883. 1992;29:482Y490.
16. Doi K, Sakai K, Fuchigami Y, et al. Reconstruction of 20. Whetzel TP, Lechtman AN. The gracilis myofasciocuta-
irreparable brachial plexus injuries with reinnervated free- neous flap: vascular anatomy and clinical application.
muscle transfer. Case report. J Neurosurg. 1996;85: Plast Reconstr Surg. 1997;99:1642Y1652. discussion
174Y177. 1653Y1655.
17. Hattori Y, Doi K, Saeki Y, et al. Obturator nerve injury 21. Core GB, Weimar R, Meland NB. The turbo gracilis myo-
associated with femur fracture fixation detected during cutaneous flap. J Reconstr Microsurg. 1992;8:267Y275.
gracilis muscle harvesting for functioning free muscle 22. Carr MM, Manktelow RT, Zuker RM. Gracilis donor site
transfer. J Reconstr Microsurg. 2004;20:21Y23. morbidity. Microsurgery. 1995;16:598Y600.
18. Mathes SJ, Nahai F. Classification of the vascular 23. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al.
anatomy of muscles: experimental and clinical correla- Donor-site morbidity of the gracilis flap. Plast Reconstr
tion. Plast Reconstr Surg. 1981;67:177Y187. Surg. 1995;95:1240Y1244.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand and Upper Extremity Surgery 10(4):252–254, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
Christophe Oberlin, MD
Service de Chirurgie Orthope´dique et Traumatologique
Hôpital Bichat-Claude Bernard
Paris, France
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Extensor Tenodesis for C7 to T1 Root Avulsions
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Goubier et al
and intrinsic function were paralyzed. In all patients, 5. Ochiai N, Nagano A, Yamamoto S, et al. Tenodesis of
ECRL has been transferred on FDP, BR was transferred extensor digitorum in treatment of brachial plexus injuries
on FPL associated with a modified Makin procedure.11,12 involving C5, 6, 7 and 8 nerve roots. J Hand Surg [Br].
Intrinsic function was restored in suturing FDS on A1 1995;20:671Y674.
pulley with 30-degree flexion of MP joint. Extensor 6. Revol M. Principles of palliative motor surgery of
tenodesis was performed as described before. With an paralysis of the hand. Ann Chir Plast Esthet. 1993;38:
average follow-up of 25 months (range, 23Y27 months), 210Y217.
all patients recovered active finger flexion. Hand opening 7. Saito H. Evolution of surgery for tetraplegic hands in
or passive finger extension was complete in 30-degree Japan. Hand Clin. 2002;18:535Y539. viii.
wrist flexion. No complications have been noted. 8. Teissier J, Fattal C, Egon G. Strategy for improving hand
opening in the tetraplegic upper limb. Hand Clin.
2002;18:497Y502.
| REFERENCES
9. Romain M, Allieu Y. Evaluation of the function of the
1. Chevallard A. New technic of palliative intervention in flexor and extensor tendons of the hand. Chir Main. 1998;
paralysis of the intrinsic muscles of the hand (cubital 17:259Y265.
paralysis in Hansen’s disease). Acta Leprol. 1987;5:65Y68. 10. Oberlin C, Teboul F, Severin S, et al. Transfer of the
2. Bonnard C. Nerve repair or muscle-tendon transfers in lateral cutaneous nerve of the forearm to the dorsal branch
posttraumatic paralysis of the upper limb. Rev Med Suisse of the ulnar nerve, for providing sensation on the ulnar
Romande. 1989;109:513Y518. aspect of the hand. Plast Reconstr Surg. 2003;112:
3. Merle M, Foucher G, Dap F, et al. Tendon transfers for 1498Y1500.
treatment of the paralyzed hand following brachial plexus 11. Oberlin C, Alnot JY. Opponensplasty through transloca-
injury. Hand Clin. 1989;5:33Y41. tion of the flexor pollicis longus. Technique and indica-
4. Hentz VR, Brown M, Keoshian LA. Upper limb recon- tions. Ann Chir Main. 1988;7:25Y31.
struction in quadriplegia: functional assessment and 12. Makin M. Translocation of the flexor pollicis longus
proposed treatment modifications. J Hand Surg [Am]. tendon to restore opposition. J Bone Joint Surg Br. 1967;
1983;8:119Y131. 49:458Y461.
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Techniques in Hand and Upper Extremity Surgery 10(4):255–258, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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Adani et al
FIGURE 1. Surgical technique. A, The eponychium is vascularized by longitudinal branches from the distal dorsal arterial
arch of the digit. B, A skin rectangle is drawn at a distance of 0.5 to 0.6 cm from the eponychium. It is 0.2 to 0.3 cm high
and as wide as the residual nail. C, De-epithelialization of the skin rectangle, leaving the underlying vascular network
intact. D, The eponychial flap is transposed backward and sutured by exteriorizing the nail matrix and the nail bed.
fingernail and that of the injured finger, considering that prevent proximalization and, in particular, separation of
the maximum limit is 0.4 cm (generally ranges between the eponychium along its whole length and width.16 The
0.2 and 0.3 cm).14 eponychium is detached using a fine elevator.
After de-epithelialization of the rectangular area, Now, the eponychial flap can be delicately slid
leaving the underlying subcutaneous vascular network proximally and its end sutured; this makes it possible to
intact to ensure the survival of the eponychial flap and exteriorize the nail matrix, increasing the extent of
nail matrix, the lateral margins of the flap are incised. exposure of the nail bed. In this way, a nail with total
Proper execution requires complete removal of the length of 3 mm is obtained even in cases where the
remaining portion of the nail, because its presence would surgical removal of the nail matrix is considered.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nail Salvage Using the Eponychial Flap
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adani et al
The eponychial flap is then plicated backward and 4. Hsieh S-C, Chen S-H, Chen T-M, et al. Thin split-
fixed by stitches; finally, some stitches are made on the thickness toe nail bed grafts for avulsed nail bed defects.
medial and lateral borders. Ann Plast Surg. 2004;52:375Y379.
The nail bed should then be protected through the 5. Dumontier C, Tilquin B, Lenoble E, et al. Reconstruction
application of a Silastic or polypropylene nail17 to avoid of distal defects of the nail bed a de-epithelialized palmar
possible hematoma or scar adhesions between the advancement flap. Ann Chir Plast Esthet. 1992;37:
eponychial flap and nail matrix. 553Y559.
Pulp reconstruction is performed using either a large 6. Endo T, Nakayama Y. Short pedicleYvascularized nail
Tranquilli-Leali flap18 or a modified Venkataswami flap. Plast Recontr Surg. 1996;97:656Y661.
flap.19 The apex of the local flaps should be fixed into 7. Koshima I, Moriguchi T, Soeda S, et al. Free second toe
the underlying bone phalanx using a needle to avoid transfer for reconstruction of the distal phalanx of the
traction on the nail bed. fingers. Br J Plast Surg. 1991;44:456Y458.
8. Koshima I, Moriguchi T, Soeda S, et al. Free thin osteo-
| DISCUSSION onychocutaneous flaps from the big toe for reconstruction
The nail should protrude from the eponychium by at least of the distal phalanx of the fingers. Br J Plast Surg.
1992;45:1Y5.
2 mm for precision grip and good cosmetic appearance.1
The eponychial flap is simple, safe, and rapid 9. Koshima I, Inagawa K, Urishubara K, et al. Fingertip
technique that restores the visible length of a short nail reconstruction using partial toe transfer. Plast Reconstr
after distal fingertip injuries (Figs. 2, 3). According to Surg. 2000;105:1666Y1674.
the type of amputations, it allows the surgeon to 10. Dufourmentel C. Correction chirurgicale des extremites
proximalize the whole eponychium and exteriorize the digitales en massue. Ann Chir Plast. 1963;8:9Y102.
nail matrix almost completely.14 When the proximal 11. Dufourmentel C. Problemes esthetiques dans la recon-
translation of the eponychium is marked, chromatic struction des maignons digitaux. Ann Chir. 1971;25:
changes of the nail can be present because of the exposure 995Y999.
of the underlying nail matrix, whose physiological whitish 12. Foucher G, Lenoble E, Goffin D, et al. Escalator flap in
color differs from the pink of the nail bed. Moreover, a the treatment of claw nail. Ann Chir Plast Esthet.
change about nail consistency is often observed after the 1991;36:51Y53.
backward transposition of the eponychium.14,16 13. Marin-Braun F, Lorea P, Dury M. Emergency treatment
The final result depends on the surgical technique by nail recession: a new method for the repair of fingertip
adopted for pulp reconstruction: in the cases of transver- amputations. Chir Main. 2000;2:294Y299.
sal amputations where pulp loss does not exceed 1 cm, the 14. Adani R, Marcoccio I, Tarallo L. Nail lengthening and
Tranquilli-Leali flap18 is indicated; when pulp loss ranges fingertip amputations. Plast Reconstr Surg. 2003;112:
between 1.5 and 2.5 mm, the modified Venkataswami 1287Y1294.
flap satisfies the requirements for reconstruction.
15. Bakhach J. Le lambeau d’eponychium. Ann Chir Plast
The eponychial flap permits nail salvage in situations Esthet. 1998;43:259Y263.
that are often difficult to resolve and represents an
16. Bakhach J, Demiri E, Guimberteau JC. Use of the
alternative technique to microsurgical transfer from toes.
eponychial flap to restore the length of a short nail: a
review of 30 cases. Plast Reconstr Surg. 2005;116:
| REFERENCES 478Y483.
1. Brown RE, Zook EG, Russel RC. Fingertip reconstruction 17. Ogunro EO. External fixation of injured nail bed with the
with flaps and bed grafts. J Hand Surg [Am]. 1999;24: INRO surgical nail splint. J Hand Surg [Am]. 1989;14:
345Y351. 236Y241.
2. Shepard GH. Management of acute nail bed avulsion. 18. Elliot D, Moiemen NS, Jigjnni VS. The neurovascular
Hand Clin. 1990;6:39Y58. Tranquilli-Leali flap. J Hand Surg [Br]. 1995;20:
815Y823.
3. Raja Sabapathi S, Vankatramani H, Bharathi R, et al.
Reconstruction of finger tip amputations with advance- 19. Adani R, Busa R, Castagnetti C, et al. Homodigital
ment flap and free nail bed graft. J Hand Surg [Br]. 2002; neurovascular island flap with ‘‘direct flow’’ vasculariza-
27:134Y138. tion. Ann Plast Surg. 1997;38:36Y40.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand and Upper Extremity Surgery 10(4):259–264, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| T E C H N I Q U E |
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van Riet and Bain
FIGURE 1. Radiographs demonstrating SLAC wrist. A, Anteroposterior (AP) view with widening of the scapholunate
interval, degenerative arthritis over the radial styloid. Importantly, the lunate and lunate facet are intact. B, Lateral view of
the wrist showing a dorsally rotated lunate and volar flexed scaphoid.
A capitolunate fusion with resection of the scaphoid Shape memory alloys consist of a nickel-titanium or
and triquetrum has been advocated but has so far had a nitinol alloy. Memory staples are open, and the legs
higher chance of nonunion.7 Previously reported techni- close when they are heated.10 Different companies
ques of fixation for fusion have included Kirschner distribute memory staples. Some need to be kept at less
wires (K-wires), screws, staples, or plate fixation.8 A than 0-C and change shape with body temperature,
previous cadaveric study identified increased range of whereas others can be kept at room temperature and
motion as a major advantage of resection of both the need an external heating source such as the electro-
triquetrum and scaphoid.9 cautery device. Closing of the staple compresses the
osteotomy site. Memory staples in the wrist have
previously been suggested for radioscapholunate fusions
after Kienböck disease11 and in the treatment of
scaphoid fractures.12
The following technique described involves resec-
tion of both the scaphoid and the triquetrum and fusion
of the lunate, capitate, and hamate using triquetral
cancellous bone graft and dynamic fixation using
memory staples.
| INDICATIONS/CONTRAINDICATIONS
The main indication for this procedure is degenerative
arthritis of the wrist due to a SLAC or SNAC wrist. We
have also used it for LTAC in which there is a VISI with
midcarpal degenerative arthritis and widening of the
lunotriquetral articulation (Fig. 3).
Clinical examination is key in the diagnosis.
Patients are typically middle-aged men with a manual
profession. Patients have decreased grip strength and
decreased range of motion with pain at testing.
Instability of the wrist is assessed. Anteroposterior and
FIGURE 2. Computed tomography scan of SNAC wrist. lateral radiographs are indicative of a SLAC, SNAC, or
Note the intact scapholunate interval and degenerative LTAC wrist. A scaphoid nonunion is obvious in the
changes between the distal pole of the scaphoid and the
radius as well as between scaphoid and the capitate. The SNAC wrist, with degenerative changes between the
relationship between the lunate and the radius remains radius and the distal pole of the scaphoid and between
normal. the scaphoid and capitate. The scapholunate interval is
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Three-corner Wrist Fusion Using Memory Staples
FIGURE 3. Anteroposterior (A) and lateral (B) radiographic views. Lunotriquetral advanced collapse showing VISI with
volar flexion of the scaphoid and lunate. Widening of the lunotriquetral articulation and midcarpal degenerative arthritis
is shown.
typically normal. A dorsal intercalated segment insta- congruent articulation between the lunate fossa on the
bility deformity can be found in the SLAC wrist, with radius and the lunate.
widening of more than 3 mm of the scapholunate
interval and degenerative changes between the scaph- | TECHNIQUE
oid and the scaphoid facet on the radius. There may
After administration of an anesthetic, the arm is placed
or may not be degenerative changes between the
on a hand table, and a tourniquet is placed around the
lunate and capitate. A VISI deformity, lunotriquetral
upper arm. An incision is made over the dorsum of the
widening, and midcarpal degenerative arthritis are
wrist. The incision is placed just ulnar to Lister tubercle
visible on plain radiographs in patients with an LTAC
(Fig. 4). Subcutaneous fat is retracted, and the third
wrist.
extensor compartment is visualized. The fascia overly-
The absence of capitolunate degeneration is not a
ing the third compartment is incised while protecting the
contraindication to perform a limited wrist fusion,
whereas a proximal row carpectomy should not be
performed in the presence of capitolunate degeneration.
Contraindications include severe radiolunate arthritis,
Kienböck disease, malunion or nonunion of lunate,
intra-articular distal radius fractures involving the lunate
facet, and other situations where the bone stock is
insufficient for a predictably strong fusion between the
lunate and capitate or where it is not possible to obtain a
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van Riet and Bain
FIGURE 6. Scaphoid and triquetrum are excised. The FIGURE 8. The legs of the memory staple are pushed
midcarpal joint is debrided in preparation for the bone into the predrilled holes with the introducer. Introduction of
graft and staple stabilization. the staple should be controlled, with minimal force applied
via a small mallet.
extensor pollicis longus (EPL) tendon. The EPL is
retracted radially and protected throughout the proce- expose the subchondral bone, and the surfaces are
dure. The capsule of the wrist is entered through a shaped to obtain a conforming fit. Morselized cancel-
longitudinal incision and is reflected to expose the lous bone graft from the resected triquetrum was placed
proximal and distal row (Fig. 5). The scaphoid and between the lunate and the capitate.
triquetrum are resected using a rongeur. The intact Once the surfaces are prepared, the bone graft is
radioscaphocapitate ligament will become visible after added. Two memory staples (DePuy, Warsaw, IN) are
complete resection of the scaphoid. Care should be used to fuse the midcarpal joint. The staples are
taken to preserve this ligament, to prevent possible ulnar supplied in a freezer and kept at less than 0-C until
translocation of the remaining carpus.1 The triquetrum they are inserted in the wrist. As was stated earlier,
is resected in the same fashion (Fig. 6), taking care not other conditions may apply for specific staples. The
to leave any bone and not to injure the ulnar nerve, radial staple is placed first to avoid excessive ulnar
which is ulnar to the underlying pisiformis. Care must deviation. A guidewire is drilled into the lunate, a
be taken to resect both bones completely without cannulated drill is advanced over the wire to produce
leaving fragments. Cancellous bone is harvested from the first hole, and the drill is left in place. A drill guide
the resected triquetrum. is placed over this first drill and acts as a guide to ensure
Traction is applied to the carpus, and the wrist is the correct positioning of the second drill hole. The
flexed to expose the capitate, hamate, and lunate width of the staple is predetermined and cannot be
articular surfaces. Articular cartilage is removed to changed. The position of the drill holes is therefore
crucial to obtain compression after insertion of the
staple. The guide is positioned between the lunate and
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Three-corner Wrist Fusion Using Memory Staples
distal carpal row (Fig. 7). The second drill hole is made,
and both drills are removed. A depth gauge is used to
determine the desired length of each leg of the memory
staple. The length of the legs should be determined
individually as combinations of leg lengths can be used.
The appropriate-size staple is removed from the freezer.
The legs of the staples are opened slightly to facilitate
insertion. In this way, the staple will compress the
lunate and capitate when it regains its original shape
after insertion. Both legs of the staple are then fully
seated onto the lunate and the capitate (Fig. 8). While
the staples are warming up to body temperature, they
regain rigidity and return to their original shape,
compressing the lunate and capitate. The same proce-
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van Riet and Bain
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Techniques in Hand and Upper Extremity Surgery 10(4):265–270, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| C O M M E N T A R Y |
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Goldfarb
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Reconstruction of Radial Polydactyly
FIGURE 3. A, Clinical photograph demonstrating thumbs of equal size. B, Radiograph of same patient with thumbs of
equal size.
make the surgery technically more straightforward. I the thumb and may limit motion; therefore, in the design
delay the procedure for thumbs that are types 1 and 2 to of the final closure for a racquet incision, 1 or more V-Y
allow enlargement and further ossification. On the other advancement flaps are incorporated.
hand, I reconstruct type 4 radial polydactyly without
alignment issues as early as 6 or 9 months of age. Nerves, Vessels, and Tendons
The priorities of the surgeon dictate the surgical Although it has been shown that the vascular patterns in
technique in the reconstruction of the complicated radial polydactyly are abnormal (a single artery for each
thumb. I seek to first reconstruct a stable thumb with of the thumbs is the most common pattern),11 I do not
good alignment to improve the appearance of the perform vascular studies before treatment. Instead, the
thumb. These features are, in most patients, more arterial supply to the radial thumb is identified at the
important than the size of the thumb. Some authors time of surgery and ligated. The ulnar side of the re-
have suggested that the reconstructed thumb should be tained ulnar thumb is not explored routinely. The digital
Bno smaller than the normal opposite one.[[10] Al- nerves are also variable. Most commonly, 1 nerve in
though I seek to avoid a dramatically smaller thumb, I the radial thumb is identified, and, once traced to its
do not feel the size of the thumb is the primary issue in
most patients.
| TECHNIQUE
The basic principles of thumb reconstruction in radial
lpolydactyly are outlined below. These principles apply
to most common scenario in which the radial thumb is
excised, and the ulnar thumb is reconstructed.
Skin Incision
The skin incision may be a racquet incision on the radial
thumb with proximal and distal extensions on the ulnar
thumb (Fig. 4) or a central zigzag incision designed to
incorporate thumb excision. Once the reconstruction has
been completed, excess skin is excised, and the incision
is closed. A straight-line closure is avoided, as any FIGURE 4. Racquet incision in Wassel type 7 radial
resulting scar contracture may lead to radial deviation of polydactyly that allows excision of the radial thumb.
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Goldfarb
| SPECIAL CONSIDERATIONS
The Zigzag Deformity
Angular deformity in radial polydactyly should be
corrected at the time of the primary reconstruction
(Fig. 6). Correcting the angular deformity by tightening
collateral ligaments, forcing the thumb into a straight
alignment, and holding the alignment with a longitudi-
nal Kirschner pin insertion is not advised, as the
FIGURE 5. Preservation of the collateral ligament with deformity is likely to recur. As noted above, an
periosteal sleeve allows a more straightforward collateral eccentric tendon insertion can contribute to deformity
ligament reconstruction.12
at either the extensor or flexor site. In addition, the pull
of the adductor pollicis on the ulnar thumb and the
bifurcation from the radial digital nerve in the ulnar
abductor pollicis brevis on the radial thumb can lead to
thumb, it is sharply excised. Similarly, if a clear
deformity.10 These forces cause thumb deviation at the
bifurcation point is identified for the flexor and extensor
proximal phalanx level; the distal phalanges typically
tendons, the tendon to the excised thumb is divided just
converge due to the pull of the extrinsic flexor and
distal to the bifurcation point; no imbrication or overlap
extensor tendons.
procedure is performed. I do not use the excess tendon
If the primary cause of the deformity is identified, it
because once the extra thumb is excised, the muscle
should be corrected. This includes eccentric tendon
power will be concentrated on the reconstructed thumb,
insertion and abnormal muscle insertions. However, there
and additional tendon substance from the excised thumb
is often an underlying bony angulation or curvature
is usually not necessary. However, if the thumb is not
associated with the deformity. These thumbs require a
aligned, an eccentric tendon insertion may be responsi-
corrective osteotomy to obtain a long-lasting improvement
ble. In these cases, the insertion of the flexor and
in the alignment.7,10,13 A single or multiple closing wedge
extensor tendons should be explored; if an eccentric
insertion is discovered, it may be centralized. Alterna-
tively, a corrective osteotomy can be used to align the
thumb without realigning the eccentric tendon; this
technique has worked well for me.
Ligaments
Manske12 described the use of a ligamentous/periosteal
flap for the reconstruction of the radial collateral
ligament. In this technique, the radial thumb is excised
with care given to detaching the radial collateral
ligament from its distal boney insertion in continuity
with a periosteal sleeve of tissue. The periosteum
provides additional substance and length to the collat-
eral ligament to allow a more satisfactory reconstruction
of the radial collateral ligament. If notably widened, the
head of the phalanx or metacarpal can be narrowed to a
size more closely approximating the width of the base
of the retained phalanx. It is important to protect the
proximal origin of the collateral ligament if the
proximal bone narrowed. The phalanx is then central-
ized and stabilized with a longitudinal Kirschner wire,
and the radial collateral ligament/periosteal flap is
repaired to the base of the retained phalanx (Fig. 5). FIGURE 6. Zigzag deformity. The radiograph demon-
Duplications of types 4, 5, and 6 require the surgeon to strates that the proximal phalanges are divergent, where-
address the abductor pollicis brevis and flexor pollicis as the distal phalanges converge.
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Reconstruction of Radial Polydactyly
FIGURE 8. A, Wassel type 3 polydactyly with thumbs of equal size. B, The same thumb after reconstruction using the
Bilhaut procedure. Although the thumb has a relatively normal appearance, the central ridge is noticeable.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Goldfarb
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand and Upper Extremity Surgery 10(4):271–272, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia
| L E T T E R T O T H E E D I T O R |
FIGURE 1. A and B,
Loose-dressing. Tough-
ened gauzes because of
the blood leakage from the
surgical area which is
sutured loosely. C, Tough-
ened gauzes around
revascularized finger 8
hours after the operation.
D, Postoperative view of
revascularized finger.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letter to the Editor
FIGURE 2. A, A glove filled with warm water. B and C, Fingers of water-filled glove are placed between the patient’s
fingers from the volar side and into the web spaces. D and E, View of the hand after dressing with the water-filled glove.
spaces. The standard soft dressing is applied over the space and surrounding tissues. The method is inexpen-
water-filled glove and the patient’s hand (Fig. 2). sive, effective, and easy to apply. It has numerous
advantages as noted above, and in our experience, has
| DISCUSSION no disadvantages or complications.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
December 2006 ISSN:
Volume 10(4) (C) 2006 Lippincott Williams & Wilkins, Inc. 1089-3393
pg. 200-205
02 A Unified Approach to Radial Tunnel Syndrome and
Lateral Tendinosis.
Henry, Mark MD; Stutz, Christopher MD
[REVIEWS]
pg. 206-211
03 Dynamic Assist Splinting for Attenuated Sagittal Bands in
the Rheumatoid Hand.
Chinchalkar, Shrikant J. OTR, CHT 1; Pitts, Shanley MScOT, OT Reg
(ONT) 2
[REVIEWS]
pg. 212-223
04 Dorsal Distal Radius Vascularized Pedicled Bone Grafts for
Scaphoid Nonunions.
Larson, A. Noelle MD; Bishop, Allen T. MD; Shin, Alexander Y. MD
[TECHNIQUES]
pg. 224-230
05 A New Modification of Corrective Osteotomy for
Treatment of Distal Radius Malunion.
Viegas, Steven F. MD
[TECHNIQUES]
pg. 231-234
06 Lunocapitate Fusion Using the OSStaple Compression
Staple.
Ronchetti, Peter J. MD 1; Topper, Steven M. MD 2
[TECHNIQUES]
pg. 235-238
07 The Anterior Cubital Approach for Displaced Pediatric
Supracondylar Humeral Fractures.
Ay, Sadan MD; Akinci, Metin MD; Ercetin, Omer MD
[TECHNIQUES]
pg. 239-244
08 Simultaneous Reconstruction of Medial and Lateral Elbow
Ligaments for Instability Using a Circumferential Graft.
van Riet, Roger P. MD, PhD 1; Bain, Gregory I. MBBS, FRACS 2;
Baird, Rob MBBS 3; Lim, Yeow Wai MD 4
[TECHNIQUES]
pg. 245-251
09 Technique of Harvesting the Gracilis for Free Functioning
Muscle Transplantation.
Addosooki, Ahmad I. MD; Doi, Kazuteru MD, PhD; Hattori, Yasunori
MD, PhD
[TECHNIQUES]
pg. 252-254
10 Extensor Tenodesis for Plexic Hands With C7 to T1 or C8,
T1 Root Avulsions: A New Technique.
Goubier, Jean-Noel MD, PhD 1; Teboul, Frederic MD 1; Oberlin,
Christophe MD 2
[TECHNIQUES]
pg. 255-258
11 Nail Salvage Using the Eponychial Flap.
Adani, Roberto MD; Leo, Giovanni MD; Tarallo, Luigi MD
[TECHNIQUES]
pg. 259-264
12 Three-corner Wrist Fusion Using Memory Staples.
van Riet, Roger P. MD, PhD 1; Bain, Gregory I. MBBS, FRACS,
FA(OrthA) 2
[TECHNIQUES]
pg. 265-270
13 Reconstruction of Radial Polydactyly.
Goldfarb, Charles A. MD
[COMMENTARY]
pg. 271-272
14 Hand Dressing Using a Water-filled Surgical Glove.
Bayraktar, Alper MD; Aydn, Ufuk MD [latin dotless i]; Kahveci,
Ramazan MD
[LETTER TO THE EDITOR]