Professional Documents
Culture Documents
September 2006
ISSN:
1089-3393
pg. 130-138
pg. 162-165
E D I T O R I A L
Jesse B. Jupiter, MD
Massachusetts General Hospital
Harvard Medical School
Boston, MA
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
123
R E V I E W
| ABSTRACT
The decision to replant a severed part is based on the
numerous factors that influence survival of the part and
the functional and aesthetic benefits gained from
replanting. Not all amputees will benefit from or are
candidates for replantation. The decision to proceed is
therefore made by the surgeon who must consider the
mechanism and extent of injury, the age of the patient,
the presence of other medical or surgical conditions, the
likely functional outcomes, and the patients motivation
to undergo a difficult procedure, which is followed by a
lengthy recovery. This is a meta-analysis of the available
studies that tracks the outcomes, based on 9 criteria, after
the amputation of a total of 1803 digits in 1299 patients.
By combining the data from numerous sources, a statistically significant picture emerges which may be used to
educate patients and help guide the surgeon in the decision
to replant.
Keywords: microsurgery, hand, amputation, reattachment, digit, finger
| HISTORICAL PERSPECTIVE
Ever since Ronald Malt performed the first replantation
in 1962, thousands of body parts have been reattached,
and the medical community and the general population
have become educated about the possibility of reattachment. This has resulted in the severed part often
accompanying the patient to the hospital. The proper
way of transporting an amputated body part is wrapped in
gauze in a plastic bag, which, in turn, is placed into ice
water.1 This is particularly true in the case of replants
that contain muscle tissue, which is especially vulnerable
to ischemia. Direct contact with ice is to be avoided to
prevent frostbite injury.
Address correspondence and reprint requests to Wojciech Dec, BA,
NYU School of Medicine, 545 First Avenue, Suite 7R, New York,
NY. E-mail: wd271@med.nyu.edu.
124
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| RESULTS
The mechanisms of injury (Table 1) have been divided
into 3 categories. Clean-cut amputation refers to a
guillotine injury as may occur from a knife, a laceration
which may be the result of a circular saw, or a local
crush injury involving little tissue beyond the site of
amputation as may occur from a finger placed in the
way of a closing car door. Crushing refers to an injury
that affects tissue beyond the site of the amputation and
is often seen in industrial accidents involving a press.
Finally, avulsion injury occurs when a digit is rapidly
pulled out of the hand and occurs in accidents involving
lathes and other fast-moving machines. Tissue is
damaged proximally and distally to the site of amputation in avulsion injuries.
Cleanly amputated fingers were saved at a rate of
91.4%. Amputations from crushing injury were saved at
a rate of 68.4%, and avulsed digits were saved at a rate
of 66.3%.
Clean cut
16 of 16
10 of 16
91 of 129
V
42 of 48
117 of 144
172 of 204
842 of 854
1290 of 1411 (91.4)
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
125
Dec
TABLE 2. Zone of injury and success of replantation
Hattori et al
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Distal
phalanx
Distal IP
joint
Middle
phalanx
Proximal IP
joint
Proximal
phalanx
MP joint
37 of 44
21 of 36
V
5 of 5
48 of 64
2 of 3
V
33 of 36
146 of 188
(77.7)
18 of 20
9 of 21
V
5 of 7
62 of 71
17 of 22
V
138 of 139
249 of 280
(88.9)
V
V
V
V
V
76 of 97
V
208 of 227
284 of 324
(87.7)
V
V
V
V
V
17 of 17
V
171 of 195
188 of 212
(88.7)
V
V
55 of 84
V
V
4 of 4
V
372 of 397
431 of 485
(88.9)
V
V
20 of 32
V
V
1 of 1
V
24 of 24
45 of 57
(78.9)
The meta-analysis suggests that the zone of amputation makes little difference in the success of the replant
(P 9 0.05), except in the case when the amputation
occurred in the distal phalanx (P G 0.05). An odds ratio
analysis indicates that a digit severed through the distal
phalanx is 2.14 less likely to survive than one amputated
at any other level of the digit. This difference stems
from the diminished diameter of vasculature present in
the distal phalanx and the inherent difficulty of forming
successful anastomoses.
The amputated digits have been classified on the
following basis: thumb, index finger, middle finger, ring
finger, and little finger (Table 3).
Thumbs were saved at a rate of 68.1%. Index
fingers were saved at a rate of 75.0%. Middle fingers
were saved at a rate of 82.8%. Ring fingers were saved
at a rate of 82.8%, and little fingers were saved at a
rate of 88.9%.
The meta-analysis suggests that thumbs are more
difficult to salvage than the other fingers (P G 0.05). It
also seems that index fingers are less likely to survive
than all the other fingers; however, this difference is not
considered statistically significant (P 9 0.05). An odds
ratio analysis indicates that a thumb is 1.95 times less
likely to survive after replantation than any of the other
126
Thumb
14 of 14
V
89 of 140
V
V
V
36 of 50
V
139 of 204 (68.1)
Index
12 of 15
V
V
5 of 6
V
V
28 of 39
V
45 of 60 (75.0)
Middle
10 of 13
V
V
3 of 3
V
V
15 of 18
V
28 of 34 (82.8)
Ring
12 of 13
V
V
1 of 2
V
V
11 of 14
V
24 of 29 (82.8)
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Little
6 of 8
V
V
1 of 1
V
V
17 of 18
V
24 of 27 (88.9)
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Regular
smokers
Nonsmokers
V
V
V
V
V
V
V
44 of 72
44 of 72
(61.1)
V
V
V
V
V
V
V
464 of 480
464 of 489
(96.7)
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Male
42 of 52
19 of 34
V
6 of 8
V
V
V
327 of 366
394 of 460 (85.7)
Female
12 of 12
9 of 19
V
4 of 4
V
V
V
181 of 186
206 of 221 (93.2)
Alcohol use
V
V
V
V
V
V
V
60 of 66
60 of 66
(90.9)
No alcohol use
V
V
V
V
V
V
V
448 of 486
448 of 486
(92.2)
Hattori et al5
Heistein and
Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Child
7 of 9
13 of 34
Adult
48 of 55
15 of 19
7 of 15
V
V
V
43 of 56
34 of 36
104 of 150
(69.3)
104 of 152
10 of 12
V
V
185 of 342
474 of 516
836 of 1096
(76.3)
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
127
Dec
128
Diabetic
Not diabetic
V
0 of 8
V
V
V
V
V
V
0 of 8 (0.0)
V
28 of 47
V
V
V
V
V
V
28 of 47 (59.6)
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Short
(G12 hours)
Long
(912 hours)
V
V
V
V
V
9 of 9
V
899 of 966
908 of 975
(93.1)
V
V
V
V
V
64 of 76
V
47 of 52
111 of 128
(86.7)
| DISCUSSION
There are numerous inherent problems in creating a
meta-analysis. The various problems in each individual
study, such a subject selection bias, are passed on to
influence the meta-analysis. There are also several
problems specific to this particular report. In reporting
the zone of digit injury, some articles used the Tamai
zone classification scheme, whereas others described
the injuries in which phalanx or joint was involved. To
achieve uniformity, all reports were translated to the
latter scheme. In some cases, this may have resulted in a
sublunula zone II amputation through the extremely
proximal aspect of the distal phalanx being translated to
an amputation through the distal IP joint. Likewise,
various studies reported the age of patients in grossly
different ways. This resulted in the need to divide the
age category of the report into 2 somewhat nonspecific
subgroups of child and adult. In reporting the data for
ischemia time, no distinction was made between cold
and warm ischemia. Finally, the outcome of replantation
is, in a large part, based on the skill of the surgeon
performing the operation. The 1803 digits tracked in
this meta-analysis were reattached by numerous surgeons of variable skill at different times and in different
hospitals while following different replantation procedures. Such an arrangement eliminates the consistency
of results that could be achieved by following the results
of a single surgeon.
| SUMMARY
Numerous factors influence the survivability of digits
after replantation. Patients with a history of diabetes,
smoking, and an injury caused by either crushing or
avulsion seem to have the worst prognosis after
replantation. The amputations of the distal phalanx and
the thumb, being male, and ischemia time of greater
than 12 hours seem to have a somewhat worse
prognosis. Age and history of alcohol use do not seem
to be very influential in replanted digit survival. It must
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| REFERENCES
1. Wilhelmi BJ, Lee WP, Pagenstert GI, et al. Replantation
in the mutilated hand. Hand Clin. 2003;19:89Y 120.
2. Idler R, Steichen JB. Complications of replantation
surgery. Hand Clin. 1992;8:427 Y 451.
3. Sud V, Freeland AE. Skeletal Fixation in Digital Replantation. Microsurgery. 2002;22:165 Y 171.
4. Janezic TF, Arnez ZM, Solinc M, et al. One hundred sixtyseven thumb replantations and revascularizations: early
microvascular results. Microsurgery. 1996;17:259Y 263.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
129
T E C H N I Q U E
| ABSTRACT
A new modification of trapeziectomy, soft-tissue interposition arthroplasty with a one-half slip of the flexor
carpi radialis tendon and advancement of the abductor
pollicis longus tendon for treatment of thumb carpometacarpal degenerative arthritis and instability is presented. This procedure facilitates tenodesis of the flexor
carpi radialis slip at the first metacarpal and realigns and
rebalances the thumb posture by using and advancing the
abductor pollicis longus tendon. Therefore, this new modification eliminates the need for perioperative pin fixation
of the first metacarpal, offers better soft tissue tenodesis of
the ligament reconstruction component of the procedure,
and results in improved intraoperative thumb alignment.
Keywords: trapeziectomy, interposition arthroplasty,
abductor pollicis longus advancement
| INDICATIONS
| HISTORICAL PERSPECTIVE
The carpometacarpal joint of the thumb is certainly one
of, if not the most common location of development of
degenerative arthritis in the wrist and hand, particularly
in women. In 1949, Gervis1 studied trapeziectomy as a
treatment of osteoarthritis of the trapeziometacarpal
joint of the thumb. In fact, he, himself, underwent this
surgical procedure. The combination of ligament reconstruction and tendon interposition with trapezium
excision addresses ablation of the arthritic joint surfaces
by trapezial excision, reconstruction of the anterior
oblique ligament to prevent thumb metacarpal instability and limit or prevent axial shortening, and fascial
interposition to reduce the likelihood of impingement
between the thumb metacarpal base and the scaphoid.
Burton and Pellegrini2 originally described this combiAddress correspondence and reprint requests to Steven F. Viegas, MD,
Professor and Chief, Division of Hand Surgery, Department of
Orthopaedics and Rehabilitation, Rebecca Sealy Hospital, Rm 2.616,
301 University Boulevard, Galveston, TX 77555-0165. E-mail:
sviegas@utmb.edu.
130
| SURGICAL TECHNIQUE
The surgery is performed under tourniquet control. An
L-shaped incision is made over the dorsoradial aspect of
the first metacarpal base, angling volar at the level of the
trapezium and extending just to the volar radial aspect of
the palpated FCR tendon (Fig. 1). Careful subcutaneous
dissection is carried out to identify and protect the sensory branches of the radial nerve. Dissection is carried
out between the extensor pollicis brevis and abductor
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
131
Viegas
132
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 8. (continued).
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
133
Viegas
FIGURE 10. A series of intraoperative photographs and diagrams showing (A) a photograph of a hemostat splitting the APL
tendon and another hemostat passing through the split APL to grasp and deliver the FCR slip through the split APL, (B) the FCR
passing through the split APL, (C) a diagram showing the path of the FCR slip, (D) the FCR slip passed through the split APL
tendon (note the adducted posture of the thumb metacarpal), (E) distal axial traction placed on the FCR tendon slip to advance
the APL (note the abducted posture of the thumb metacarpal), and diagrams showing the path of the FCR tendon slip and
thumb posture (F) before and (G) after traction and tenodesis of the FCR tendon slip to the APL tendon.
134
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
135
Viegas
FIGURE 12. A series of diagrams and intraoperative photographs showing the FCR tendon slip (A) clamped in a straight
hemostat and (B, C) rolled over the hemostat, (D) sutured to itself, then (E Y H) using the same suture advancing and rolling
the tendon slip once more.
136
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| COMPLICATIONS
Complications can include numbness or hypersensitivity
in the distribution of the sensory branch of the radial
nerve. Infection is always a possible complication with
any surgical intervention as well. Generally, however,
| REHABILITATION
Skin sutures are removed at 2 weeks and a new plaster
splint and Ace wrapping are applied. At 6 weeks after the
surgery, the patient is converted to a removable radial
thumb gutter splint, which also has the interphalangeal
joint free, and the patient is to wean from the splint
working on range of motion and increasing grip and
pinch strength. This routine is continued for a 6-week
period. Then, at 3 months after the surgery, splinting is
discontinued and the patient is encouraged to use the
thumb and hand increasingly and without restrictions.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
137
Viegas
| SUMMARY
This technique, which uses the 3 fundamental principles
described by Burton and Pellegrini of removing the
arthritic joint, reconstructing the anterior oblique ligament, and reducing or eliminating impingement between
the thumb metacarpal base and the scaphoid, has worked
well. The additional modifications of using a single
transverse incision at the musculotendinous junction of
the FCR and a suture loop to split the FCR tendon
minimizes the size of the incision and postoperative
morbidity of the procedure; whereas, additionally, the
advancement of the APL tendon improves the intraoperative and postoperative position of the thumb
metacarpal and eliminates the need for pin fixation of
the thumb metacarpal.
138
| ACKNOWLEDGMENTS
The author thanks Randal Morris for his assistance and
collaboration in the illustrations used in this manuscript
and Kristi Overgaard for her editorial assistance.
| REFERENCES
1. Gervis W. Excision of the trapezium for osteoarthritis of
the trapeziometacarpal joint. J Bone Joint Surg. 1949;31B:
537 Y 539.
2. Burton RI, Pellegrini VD Jr. Surgical management of basal
joint arthritis of the thumb: II Ligament reconstruction with
tendon interposition arthroplasty. J Hand Surg. 1986;11A:
324 Y 332.
3. Tomaino NM, Coleman K. Use of the entire width of the
flexor carpi radialis tendon for the LRTI arthroplasty does
not impair wrist function. Am J Orthop. 2000;29:283 Y 284.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
The clinical outcome of an intraarticular distal radius
fracture is generally thought to be associated with the
following factors: amount of radial deformity, joint
congruity, and associated soft-tissue injuries.
The proposed technique to manage this fracture
pattern that involves a displaced volar lunate facet
fragment uses wrist arthroscopy and pinning. Distraction of the fracture before arthroscopy is accomplished
either by external fixation or by the arthroscopy tower.
A freer elevator is introduced dorsally to disimpact the
fragments, and next, a nerve hook is used to reduce the
volar lunate facet, which is subsequently pinned to the
radial styloid. The remaining fragments are reduced
with interfragmentary pin fixation, and this anatomical
articular construct is fixed to the radial metaphysis.
The advantages of this technique are: (a) accurate
assessment of articular congruency by direct visualization, (b) identification and repair of associated
lesions, and (c) minimal soft tissue disruption. Potential
disadvantages of external fixation supplemented by
interfragmentary pins may be that it does not provide
for rigid stable fixation, and therefore, does not allow
for early motion compared to open reduction and
internal fixation. Furthermore, it is technically challenging, and is therefore suggested as an alternative for the
aforementioned fracture pattern.
Keywords: distal radius, fractures, arthroscopy, pins,
volar lunate facets
| HISTORICAL PERSPECTIVE
The clinical outcome of an intraarticular distal radius
fracture will be affected by the amount of radial
shortening, angulation, joint congruity (radio-carpal
This work has not received financial support, and the authors declare
no conflict of interest.
Address correspondence and reprint requests to Ethan R. Wiesler, MD,
Department of Orthopaedic Surgery, Wake Forest University School
of Medicine Medical Center Boulevard, Winston-Salem, NC 27157.
E-mail: ewiesler@wfubmc.edu.
| INDICATIONS
Plain radiographs are generally sufficient to diagnose
comminuted, intraarticular fractures of the distal radius.
However, in certain situations, accurate preoperative
diagnosis is essential to determine the fracture configuration, and this may be augmented by computerized
tomography, or better by the newly developed 3dimensional computerized tomography technique. Relative indications include: (1) age between 18 and 65
years without evidence of metabolic bone disease; (2) a
3- or 4-part compression type fracture of the distal
radius (Fig. 1) involving the volar lunate facet (either
impacted or rotated) with an articular step-off of equal
or greater than 2 mm that remains irreducible after
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
139
Wiesler et al
FIGURE 2. Operating room arrangement. The intraarticular reduction is directly assessed with the arthroscope,
while simultaneously, the C-arm will evaluate the restoration of the anatomical parameters of the distal radius, and
guide the K-wire insertion. (Reproduced with permission
from: Koman LA, ed. Wake Forest University School of
Medicine Orthopaedic Manual 2006. Winston-Salem, NC:
Orthopaedic Press).
140
| CONTRAINDICATIONS
Contraindications include: (1) significant metaphyseal
or radial styloid comminution, (2) infection, (3) open
injuries, (4) extensive soft-tissue damage, (5) unreduced
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| TECHNIQUE
The selection of general or regional anesthesia is based
on the patients and anesthesiologists preference. The
technique uses standard small joint arthroscopic equipment. The patient is positioned supine on the operating
table with the arm draped free on a radiolucent handtable. A pneumatic tourniquet is applied on the upper
arm and inflated at 250 mm Hg. After prepping and
draping, assessment of the fracture is carried-out using a
C-arm. In the case of metaphyseal comminution, the
FIGURE 6. Manipulation under arthroscopic visualization improves articular congruency. RS indicates radial styloid; LF,
lunate facet. (Reproduced with permission from: Koman LA, ed. Wake Forest University School of Medicine Orthopaedic
Manual 2006. Winston-Salem, NC: Orthopaedic Press).
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
141
Wiesler et al
FIGURE 7. The lowercase letters refer to K-wires. A, K-wires are drilled and used to maintain reduction, firstly of the
dorsal (a) and volar (b) lunate facet fragments to the radial styloid. B, Additional K-wires are further used to stabilize the
dorsal and volar lunate facets (c) and (d). C, The construct is fixed to the metaphysis (e) and (f). (Reproduced with
permission from: Koman LA, ed. Wake Forest University School of Medicine Orthopaedic Manual 2006. Winston-Salem,
NC: Orthopaedic Press).
142
under image intensifier combined with direct visualization. Next, the dorsal lunate facet fragment is reduced
to the styloid volar fragment construct and fixed with
interfragmentary pins (Fig. 7A). Additional K-wires
may be inserted to fix the volar and dorsal lunate
fragments (Fig. 7B). The construct may then be
stabilized to the radial shaft using 0.62-inch K-wires
(Fig. 7C). It is worthwhile noting that in previous
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| COMPLICATIONS
Complications secondary to the arthroscopy itself are
minimal if the aforementioned indications are respected;
however, potential complications include: (1) loss of
reduction due to comminution of the volar cortex, (2) pin
track infections, (3) potential for injury to the dorsal
sensory nerves of the radial or ulnar nerves may lead to
painful neuroma formation and sometimes to complex
regional chronic pain syndrome,26 (4) rupture of extensor
tendons caused by the dorsal subcutaneous K-wires, (5)
acute postoperative compression of the median nerve,
and (6) acute postoperative compartment syndrome.
A disadvantage of external fixation supplemented by
inter-fragmentary pins is that it does not provide for
rigid stable fixation and early motion, especially in
comminuted fractures, as does open reduction and
internal fixation. However, this drawback may be offset
by the decreased swelling and scar, an unavoidable
consequence of open reduction. In addition, no hardware related problems or removal are necessary, which
can occur with internal fixation.
FIGURE 8. A, Anteroposterior and lateral preoperative
radiographs. B, Intraoperative view showing a nerve hook
that has been introduced obliquely through the fracture
line and serving to hook the lunate facet under the volar
cortex of the volar lunate facet fragment. The volar lunate
facet fragment will be tilted, disimpacted, and then
reduced. C, Postoperative radiographs showing the final
fixation.
| REHABILITATION
A volar splint is applied, and the patient is instructed to
begin range of motion of the fingers, forearm rotation,
elbow flexion, and shoulder motion immediately to
prevent stiffness. Close postoperative follow-up is
mandatory, to inspect for any loss of reduction, which
would require revision. K-wires are removed at 6 weeks
postoperatively, whereas the external fixator and the
splint are removed at 8 weeks. Muscle strengthening is
initiated at 10 weeks postoperatively.
Illustrative Case
Radiographs illustrating the case of a 19-year-old
woman with a comminuted fracture of her left distal
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
143
Wiesler et al
| CONCLUSIONS
| ACKNOWLEDGMENT
The authors would like to thank Anne-Marie Johnson,
CMI, for providing the illustrations contained in this
manuscript.
| REFERENCES
1. Fernandez DL, Geissler WB. Treatment of displaced
articular fractures of the radius. J Hand Surg [Am].
1991;16:375Y384.
2. Knirk JL, Jupiter JB. Intra-articular fractures of the distal
end of the radius in young adults. J Bone Joint Surg Am.
1986;68:647Y659.
3. Melone CP Jr. Articular fractures of the distal radius.
Orthop Clin North Am. 1984;15:217Y236.
4. Trumble TE, Schmitt SR, Vedder NB. Factors affecting
functional outcome of displaced intra-articular distal
radius fractures. J Hand Surg [Am]. 1994;19:325Y340.
5. Fernandez DL, Jupiter JB. Fractures of the Distal Radius:
A Practical Approach to Management, 2nd ed. New York:
Springer-Verlag, 2002.
6. Geissler WB. Arthroscopically assisted reduction of intraarticular fractures of the distal radius. Hand Clin.
1995;11:19Y29.
7. Sanders RA, Keppel FL, Waldrop JI. External fixation of
distal radial fractures: results and complications. J Hand
Surg [Am]. 1991;16:385Y391.
8. Cooney WP III, Dobyns JH, Linscheid RL. Complications
of Colles fractures. J Bone Joint Surg Am. 1980;62:
613Y619.
144
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
Biologic resurfacing of the glenoid is a treatment
alternative for young patients who develop rapid and
aggressive destruction of glenoid. In 2001, a technique
was developed to allow secure fixation of a meniscal
allograft to the glenoid in combination with hemiarthroplasty replacement of the humeral head. The
authors have modified this technique by addressing
posterior wear factors, as well as circumferential covering of the glenoid perimeter. The meniscal horns are
sutured together to fashion the allograft in an ovoid
shape. The meniscus closely matches the circumference
of the glenoid and therefore 180- coverage of the
glenoid rim is achieved. In addition, the wedge shape of
the meniscus may enhance comfort and stability.
Keywords: biologic resurfacing, glenoid, meniscal
allograft, shoulder, hemiarthroplasty
| HISTORICAL PERSPECTIVE
Total shoulder arthroplasty has historically offered the
most predictable functional results and successful pain
relief amongst patients with advanced arthritis of the
glenohumeral joint.1Y5 Young active patients with
higher loads and joint reactive forces on their glenoid
component6 are at higher risk for glenoid failure and
revision surgery. Therefore, in this group of patients,
joint sparing alternatives should be considered that
avoid placing a prosthetic glenoid component.
Biologic resurfacing was first described by Baer7 in
1918, and is indicated in the management of young or
active patients who might develop rapid and excessive
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
145
Themistocleous et al
Surgical Technique
| INDICATIONS/
CONTRAINDICATIONS
The best candidate is a young adult with severe shoulder
pain, with restriction of motion, compromised activities
of daily living, and failed arthroscopic treatment or nonoperative measures. Radiographic documentation of
asymmetric wear or structural damage of the glenoid
should be present.18 This technique is contraindicated in
skeletally immature patients, active shoulder septic
arthritis, or adjacent osteomyelitis.18
| TECHNIQUE
Preoperative Evaluation
The routine preoperative evaluation for total shoulder
arthroplasty candidates is performed. This includes an
anteroposterior radiograph of the affected shoulder with
the arm in neutral rotation, an anteroposterior radiograph with the arm in external rotation, a scapular
lateral view, and an axillary view.19 The bony structures
should be evaluated for quantity, quality, and deformity.
CT scanning of the glenohumeral joint is particularly
useful in bone loss quantification, as well as in spatial
interpretation of bone deformity and bone version. 20Y22
For patients with suspected rotator cuff deficiency,
magnetic resonance imaging (MRI) is necessary to
evaluate both the rotator cuff integrity and the degree
of osteoarticular destruction.23 Final assessment of
glenoid status is achieved by intraoperative direct
inspection and palpation.
146
FIGURE 2. Intraoperative photograph showing bioabsorbable suture anchors passing through 8 matching
hash marks in the glenoid circumeference.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| CASE
The patient is a 28-year-old right-hand dominant woman
with combined anterior shoulder instability and glenoid
wear who had undergone previous stabilization procedures (capsulorraphy) (Figs. 5A, B). She complained of
pain, decreased range of motion and crepitus. Radiographic evaluation revealed glenoid erosion. The
patient underwent meniscal allograft interposition with
hemiarthroplasty.
At 16 months follow up the pain has completely
subsided. Arm elevation, increased from 80- preoperative to 110-, external rotation increased from 35preoperative to 45- and internal rotation improved from
sacroiliac joint to L2 spinous process.
The Disabilities of the Arm, Shoulder and Hand
(DASH) score range (0Y100) was improved from 63 to
9. The patient was able to return to her daily activities
and she rated her results as excellent. She was very
satisfied and stated that she would have undergone the
procedure again under the same hypothetical scenario.
The humeral stem was radiographically stable without
radiolucent lines at the bone cement interface. Glenoid
erosion was halted with preservation of the joint space
(Figs. 6A, B).
| COMPLICATIONS
FIGURE 3. Intraoperative photograph showing the
sutures passing through the meniscus at the previously
described predetermined points.
Patients who undergo biologic resurfacing are susceptible to the same complications associated with total
shoulder replacements. These include wound infection,
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
147
Themistocleous et al
| REHABILITATION
Postoperative rehabilitation is similar to that of total
shoulder arthroplasty. The first 2 weeks postoperatively,
the shoulder is kept immobilized in a sling. After that a
progressive passive range of shoulder motion exercise is
started that gradually evolves into active stretching and
strengthening. The patients arm remains in the sling
between sessions. Activities of daily living are encouraged, and active motion is begun after 3 weeks followed
by full active motion by 6 weeks. Physical therapy
FIGURE 5. Anterioposterior (A) and axillary (B) radiographs of a young female with a history of stabilization
procedure as evidenced by bone anchors. Glenohumeral
osteoarthritis is seen in association with wear of the
glenoid and joint space narrowing. The patient underwent
meniscal allograft interposition with hemiarthroplasty.
148
FIGURE 6. Anterioposterior (A) and axillary (B) radiographs of the patient at 16 months follow up. The glenoid is
well maintained with clear alteration of the erosion process.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| REFERENCES
1. Barrett WP, Thornhill TS, Thomas WH, et al. Nonconstrained total shoulder arthroplasty in patients with
polyarticular rheumatoid arthritis. J Arthroplasty. 4:91Y96.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
149
T E C H N I Q U E
| ABSTRACT
The hypothenar fat pad flap has been shown to produce
reliable clinical results for the treatment of recurrent
carpal tunnel syndrome secondary to cicatricial tethering. The flap utilizes soft vascularized tissue that does
not compromise hand function and is of sufficient size
to provide median nerve coverage in the carpal tunnel.
We describe technical modifications that facilitate
improved, tension-free transposition of the pedicled fat
pad flap. These modifications enable transfer of vascularized tissue and decrease iatrogenic damage to the
important perforator vessels. The hypothenar fat pad
transposition flap provides a reliable source of vascularized local tissue that can be used successfully as an
adjunct to neurolysis for the treatment of recurrent
idiopathic CTS secondary to perineural scarring.
Keywords: carpal tunnel syndrome, flap, hypothenar,
fat pad, recurrent
| HISTORICAL PERSPECTIVE
Carpal tunnel syndrome (CTS) is the most common
entrapment neuropathy afflicting 0.1% to 10% of the
general population and up to 15% of those in high-risk
occupations. According to Palmer,1 medical costs in the
US are estimated to be more than $2 billion per year.
Greater than 400,000 surgical procedures are being
performed annually.
Kulick2 and Plancher3 found that the incidence of
persistent symptoms following carpal tunnel release (CTR)
varies from 10% to 25%. The most commonly cited causes
are inadequate distal ligament release, recurrent flexor
tenosynovitis, postoperative adhesions and neural fascicular
scarring. Reoperation is needed in up to 3% of patients.
According to Cobb,4 persistent symptoms following
reoperation are likely and failure is more frequent than
after primary carpal tunnel surgery. Langloh5 stated that
the most common pathologic finding at reexploration
was nerve compression secondary to tenosynovial
hypertrophy.
Address correspondence and reprint requests to Minas T. Chrysopoulo,
M.D., PRMA 9635 Huebner Road, San Antonio, TX 78240. E-mail:
minas@dr.com.
150
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 1. Diagrammatic cross section demonstrating the hypothenar fat pad in relation to the scarred median nerve
nonadherent to the TCL.
the distal third of the fat pad after branching from the
ulnar nerve in Guyons canal.
Cramer,7 Strickland,8 and Plancher3 emphasized that
the deep dissection necessary to mobilize the hypothenar fat pad flap was safe, provided it terminated as
soon as the neurovascular structures in the canal of
Guyon are visualized (Fig. 3). A segment of the ulnar
leaf of the TCL was then excised. Once freed, the flap
was either advanced or turned over and secured deep to
the radial leaf of the transverse carpal ligament. Postoperatively, the hand was immobilized with a fair
amount of radial-ulnar compression for 2 weeks with
the thumb abducted to relieve tension on the repair.
Mathoulin9 advocated routine division of the deep
branch of the ulnar artery that runs alongside the deep
motor branch of the ulnar nerve. He subsequently
dissected the ulnar artery away from the ulnar nerve
completely (Fig. 4). Only with these maneuvers was he
able to free up the flap sufficiently to allow coverage of
the median nerve.
Surprisingly, all these previous descriptions of
surgical technique have been extremely vague. The
purpose of this study was to fully describe our
modification of the hypothenar fat pad flap transfer.
| INDICATIONS/CONTRAINDICATIONS
The hypothenar fat pad flap is indicated as an adjunct to
neurolysis for the treatment of recurrent idiopathic CTS
secondary to cicatricial tethering of the median nerve at
the wrist. The diagnosis of recurrent CTS should be
made based on history and clinical exam and supported
by confirmatory electrodiagnostic studies. The hypoth-
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
151
Chrysopoulo et al
FIGURE 3. Representation of the traditional dissection, terminating at the neurovascular structures in Guyons canal.
| TECHNIQUE
Under regional anesthesia, previous incisions are incorporated into an incision with proximal and distal oblique
extensions (Fig. 5). A large hypothenar skin flap is
elevated.
The subdermal rete vasculature supplying the
hypothenar skin flap is preserved by leaving a thin
layer of adipose tissue on the skin flap (Fig. 6).
Maintenance of skin vasculature minimizes the risk of
postoperative wound complications. This superficial
FIGURE 4. Adaptation of Mathoulins original diagrammatic representation. Demonstrates skeletonization of the ulnar
neurovascular bundle and division of the deep branch of the ulnar artery (Mathoulin C, Bahm J, Roukoz S, Pedicled
hypothenar fat pad flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Hand Surg 2000;5(1):33Y40).
152
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| REHABILITATION
A postoperative splint keeping the wrist in neutral
position is applied for 2 weeks. Postoperative radialulnar compression is not necessary.
| DISCUSSION
down to the hamate and the entire ulnar leaf of the TCL
is excised off the hamate hook (Figs. 7, 8). Complete
ulnar leaf excision facilitates maximal elevation of the
flap along with the ulnar NV bundle.
FIGURE 6. The superficial dissection preserves the subdermal rete vasculature supplying the hypothenar skin flap.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
153
Chrysopoulo et al
FIGURE 7. The flap is raised deep to the ulnar neurovascular pedicle. The ulnar leaf of the TCL is excised.
FIGURE 8. Hypothenar fat pad flap prior to transposition demonstrates segmental fat pad blood supply.
154
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 10. Diagrammatic view of the volar wrist demonstrating the inset fat pad providing vascularized protection to the
neurolysed median nerve.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
155
Chrysopoulo et al
| REFERENCES
1. Palmer DH, Hanrahan LP. Social and economic costs of
carpal tunnel surgery. Instr Course Lect. 1995;44:
167Y172.
2. Kulick ML, Gordillo G, Javidi T, et al. Long-term analysis
of patients having surgical treatment for carpal tunnel
syndrome. J Hand Surg [Am]. 1986;11:59Y66.
3. Plancher KD, Idler RS, Lourie GM, et al. Recalcitrant
carpal tunnel. The hypothenar fat pad. Hand Clinics.
1996;12:337Y349.
156
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
Avulsion fractures of the phalanges are among challenging problems encountered in the hand surgery. These
fractures are characterized by existence of small bone
fragments usually attached to a collateral ligament. They
mostly occur in metacarpophalangeal and proximal
interphalangeal joints. Bony gamekeepers thumb is one
of the well-known. Inadequate reduction and healing of
these fractures may lead to joint deformity, chronic
instability and posttraumatic arthritis. Existence of very
small bone fragments and involvement of joint surface
are the obvious factors predisposing to technical problems in reposition and fixation of these fractures.
Avulsion fractures are intraarticular according to their
configuration and need anatomic reduction. AO principles depending on stable fixation and compression have
difficulties to be applied to these fractures owing the
inconvenience of the osteosynthesis materials and implants available are designed for fracture fixation of
larger bones. Fixation may result in further comminution
of the fragments.
Keywords: fracture, phalanx, osteosynthesis, avulsion
fracture
| HISTORICAL PERSPECTIVE
Avulsion fractures from the base of phalanges are wellrecognized injuries especially at the metacarpophalangeal joint of the thumb. In 1963, Lee1 reported a large
series of 223 cases of fractures of the phalanges, and 34
of them were named as Bproximal phalangeal corner
fractures.^ The main treatment was conservative; only 2
were surgical; one was stabilized by catgut sutures, and
in another case, the fragment was excised. Perkins
(1958) recommended fragment removal if rotated,
whereas Flatt (1959) recommended immobilization for
3 weeks. Studies have grouped these fractures along
Address correspondence and reprint requests to Halil Bekler, MD.
Devlet yolu Ankara Cad No. 102-104, Istanbul, Turkey. E-mail:
hbekler@yahoo.com.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
157
Bekler et al
| TECHNIQUES
Operative interventions of the phalanges are accomplished with intravenous regional, general anesthesia, or
brachial plexus block according to the needs and
preferences of the patient, surgeon, and anesthesiologist.
The extremity is prepared, draped. Exsanguination is
performed with Esmarch bandage, and a tourniquet is
elevated to 250 mm HG for adults.
For avulsion fractures from the base of proximal
phalanges, gentle longitudinal curved incision is performed on the dorso-ulnar side of the mentoposterior
position joint. The incision should allow access to the
avulsed fracture site. Care must be taken not to injure the
cutaneous nerve. The adductor tendon aponeurosis,
extensor hood is divided at its insertion onto the extensor
tendon and tagged for further repair. The joint capsule, if
not ruptured, is open longitudinally. Fracture fragment,
collateral ligament, and articular cartilage are then
viewed. Volar plate may also be examined with gentle
distraction. Hematoma is irrigated and removed. We
158
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
159
Bekler et al
| COMPLICATION
| DISCUSSION
160
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| REFERENCES
1. Lee MLH. Intra-articular and peri-articular fractures of
the phalanges. J Bone Joint Surg Br. 1963;45:103 Y 109.
2. Shewring DJ, Thomas RH. Avulsion fractures from the
base of the proximal phalanges of the fingers. J Hand
Surg Br. 2003;28:10 Y 14.
3. Sakuma M, Nakamura R, Inoue G, et al. Avulsion fracture
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
161
T E C H N I Q U E
| ABSTRACT
Injuries to the radial nerve or posterior interosseous nerve
can lead to significant functional limitation. Inability to
extend the wrist and/or digits prevents the hand from being
positioned properly for functional tasks. Therapy after
radial nerve injury is geared toward maintaining passive
extension of the wrist and digits. Sensory reeducation can
also be performed but often not necessary since the distribution of the nerve distally is on the dorsoradial surface
of the hand. Since nerve regeneration is often a lengthy
process and the extent of recovery is variable, splinting the
involved extremity is used to prevent contractures and
maximize function. This article introduces a new splint
that allows patients to extend the fingers and thumb via a
tenodesis effect at the wrist. In early trials, it has produced
excellent results for enhancing functional use of the
injured extremity while nerve regeneration occurs or until
tendon transfers have been performed.
Keywords: radial nerve, splinting, functional orthotics
| HISTORICAL PERSPECTIVE
Patients with trauma to their radial nerve may be unable
to extend either their wrist and/or digits depending on
the level and extent of nerve injury. This often leads to
Address correspondence and reprint requests to Mike Szekeres,
Department of Hand Therapy, Hand and Upper Limb Centre, 268
Grosvenor Street, London, Ontario, Canada N6A 4L6. E-mail:
mikes@sjhc.london.on.ca.
162
severe impairment in hand function. Initial rehabilitation of these injuries depends on several factors,
including the level of nerve injury, amount of axonal
disruption, and associated injury of surrounding tissues.
Several splints have been outlined as an extension
assistance for patients with radial nerve trauma and are
used as temporary orthotics to enhance function while
nerve regeneration occurs or until tendon transfers are
performed to restore wrist and digital extension. Hannah
and Hudak1 reviewed the functional improvements that
occurred with 3 different splint designs after radial nerve
palsy. The three spints that were compared were a static
wrist splint, a tenodesis suspension splint, and a dynamic
extension splint. This single case design showed that a
static wrist splint was not beneficial for improving functional use of the hand. A tenodesis suspension splint and a
dynamic extension splint both improved functional use in
their tests.
A splint originally described by Crochetiere et al2 and
later modified by Hollis3 and Colditz4 uses static cord
instead of dynamic rubber bands to suspend the proximal
phalanges. These splints are effective in recreating the
tenodesis effect for the digits to allow flexion and extension, but do not include an outrigger to allow thumb
extension and abduction. The rationale for not including
the thumb has been that it is an awkward outrigger
placement on those splint designs.5 The use of a wrist
hinge allows for simple placement of a radial outrigger.
The functional benefits that we have seen with thumb
inclusion seem to far outweigh any Bawkwardness^ of a
radial outrigger.
| TECHNIQUE OF SPLINT
FABRICATION
1. Start by fabricating a wrist hinge with only the hinge
for hardware as outlined in Figure 1. Note that the
base of the splint is placed on the dorsal aspect of the
forearm instead of the volar side. (We make all static
progressive hinges for stiff wrists in this fashion
because it improves the angle of pull and reduces the
counterforce to prevent the base of the splint from
migrating distally.)
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
163
Szekeres
| DISCUSSION
One biomechanical issue that arises with this splint is the
less than optimal angle of pull on the proximal phalanx.
The wrist hinge does not have enough length to allow a
90-degree angle of pull. This can be overcome by
FIGURE 6. A, A patient with radial nerve palsy. Note the extreme wrist flexion required to achieve a small amount of digital
extension. B, Same patient using the splint. C, Grasping larger objects is possible owing to the thumb assistance.
164
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
| REFERENCES
1. Hannah SD, Hudak PL. Splinting and radial nerve palsy: A
single-subject experiment. J Hand Ther 2001;14:195Y201.
2. Crochetiere W, Granger CV, Ireland J. The BGranger^
orthosis for radial nerve palsy. Orthop Pros 1975;29:27.
3. Hollis I. Innovative splinting ideas. In: Hunter Jea, ed.
Rehabilitation of the Hand. St. Louis: Mosby, 1978.
4. Colditz J. Splinting for radial nerve palsy. J Hand Ther
1987;1.
5. Colditz J. Splinting the Hand With a Peripheral Nerve
Injury. Rehabilitation of the Hand and Upper Extremity,
5th ed. St. Louis, Missouri: Mosby, 2002:622Y 634.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
165
T E C H N I Q U E
Milan Sen, MD
Department of Orthopaedics
University of California
San Francisco General Hospital
San Francisco, CA
Paul Martineau, MD
Department of Orthopaedics and Sports Medicine
University of Washington
School of Medicine
Seattle, WA
| ABSTRACT
| HISTORICAL PERSPECTIVE
166
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tensor compartment base) on the distal radius. Harvesting of the extensor retinaculum and bone block allowed
the fashioning of a bone-retinaculum-bone composite
graft that was used to reconstruct the dorsal portion of
the SLIL. Biomechanical testing was reported.25 The
BTB autograft was significantly weaker than the SLIL.
Other authors began to look at options based within the
hand itself that might have better biomechanical characteristics to replace the SLIL. The carpometacarpal boneligament-bone complex at the base of the second or
third metacarpal was proposed as a replacement for the
SLIL. These articulations are relatively immobile and,
therefore, were seen as expendable if needed for SLIL
reconstruction. Both of these grafts were also easily obtainable through the same dissection used for SLIL repair. These grafts also give a cartilaginous replacement
for the SLIL interval on both the scaphoid and lunate
surfaces. Harvey and Hanel6 carried out a study of cadaveric matched SLIL, second metacarpal-trapezoid
ligament, third metacarpal-capitate ligament, and dorsal
retinaculum. Stiffness and strength were obtained from
fresh-frozen specimens tested to failure with a servohydraulic apparatus, as accomplished in previous studies.
The second metacarpal-trapezoid ligament and the third
metacarpal-capitate ligament most closely approximated
the stiffness and strength of the SLIL. The dorsal periosteal retinaculum was significantly less stiff and weaker
than the SLIL. These 2 new grafts were seen as desirable
graft replacements. Another group of researchers substantiated these findings.22 A small clinical series with
short-term follow up showed that the third metacarpalcarpal BTB has been successful.7 In general, the clinical
outcome for BTB grafts is excellent and has been successful in the hands of several surgeons.
The 2 main complications with BTB procedures (nonvascularized) are graft pullout, usually from the lunate,
and graft stretching (Fig. 1), with an increased scapholunate interval but no loss of the scapholunate angle. Graft
pullout occurs from a lack of healing in a patchy vascularized lunate, typically seen in chronic dissociations or
lunate dislocations. Lack of healing eventually results in
hardware failure. Stretching of the SLIL replacement
occurs after several months with loss of the tight SLIL
interval. Presumably, this is due to the revascularization
phase of healing.
In an attempt to prevent these 2 observed complications, a vascularized BTB has been designed and is in
current usage. A typical third metacarpal-carpal graft can
be harvested based on the radial-sided intermetacarpal
artery. This artery is lifted and protected as it is traced
back to the radial artery. The dorsal intercarpal ligament
is incised and repaired during the procedure. The artery
origin from the radial artery is freed and the resultant
pedicle is sufficient to allow placement of the graft in the
trough fashioned on the scaphoid and lunate as per Weiss.
| INDICATIONS/CONTRAINDICATIONS
The original technique of third metacarpal-capitate BTB
(without vascular pedicle) was used for all chronic scapholunate deficient wrists. Results are no worse than the
literature results for all comers. However, the best results
observed in short-term follow-up have been in those
patients with shorter time from injury to treatment, those
with a more dynamic component than static, or in those that
did not have a fixed radio-lunate angle of greater than 30-.
The few patients treated as acute injuries have done well.
Primary repair of the scapholunate ligament has been
largely unsuccessful as an isolated procedure.4,19 The
procedure described in this manuscript is primarily indicated for wrists with scapholunate dissociation that
is acute (less than 6 months) in nature. In addition, the
scapholunate dissociations should have a correctable instability pattern by manipulation of the lunate. Wrists
that are more chronic in nature may be fixed in dorsal
intercalated segment instability, with a lunate that is not
correctable by manipulation. In this setting, the current
technique alone would not be sufficient to correct the
wrist deformity. If a patient with chronic dissociation
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
167
Harvey et al
FIGURE 2. Approach to the dorsal wrist for this procedure. The straight line between Listers tubercle (large
white oval) and the base of the third metacarpal (white
arrow) is the normal incision use for third metacarpal
nonvascularized BTB. This incision can be used for a
vascularized graft but if better visualization is wanted of
the radial artery origin of the pedicle, the curved incision
along the dotted line is more optimal.
| TECHNIQUE
The surgical procedure is accomplished through a single
extensile incision on the dorsum of the wrist.26 The interval
between the third and fourth extensor compartment is
extended by 1 to 2 cm, to include the base of the third
metacarpal. With minimal undermining of the skin flap,
168
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
169
Harvey et al
relationship of the radius and the lunate (no dorsal intercalated segment instability deformity).
| COMPLICATIONS
| REHABILITATION
Rehabilitation is started after the removal of the cast at
8 weeks postoperatively. Pins are removed and a
FIGURE 8. One-year postoperative radiographs of the SLIL graft. Screw placement in the scaphoid and lunate is stable
with a maintained SLIL gap (A). The scapholunate angle is maintained on the lateral radiograph (B).
170
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
removable splint is prescribed. Gentle-active and activeassisted range of motions are initiated. Passive range of
motion is started at 12 weeks postoperatively. Finger and
elbow range of motion and strengthening are encouraged
throughout the postoperative course (Fig. 8).
| CONCLUSIONS
There exist several published options to repair a SLIL
insufficiency. The technique discussed in this manuscript
represents merely the newest approach to the problem.
Unquestionably, the early results for these BTB procedures, in general, are excellent compared with other historical options. Although this procedure is technically
demanding, it may not be beyond the scope of many hand
surgeons. The BTB repair, in whatever form the surgeon
chooses, is a good option for scapholunate repair and may
become part of the future armamentarium of all hand
surgeons. This technique is a new modification of an
established technique. The clinical experience of only
3 patients at one-year follow-up is a small number. There
have been no complications in shorter-term follow-up
patients. The procedure is no harder than the performance
of a vascularized pedicle used for other bone defects in
the hand and wrist. It is taken from the same region as the
second metacarpal graft commonly used for vascularized
scaphoid grafts. As such, surgeons that are able to harvest
a pedicled vascular graft in the wrist should have no difficulty with the procurement of his graft.
Currently, more common hand based grafts are boneretinaculum-bone, third or second metacarpal-carpal
bone, or hamate-capitate grafts. There still exist some
failures in the outcome after any of these procedures.
The current manuscript illustrates the use of an autograft
reconstruction with a vascularized pedicle to address
this pathology. This procedure is the natural extension
of the third or second metacarpal-carpal bone autograft,
previously reported in the literature. The use of this proven
graft with a pedicle, based on the intermetacarpal artery,
may avoid some of the late complications seen with
other autografts and potentially improve the outcomes
of SLIL reconstruction.
6. Harvey E, Hanel D. Autograft replacements for the scapholunate ligament: a biomechanical comparison of hand
based autografts. Journal of Hand Surgery. 1999;24A:
963 Y 967.
7. Harvey E, Hanel D. What is the ideal replacement for the
scapholunate ligament in a chronic dissociation? Can. J.
Plast. Surg. 2000;8:143 Y146.
8. Kleinman W, Carrol C. Scapho-trapezio-trapezoid
arthrodesis for treatment of static and dynamic scapholunate instability: a ten year prospective on pitfalls and
complications. J Hand Surg. 1990;15A:408 Y 414.
9. Krakauer J, Bishop A, WP C. Surgical treatment of
scapholunate advanced collapse. J Hand Surg. 1994;
19A:751Y759.
10. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. J Hand Surg [Am]. 1992;17:354 Y359.
11. Linscheid RL. Scapholunate ligamentous instabilities (dissociations, subdislocations, dislocations). Ann Chir Main.
1984;3:323 Y330.
12. Linscheid RL, Dobyns JH. Treatment of scapholunate
dissociation. Rotatory subluxation of the scaphoid. Hand
Clin. 1992;8:645 Y 652.
13. Misra A, Hales P. Blatts capsulodesis for chronic scapholunate instability. Acta Orthop Belg. 2003;69:233Y238.
14. Muermans S, De Smet L, Van Ransbeeck H. Blatt dorsal
capsulodesis for scapholunate instability. Acta Orthop
Belg. 1999;65:434 Y 439.
15. Viegas SF, Dasilva MF. Surgical repair for scapholunate
dissociation. Tech Hand Up Extrem Surg. 2000;4:
148 Y153.
16. Weiss A-P. Scapholunate ligament reconstruction using a
bone-retinaculum-bone autograft: a new technique. AAOS
Trans. 1996;213:169.
17. Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg
[Am]. 1997;22:344 Y349.
| REFERENCES
1. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997;13:
39 Y 49.
18. Wolf JM, Weiss AP. Bone-retinaculum-bone reconstruction of scapholunate ligament injuries. Orthop Clin North
Am. 2001;32:241Y246. viii.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
171
Harvey et al
20. Zarkadas PC, Gropper PT, White NJ, et al. A survey of
the surgical management of acute and chronic scapholunate instability. J Hand Surg [Am]. 2004;29:848Y857.
21. Berger RA, Imeada T, Berglund L, et al. Constraint and
material properties of the subregions of the scapholunate
interosseous ligament. J Hand Surg [Am]. 1999;24:
953 Y962.
22. Cuenod P, Charriere E, Papaloizos MY. A mechanical
comparison of bone-ligament-bone autografts from the
wrist for replacement of the scapholunate ligament. J Hand
Surg [Am]. 2002;27:985Y990.
23. Viegas SF, Yamaguchi S, Boyd NL, et al. The dorsal
172
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
Scalene muscle block is often performed to assist with
the clinical differentiation of primary sources of pain
and weakness in the upper limb when the differential
diagnosis includes thoracic outlet syndrome. This
presentation offers a simple clinical method to assess
needle placement in the scalene muscle before an
injection of local anesthetic which, if properly placed,
weakens the scalene muscle and often leads to temporary relief of symptoms associated with neurovascular
compression. An appropriate scalene block response
provides assistance with medical decision making.
Keywords: thoracic outlet syndrome, scalene muscle
block, scalene block
| HISTORICAL PERSPECTIVE
In 1939, Gage1 described a patient with disabling
symptoms associated with spasticity in the scalenus
anticus muscle. A technique for accurate anatomical
needle placement is not found in this single case report;
however, injection of local anesthetic into the scalene
muscle resulted in a major reduction in the patients
symptoms. Operative scalenotomy was successful in
providing permanent relief for this patient.
In 1991, Sanders2 described the relevant anatomy of
the scalene muscle block, a specific procedure to follow
when performing the injection, and the use of this test as
a significant prognostic indicator for patients who later
required surgical treatment of thoracic outlet syndrome
(TOS).
Atasoy3 provided accurate anatomical markings on
the surface of the neck for guidance during the muscle
block procedure. He noted that major symptomatic
improvement associated with scalene muscle block
was associated with a good surgical outcome.
| INDICATIONS/
CONTRAINDICATIONS
Thoracic outlet syndrome may be suspected in patients
who present with localized tenderness over the brachial
plexus in the affected supraclavicular area, pain and
fatigue with use of the limb, and increased disability
while working overhead. These patients often experience sensory abnormalities that may include numbness,
paresthesias, or hypersensitivity directly over the brachial plexus or along the medial arm and forearm.
Scalene muscle block is considered an adjunct to the
standard diagnostic postural provocations used to
identify this clinical condition.6Y8 The block is particularly helpful when a neurogenic type of TOS is
suspected, and there is no obvious pulse loss with arm
elevation or shoulder depression, suggesting a negative
or normal Wright or Adson response.
Contraindications to scalene muscle block may include allergies to local anesthetic drugs or unstable medical or psychological conditions. An appropriate subjective
response is important for the evaluation of the test. It is
necessary for the subject to be a reliable reporter.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
173
Braun et al
174
needle placement test. Appropriate synchronous movement of the needle during respiration confirms scalene
localization.
| TECHNIQUE
The patient may be seated, as suggested by Sanders,2 or
placed in a supine position, as described by Atasoy.3
The patients head faces forward with the neck slightly
extended.
Although complications of this injection are rare,
reasonable caution and proximity of resuscitation equipment may be advisable.
The clavicle is palpated and/or marked as the lower
border of the posterior cervical triangle. The anterior border of the triangle is the lateral edge of the sternomastoid
muscle, which can be palpated and marked. These 2 significant structures are easily identified and provide
orientation for the location of the anterior scalene muscle,
which descends at approximately 30-degree angle away
from the lateral border of the sternomastoid, toward the
medial third of the clavicle.
The site for the injection is approximately 2 fingerbreadths above the clavicle at the lateral edge of the
sternomastoid muscle along the line of scalene descent
onto the first rib (Fig. 1A).
An alternative needle placement may be directed
through the lateral fibers of the sternomastoid muscle. In
thin individuals, the firm scalene muscle is palpable
because the superficial tissues and the soft featureless
scalene fat pad offers no resistance to the examiners
finger.
If approaching from the lateral border of the
sternomastoid muscle, the 1- to 1.5-in, 25-gauge needle
on a Luer-Lok syringe is introduced in a slightly
cephalad angle and slightly medial direction. If
approaching through the lateral fibers of the sternomastoid, the needle passes more directly posterior and
slightly cephalad (Fig. 1B).
Aspiration is advised before any injection of local
anesthetic is made. A grossly bloody aspirant probably
means that the needle has entered one of the large veins
in the area.
Specific concern is advised for medial needle
placement resulting in a venipuncture of the jugular
vein in the carotid sheath of the neck. An accessory
jugular or transverse cervical vein may be entered,
which may produce gross blood on aspiration. Should
this occur, the needle is moved to avoid an intravascular
injection.
Needle proximity or entry into brachial plexus
nerves is associated with pain and paresthesias, often
radiating into the limb. Should this occur, the needle is
moved to avoid a resultant brachial plexus nerve block,
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Needle Placement
| COMPLICATIONS
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
175
Braun et al
1% lidocaine injection. Hoarseness may also be experienced for approximately 1 hour after the block.
| SUMMARY
| REFERENCES
176
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
A new modification of 2-stage flexor tendon reconstruction is described. This new modification includes
the utilization of the insertion of the flexor digitorum
profundus tendon to develop a distal tunnel for initial
placement of the silicon rod at the first stage and
subsequent placement of the tendon graft at the second
stage. This allows a more distal attachment of the
tendon graft at the second stage of the reconstruction, to
maximize tendon excursion and minimize adhesions to
the volar plate of the distal interphalangeal joint.
Therefore, this new modification offers better distal
interphalangeal joint function and ease of second stage
distal tendon graft attachment.
Keywords: flexor tendon, reconstruction, 2-stage
| INDICATIONS
Indications to embark on a 2-stage tendon reconstruction procedure include severe soft tissue trauma to the
tendon sheath, pulleys, soft tissue, and/or skin. Significant delay between the initial injury and attempt at
delayed primary repair may also result in inability to
successfully reapproximate and repair the lacerated
flexor tendons because of retraction and atrophy of the
tendon and/or muscle.
| SURGICAL TECHNIQUE
Stage 1 Surgery
| HISTORICAL PERSPECTIVE
Hunter1 first described the use of tendon implants in the
reconstruction of flexor tendon lacerations in 1965.
Subsequently, in 1971, Hunter and Salisbury2 reported
their 10-year experience using tendon implants as part of
a staged technique to reconstruct severely damaged flexor
tendons. Hunters technique, which was based on earlier
studies by Bassett and Carroll, attached silicon rods at the
distal end, leaving the proximal aspect of the tendon
implant in the distal forearm. A passive exercise program
was used during wound healing and, subsequently, to
regain full passive range of motion of the finger, during
which time a smooth, well-organized pseudotendon
sheath would form around the tendon implant. The subsequent stage of the tendon reconstruction was performed
approximately 3 months or more after the first stage,
where the tendon implant was replaced by a tendon graft.
Despite various methods of tendon attachment, tendon
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
177
Viegas
178
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Stage 2 Surgery
After adequate healing and once full passive range of
motion has been regained in the digit, which usually
takes 3 months, the proximal curvilinear incision in the
distal forearm is reopened, and the proximal stump of
the flexor tendon implant is identified. The most distal
aspect of the volar zigzag incision is also opened, again
under tourniquet control. The distalmost insertion site of
the stump of the FDP tendon is split centrally, and the
distal aspect of the tendon implant is identified. Next,
the palmaris longus tendon is identified and harvested in
its entirety, including a segment of the palmar aponeurosis to maximize the length of the tendon graft.
The proximal stump of the palmaris longus tendon
graft is used to create the proximal juncture. This is
performed first as a number of authors 3Y5 have
expressed as their preference, which is shared by the
current author. Adjustment at the fingertip level for final
modification of tendon graft length and tension is
subsequently performed. A Pulvertaft weave is used to
attach the proximal stump of the palmaris longus tendon
graft to the flexor profundus tendon, just distal to the
musculotendinous junction at the common profundus
| REHABILITATION
After stage 1, the wounds are dressed, and a posterior
plaster splint, maintaining the wrist in approximately
30 degrees short of full flexion, metacarpophalangeal
joints in 70 degrees of flexion, and IP joints extended, is
applied and incorporated with Ace wrapping. Two weeks
after surgery, the sutures are removed, and the patient is
fitted with a removable splint, positioning the wrist and
digits in the same way as the intraoperative plaster splint.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
179
Viegas
| COMPLICATIONS
Adhesions and/or joint contractures can develop. The
best approach to minimize or avoid this problem is the
compliance with the postoperative rehabilitation program. Infection is always a possibility after either stage 1
or 2 procedures. Impingement or breakage of the tendon
implant can result in inflammation and swelling along the
pseudosheath formed around the silicon tendon implant.
180
| SUMMARY
The modification of the distal attachment of the tendon
graft seems to better protect the integrity of the volar plate
of the DIP joint, which better avoids subsequent DIP joint
flexion contracture and maximizes DIP joint motion.
| ACKNOWLEDGMENT
The author thanks Randal Morris for his assistance and
collaboration in the illustrations used in this manuscript
and Kristi Overgaard for her editorial assistance.
| REFERENCES
1. Hunter JM. Artificial tendons: early development and
application. Am J Surg. 1965;109:325Y338.
2. Hunter JM, Salisbury RE. Flexor tendon reconstruction in
severely damaged hands: a two staged procedure using a
silicon dacron reinforced gliding prosthesis prior to tendon
grafting. J Bone Joint Surg. 1971;53A:829Y858.
3. Pulvertaft RG. Suture materials and tendon junctures. Am J
Surg. 1965;109:346Y352.
4. Snow JW, Littler JW. A non-suture distal fixation technique for tendon grafts. Plast Reconstr Surg. 1971;47:91Y92.
5. Stenstrom S. A new method for distal anastamosis in flexor
tendon grafting. Scand J Plast Reconstr Surg. 1967;
1:64Y67.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
| ABSTRACT
Isolated traumatic dislocation of the trapeziometacarpal
joint is rare compared with fracture-dislocation of the
joint. The mechanism of injury is usually axial loading
on a flexed thumb metacarpal, leading to dorsal dislocation of the joint. Closed reduction with immobilization is an acceptable method of treatment if the joint is
stable after the reduction. Otherwise, early ligamentous
reconstruction is recommended to reduce the likelihood
of secondary arthritis. Various surgical techniques have
been used to reestablish the ligamentous integrity of the
joint; however, these techniques usually reconstruct
only 1 or 2 ligaments around the joint. The current
technique is aimed to reconstruct all 4 ligaments of the
trapeziometacarpal joint using a half strip of extensor
carpi radialis brevis tendon.
Keywords: extensor carpi radialis brevis, ligament reconstruction, trapeziometacarpal joint, traumatic dislocation
| HISTORICAL PERSPECTIVE
Trapeziometacarpal (TM) joint dislocation is a rarely
reported injury in the English literature. Almost all cases
are dorsal dislocations with axial loading injury.1 Y 5
Recommended treatment modalities show a wide variety depending on duration of the dislocation, condition
of the joint surfaces, and inherent stability of the joint
after reduction. For acute dislocations, it is generally
agreed to perform closed reduction and immobilization
for 4 to 6 weeks provided that the joint is stable after
reduction.6,7 Some authors add percutaneous pinning to
this treatment. For subacute and chronic cases, however,
this approach may result in persistent instability and
redislocation of the joint. Watt and Hooper6 treated 9
patients with closed reduction and cast immobilization
and 3 with closed reduction and percutaneous Kirschner
Address correspondence and reprint requests to Kagan Ozer, MD,
Denver Health Medical Center, 777 Bannock Street, MC:0188,
Denver, CO 80204. E-mail: Kagan.Ozer@dhha.org.
Anatomy
Four ligaments and the joint capsule are the main stabilizers of the TM joint. The ligaments include dorsoradial,
intermetacarpal, palmar (anterior oblique), and dorsal
(posterior oblique) ligaments5,9 (Fig. 1). The importance
of each one of these ligaments on the stability of the TM
joint is debated. Eaton and Littler10 believed that the
palmar (anterior oblique) ligament is the key stabilizing
structure and gave little credit to the dorsal ligaments in
joint stability. Others, however, found the dorsal (posterior oblique) and intermetacarpal ligaments to be the key
stabilizers of the joint.11,12 Pellegrini13 showed that the
degeneration of the palmar (anterior oblique) ligament
increases shear forces across the joint, leading to osteoarthritis and subluxation of the joint. Strauch et al5 studied
the importance of the TM joint ligaments in providing
stability to the joint. Serial sectioning of the ligaments
was performed on 38 cadaver thumbs. Unlike previous
studies, the stability of the joint was evaluated with the
first metacarpal in neutral, flexed, and extended positions.
The primary restraint to dorsal dislocation was found to
be the dorsoradial ligament with significant contributions
from the other 3 ligaments. In light of these studies, it is
clear that all 4 ligaments contribute to TM joint stability.
| INDICATIONS/
CONTRAINDICATIONS
The following are indications for open reduction and
ligamentous reconstruction of the TM joint:
1. irreducible dislocations (acute or chronic),
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
181
Ozer
| SURGICAL TECHNIQUE
Reduction and Assessment of the Joint Status
FIGURE 1. Schematic representation of the anatomy of
ligaments of the TM joint. (1) Dorsoradial ligament, (2)
intermetacarpal ligament, (3) palmar (anterior oblique)
ligament, and (4) dorsal (posterior oblique) ligament.
FIGURE 2. A, The patient had an irreducible dislocation, presented 2 weeks after the injury. B, The first tunnel hole is
made at the base of the metacarpal from dorsal to palmar direction. C, A second tunnel hole connecting to the first one
perpendicularly is made from ulnar to radial direction. D, A third tunnel hole is made through the trapezium from dorsal to
palmar direction. First and second tunnels are connected at the base of the thumb; first and third tunnels are parallel to
each other.
182
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 3. A, Split ECRB tendon is turned 90 degrees inside the bone, passed from ulnar to palmar hole with the aid of
stainless steel wires; this passage reconstructs the intermetacarpal ligament. B, The tendon crosses the joint on the
palmar side and pulled from palmar to dorsal through the trapezium tunnel; this passage reconstructs the palmar
(anterior oblique) ligament. C, Then the tendon crosses the joint on the dorsal side and is passed from dorsal to radial
hole at the base of the metacarpal; this reconstructs the dorsal (posterior oblique) ligament. D, The tendon is sutured to
itself on the dorsal surface of the trapezium. This final pass forms the dorsoradial ligament.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
183
Ozer
TABLE 1. Collected presentation of cases that underwent trapeziometacarpal joint ligament reconstruction using the split extensor
carpi radialis brevis tendon
Duration from
time of injury to
surgery (wk)
3
Mechanism
of injury
Clenched
fist injury
Initial
treatment
None
Indication for
surgery
Persistent
dislocation
Male, 50,
RHD
Motorcycle
accident
Closed reduction,
thumb spica
cast for 8 wk
Recurrent
dislocation
11
Male, 30,
RHD
Fall during a
soccer game
Closed reduction,
thumb spica
cast for 12 wk
14
Male, 45,
RHD
MVA
Closed reduction,
thumb spica
cast for 12 wk
Recurrent
dislocation
(in 4 d after the
completion
of casting)
Persistent
instability
16
Follow-up
Full, pain-free ROM; returned
to ADL in 3 mo with no
restrictions, no arthritic changes
at 24 mo with concentric
reduction of the joint
Able to oppose against middle
phalanx of the small finger,
otherwise pain-free ROM,
minimal subchondral sclerosis
at the TM joint on both sides at
18 mo, returned to ADL and
bike riding with no restrictions
in 3 mo after the surgery
Full, pain-free ROM; returned
to ADL with no restrictions in
4 mo after the surgery, no
arthritic changes at 20 mo
Able to oppose against the tip of
the small finger, pain-free
ROM, no arthritic changes at
19 mo, returned to ADL with
no restrictions in 3 mo after
the surgery
ADL indicates activities of daily living; RHD, right hand dominant; MVA, motor vehicle accident; ROM, range of motion.
184
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 5. Follow-up examination 18 months after the surgery shows full ROM in all planes. X-ray shows congruent
reduction with no arthritis.
| RESULTS
The technique described in this article was used on 4
patients with complete disruption of ligamentous support
around the TM joint (Table 1). Cases presented in the
study had a minimum 18 months of follow-up. One patient
(50 years old, right hand dominant) had a limited abduction
of the thumb (60 vs 85 degrees on the contralateral site)
due to tight reconstruction of intermetacarpal ligament.
During the follow-up, all cases had concentric reduction of
the joint with no signs of arthritis of the TM joint or
avascular necrosis of the trapezium (Figs. 4, 5; Video 1).
| DISCUSSION
Clinically, there have been several reports of various
techniques of ligament reconstruction for persistent and
recurrent instability after TM joint dislocation and instability.14 Y 24 Among these, the Eaton-Littler10,17,19,20,25
technique is one of the most commonly used and timetested techniques. The Eaton-Littler technique uses split
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
185
Ozer
| REFERENCES
1. Chen VT. Dislocation of the carpometacarpal joint of the
thumb. J Hand Surg. 1987;12B:246 Y 251.
2. Moore JR, Webb CA, Thompson RC. A complete dislocation of the thumb metacarpal. J Hand Surg. 1978;3:547Y 549.
3. Shah J, Patel M. Dislocation of the carpometacarpal joint
of the thumb. Clin Orthop. 1983;175:166 Y 169.
4. Hooper GJ. An unusual variety of skiers thumb. J Hand
Surg. 1987;12A:627 Y 629.
5. Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic
and cadaver study. J Hand Surg. 1994;19A:93 Y 98.
6. Watt N, Hooper G. Dislocation of the trapezio-metacarpal
joint. J Hand Surg. 1987;12B:242 Y 245.
7. Uchida S, Sakai A, Okazaki Y, et al. Closed reduction and
immobilization for traumatic isolated dislocation of the
carpometacarpal joint of the thumb in rugby football
players. Am J Sports Med. 2001;29:242 Y 244.
8. Simonian PT, Trumble TE. Traumatic dislocation of the
thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand
Surg. 1996;21A:802 Y 806.
9. Pieron AP. The mechanism of the first carpometacarpal
joint. Acta Orthop Scand. 1973;148(Suppl):7 Y 104.
10. Eaton RG, Littler JW. Ligament reconstruction for the
painful thumb carpometacarpal joint. J Bone Joint Surg.
1973;55A:1655 Y 1666.
11. Harvey FJ, Bye WD. Bennetts fracture. Hand. 1976;8:
48 Y 53.
186
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T E C H N I Q U E
Jesse B. Jupiter, MD
Orthopaedic Hand Service
Massachusetts General Hospital
Boston, MA
Harvard Medical School
Boston, MA
| ABSTRACT
External fixation is an effective means of addressing
several pathologies of the hand. The advantages of its use
include the ability to achieve stable fixation, minimize soft
tissue trauma at the site of injury, and allow wound care
and mobilization of adjacent joints. External fixators can
be constructed from material readily available in the
operating room or obtained from a commercial source.
Sufficient rigidity can be achieved by any of these means.
Improper placement, although achieving rigid fixation, may
compromise motion and overall function if basic principles
of external fixation are not followed or if the anatomy of the
hand is not taken into consideration. The objective of this
article is to describe the technique of application of mini
external fixation, emphasizing the basic principles of
external fixation as they relate to the specific anatomy of
the hand. In addition to fracture fixation, various other uses
are described including distraction lengthening, arthrodesis,
treatment of nonunion, and infection.
Keywords: mini external fixation, handfracture, arthrodesis,
lengthening, nonunion
| HISTORICAL PERSPECTIVE
| INDICATIONS/CONTRAINDICATIONS
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
187
188
| TECHNIQUE
Fractures
External fixation of a fractured phalanx leads to the best
functional result if applied within the limits of the
involved phalanx or metacarpal, avoiding involvement
of the adjacent joints. This is not always possible
especially in fractures with intraarticular extension or
extraarticular fragments too small for pin placement.
FIGURE 4. The mini Arbeitsgemeinschaft fur Osteosynthesefragen (AO) external fixation for thumb injury.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 5. The basic components of the AO mini external fixation system. A, Two sizes of pin-holding clamps. B, 3.0/3.0-mm
bar-to-bar connecting clamps. C, 1.25- and 1.6-mm threaded trocar tipped Kirschner wires. D, Carbon fiber connecting rods.
FIGURE 6. The basic steps of mini external fixation application. A, Two Kirschner wires are placed on either side of the
fracture. B, Each wire is connected to pin-holding clamps into the larger of the two holes. C, The 2 clamps are connected
with a carbon fiber rod. D, Two additional Kirschner wires are placed through the pin-holding clamps.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
189
When possible, it is preferable to place pins dorsolaterally for border digits to limit contact and interference with neighboring digits.
The same principles of achieving rigidity in the
lower extremity apply to the hand. Pin diameter has
the greatest effect on rigidity. Other factors associated
with increased rigidity include number of pins, decreasing interpin spacing, and decreasing bone to fixator
distance.
Middle Phalanx. The basic components of any type of
mini external fixation system that has application in the
hand will include pin-holding clamps, threaded-tip
wires or pins, a variety of lengths of connecting bars,
and clamps to connect rods to each other and to the pinholding clamps (Fig. 5). The versatility of these devices
will permit a variety of applications both in location and
in frame construction.
The authors have the most experience with the
mini external systems manufactured by Synthes, Ltd
and Howmedica.
Using the proximal phalanx as an example, a threadedtipped 1.2- or 1.6-mm Kirschner wire initially is placed on
either side of the fracture or defect. A pin-holding clamp is
FIGURE 7. Additional components of the AO mini external fixation system. A, Angled connecting bar to permit the
connecting rod to rest above the digit. B, The frame construct with the angled bar. C, 3.0/3.0-mm bar-to-bar clamps. D,
The use of this connecting clamp holding 2 small carbon fiber rods.
190
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Arthrodesis
The most commonly fused joints in the hand are the interphalangeal joints. Fusion success rates are comparable
FIGURE 8. A and B, A complex proximal phalanx fracture in a 16-year-old male patient seen 3 weeks after injury with
early callous. C, A closed reduction was accomplished and held in place with a mini Hoffman external fixation frame.
D, Excellent healing with good digital function.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
191
Infection
Although external fixation is a well-established method for
the treatment of infected nonunion of long bones in the
lower extremities, its use in the upper extremity is less
frequent.29 External fixation represents a major advance in
the management of septic conditions of the hand.15,25,30,31
The advantages also include the ability to achieve rigid
FIGURE 9. A complex fracture of the thumb proximal phalanx with vascular injury. A, The x-ray of the injury. B, After
revascularization and 2 long screws, the fracture is bridged with a mini external fixator. C, The frame construct for the
complex thumb injury. D, 2 weeks after frame removal, early thumb function.
192
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 10. A, A complex impacted articular fracture at the base of the thumb metacarpal (case courtesy of Dr Lady
Nagy). B, After open reduction and cancellous grafting, the reduction is protected with a small external fixation construct with
pins in both thumb and index metacarpal.
Repeated debridement, especially in acute infections, may be necessary for excision of necrotic tissue.
This type of staging minimizes recurrence of infection.
Once adequate debridement is achieved, definitive
management can be implemented. If bone loss is not
severe, cancellous bone grafting may be all that is
needed. If there is segmental bone loss, corticocancellous bone grafting should be considered for bone
replacement. External fixation can be used throughout
the stages of treatment or used just during the debridement stage. It is recommended that bone grafting be
performed within 10 days of these severe injuries.
Distraction Lengthening
Distraction lengthening can be performed with or
without neo-osteogenesis or callotasis. Distraction
lengthening with neo-osteogenesis has several advantages over lengthening without neo-osteogenesis. Some
of the advantages include less risk of needing bone
grafting; pain is less likely and when encountered is less
severe; stretch adaptation of soft tissue is more easily
accommodated; and catastrophic problems such as
excessive fibrosis, severe or chronic pain reactions, or
gangrene are much less likely.32
The technique of distraction osteogenesis involves
an osteotomy, a brief delay period to allow callus
formation, followed by slow lengthening through a
healing fracture callus. For digital lengthening, we
usually make a midline dorsal incision over the
bone to be lengthened. The extensor apparatus is
reflected to expose the periosteum. Two pins are placed
distal and 2 proximal to the intended osteotomy site.
FIGURE 11. An alternative method of mini external fixation for a complex base of thumb fracture is with a mini lengthener
with one pin in the trapezium and one in the thumb metacarpal.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
193
FIGURE 12. A, A severe infection after replantation of the index and long fingers. The long finger required an amputation;
the index finger survived, but with an infected proximal interphalangeal joint. B, A mini external fixator was used to
stabilize the joint and allow rehabilitation of the injured ring and little digits. C, Radiographs at 6 months show fused joint.
D, Functional results.
194
| POSTOPERATIVE CARE
To control postoperative swelling, the hand should be
kept elevated. A sling can be worn to help keep the hand
elevated while walking. Digital range of motion should
be started after a few days.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 13. A thumb lengthening using a mini distracter with later plate fixation.
| COMPLICATIONS
External fixation can cause significant morbidity if attention is not given to pin placement. Misdirected pins can
injure musculotendinous structure, nerves, or vessels. The
overall incidence of neurovascular injury is less than 1%.33
Pin-tract infection can occur. Overall incidence is
estimated at 8%, with actual sequestrum and osteomyelitis developing in less than 1%.33 In our series, there
was only one pin tract infection, which required pin
removal but did not alter the clinical course.15 Predrilling may help reduce this incidence by reducing the
heating of bone and associated necrosis.
Malunion and nonunion were more common with
older external fixators because of the limited ability
to modify their position or apply compression once placed.
| REFERENCES
1. Freeland A, Jabaley M. Stabilization of fractures in the
hand and wrist with traumatic soft-tissue and bone loss.
Hand Clin. 1988;4:425Y36.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
195
196
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
L E T T E R T O T H E E D I T O R
Dear Editor:
I would like to comment on the article by
Slesarenko et al,1 BPercutaneous release of A1 pulley.^
I would like to congratulate the authors for their
valuable contribution to the relevant literature.
Stenosing tenosynovitis, or trigger finger, is an
entity seen commonly by hand surgeons.
The authors found in their cadaver study that a
percutaneous trigger digit release resulted in a high
percentage of incomplete releases of the A1 pulley,
especially in the thumb, index, and little fingers.1 In the
authors study, some of the most current literature, noting
that percutaneous release of trigger finger was a safe and
effective outpatient procedure, was not cited.2Y4
I assume that in the authors study, there was no
clinical evidence of a trigger digit.1
In a clinical patient setting using the percutaneous
technique, the sudden release of resistance can be noted
by the hand surgeon and the patient at the needle tip.
This observation aids in an adequate release. The oftenobserved fibrous nodule in the A1 pulley is also a useful
guide for the insertion of needle tip.
In my opinion, another important factor for a high
clinical success rate in percutaneous release of trigger
digits is the communication with the patient during the
| REFERENCES
1. Slesarenko YA, Mallo G, Hurst LC, et al. Percutaneous
release of A1 pulley. Tech Hand Up Extrem Surg. 2006;
10:54Y56.
2. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger
finger release: the lift-cut` technique. Br J Plast Surg.
2005;58:817Y821.
3. Park MJ, Oh I, Ha KI. A1 pulley release of locked trigger
digit by percutaneous technique. J Hand Surg [Br]. 2004;
29:502Y505.
4. Maneerit J, Sriworakun C, Budhraja N, et al. Trigger
thumb: results of a prospective randomised study of
percutaneous release with steroid injection versus steroid
injection alone. J Hand Surg [Br]. 2003;28:586Y589.
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
197