The Hand- Fundamentals of Therapy

This book is dedicated to Kevin, Nina, Hildegard, Birger,Holger, Gunder, Ingo and Patrick

Joyce, John, Christine and Bruce

Acquisitions editor: Heidi AllenDevelopment editor: Myriam BrearleyProduction controller: Chris JarvisDesk editor: Jane CampbellCover designer: Fred Rose

Butterworth-Heinemann Linacre House, Jordan Hill, Oxford OX2 8DP225 Wildwood Avenue, Woburn, MA 01801-2041A division of Reed Educational and Professional Publishing Ltd

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First published 1985Reprinted 1987, 1990Second edition 1992Reprinted 1995, 1997Third edition 2001

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British Library Cataloguing in Publication DataBoscheinen-Morrin, Judith

The hand: fundamentals of therapy – 3rd ed.1. Hand – Surgery – Patients – Rehabilitation2. Hand – Wounds and injuries – Patients – RehabilitationI. Title II. Conolly, W. Bruce617.5�75

Library of Congress Cataloguing in Publication DataThe hand: fundamentals of therapy/[edited by] Judith Boscheinen-Morrin,W. Bruce Conolly. – 3rd ed.

p. cm.Includes bibliographical references and index.ISBN 0 7506 4577 61. Hand – Wounds and injuries – Patients – Rehabilitation.2. Hand – Surgery – Patients – Rehabilitation.3. Hand – Diseases – Patients – Rehabilitation 4. Physical therapy.I. Boscheinen-Morrin, Judith. II. Conolly, W. Bruce.RD559.B67617.5�75–dc21 00-051928

ISBN 0 7506 4577 6

Composition by Genesis Typesetting, Rochester, KentPrinted and bound in Great Britain by The Bath Press, Avon

Foreword

When ‘The Hand: Fundamentals of Therapy’ wasfirst published in 1985, the importance of thissubject was only just starting to be appreciated.Since that time, hand therapy has grown to be awell-recognized and respected specialty. Nowa-days, it would be a short-sighted surgeon indeed,who did not acknowledge the vital role that thetherapist plays in the overall management ofpatients with disorders of the hand.

This book has fulfilled an important task indelineating this role, and the fact that it is now inits third edition, bears witness to its success. In thislatest edition, new chapters have been added tocover the important topics of the wrist and free

tissue transfer. At the same time, existing chaptershave been updated to keep pace with the rapidchanges that are occurring in the fields of handsurgery and therapy.

While intended primarily as a guide for the non-specialist, I believe that this book has a widerappeal. Not only does it provide an excellent quickreference for anyone involved in treating patientswith disorders of the hand, it also offers the sort ofclear and simple overview of a specialized subjectthat will make it attractive to students and traineesas well.

Timothy J. Herbert, FRCS, FRACSMarch 2000

Preface

That hand surgery and therapy have become suchareas of specialization (and even sub-special-ization) comes as no surprise when one considersthe extent to which the hand is represented withinthe homunculus.

While diagnostic evaluation, surgical proce-dures and therapeutic techniques have becomeincreasingly sophisticated, the basic principlesand practices of aftercare remain unchanged.Careful clinical assessment, the formulation of a

treatment plan and regular patient review, con-tinue to be the cornerstones of successful patientmanagement.

This third edition aims to highlight, in con-densed form, the current thinking and practice inhand surgery and therapy. The hand therapyprogrammes emphasize treatment techniques thatcan be used by the patient outside the formaltherapy milieu and thereby encourage self-relianceearly in the rehabilitation process.

Contributors

Jacki Shannon-Johnstone, B.App.Sc. (OT)Hand Therapist, MAHTA, South West HandTherapy, Sydney, Australia

Dr Peter Scougall, FRACS, FAOrthAConsultant Surgeon, Sydney Hospital, St Luke’sHospital, Sydney, Australia

Dr James Masson, MB, B.S.(Hons) UNSW,FRACS (Plastics)Consultant Hand Surgeon, Sydney Hospital,St Luke’s Hospital and NSW Private Hospital,Sydney, Australia.Consultant Plastic Surgeon, Liverpool Hospital,Concord Hospital, Sydney, Australia

Acknowledgements

Heartfelt thanks are extended to the followingindividuals who have helped bring this book tofruition: Becci Boscheinen, and Nina and KevinMorrin for their enhancement of the text with linedrawings; Jacki Shannon-Johnstone, Dr PeterScougall and Dr James Masson for their chaptercontributions; Jacki Shannon-Johnstone, JoMunro-Hick and Dr James Masson for assistancewith proofreading; Dr Ian Isaacs, Director ofSydney Hospital Hand Unit, for making availableclinical slides for reproduction; Dr Lionel Chang,for providing clinical photographs; David Robin-son and Karen Spragg for their assistance with thedevelopment of prints; ‘Tad’ for his role asanamchara; Helen McElhone and Anne Smidlin,

both wonderful past mentors; ‘Lola’ for her wordsof inspiration; Caroline Makepeace and Zoe Youdof Butterworth-Heinemann for their assistance andencouragement during manuscript preparation; andthe many patients who so willingly subjectedthemselves to photographic sessions.

Special gratitude is reserved for those on thehome front – Kevin, Nina and ‘Nanny Hildegard’,who have helped ‘carry’ this book in every senseof the word, and to Jacki Shannon-Johnstone forthe many ways in which she has shown greatgenerosity of spirit.

The authors would like to acknowledge andthank their erstwhile colleague, Victoria Davey, forher contribution to the two previous editions.

List of abbreviations

ADL, activities of daily livingAP, anteroposteriorAPL, abductor pollicis longusAROM, active range of motionCLIP, capitate-lunate instability patternCMC, carpometacarpalCRPS, chronic regional pain syndromeCT, computed tomographyCTS, carpal tunnel syndromeDIP, distal interphalangeal jointDISI, dorsal intercalated segment disabilityDRUJ, distal radioulnar jointECRB, extensor carpi radialis brevisECRL, extensor carpi radialis longusECU, extensor carpi ulnarisEDC, extensor digitorum communisEDM, extensor digiti minimiEDQ, extensor digiti quintiEIP, extensor indicis propriusEMG, electromyographyEPB, extensor pollicis brevisEPL, extensor pollicis longusFCR, flexor carpi radialisFCU, flexor carpi ulnarisFDMA, first dorsal metatarsal arteryFDP, flexor digitorum profundusFDS, flexor digitorum superficialisFPL, flexor pollicis longusFR, flexor retinaculumIP, interphalangealK-wire, Kirschner wireMAMTT, minimal active muscle-tendon tension

MCP, metacarpophalangealMRI, magnetic resonance imagingNCV, nerve conduction velocityOA, osteoarthritisORIF, open reduction and internal fixationORL, oblique retinacular ligamentPA, posteroanteriorPIN, posterior interosseous nervePIP, proximal interphalangeal jointPL, palmaris longusPOSI, position of safe immobilizationPROM, passive range of motionPT, pronator teresRA, rheumatoid arthritisSIP, sympathetically independent of painSLAC, scapholunate advanced collapseSLE, systemic lupus erythematosusS-L, scapholunateSMP, sympathetically maintained painSTT, scapho-trapezial-trapezoidTAROM, total active range of motionTCL, transverse carpal ligamentTENS, transcutaneous electrical nervestimulationTFC, triangular fibrocartilageTFCC, triangular fibrocartilage complexTPROM, total passive range of motionTROM, torque range of motionUCL, ulnar collateral ligamentUS, ultrasoundVAS, visual analogue scaleVISI, volar intercalated segment instability

1

Assessment

Introduction

The hand demonstrates remarkable mobility andmalleability. This allows it to conform to the multi-shaped objects that it needs to grasp (Tubiana,1984). The hand is a unique tool of accomplish-ment, not only in our everyday domestic, work andleisure activities, but also in music and the arts.Just as importantly, it is an organ of expression thatis used to convey emphasis and to communicatelanguage.

The hand links us intimately to others throughtouch. The abundance of receptors in the skin ofthe palm distinguishes the hand from other areas ofthe body. Unlike these other areas, the hand aloneis capable of simultaneously touching as it is beingtouched (Brun, 1963).

The hand and wrist contain 27 bones (19miniature long bones and 8 carpal bones). Thereare 17 articulations involving the digits. The handhas 19 intrinsic muscles and about the samenumber of tendons whose origin is in theforearm.

Clinical assessment

The formulation of a treatment programme isbased on a full assessment that gleans bothobjective and subjective data. As important as ourobjective findings are, Paul Brand reminds us ofthe need ‘to balance objective assessments withtrusting our impressions and to resist our tendencyto reject considerations of things that we cannotquantify’ (Brand, 1998). The treatment programme

should therefore be tailored to the unique needs ofeach patient.

Most patients will require only a limited selec-tion of all the tests that are at the therapist’sdisposal (Fess, 1995). Where hand pathology iscomplex, it is preferable to perform assessmentsover a number of sessions to avoid fatigue andstress. The assessment repertoire includes thefollowing:

History

Every history begins with the patient’s pertinentdetails, i.e. age, hand dominance, work and leisureactivities and family particulars. The most impor-tant aspect of the history, however, is the reasonthat the patient has come for treatment. This willsometimes be obvious, e.g. after amputation of adigit or contracture associated with Dupuytren’sdisease. There may, however, be no obviousoutward signs of injury or deformity as, forexample, in patients presenting with de Quervain’sdisease, carpal tunnel syndrome, trigger finger or aclosed wrist injury.

The history should include the followingdetails:

1. The recency of the injury or condition.2. The mechanism of the injury.3. The symptoms resulting from the injury or

condition and their pattern of behaviour, i.e.frequency and intensity.

4. Previous treatments and their effect.5. Associated health problems, e.g. diabetes.6. Prescribed medications.

2 The Hand: Fundamentals of Therapy

Physical examination

The physical examination has both a visual and atactile component. Much can be gleaned simply bylooking at the hand. The mobility of the moreproximal upper limb joints, i.e. shoulder, elbowand forearm, is assessed first. During examination,comparison is always made with the patient’s otherhand. It is remarkable how often features that mayappear abnormal to the examiner, e.g. swan-necking, lateral deviation of a digit or jointhypermobility are normal manifestations of bothhands.

Visual examination

The hand is inspected for presence of thefollowing:

1. Wounds.2. Scars (recent and old).3. Swelling: where this is marked swelling there

will be loss of normal skin creases (Fig. 1.1).4. Deformity e.g. flexion deformity of the prox-

imal interphalangeal (PIP) joint (Fig. 1.2).5. Soft tissue contracture.6. Muscle wasting.7. Restricted joint motion.8. Circulation (the hand may be pale, red or

cyanosed).

9. Skin mottling, excessive sweating or dryness;the texture of the skin may appear smooth andshiny with loss of pulp ridging and pulpwasting; trophic lesions may be present(Fig. 1.3).

10. Nail deformity, brittleness or ridging.11. Relevant X-rays or scans should also be

viewed by the therapist (e.g. ultrasound (US),computed tomography (CT), magnetic reso-nance imaging (MRI)).

Tactile examination

The following are assessed by touch and willconfirm much of what has been noted in the visualexamination:

Figure 1.1. Hand oedema is common following injury.It is also associated with a number of conditions thatcan affect the hand. This patient developed chronicregional pain syndrome (Type 1) within weeks ofsurgery which involved repair of an extensor tendon.Swelling and pain were the main initial features of hiscondition. Note the loss of MCP joint flexion andflexed posture of the PIP joints. Note also the loss ofnormal skin creases over the joints.

Figure 1.2. Flexion deformity at the PIP joint is thecommonest deformity seen in the hand.

Figure 1.3. Nerve damaged skin is very prone toinjury from heat, pressure, sharp objects or friction.Note the smooth, shiny skin of the thumb and indexfinger following injury to the median nerve.

Assessment 3

1. Scar condition

Palpation of the scar will determine areas ofhypersensitivity and whether the scar is supple andmobile or rigid and adherent.

2. Temperature of the skin

Increased temperature may indicate inflammation/infection or early-stage chronic regional painsyndrome (CRPS); decreased temperature may bea sign of poor circulation (e.g. Raynaud’s disease),nerve injury or later-stage CRPS.

3. Swelling

The skin is indented to determine whether oedemais soft and yielding (usually acute) or ‘woody’ anddense (subacute or chronic).

4. Thickenings or nodules

The palm is palpated for thickenings or nodulesthat are not apparent on visual inspection, e.g.thickening of the A1 pulley (trigger finger) or tightfascial bands or nodules that may indicate earlyDupuytren’s disease.

5. Soft tissue tightness

The forearm and hand are palpated for soft tissuetightness that may be limiting movement at thewrist and/or finger joints, e.g. following nerve andflexor tendon repair at the wrist, protracted flexionsplinting can result in muscle-tendon shortening.Adherence of tendons can also affect the hand’snormal tenodesis effect whereby flexion of thewrist will facilitate finger extension and con-versely, extension of the wrist will facilitate fingerflexion.

6. Moistness or dryness of the skin

Excessive sweating (hyperhidrosis) is normal insome patients; however, it can be a sign of CRPS;excessive dryness is a feature of nerve damage.

7. Joint stiffness

Joints are passively moved to determine whetherthey have a ‘springy’ or ‘hard’ end-feel; generally,the latter does not augur well for conservativetreatment outcome.

8 Palpation of the hand

This may identify painful areas, e.g. where there isa neuroma, an arthritic joint or tendonitis.

Pain

Pain is difficult to assess clinically because itsexperience is unique to each individual. Thepatient is asked to describe the nature of the pain,i.e. stabbing, burning, shooting or aching. Thepatient should indicate whether the pain is local-ized or radiating and whether it is deep orsuperficial. The intensity, duration and sources of

Figure 1.4. All relevant X-ray findings and resultsfrom diagnostic tests, e.g. nerve conduction studies,ultrasound, bone scans, magnetic resonance imaging,etc., should be recorded in the patient’s history.


provocation are also recorded (Echternach,1993).

Acute postinjury or postoperative pain is to beanticipated and generally passes uneventfully. Painthat persists can be ‘graded’ on a linear pain scaleof 0–10, with ‘0’ representing no pain and ‘10’representing the severest level of pain. This visualanalogue scale (VAS) can be used before and aftertreatment sessions as a guide to determine theefficacy of treatment.

Range of motion

Range of motion can be determined in a number ofways (Cambridge-Keeling, 1995). In everydayclinical practice, both active (AROM) and passiverange of motion (PROM) should be recorded,bearing in mind that the active motion of the jointwill be limited by the joint’s passive capacity. Thisinformation is important in determining whethertreatment measures are achieving the desiredresult, e.g. in the case of corrective splinting.Range of motion is also recorded to compare pre-and postoperative results.

Rigorous recording is less relevant in conditionswhere improvement in ROM is anticipated, e.g. inthe acutely swollen digit or hand where an increasein joint mobility occurs inevitably as oedema isresolved.

1. Active range of motion (AROM)

This refers to the arc of motion that is achievedwhen the muscles that control a joint are used tomove it. Causes of limited active range of motioncan include: loss of tendon continuity, tendonadhesion (e.g. following repair or significantinjury), tendon inflammation (e.g. rheumatoiddisease or overuse), tendon constriction (e.g.trigger finger or de Quervain’s disease), tendonsubluxation or dislocation.

2. Passive range of motion (PROM)

This refers to the arc of motion that is achievedwhen an external force, such as the examiner’shand, is used to move the joint. Factors that caninfluence a joint’s passive range include disruptionof the articular surfaces (intra-articular fracture)and/or capsular fibrosis, e.g. after prolongedimmobilization.

3. Total active range of motion (TAROM)

This refers to the total flexion range of a digit whenits three joints are flexed simultaneously and anyextension deficit over the three digital joints issubtracted.

4. Total passive range of motion (TPROM)

As for TAROM except that an external force isused to move the digit.

5. Composite finger flexion to the palm

This measures the distance of the finger pulp fromthe palm when all three finger joints are flexedsimultaneously. Where flexion range is near-normal, the finger pulp will lie over the distalpalmar crease. Where flexion range is morerestricted, the finger pulp will lie over the mid- orproximal-palm area (Fig. 1.5).

6. Torque range of motion (TROM)

Torque range of motion involves moving a jointpassively through its range of motion using aconstant force. The objective of torque angle rangeof motion is to provide a more objective PROMassessment (Brand, 1993). To measure the forceapplied during passive motion, Brand advocatesthe use of a Haldex gauge, a spring scale or a push-pull device calibrated in grams up to one kilogram.Breger-Lee and others (1990) also use the Haldexgauge and in their research have noted that higherforce levels, i.e. around 800 g, provide moreconsistent correlations during interphalangeal jointmeasurements.

Figure 1.5. Composite finger flexion can be assessedwith a ruler that measures the distance from the pulpof the finger to the palm.

Assessment 5

7. Thumb or finger web spans

These can be measured with a ruler by determiningthe distance between the tips of the various digits(Fig. 1.6).

Assessment of motion with a goniometer

Joint range of motion can be reliably assessed witha goniometer (Hellebrandt et al., 1949). The size ofthe goniometer should be appropriate to the jointbeing measured. The arm of the goniometer used tomeasure the wrist and forearm is about 15 cm inlength compared to the 4–6 cm arm needed toassess digital range of motion (Fig. 1.7).

Positioning of the hand during measuring

The position of the forearm and hand should beconsistent during each recording. When measuringfinger joint ROM, the wrist should be held inneutral and the forearm in pronation. This positioneliminates the possibility of restricted tendon glidedue to the tenodesis effect, i.e. restriction of fingerflexion when the wrist is maximally flexed andrestriction of finger extension when the wrist ismaximally extended.

Goniometer placement

To minimize intertester error, a specific protocolshould be adopted (Hamilton and Lachenbruch,1969). The goniometer can be placed laterally ordorsally. The author believes that there is lessmargin for error in dorsal placement and therefore

prefers this method. It is important that the fulcrumis centred over the joint and that the arms of thegoniometer lie over the long axes of the adjacentbones. To ensure optimum accuracy, the contact ofthe goniometer arms with the skin should be asintimate as possible (Perry and Bevin, 1974)(Fig. 1.8).

When measuring flexion range of the distalinterphalangeal joint (DIP) joint during globalflexion, proper placement of the goniometer is notalways possible. The patient is therefore asked toslightly extend the metacarpophalangeal (MCP)joints to accommodate goniometer placement. Fullextension at these joints, i.e. a hook grip, will bestfacilitate measurement of the DIP joints.

Figure 1.6. Thumb web span or interdigital span canbe measured with a ruler.

Figure 1.7. The size of the goniometer should beappropriate to the joint being measured. For wrist andforearm assessment, the goniometer will require anarm of at least 15 cm in length.

Figure 1.8. To optimize accuracy when assessingrange of motion, the contact of the goniometer armswith the skin should be as intimate as possible.


Method of recording

Range of motion is usually expressed as extension/flexion, with 0 degrees regarded as neutral. Forexample, 20/105 degrees of active movement atthe PIP joint of the right index finger would denotea 20 degree flexion deformity and 105 degrees offlexion. In other words, a total active range of 85degrees. If the minus sign appears before extensionrange, i.e. –20/105, this would denote a 20 degreerange of hyperextension at the PIP joint.

Oedema assessment

Oedema can be assessed simply with a tape measurethat is applied at specific anatomical landmarks, e.g.at the PIP joint of the single digit or around the MCPjoints when assessing hand oedema (Fig. 1.9).

In everyday clinical practice, the assessment ofhand or finger swelling has little relevance. In mostcases, oedema subsides uneventfully in response tosimple measures such as elevation, light compres-

sion bandaging and the commencement of earlyactive movement where this is not contra-indicated.

If oedema is noted to fluctuate for no apparentreason, there may be an indication for formallyrecording these changes. This fluctuation mayindicate an impending pain syndrome or rarely, thepatient may be deliberately perpetuating a swollenhand for secondary gain.

A more formal method of measuring changes tooedema is by means of water displacement when thehand is immersed in a large Perspex container, suchas the ‘Volumeter’ designed by Dr Paul Brand andHelen Wood, OTR. in Louisiana (Waylett-Rendalland Seibly, 1991). The tank is filled to a known leveland the hand and wrist are held vertically and placedinto the tank to a predetermined level markedcircumferentially on the forearm. When the watersettles after rising, the difference in volume isrecorded.

Sensibility testing

Cutaneous sensibility refers to the consciousappreciation and interpretation of a tactile stimulus(Fig. 1.10). Objective assessment of sensibility isdifficult. This is due in part to the subjectiveresponses of the patient and to the fact that there isconsiderable variation in the application of forceand velocity during hand-held examination tech-niques (Bell-Krotoski and Buford, 1988). Even theresults of nerve conduction velocity tests can beinfluenced by factors such as the size and place-ment of electrodes, temperature of the extremityand even the time of the day that testing occurs.

The reasons for assessing sensibility include:

1. To determine the extent of sensory loss follow-ing a nerve lesion.

2. To assist in the diagnosis of neuropathies, e.g.carpal tunnel syndrome.

3. To determine the most suitable time to initiatesensory re-education (i.e. upon return of mov-ing touch).

4. To monitor recovery of sensibility after nerverepair.

5. To help determine the degree of functionalimpairment for medicolegal purposes.

Types of tests

Because no single test can adequately assesssensibility, a battery of tests should be used

Figure 1.9. Hand and finger oedema can be assessedwith a tape measure that is applied at specificanatomical landmarks, e.g. at the PIP joint.

VOLAR ASPECT DORSAL ASPECT

Ulnar nerve Ulnar nerve

Mediannerve

Radialnerve

Palmar cutaneousbranch of ulnar nerve

Palmar cutaneousbranch of median nerve

Assessment 7

(Callahan, 1995). This will help determine not onlysensory acuity, but also how acuity relates tofunctional ability (Bell-Krotoski, 1995; Clark,1999). Sensibility tests can be divided into variouscategories, e.g. threshold tests, innervation densitytests, tactile gnosis tests or objective tests.

1. Threshold tests

The two threshold tests are vibration and touch-pressure (Semmes-Weinstein monofilaments). Themonofilament test is helpful in monitoring returnof sensibility following nerve repair. Both tests areused to detect the gradual change in nerve function

that occurs in compression syndromes (Dellon,1980) and that does not involve cortical integration(Szabo, 1999). When assessing compression syn-dromes, other sensibility tests, such as static andmoving two-point discrimination (which are inner-vation density tests), will not register changes untilmuch later.

Semmes-Weinstein monofilamentsThe ‘light touch-deep pressure’ monofilament testis regarded as one of the most objective forcutaneous sensibility assessment (Table 1). Lighttouch sensibility is a prerequisite for performingfine discriminatory tasks while deep pressure is aform of protective sensation. Based on von Frey’spressure sensibility test for warmth, cold, pain andtouch, Semmes, Weinstein and others (1960)developed a testing instrument to assess somato-sensory changes in adults following brain damage.This testing system was then adopted by vonPrince for assessment of the nerve-injured hand(von Prince and Butler, 1967).

The full testing kit includes 20 colour-codednylon filaments, each mounted in a Lucite rod.The monofilaments are calibrated to exert spe-cific pressures. The lightest monofilament exertsa 4.5 mg force while the heaviest filament exertsa 447 g force. A smaller set of five monofila-ments represents the highest calculated force ofeach functional sensory level (i.e. normal, dimin-ished light touch, diminished protective sensationand loss of protective sensation) and can beused without sacrificing test sensitivity (Bell-Krotoski, 1993) (Fig. 1.11).

Figure 1.10. Sensory distribution in the hand showing the areas of median, ulnar and radial nerve innervation.

Figure 1.11. The smaller set of five monofilamentsrepresents the highest calculated force of eachfunctional sensory level and can be used withoutsacrificing test sensitivity.


TechniqueThis test requires the patient’s full concentrationand should therefore be carried out in a quietenvironment, free of distractions. Because nerveconduction velocity is slowed with low tem-peratures (de Jesus et al., 1973), the testing roomshould be warm, as should the patient’s handduring testing. The hand is stabilized (exerciseputty is ideal for this purpose) and vision isoccluded (Fig. 1.12).

The area of sensory dysfunction is mapped outand the test is begun with filament 2.83. Theexaminer can commence the test with a highernumbered filament where sensibility is very poor.Each filament is applied to the skin perpendicu-larly for 1–1.5 s until it bends. The filament is heldfor 1–1.5 s and then lifted in the same timeframe.Each filament is applied to the same spot on threeoccasions. An affirmative response is recorded ifone of the three applications elicits a response. Theresponse is then recorded on the grid pattern withthe appropriate colour and dated for later compar-ison (Fig. 1.13).

When monitoring progressive nerve compres-sion, all relevant areas of nerve distribution shouldbe assessed. For other conditions, e.g. followingnerve repair, testing can be confined to the volardigital pulps where receptor density is mostconcentrated (Moran, 1981).

2. Innervation density tests

Static two-point discrimination, moving two-pointdiscrimination and localization are innervationdensity tests (also referred to as functional tests)that require complex cortical integration. Two-point discrimination is considered to relate to thehand’s ability to perform fine tasks such aswinding a watch or threading a needle (Moberg,1958). Instruments used for this test include theBoley Gauge, the ‘Disk-Criminator’ or a paperclip. This test is only relevant in the tips ofthe fingers where discrimination is required(Fig. 1.14).

Figure 1.12. The hand can be effectively stabilizedwith putty during monofilament testing.

Figure 1.13. Grid pattern for recording results ofmonofilament testing of light touch-deep pressuresensibility.

Table 1.1. Semmes-Weinstein monofilament scale of interpretation

Filament Interpretation Force (g)

1.65–2.83* (Green) Normal light touch 0.0045–0.0683.22–3.61 (Blue) Diminished light touch 0.166–0.4083.84–4.31 (Purple) Diminished protective sensation 0.696–2.0524.56–6.65 (Red) Loss of protective sensation 3.63–447Greater than 6.65 (Red-lined) Untestable (no response) Greater than 447

*Miniset monofilaments are in bold.

Assessment 9

(a) Static two-point discriminationWith vision occluded, the test is commenced with apoint-to-point distance of 5 mm. The points areapplied longitudinally with minimal pressure thatshould not cause blanching. To record an accurateresponse, 7 out of 10 responses must be correct. Thedistance between the points is increased by 1, 2 or5 mm if the response is incorrect (Callahan, 1995).

(b) Moving two-point discriminationWhen assessing moving two-point discrimination,testing is carried out in a proximal to distal directionwith the instrument initially set at a distance of8 mm (Dellon, 1978). Following nerve repair, returnof moving two-point discrimination precedes statictwo-point discrimination by several months.

(c) Point localizationPoint localization is assessed using the lowestnumbered filament that the patient is able to

perceive during light touch testing. With visionoccluded, the filament is applied to the hand. Thepatient is then asked, with eyes open, to identifythe point of contact with the other hand. Thecorrect response is then recorded with a dot on agrid pattern such as that used for recording lighttouch. Where the response is incorrect, the grid ismarked with an arrow from the point of stimulationto the area where the touch has been referred (headof arrow). As sensibility improves, follow-uptesting should show fewer and shorter arrows(Callahan, 1983).

3. Tactile gnosis tests

These tests require active patient participation andinvolve everyday objects such as a key, coin, safetypin, paper clip, screw, marble, nuts and bolts. TheMoberg pickup test (Moberg, 1958) and Dellon’smodification of this test (1981) require the patient to

Figure 1.14. The ‘Disk-Criminator’ is used to testtwo-point discrimination in the tips of the fingers.

Figure 1.15. The ‘pick-up test’ is a test of tactilegnosis that requires some motor dexterity. The patientpicks up a number of objects as quickly as possibleand places them in a box. The procedure is timed andcomparison is made with the opposite hand.

Table 1.2. Two-point discrimination in the hand*

Pulp of the thumb 2.5–5 mmPulp of the index finger 3–5 mmPulps of the other digits 4–6 mmBase of the palmar aspect of the

digits5–6 mm

Thenar and hypothenar eminences 5–9 mmMidpalmar region 11 mmDorsal aspect of the digits 6–9 mmDorsal aspect of the hand 7–12 mm

*After Tubiana, 1984.

Table 1.3. Two-point discrimination norms*

Normal Less than 6 mmFair 6–10 mmPoor 11–15 mmProtective One point perceivedAnaesthetic No points perceived

*American Society for Surgery of the Hand Guidelines.


pick up objects as quickly as possible and placethem into a box while sighting the objects(Fig. 1.15). This procedure is timed and comparisonis made with the uninvolved hand. If the patientlacks the ability to manipulate the objects becauseof poor motor function, the test is discontinued.

Where motor dexterity is adequate to perform thetest, it is repeated, this time with vision occluded.Note is taken of the manner in which the patienthandles the objects, i.e. areas of the hand that are notused due to poor sensibility. Dellon standardized theoriginal test items by choosing objects of a similarmaterial (i.e. all metallic) to avoid providing cluesthat can be gained through variation in texture andtemperature.

4. Objective tests

These tests include the Ninhydrin sweat test andwrinkle test and require no patient participation asthey rely on a sympathetic response. The sweat testidentifies areas of disturbed sweat secretion and canbe carried out with commercially available Ninhy-drin developer and fixer. The wrinkle test involvesplacing the hand in warm water (40ºC) for a periodof 30 min (O’Rain, 1973).

These tests are considered useful in the assess-ment of children, patients who are unable to complywith formal testing or those suspected of malinger-ing. While these tests can be indicative of sensoryfunction, their results do not correlate directly withsensibility during nerve regeneration, while in thecase of nerve compression syndromes, there is nocorrelation (Phelps and Walker, 1977).

Tinel’s sign

Nerve regeneration can be monitored by Tinel’ssign which was described in 1915 by both Tinel andHoffman. The paraesthesia (i.e. pins and needles)experienced by the patient when the nerve ispercussed is caused by regeneration of the sensoryaxons which are very sensitive to pressure.

According to Tinel, the sign appears about 4 to 6weeks after injury, although this timeframe can varysignificantly according to the severity of the lesion.While the test has limited functional value (it can beelicited even where there are only few regeneratingfibres), it is useful in confirming axonal growth.

Technique

Using the tip of the finger, the examiner gentlypercusses along the course of the nerve in a distal to

proximal direction. Percussion is continued untilparaesthesia is elicited. This sensation, whilstunpleasant, is not painful and should be feltperipherally in the cutaneous distribution of thenerve rather than at the point of direct pressure.

The test is repeated every few weeks. A goodprognosis is suggested where distal progression ofthe sign is noted. Tinel’s sign should be interpretedin the light of other clinical findings.

Grip strength measurement

1. Power grip

Power grip strength can be reliably assessed withthe Jamar dynamometer (Bechtol, 1954) on thecondition that calibration of the instrument ismaintained. The dynamometer has five handlepositions, each of which influence the strength of

Figure 1.16. The Jamar dynamometer is a reliable toolfor assessing grip strength. The test is performed withthe shoulder adducted, the elbow flexed to 90 degrees,the forearm in neutral rotation and the wrist in 0–30degrees of extension and slight ulnar deviation.

Assessment 11

grip (Fig. 1.16). Readings diminish in the follow-ing ‘handle position’ order: third (strongest),second, fourth, fifth and first (Fess, 1982).

The testing position is as follows: shoulderadducted, elbow flexed to 90 degrees, forearm inneutral rotation, wrist between 0 to 30 degrees ofextension and in slight ulnar deviation. The‘second handle’ position was recommended as thetest position in 1978 by the ‘Clinical AssessmentCommittee of the American Society for Surgery ofthe Hand’. The test is performed three times with ashort rest period allowed between readings so thatthe result is not affected by fatigue. The average ofthe readings is then recorded.

A patient is suspected of fudging the results if:

1. The readings are quite erratic, i.e. the discrep-ancy is greater than 20 per cent (it may be muchhigher).

2. The normal bell curve of grip strength, that isnoted when testing in each of the five positions,is absent; the result will be a flat curve witheach of the readings being very similar (Auli-cino, 1995).

2. Pinch grip strength

Pinch grip strength is assessed with a pinch gaugewhich assesses (1) tip-to-tip pinch between thethumb and index finger (weakest pinch), (2)lateral pinch where the thumb is clasped againstthe radial side of the index finger (strongest pinchgrip) and (3) three-jaw chuck where the pulp ofthe thumb is pinched against the pulps of the

index and middle fingers. As for power grip, thetest is repeated three times and the averagereading is recorded (Fig. 1.17).

Manual muscle testing

Manual muscle testing (Kendall et al., 1971) isindicated in the following circumstances:

1. To determine precisely which muscles havebeen affected following a nerve lesion.

2. As a preoperative evaluation in determiningwhich muscles can be utilized for tendontransfer.

3. In helping to monitor motor progress duringnerve regeneration.

Grading of strength is as follows:

0. No evidence of contraction.1. Evidence of slight muscle contraction; no joint

movement.2. Muscle contraction producing movement with

gravity eliminated.3. Muscle contraction producing movement

against gravity.4. Muscle contraction producing movement

against gravity with some resistance.5. Muscle contraction producing movement

against full resistance.

Functional assessment

The patient is assessed for any problems relating toroutine activities of daily living (ADL). Whereindicated, aids can be provided on a temporarybasis to encourage early use of the hand. Thecommonest aid involves the enlargement of smallhandles, e.g. cutlery, toothbrush or razor, to enablegrasp.

Complex injuries or conditions such as rheuma-toid arthritis will require full functional assess-ments involving all aspects of the patient’s life, i.e.home, work and leisure. These assessments mayneed to be carried out at regular intervals as thepatient’s functional status alters.

Psychological assessment

The hand and psyche are inextricably linked (Grant,1980). The psychological responses following hand

Figure 1.17. A pinch gauge is used to assess the threepinch grip positions: (1) tip-to-tip pinch between thethumb and index finger; (2) lateral (or key) pinchbetween the thumb and radial aspect of the indexfinger; (3) three-jaw chuck pinch between the thumband index and middle fingers (as above).


trauma vary considerably and can be complex. Tosome patients, altered body image results inserious loss of self-esteem and emotional disturb-ance. Others are more affected by potential loss offunction and what this will mean in relation towork and recreational activities. An individual’sreaction to injury is not always in proportion to theextent of physical damage. Cultural factors mayplay an important role as does a patient’s pre-morbid personality or pre-existing psychologicalproblems.

Where injury to the hand has been serious, therepercussions for the patient can be enormous.Apart from the possible financial implications ofbeing unable to work, the dynamics of the patient’sfamily and social life are also radically altered. Themental/emotional state of the patient should bemonitored closely for persisting signs of anxietyand/or depression. While these reactions are nor-mal in the short term, their persistence should betaken seriously and appropriate psychiatric inter-vention should be arranged.

References

Aulicino, P. L. (1995). Clinical examination of the hand. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 53–75,Mosby.

Bechtol, C. D. (1954). Grip test: use of a dynamometer withadjustable handle spacing. J. Bone Joint Surg., 36A, 820.

Bell-Krotoski, J. (1993). ‘Pocket filaments’ and specificationsfor the Semmes-Weinstein monofilaments. J. Hand Ther.,3(1), 26–9.

Bell-Krotoski, J. (1995). Sensibility testing: current concepts. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 109–28,Mosby.

Bell-Krotoski, J. and Buford, W. Jr. (1988). The force/timerelationship of clinically used sensory testing instruments. J.Hand Ther., 1(2), 76.

Brand, P. W. (1993). Methods of clinical measurement of thehand. In Clinical Mechanics of the Hand, 2nd edn (P. W. Brandand A. Hollister, eds) pp. 223–53, Mosby Year Book.

Brand, P. W. (1998). The mind and spirit in hand therapy. J.Hand Ther., 1(4), 145–7.

Breger-Lee, D., Bell-Krotoski, J. and Brandsma, J. (1990).Torque range of motion in the hand clinic. J. Hand Ther., 3,7–13.

Brun, J. (1963). La Main et I’Esprit. Presses Universitaires deFrance.

Callahan, A. D. (1984) Sensibility testing: clinical methods. InRehabilitation of the Hand: Surgery and Therapy, 2nd edn(J. M. Hunter, L. H. Schneider, E. J. Mackin and A. D.Callahan, eds) pp. 407–31, Mosby.

Callahan, A. D. (1995). Sensibility assessment: prerequisitesand techniques for nerve lesions in continuity and nervelacerations. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 129–52, Mosby.

Cambridge-Keeling, C. A. (1995). Range-of-motion measure-ment of the hand. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 93–107, Mosby.

Clark, T. (1999). Digital nerve repair: the relationship betweensensibility and dexterity. Thesis (MSc. – Coursework), CurtinUniversity of Technology.

de Jesus, P., Hausmanow-Petruse-Wics, I. and Barchi, R.(1973). The effect of cold on nerve conduction of humanslow and fast nerve fibers. Neurology, 23, 1182.

Dellon, A. L. (1978). The moving two-point discrimination test:clinical evaluation of the quickly-adapting fiber/receptorsystem J. Hand Surg., 3, 474.

Dellon, A. L. (1980). Clinical use of vibratory stimuli toevaluate peripheral nerve injury and compression neurop-athy. Plast. Reconstr. Surg., 65, 466.

Dellon, A. L. (1981). Evaluation of Sensibility andRe-education of Sensation in the Hand. Williams &Wilkins.

Echternach, J. L. (1993). Clinical evaluation of pain. Phys.Ther. Prac., 2(3), 14–26.

Fess, E. E. (1982). The effects of Jamar dynamometer handleposition and test protocol on normal grip strength.Procedures of the American Society of Hand Therapists. J.Hand Surg., 7, 308.

Fess, E. E. (1995). Documentation: Essential elements of anupper extremity assessment battery. In Rehabilitation of theHand: Surgery and Therapy (J. M. Hunter, E. J. Mackin andA. D. Callahan, eds) pp. 185–214, Mosby.

Grant, G. H. (1980). The hand and the psyche. J. Hand Surg., 5,417–9.

Hamilton, G. F. and Lachenbruch, P. A. (1969). The reliabilityof goniometry in assessing finger joint angle. Phys. Ther., 49,465.

Hellebrandt, F. A., Duvall, E. N. and Moore, M. L. (1949). Themeasurement of joint motion. Part III. Reliability of goniom-etry. Phys. Ther. Rev., 29, 302.

Kendall, H, Kendall, F. and Wadsworth, G. (1971). MuscleTesting and Function. Williams & Wilkins.

Moberg, E. (1958). Objective methods for determining thefunctional value of sensitivity in the hand. J. Bone JointSurg., 40B, 454–76.

Moran, C. (1981). Comparison of sensory testing methodsusing carpal tunnel syndrome patients. Unpublished MastersThesis. Medical College of Virginia, Virginia Common-wealth University.

O’Rain, S. (1973). New and simple test for nerve function in thehand. Br. Med. J., 3, 615.

Perry, J. F. and Bevin, A. G. (1974). Evaluation procedures forpatients with hand injuries. Phys. Ther., 54, 593.

Phelps, P. and Walker, E. (1977). Comparison of the fingerwrinkling test results to establish sensory tests in peripheralnerve injury. Am. J. Occ. Ther., 31, 565.

Assessment 13

Semmes, J., Weinstein, S., Ghent, L. and Teaber, H. L. (1960).Somatosensory Changes after Penetrating Brain Wounds inMan. Harvard University Press.

Szabo, R. M. (1999). Entrapment and compression neu-ropathies. In Green’s Operative Hand Surgery (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) pp. 1404–47,Churchill Livingstone.

Tinel, J. (1915). Le signe du ‘fourmillement’ dans les lesionsdes nerfs peripheriques. Press. Med., 47, 388–9.

Tubiana, R. (1984). Architecture and functions of the hand. InExamination of the Hand and Upper Limb (R. Tubiana, ed.)pp. 1–97, W. B. Saunders.

von Prince, K. and Butler, B. (1967). Measuring sensoryfunction of the hand in peripheral nerve injuries. Am. J. Occ.Ther., 21, 385.

Waylett-Rendall, J. and Seibly, D. (1991). A study of theaccuracy of a commercially available volumeter. J. HandTher., 4(1), 10–3.

2

Treatment principles and tools

Introduction

Care of the hand following injury or surgery aimsto restore function without compromising thehealing process. To formulate an aftercare pro-gramme, the therapist needs to appreciate thevarious phases of wound healing and the implica-tions for treatment that are inherent in each of thesephases.

Phases of wound healing

No matter what the wound type, the healingprocess is achieved by a series of complex eventsthat are interlinked and interdependent. Woundhealing can be influenced by many factors: infec-tion, disease (e.g. diabetes), the effect of drugs(e.g. steroids), pain, cold exposure or emotionalstress (Hunt and Hussain, 1992). Where healing isuncomplicated, the timetable of these events isfairly predictable. The three phases of healingare:

1. The inflammatory or exudative phase(the first 3 to 4 days)

The inflammatory phase is characterized byoedema, redness, heat and pain. The oedemaresulting from injury is different to that associatedwith medical conditions such as chronic heartfailure, kidney disease or postmastectomy lymph-oedema (Hardy, 1986). The oedema associated withthese conditions is referred to as ‘transudate’ and is

caused by increased hydrostatic pressure. Thisoedema is low in protein (Witte and Witte, 1971)and causes minimal fibroplasia. The potential foradhesion formation is therefore negligible.

Injury to the hand, however, causes disruption ofcapillary integrity. The exudate that leaks fromdamaged vessels is a protein fluid that is rich infibroblasts. Propensity for adhesion is thereforehigh. Where the inflammatory phase of healing isprolonged through careless wound handling or tooearly or vigorous movement, increased fibroplasiaand scarring can ensue.

At the time of injury, blood flow is arrested by ashort period of vasoconstriction. This is followedby vasodilation when histamine is released into theinjured area and there is an increase in blood flowand the leaking of plasma into the wound region.This inflammatory exudate causes pain, partlythrough tissue distension and partly from irritationof the nerve endings by substances containedwithin the exudate, e.g. prostaglandins (Peacock,1984).

Blood flow then ceases as a result of plateletaggregation. This clotting process precipitatesfibrin formation and the creation of a network offibres that joins the sides of the wound together.Devitalized tissue and debris is then cleared fromthe wound by leuocytes and macrophages in aprocess known as phagocytosis (Smith, 1995).This is followed by the growth of new capillarybuds that bridge the wound.

The surface of the wound is usually covered bythe third day as epithelial cells migrate into thewound from the basal layers of the epidermis. This


migration follows converging paths from every partof the wound edge. When the migrating cells meeteach other, they stop moving due to a recognitionprocess called ‘contact inhibition’. They thencontinue to divide, thereby restoring the thicknessof the epidermis. The mitotic rate of epithelial cellsat the wound surface is about 40 times higher thanthat of uninjured tissue (Hugo, 1977). Wound coverprevents fluid loss and provides a barrier againstinfection (Peacock, 1984).

Aims of treatment

(a) To protect the vulnerability of thewound

Wounds should be covered with dressings thatprevent fluids escaping from the wound bed.Maintenance of wound humidity enhances cellularactivity (Alvarez, 1989) and advances the processof angiogenesis. The newer ‘microenvironmental’dressings, e.g. Tegaderm, Lyofoam, Intrasite andDuoderm, are used for specific types of wound andmaintain an environment that promotes healing.The wound is further protected with supportivebandaging or splinting. Dressings that tend todehydrate, e.g. the paraffin gauzes, are difficult andpainful to remove (particularly in the case offingertip injuries) and can disrupt or retard thehealing process.

(b) To reduce pain

Dressings that maintain wound humidity decreasepain and reduce mechanical trauma when thedressing is removed. Supportive splinting andelevation will help reduce pain by relieving tissuedistension. Short-term use of analgesics may beindicated.

(c) To promote resolution of oedema

To minimize the potential for fibrosis and scarring,oedema reduction is a priority after injury orsurgery. This is achieved with gentle compressivedressings and elevation above heart level. Whereappropriate, gentle active finger movement iscommenced.

2. Fibroplastic or regenerative phase

This phase of healing begins after about the 5thday and can last from 2 to 6 weeks depending onthe extent of the wound. The key cell during this

phase is the fibroblast. This is a connective tissuecell that synthesizes and secretes collagen andother intercellular substances required to producenew tissue. The formation of granulation tissue isdependent on a network of blood vessels beingformed in the injured tissue bed (i.e. angiogenesis).A capillary network has usually formed by the endof the second week. This network provides thefibroblasts with oxygen and nutrients so that theyare able to synthesize collagen properly.

A subpopulation of fibroblasts become myo-fibroblasts. These specialized fibroblasts have thecontractile properties of smooth muscle cells andexert a central pull on the wound edges, therebydecreasing the size of the wound. This process ofwound contraction has usually been achieved bythe third week. The rapid rise in tensile strengthduring this period parallels the increase in collagencontent although the wound still has less than15 per cent of its ultimate strength at this time(Madden, 1976; Madden and Peacock, 1971).

Management

The wound is now able to withstand the stress ofgentle active movement. Protective splinting willneed to be maintained in certain circumstances,e.g. following tendon repair. Pressure to scar ismaintained during this period; however, as thewound is still thin and fragile, overzealous exerciseand excessive pressure should be avoided. Oedemamanagement may still be necessary and remains apriority until it is eliminated. Where significantoedema persists, the tissues of the hand are in astate of reduced nutrition and inelasticity whereadhesion formation can readily ensue (Hunter andMackin, 1995).

3. Remodelling or maturation phase

The remodelling phase lasts a minimum of 6months but can continue for up to 2 years. At thebeginning of this phase, the scar may be raised,red, thick and unyielding. With time, the scar willsoften, becoming paler, flatter and more pliable.This phase sees a decrease in fibroplastic activityand a shutdown in mitotic activity. The woundgradually becomes stronger as the amount ofcollagen decreases although the tensile strength ofscar tissue is never more than 80 per cent of thatof uninjured skin.

Scar remodelling is characterized by the rapid,ongoing production of new collagen and theremoval of old collagen. The initial gel-like

Treatment principles and tools 17

collagen with its randomly arranged fibrils and lowtensile strength is gradually replaced with strongerand more highly organized collagen.

Management

It is during this stage of high collagen turnover (2to 4 months postinjury) that clinical treatmentmethods can exert their greatest influence andhence optimize functional outcome. The process ofscar remodelling is favourably influenced by theapplication of low-load forces that are applied atthe appropriate time (Arem and Madden, 1976).This is achieved through splinting and pressuretherapy.

Tools of treatment

Hand injuries or conditions invariably present withone or all of the following:

1. Pain.2. Swelling.3. Scar.4. Stiffness.

The therapist has a variety of treatment tools at hisor her disposal. Choice of treatment modalities willbe influenced by the professional and clinicalbackground of the therapist (i.e. occupational orphysiotherapist), possible budget restraints and therequests of the referring surgeon.

The therapist

At the patient’s initial session, the most importanttreatment tool is the therapist. It is at this time thatthe patient’s trust and confidence will need to beengendered for therapy to proceed. This means thatthe patient must be handled with great care, bothphysically and psychologically. Assessment andtreatment should be as pain-free as possible andinstructions to the patient should be clear and fewin number. Ideally, they should be written downand accompanied by easily understood line draw-ings for home reference.

There are occasions when family involvementwill be required. These situations include: thecomplex hand injury, children, the frail elderly,where there is a language difficulty or wherepatients feel unable to cope with the aftercareprogramme. The therapist also plays an importantrole in providing emotional support and as a

motivator. This is especially important followingmajor trauma where a protracted rehabilitationprocess is anticipated.

Clinical aspects of treatment

The therapy programme will need to address atleast one, if not all, of the following:

1. Wound care.2. Pain management.3. Oedema control.4. Exercise.5. Scar management.6. Splinting.7. Desensitization.8. Sensibility assessment/retraining.9. Nerve gliding exercises.

10. Functional activity.11. Psychological support.

Specific treatment modalities

The treatment modalities described below arethose that the author believes are indispensable tohand therapy practice. These are also modalitiesthat the patient is able to use away from the formaltherapy environment. The home programme is avital part of the rehabilitation process. Self-reliance is an essential component of psychologicaland emotional well-being and is encouraged assoon as the patient is ready. Patient education istherefore an important element in management.

Because many of these modalities can fre-quently address several clinical problems simulta-neously, this section describes each modality inturn rather than management of individual clinicalproblems, i.e. pain, swelling, stiffness or scar.While this list is by no means exhaustive, it willaddress most of the clinical problems that thetherapist is likely to encounter.

1. Exercise

Movement, both passive and active, is importantin:

1. Maintaining joint mobility.2. Maintaining the gliding function of tendons and

nerves.3. Helping eliminate oedema through compression

and relaxation of the hand’s tissues.


Active exercise

Active movement, where not contraindicated (e.g.following tendon repair), is begun as soon aspossible after injury or surgery. In the early phaseof therapy, exercise sessions are brief and frequentbut should not exacerbate pain, inflammation orswelling. Movements should, however, be carriedout in a systematic fashion that does not merelyinvolve wriggling the fingers. Patients are given aspecific number of repetitions to perform, e.g. 5 to10 movements every 1 or 2 hours.

Where possible, movements should be per-formed in a stabilized manner so that differentialtendon glide can occur. This entails stabilizing thejoint or joints proximal to the joint being moved(Fig. 2.1). Individual stabilized movements gen-erally result in a greater arc of motion than docomposite joint movements. This is especially truewhere dorsal hand skin is ‘taken up’ by oedemawith the effect of limiting global flexion.

Passive exercise

Passive exercises should be performed with greatcare so that again, pain, inflammation and oedema

are not exacerbated. This is particularly importantin the acute phase of management. For this reason,passive exercises are best performed by the patientwho will generally perform them to a pain-freelimit. Where appropriate, passive exercise shouldprecede active exercise so that the muscle-tendonunit does not have to overcome the resistance of astiff joint. This is particularly important in tendonrehabilitation (Fig. 2.2).

2. Coban wrap

Coban wrap is a thin, self-adherent elastic wrapthat comes in various widths, the narrowest ofwhich is 25 mm. Its sheerness makes it particularlysuitable for use with fingers as it does not impedeinterphalangeal joint motion. Coban wrap shouldbe replaced if it becomes wet. It is used:

(a) To control oedema

Acute digital oedema is effectively managed withthe narrowest Coban wrap. A single layer isapplied in a distal to proximal direction withnegligible tension, so that the Coban is lain, ratherthan stretched onto the finger (Fig. 2.3). Patientinstruction in its application is most important sothat circulation is not compromised. Signs that thewrap has been applied too tightly include: (i)discoloration of the fingertip, (ii) throbbing and(iii) numbness or paraesthesia. These signs willusually manifest themselves within minutes ofapplication and indicate that the wrap needs to beremoved and reapplied.

Figure 2.1. Unless contraindicated, active exercise iscommenced as soon as possible after injury or surgery.Stabilized joint movement promotes differential tendonglide and generally results in a greater arc of motion,particularly when oedema is present.

Figure 2.2. Passive movements need to be performedwith great care to avoid exacerbating or causing painand inflammation. For this reason, it is best if patientsare taught to carry out their own exercises.


Coban wrap is ideal for holding dressings inplace as its minimal bulk allows greater ease ofinterphalangeal joint movement. Wider sizes ofwrap can be applied to the dorsum of the hand;however, more economical alternatives include theuse of an elastic crepe bandage or a single ordouble layer of appropriately sized tubularstockinette.

(b) To help prevent a PIP joint flexiondeformity

The anatomy of the PIP joint favours flexion. Thenormal resting position of this joint is between 30to 40 degrees (Bowers, 1987) and because oedemais more comfortably accommodated in this flexedposition, a flexion deformity can quickly ensue.The gentle elastic tension of Coban wrap not onlyhelps eliminate oedema but also exerts a mildextension force in the acute phase of treatment(e.g. after phalangeal fracture or Zone II flexortendon repair).

(c) To help manage scar

The intimate contact that Coban wrap has with theskin makes it ideal for early pressure therapy overdigital scar. The skin tolerates this wrap very welland it is relatively easy to remove and replace.

(d) To relieve pain

Patients frequently report pain relief when someform of gentle elastic support is applied to the areain question, e.g. an elastic wrist brace to support a

painful wrist (Fig. 2.4). The PIP joint is a commonlocation of pain in the hand. Coban wrap canfacilitate increased interphalangeal joint range ofmovement through its pain-relieving effect.

3. Splinting

Hand splinting is an integral part of therapy duringeach phase of healing. Its initial role of protectionand support is gradually supplanted by its correc-tive role in overcoming soft tissue and jointcontracture, both of which can be the consequenceof significant injury.

Types of splint

Splints can be categorized in a number of ways, i.e.static or dynamic, supportive or corrective, rigid orsoft, volar or dorsal and forearm-, hand- or finger-based. A static splint has no moving components,unlike a dynamic splint which applies forcethrough rubber bands or coils. Static splints aregenerally used to provide support and protection;however, they can behave dynamically when thesplint is applied at the maximum range of jointmovement or maximum soft tissue stretch. This isreferred to as serial casting or splinting.

Splints can be used to optimize function bypositioning the wrist and/or fingers when musclepower is absent (e.g. the radial nerve palsy splintthat facilitates the reciprocal tenodesis effect)(Fig. 2.5) or to prevent joint and soft tissuecontracture by controlling deformity and restoringbalance in nerve lesions, e.g. the static ‘spaghetti’splint for correction of ulnar ‘claw’ deformity

Figure 2.3. Acute digital oedema is most effectivelymanaged with the narrowest Coban wrap (i.e.25-mm-width). A single layer is applied in a distal toproximal direction under negligible tension.

Figure 2.4. Gentle elastic support often provides painrelief.


(see Figure 5.14). The Capener splint is anexample of a finger-based dynamic splint. Thissplint has a corrective function in overcomingPIP flexion deformities in the range of 15 to 35degrees (Fig. 2.6). It is fashioned from pianowire, thermoplastic material and moleskin (seeColditz, 1995).

Splinting for tissue remodelling

Where exercise and soft tissue techniques proveinsufficient in restoring joint and soft tissue

mobility, corrective splinting is mandatory inachieving optimum functional results. Splinting is‘the only available therapeutic modality thatapplies controlled gentle forces to soft tissuesfor sufficient lengths of time to induce tissueremodelling without causing detrimental micro-scopic disruption of cellular structures’ (Fess andMcCollum, 1998).

The remodelling process cannot be achievedunless this gentle force is maintained over a periodof weeks (and sometimes months). The tissue mustbe held under tension that is higher than its restingtension and must be applied continuously ifpermanent elongation of skin and other soft tissuesis to occur (Bell-Krotoski and Figarola, 1995). Also,the viscous property of connective tissue must besubjected to a load of adequate intensity (Cyr andRoss, 1998). Forces ranging from 100 to 300 g arerecommended for correcting contractures of thesmall joints of the hand (Brand, 1995).

It is preferable to err on the side of caution whensplinting is begun so that tissue response can bemonitored for any sign of swelling or inflamma-tion. When the desired result has been achieved,intermittent splinting should be maintainedthroughout the remodelling phase until the tend-ency for relapse has been overcome. The time-frame for this will vary from patient to patient. Aminimum of 6 months is recommended; however,patients should be encouraged to persevere for 12to 18 months where the tendency for recidivism ishigh.

Principles of splinting

1. Prior to splint application, the patient will needto be educated in relation to the splint’spurpose, application and wearing regimen(Fess, 1995). To maximize patient compliance,the splint should be simple in design, be easy todon and doff, be free of pressure areas and be ascosmetically pleasing as possible.

2. The splint should provide the minimum possi-ble pressure so that the tissues of the hand cantolerate prolonged wear where necessary. Thisis best achieved by covering a larger area.Likewise, straps should be sufficiently wide andbe angled to the contour of the forearm, hand ordigit so that shear forces are avoided (Wilton,1997). Slings used in dynamic splints need topull at precisely 90 degrees if shear forces to thedigit are to be avoided (Fig. 2.7).

3. The static portion of a dynamic splint shouldcover a sufficient area to ensure stability so that

Figure 2.5. This forearm-based radial palsy splintrestores the reciprocal tendosesis action of wristextension-finger flexion and wrist flexion-fingerextension.

Figure 2.6. The dynamic hand-based Capener splint ismanufactured from piano wire, thermoplastic materialand adhesive moleskin. This splint is effective forovercoming PIP joint flexion deformities of 35 degreesor less.


migration or rotation does not occur whenforces are applied.

4. During flexion, the fingers converge toward thescaphoid bone. When applying a flexion forceto the digit, the line of pull should follow thisnatural orientation (Fig. 2.8).

5. The joint proximal to the joint being mobilizedneeds to be well stabilized, e.g. the MCP joint isstabilized when an outrigger is applied to correcta PIP joint flexion deformity (Fig. 2.9).

6. Tolerance to splinting will need to be carefullyassessed during the first few days. Skin ischecked for signs of pressure areas or excessivesweating which may lead to skin maceration.Corrective splints are removed regularlythroughout the day so that active movement andfunction can be maintained.

Soft splinting

Soft splinting refers to the use of soft materialssuch as neoprene (Clark, 1997), lycra, bandages(for flexion bandaging) or taping (e.g. Microfoam).These materials can address the following clinicalproblems:

1. Provide support and warmth to a painful joint.2. Help to eliminate oedema.3. Flatten scar that is raised or hypertrophic.4. Exert a gentle corrective force to stiff or

contracted joints (Figs 2.10 and 2.11).5. Protect areas of hypersensitivity due to scar or a

neuroma.

Figure 2.7. (a) When applying dynamic traction, theline of pull should be at a right angle to the axis ofthe skeletal segment being moved. (b) Where the lineof pull is not at 90 degrees, a shear stress to the digitor hand segment will occur.

Figure 2.8. During flexion, the fingers convergetowards the scaphoid bone. When applying a flexionforce to the digit, this natural orientation will need tobe accommodated.

Figure 2.9. The joint proximal to the joint beingmobilized will need to be well stabilized so that thecorrective force that is applied remains constant. In thecase of this dynamic outrigger to the PIP joint, theMCP joint has been stabilized in extension.


The extension force that a lycra glove cantransmit through the interphalangeal joints isreadily observed when a gloved and unglovedhand are compared. While lycra gloves areusually fitted to overcome hand oedema, in thepainful hand they can be effectively used as afirst-stage ‘extension splint’ prior to the fitting ofa ‘hard’ splint (Fig. 2.12).

Advantages of neoprene and lycra1. A high comfort factor ensures excellent patient

compliance. For example, a neoprene finger-stall to correct a PIP joint flexion deformity canbe worn around the clock without interferingwith function because the fingertip can remainfree and the stall allows virtually unrestrictedflexion range (Fig. 2.13).

2. These fabrics are relatively economical.3. The risk of pressure areas is negligible (partic-

ularly with neoprene).4. Fingerstalls and wrist/thumb wraps can be

manufactured in minutes. An older style sewingmachine can be purchased at low cost and is ableto handle thicker fabrics with ease. The sewingmachine has become almost as integral tosplinting as have the heating pan and heat gun.

5. Soft splints can be used in combination withthermoplastic splinting.

Because neoprene does not fray when cut, it is avery practical material to work with. To avoidpressure on the skin, seams are worn to the outside.

Figure 2.10. Microfoam (3M) tape makes an excellentinterphalangeal joint flexion strap. It is soft, flexibleand lightly adhesive.

Figure 2.11. A crepe bandage (minimum 10 cmwidth) makes an excellent flexion wrap. Itseffectiveness is augmented when the hand isimmersed in warm water.

Figure 2.12. The ‘extension force’ of a lycra glovebecomes apparent when a gloved and ungloved handare compared.


While not entirely cosmetic, the effectiveness ofthese stalls and garments far outweighs this slightdisadvantage and is of little concern to mostpatients.

4. Silicone gel for scar management

Clinical studies have demonstrated the benefits ofsilicone gel sheeting in the prevention and treat-ment of hypertrophic scar (Katz, 1992). Cica-caregel is ideal for use on the hand because, althoughthis product is quite expensive, hand scars aregenerally quite small. This, combined with the factthat the gel can be reused for some weeks, makesit a cost effective treatment (Fig. 2.14).

The gel is worn at least 12 h each day for 6 to 8weeks in ‘non-aggressive’ scar and for up to 6months where scar is hypertrophic or keloid. It isthought that hydration of the scar may reducecollagen deposition by decreasing capillary activ-ity (Davey et al., 1991). Although the gel isadhesive, it should be held in place with tubularstockinette or paper tape (e.g. Micropore) so that itis not lost.

The gel is applied to skin that is healed, cleanand dry. All traces of massage cream or oil shouldbe removed prior to its application. Initial wearingtimes should be restricted to about 4 h so skinreaction to the gel can be assessed. Reaction is rareand will usually manifest as small red dots thatresemble a heat rash. The skin should be ‘aired’regularly to avoid maceration and the gel washedin a mild soapy solution at least once a day. Careshould be taken to rinse and dry the gel thoroughlybefore reapplication.

Figure 2.13. A neoprene fingerstall can make aneffective ‘extension’ splint when continuously worn. Italso helps eliminate digital oedema and provideseffective compression to scar.

Figure 2.14. Silicone gel is the most effectivetreatment for raised or hypertrophic scarring. It can beused on its own or worn beneath a compression glove,tubular stockinette or Coban.

Figure 2.15. Gentle scar massage and percussionexercises initiate the desensitization process. Thepatient is encouraged to ‘handle’ the scar regularlythroughout the day.


Apart from impacting on the scar’s topographyand rendering it flat, pale and supple, the geldecreases pain and acts as a ‘shock absorber’ tosudden contact. The author believes that use ofsilicone gel is superior to scar massage as atreatment to soften scar. Scar massage is beneficialas a desensitizing exercise and to moisturize theskin.

5. Opsite Flexifix

Opsite dressings have been known to relieve painwhen applied to wounds (Neal et al., 1981). Painrelief from contact of Opsite on unbroken skin indiabetic patients with painful neuropathy wasanecdotal until a study was undertaken by theDiabetic Department of King’s College Hospital inLondon (Foster et al., 1994). This study concludedthat Opsite reduced pain in a significant number ofpatients with painful diabetic neuropathy.

While the pain of neuropathy results from adisease process rather than direct nerve or softtissue injury, the types of symptoms commonlydescribed by hand patients are common to both

pathologies, i.e. shooting (lancinating), burning(causalgia), pins and needles (paraesthesia) or theextreme contact discomfort known as allodynia(Boscheinen-Morrin and Shannon, 2000).

Rationale

It is thought that Opsite may act in a similar way totranscutaneous electrical nerve stimulation (TENS)in that continuous contact of the film with the skinmay stimulate the large, light touch A-beta afferentfibres and, in doing so, inhibit the nociceptiveactivity of the small A-delta and C-fibres, i.e.Melzack and Wall’s ‘gate-control theory’ (Melzack,1973).

The product

Opsite Flexifix (i.e. ‘Opsite on a roll’) is a non-sterile version of the original Opsite dressing.Opsite is an adherent polyurethane film which iswaterproof and permeable to oxygen and watervapour. It is used in conjunction with ‘Skin-Prep’wipes which enhance adhesion of the film to the

Figure 2.16. Silicone-lined fingerstalls help softenscar, shape the stump and provide protection.

Figure 2.17. Opsite Flexifix is used to provide reliefof pain and hypersensitivity related to scar, neuroma,fingertip injury, stumps, causalgia related to CRPS andparaesthesia associated with nerve regeneration. In thiscase it is used to lessen scar hypersensitivity followingopen carpal tunnel decompression.


skin. Opsite Flexifix is available in two widths.The narrower version, i.e. 5 cm roll, is moresuitable for use on the hand.

Indications for use

1. Fingertip injuries.2. Amputation stumps.3. Causalgic pain associated with chronic regional

pain syndrome.4. Neuroma.5. Scar hypersensitivity.6. Paraesthesia associated with nerve regeneration.

The film is applied as soon as skin has healed. It iswell tolerated by the skin and often remains inplace for several days before needing to bereplaced. Its sheerness and elasticity mean thatmovement is not affected when the film is appliedacross joints. Its use after fingertip injuries is idealas sensibility is not impeded. The finest monofila-ment can be detected through the film. Opsite canbe used beneath silicone gel. Even when used onits own, Opsite has a positive influence on scar asit exerts a gentle compressive force.

6. Transcutaneous electrical nervestimulation

The advantage of TENS over other forms of painrelieving treatment is that pain relief is ongoingand not therapy dependent. Sensory level stimula-tion, i.e. conventional TENS (high pulse rate andnarrow pulse width) delivers a therapeutic current

to the cutaneous sensory afferent fibres. Theamplitude is monitored to ensure that no musclecontraction is evident (Fig. 2.18).

Electrodes should only be used on skin that isintact and has sensation. TENS is not used bypatients with pacemakers. Electrode placement isoften a matter of experimentation. Electrodesshould not be placed immediately over the painfularea. The electrode is placed over the peripheralnerve, proximal to the site of pain or injury or oneither side of the area (i.e. proximal and distal).The current is increased gradually until the patientperceives a comfortable level of stimulation whichis continued for 30–60 min at a time. A carry-overeffect is often experienced for several hours. Theunit is reapplied when this effect begins todiminish.

Some specific indications for use

1. Causalgic (burning) pain associated withchronic regional pain syndrome (Types 1 and 2).

2. Neuritis following surgery or injury, e.g. irrita-tion of the superficial branch of the radial nerveafter surgery for Colles’ fracture or decompres-sion of the first dorsal compartment for deQuervain’s syndrome.

Figure 2.18. Transcutaneous electrical nervestimulation can be particularly effective in managingneuritis that can follow surgical procedures, causalgiaassociated with CRPS or neuroma pain.

Figure 2.19. The most common functional aidinvolves the enlargement of handles. This is achievedeasily and economically with different sizes ofinsulation tubing.


3. Hypersensitivity following carpal tunneldecompression.

4. Neuroma.

It is important that patients do not over-exercise oroveruse the hand during periods of pain relief.Exercises and activity are carried out slowly andgently and response is monitored prior to upgrad-ing the therapy programme.

7. Aids to daily living

Until a functional range of motion has beenrestored, it can be helpful to modify the smallhandles of everyday utensils. This is achievedsimply and economically with insulation tubingusually referred to as ‘Handitube’ (Fig. 2.19). Thisproduct is available from most major hardwarestores. For patients with ongoing functional limita-tion and/or weakness, many excellent labour-saving devices are now available from departmentstores.

References

Alvarez, O. (1989). Moist environment in healing: Matchingdressing to wounds. Wounds, 2, 59.

Arem, A. and Madden, J. (1976). Effect of stress on healingwounds: Intermittent noncyclical tension. J. Surg. Res., 20, 93.

Bell-Krotoski, J. A. and Figarola, J. H. (1995). Biomechanics ofsoft tissue growth and remodeling with plaster casting. J.Hand Ther., 8(2), 131–7.

Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix:An effective adjunct in the management of pain andhypersensitivity in the hand. Aust. J. Occ. Ther., (submittedSeptember, 2000).

Bowers, W. H. (1987). The anatomy of the interphalangealjoints. In The Interphalangeal Joints (W. H. Bowers, ed.) pp.13–20, J. B. Lippincott.

Brand, P. W. (1995). The forces of dynamic splinting: Tenquestions before applying a dynamic splint to the hand. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1581–7,Mosby.

Brand, P. W. (1998). Mechanical factors in joint stiffness andtissue growth. J. Hand Ther., 8(2), 91–6.

Clark, E. N. (1997). A preliminary investigation of the neoprenetube finger extension splint. J. Hand Ther., 10(3), 213–21.

Colditz, J. C. (1995). Spring-wire extension splinting for theproximal interphalangeal joint. In Rehabilitation of the

Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin andA. D. Callahan, eds) pp. 1617–29, Mosby.

Cyr, L. M. and Ross, R. G. (1998). How controlled stress affectshealing tissues. J. Hand Ther., 11(2), 125–30.

Davey, R. B., Wallis, K. A. and Bowering, K. (1991). Adhesivecontact media: an update on graft fixation and burn scarmanagement. Burns, 17, 313–9.

Fess, E. E. (1995). Principles and methods of splinting formobilization of joints. In Rehabilitation of the Hand: Surgeryand Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan,eds) pp. 1589–1598, Mosby.

Fess, E. E. and McCollum, M. (1998). The influence ofsplinting on healing tissues. J. Hand Ther., 11(2), 157–61.

Foster, A. V. M., Eaton, C., McConville, D. O. and Edmonds,M. E. (1994). Application of Opsite Film: A new andeffective treatment of painful diabetic neuropathy. Diab.Med., 11, 768–772.

Hardy, M. A. (1986). Preserving function in the inflamed andacutely injured hand. In Hand Rehabilitation (C. A. Moran,ed.) pp. 1–15, Churchill Livingstone.

Hugo, N. (1977) General aspects and healing of skin. InBiological Aspects of Reconstructive Surgery (D. Kernahanand L. Vistness, eds) p. 339, Little, Brown and Co.

Hunt, T. K. and Hussain, Z. (1992). Wound microenvironment.In Wound Healing: Biochemical and Clinical Aspects (I. K.Cohen, R. F. Diegelmann and W. J. Lindblad, eds) pp. 274–81, W. B. Saunders.

Hunter, J. M. and Mackin, E. J. (1995). Edema: Techniques ofevaluation and management. In Rehabilitation of the Hand:Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D.Callahan, eds) pp. 77–85, Mosby.

Katz, B. E. (1992). Silastic gel sheeting is found to be effectivein scar therapy. Cosm. Derm., 1, 3.

Madden, J. W. (1976). Wound healing: The biological basis ofhand surgery. Clin. Plast. Surg., 3(1), 3.

Madden, J. W. and Peacock, E. E. (1971). Studies on thebiology of collagen during wound healing. III: Dynamicmetabolism of scar collagen and remodeling of dermalwounds. Ann. Surg., 174, 511.

Melzack, R. (1973). The Puzzle of Pain. Penguin Education.Neal, D. E., Whalley, P. C., Flowers, M. W. and Wilson, D. H.

(1981). The effects of an adherent polyurethane film andconventional absorbent dressing in patients with small partialthickness burns. Br. J. Clin. Pract., 35, 7–8.

Peacock, E. E. (1984). Wound Repair. W. B. Saunders.Smith, K. L. (1995). Wound care for the hand patient. In

Rehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 237–50,Mosby.

Wilton, J. C. (1997). Biomechanical principles of design,fabrication and application. In Hand Splinting: Principles ofDesign and Application. pp. 22–42, W. B. Saunders.

Witte, C. and Witte, M. (1971). Significance of protein inedema fluid. Lymphology. 4, 29.

3

Flexor tendons

Function and anatomy

The function of tendons is to attach muscle to boneand transmit muscle action across joints. Tendonsare dense connective tissues composed largely ofcollagen. Individual bundles of collagen are cov-ered by endotenon. The surface of the tendon iscovered by a fine fibrous outer layer called theepitenon. A thin visceral layer, the paratenon,covers the flexor tendon fascicles in the hand(Strickland, 1999).

The orderly parallel arrangement of the collagenfibres equips tendons to cope with the highunidirectional tensile loads to which they aresubjected during activity. While tendons are strongenough to sustain these tensile forces, they are alsosufficiently flexible to curve around bone and jointsurfaces and to deflect beneath the retinacularpulley system during finger flexion.

Like bone, tendon remodels in response to themechanical demands placed upon it. Collagenorganization is significantly disturbed in theabsence of tension. Tendon becomes stronger whensubjected to increased stress and weaker whenstress is reduced (Hitchcock et al., 1987).

The flexor sheath and pulley system

The flexor tendon sheath is composed of synovialand retinacular components. The synovial compo-nent is a tube which is sealed at both ends where itsvisceral and parietal layers merge (Doyle, 1989).In the index, middle and ring fingers, the synovialportion of the sheath begins at the metacarpal neckand extends as far as the DIP joint. The synovial

sheath of the little finger and thumb extendsproximally to the wrist (Fig. 3.1).

The synovial portion of the sheath is overlainwith a series of pulleys of varying configurations,i.e. transverse, annular and cruciform. Thesepulleys represent the retinacular portion of theflexor sheath. The palmar aponeurosis (PA) pulleyis formed from the transverse fibres of the palmaraponeurosis and was described by Manske and

Figure 3.1. The synovial component of the flexortendon sheath. The synovial sheaths of the thumb andlittle finger extend proximally to the wrist. The sheathof the thumb is the radial bursa; the sheath of the littlefinger is the ulnar bursa.


Lesker (1983). The cruciate pulleys, i.e. C1, C2and C3, are thin and pliable and collapse tofacilitate full digital flexion (Fig. 3.2).

In the digits there are five rigid annular (orring-shaped) pulleys, i.e. A1, A2, A3, A4 and A5.The thumb has one oblique and two annularpulleys. These pulleys keep the flexor tendons inclose proximity to the phalanges and joints. Thisfacilitates efficient joint motion with minimaltendon excursion via a short moment arm. Bio-mechanically, the most important of the pulleysare the A2 and A4 pulleys. Their absence resultsin bowstringing of the tendon and an increase inmoment arm. This, in turn, results in loss ofdigital movement (Fig. 3.3).

Tendon nutrition

Flexor tendons receive nutrition from vascular andsynovial sources. Vascular perfusion outside thedigital sheath is via mesotendineal vessels. Withinthe digital sheath, blood supply is providedsegmentally via the long and short vincula(Armenta and Lehrman, 1980) (Fig. 3.4).

Synovial fluid diffusion delivers nutrients to thetendon and retinacular system via a process knownas imbibition. This is a pumping mechanism wherefluid is forced into the interstices of the tendon asthe digit is being flexed and extended. This processis especially important to the two avascularstructures where friction and gliding take place, i.e.

Figure 3.2. The pulley system overlying the synovial component of the flexor tendon sheath represents theretinacular portion of the sheath. These pulleys hold the tendon in close proximity to the skeleton and facilitateefficient joint motion with minimal tendon excursion. They also prevent the tendon from bowstringing. They arecomprised of: the palmar aponeurosis pulley (PA), five rigid annular pulleys and three thin, pliable cruciatepulleys.

Figure 3.3. (a) The A2 and A4 pulleys are the most important biomechanically. The close proximity of the flexortendons to the phalanges and joints creates a short moment arm and efficient motion. (b) When portions of thesetwo pulleys are resected, an increase in moment arm occurs and greater tendon excursion is required to move thejoint through the same arc of motion. Note the bowstringing of the unrestrained tendon. (Reproduced fromStrickland, J. W. Flexor tendons-acute injuries. 1999. In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) p. 1855, Churchill Livingstone, with permission.)

Flexor tendons 29

the palmar aspect of the flexor tendons and theinner aspect of the pulleys.

As well as providing nutrition to the retinacularsystem and tendon, synovial fluid acts as alubricating agent to facilitate the tendon turning acorner.

Tendon healing

Tendons have both an intrinsic and extrinsic abilityto heal. For some time it was thought that thetendon itself was not involved in the healingprocess but rather that union could only beachieved via invasion of the healing area byparatendinous tissues. Research, however, hasshown that the tendon does play an active role inthe repair process (Lundborg et al., 1985).

Extrinsic healing is characterized by adhesionsbetween the tendon and its surrounding tissues.Intrinsic healing results in fewer and less denseadhesions. The healing process involves threedistinct but overlapping phases:

1. Inflammatory – this phase lasts 3 to 5 days. Thestrength of the repair at this stage is tenuous andis imparted almost entirely by the suture.

2. Fibroblastic – this phase begins at about thefifth day and lasts for 3 to 6 weeks. This is thecollagen-producing phase during which strengthincreases rapidly.

3. Remodelling – this maturation phase continuesfor 6 to 9 months. This phase sees a continuationof collagen synthesis and longitudinal orienta-tion of fibroblast and collagen fibres. The repaircontinues to gain strength during this period.

Timing of tendon repair

Although no longer considered an emergency,primary tendon repair should ideally be performed

within the first few days of injury to yield the bestpossible outcome (Gelberman et al., 1991b). Whiledelayed primary repair can be performed up to 3weeks, some deterioration of tendon ends andshortening of the muscle-tendon unit becomesinevitable.

Contraindications for primary repair include:severe injury to multiple tissues, wound con-tamination or significant skin loss over the flexorsurface. Tendon reconstruction can be managed ata later date by two-stage tendon grafting.

Incisions for surgical exposure

The wound sustained by the injury is usuallytransverse or oblique and will need to be extendedto allow tendon repair. The skin laceration isusually extended to produce a zigzag approachusing points and lines of minimal tension to reducescar. Alternatively, a midaxial approach is made oneither side of the finger and then connected to theoriginal laceration. Retrieval of retracted tendonends is achieved by proximal-to-distal milking ofthe tendons or with the help of a silastic cannula.

Tendon repair technique

Repair of the tendon is performed as atraumaticallyas possible. Wherever the tendon surface ispunctured by forceps, a site of potential tendonadhesion is created (Potenza, 1964). Both flexortendons should be repaired. The tendon sheath isrepaired whenever possible so that the potential forsynovial fluid nutrition is restored. The repairedsheath also serves as a barrier to the formation ofextrinsic adhesions.

The divided tendon ends are repaired as accu-rately as possible without tension and with the leastinterruption to the blood supply. A core suture with3–0 or 4–0 nonabsorbable thread is used. Aperipheral circumferential epitendinous suture(continuous 6–0 monofilament) is used in additionto the core suture (Mashadi and Amis, 1992). Thissuture provides significant increase in the strengthof the repair and reduction of gapping between thetendon ends.

Biomechanical studies suggest that strength ofthe repair is proportional to the number of suturestrands that cross the repair site (Wagner et al.,1994). Four-strand core sutures are about twice asstrong as two-strand methods and six-strandsutures, three times stronger. When using a two-strand method, the repair is considered somewhatvulnerable for the first three weeks after surgery.

Figure 3.4. Vincular blood supply of the flexortendons.


Four- and six-strand repairs however, are con-sidered capable of withstanding light unresistedactive motion in the presence of full passiveinterphalangeal flexion (Fig. 3.5).

Zones of tendon repair

Zone I is the most distal zone where only the flexordigitorum profundus (FDP) can be divided. Thiszone is distal to flexor digitorum superficialis(FDS) insertion.

Zone II has been called ‘no man’s land’ becauseof previously poor results following repair in thiszone which extends from the A1 pulley to the FDSinsertion and where both flexor tendons travel inthe flexor sheath.

Historical note

The term ‘no man’s land’ originated in theMiddle Ages and refers to an area outside thenorthern wall of London where the bodies ofcriminals were displayed following hanging,beheading or impaling. This served as a warningto others. When gallows were eventually builtinside the city proper and the surrounding landwas settled and fields were cultivated, the formerexecution grounds were claimed by no man.

Much later, around 1900, the phrase became partof military parlance.

Zone III extends from the A1 pulley to the distaledge of the transverse carpal ligament. This is thezone of lumbrical origin. Injuries to this zone have

Figure 3.5. Various techniques of repairing flexor tendons. (a) Bunnell, (b) modified Kessler, (c) singlecross-grasp six-strand (Sandow and McMahon), (d) Becker (bevel technique), (e) Tsuge (f) six-strand using threesuture pairs (Lim and Tsai).

Figure 3.6. The five zones of flexor tendon repair inthe digits and three zones of repair for flexor pollicislongus.

Flexor tendons 31

good results because it lies beyond the flexorsheath and restrictive adhesions are less likely.

Zone IV is the carpal tunnel and tendonlaceration in this zone can be accompanied byinjury to the median and/or ulnar nerves. Tendoninjuries are less common in this zone due to therelative protection afforded by the transversecarpal ligament and bony architecture of thetunnel. Zone V covers the distal portion of theforearm extending from the musculotendinousjunction to the proximal edge of the transversecarpal ligament (Fig. 3.6).

Early application of stress followingtendon repair

Early application of stress to a healing tendon canbiologically affect scar remodelling. Gelbermanand others (1980, 1990, 1991a) have demonstratedthe following benefits associated with early pas-sive mobilization of tendons in dogs:

1. Faster recovery of tensile strength.2. Fewer adhesions.3. Improved tendon excursion.4. Minimal deformation at the tendon site.

Historical perspective of postoperativeflexor tendon management

A number of postoperative programmes haveevolved over the past few decades. Their aim hasbeen to provide differential gliding of the FDS andFDP tendons within the constricted space of ZoneII. Passive flexion of the interphalangeal jointspushes the tendon proximally while active orpassive interphalangeal joint extension pushes thetendon distally.

These programmes have undergone and con-tinue to undergo modifications in response toincreased knowledge of tendon nutrition andbiology. The original controlled motion protocolwas devised by Kleinert (1967). This involvedrubber band traction which maintained the digit ina flexed posture while allowing active extension ofthe interphalangeal joints against the tension of therubber band.

Duran and Houser (1975) later devised aprotocol which maintains the interphalangeal jointsin extension. Passive flexion exercises are per-formed individually at the DIP joint, then the PIPjoint and finally at all three finger joints simultane-ously (Fig. 3.7).

Figure 3.7. The controlled passive motion method originally recommended by Duran and Houser. (Reproducedfrom Strickland, J. W. Flexor tendons-acute injuries. 1999. In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) p. 1866, Churchill Livingstone, with permission.)


McGrouther and Ahmed (1981) concluded that itwas necessary to passively flex the joints distal tothe repair in order to achieve glide of the repair site.Subsequent studies suggest that aftercare pro-grammes should aim at maximum passive flexion ofboth interphalangeal joints. This has resulted in theincorporation of a distal palmar pulley (BrookeArmy splint) such as that seen in the ‘Washingtonregimen’ described by Chow and associates (1990).The addition of a distal palmar pulley (which hasalso been incorporated into the Kleinert regimen)maintains both interphalangeal joints at almost fullflexion when the hand is at rest (Fig. 3.8).

Controlled active motion protocols

The last decade has seen the evolution of con-trolled active motion protocols (Bainbridge,1994). The introduction of four- and six-strandrepair methods together with strong peripheralepitendinous suturing have facilitated ‘place andhold’ flexion of the interphalangeal joints using

Figure 3.8. The incorporation of a distal palmar pulleyprovides maximum passive flexion of bothinterphalangeal joints. This splint was designed byLinwood Thomas, OTR, for the ‘Washington regimen’.(Reproduced from Chow, J., Thomas, L., Dovelle, S.,et al. 1987. A combined regimen of controlled motionfollowing flexor tendon repair in ‘no man’s land’.Plast. Reconstr. Surg., 79, 447–453, with permission.)

Figure 3.9. Controlled active motion protocol used at the Indiana Hand Centre following flexor tendon repair. (a)The conventional dorsal splint is worn most of the time. (b–d) The dynamic tenodesis splint, which is only usedfor the first four weeks after surgery, is used on an hourly basis following passive finger flexion exercises withinthe static splint. (Reproduced from Strickland, J. W. Flexor tendons-acute injuries. 1999. In Green’s OperativeHand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) p. 1867, Churchill Livingstone, withpermission.)

Flexor tendons 33

minimal muscle-tendon tension. Some surgeonsbelieve that a two-strand repair with strong periph-eral epitendinous suturing can withstand earlyactive motion. The ‘place and hold’ manoeuvre isperformed with the wrist in 45 degrees of exten-sion and maximum MCP joint flexion as thisposition produces the least tension on the repairedtendon (Savage, 1988) (Fig. 3.9).

The dynamic tenodesis splint developed at theMayo clinic by Cooney et al. (1989) uses thisprinciple. Controlled active motion protocols havebeen described by Allen et al. (1987), Cullen et al.(1989), Small et al. (1989), Strickland (1993),Cannon (1993), Evans and Thompson (1993) andSilverskjoeld and May (1994).

Choice of treatment programme

Many hand centres have developed their ownprogramme using different aspects of one or all ofthe described methods. The programme used withour patients for Zone II is outlined below andexemplifies a combined approach.

Each surgeon has particular views and prefer-ences and the therapy regimen will obviously beinfluenced by these. The level of experience of thetreating therapist will also dictate treatment choice.Other important factors influencing the choice ofprogramme include:

1. The presence of associated injuries, e.g. damageto the neurovascular bundle or fractures.

2. The age of the patient.3. The patient’s ability and/or willingness to

comply with the programme.4. The type of scar produced by the patient, i.e.

supple tissue with minimal reaction or dense,fibrous tissue.

Aims of therapy

Regardless of which particular programme is used,the following aims are inherent in achieving afavourable outcome:

1. Control of postoperative oedema.2. Regaining flexibility of the interphalangeal

joints.3. Prevention of PIP joint flexion deformity.4. Scar management.

Postoperative management

The protocol outlined below refers specifically torepair of the flexor tendon(s) in Zone II. It is,however, applicable to all zones.

Splint position

Following surgery the hand is placed in a dorsalplaster which maintains the wrist in neutralextension and the MCP joints in maximum flexion,this usually ranging from 75 to 90 degrees.Elevation of the limb is maintained. Shoulder andelbow exercises are begun within a day of surgeryand repeated every 1 to 2 hours.

Exercise protocol from 3rd to 24th day

On the 3rd or 4th postoperative day, when theinflammatory response has usually settled, theplaster is replaced with a thermoplastic splint whichmaintains the hand in the same position as thepostoperative plaster. Gentle passive interpha-langeal (IP) joint flexion exercises are commencedand performed only within comfortable limits(Fig. 3.10). The index finger can be placed behind

Figure 3.10. Gentle passive interphalangeal jointflexion exercises are commenced on the 3rdpostoperative day. They are performed withincomfortable limits and repeated on an hourly basis.


the proximal phalanx of the involved digit while thethumb places light pressure to the fingernail so thatboth IP joints are flexed simultaneously. If there hasbeen associated digital nerve repair, the exercisesare carried out with even greater care as hyper-sensitivity at the repair site is common.

Each passive flexion manoeuvre is held for ashort period (i.e. 30–60 s) and is followed by activeintrinsic IP joint extension (Fig. 3.11). Both passiveflexion and active intrinsic extension are usuallylimited at this early stage by digital oedema anddiscomfort; however, when performed on an hourlybasis with 5 to 10 repetitions, improvement isusually seen quite rapidly within the first few days.Under ideal circumstances, full passive IP jointflexion and full active IP joint extension should beachieved by the end of the second postoperativeweek. Sutures are removed at this time.

Active movement of flexor digitorumsuperficialis (FDS)

If FDS is intact, it can be exercised by trapping theDIP joints of the unaffected fingers in extensionand then gently flexing the PIP joint of the affecteddigit. This helps maintain glide of the uninjuredFDS tendon. This exercise is only performed whenthe IP joints can be passively flexed to full rangewith ease.

Note: If a controlled active motion protocol hasbeen requested, the author uses the ‘tenodesismanoeuvre’ described in the ‘Day 24 to end ofweek 6’ section. This manoeuvre is performed two

to three times every 4 h during these first 312 weeks

and is held for 1 to 2 seconds only with minimaleffort. It is only performed when full passiveflexion has been achieved.

Resolution of digital oedema

Digital swelling often subsides significantly follow-ing the commencement of the exercise routine.Application of a single layer of Coban (25 mm) willeffectively address residual oedema. This is appliedcarefully by the therapist in a distal to proximaldirection and can be done so more easily if the handis removed from the splint, the elbow rested on thetable and the wrist allowed to fall into maximumflexion; this will result in the fingers assuming arelaxed position of IP joint extension which will seethe digits slightly separate (Fig. 3.12).

Flexion deformity of the PIP joint

The combination of hourly active intrinsic IP jointextension exercises and Coban is usually sufficient

Figure 3.11. Active intrinsic interphalangeal jointextension exercises are also repeated on an hourlybasis. The patient should aim to extend to the limit ofthe splint, i.e. full IP joint extension. This is often notpossible during the first few days due to oedema andwound discomfort.

Figure 3.12. Coban wrap compression (25 mm)provides an excellent means of eliminating digitaloedema. It is applied more easily when the hand isremoved from the splint and allowed to fall intomaximum wrist flexion so that the fingers relax inextension where they will fall slightly apart. One layerof Coban applied under negligible tension is sufficient.

Flexor tendons 35

to prevent the development of a PIP joint flexiondeformity. Where a deformity has developed, it canbe addressed with a small thermoplastic splint thatis applied to the dorsum of the joint in a position ofslight correction; this is gradually modified untilfull correction has been achieved.

Alternatively, a soft ‘sling’ is placed on the volaraspect of the middle phalanx. Nylon thread is thenattached to holes punched through the sides of thesling. The nylon is then threaded through a holemade in the splint and attached to a hook on theoutside of the splint. The tension applied by thesling should be negligible and the line of pullshould be at right angles to the middle phalanx.The sling is removed for hourly passive IP jointflexion exercises and intrinsic IP joint extensionexercises (Fig. 3.13).

Scar management

Following suture removal, the hand is bathed inwarm soapy water to cleanse the skin. To protectthe tendon repair, the wrist should be passivelyheld in maximum flexion range. If passive IP jointflexion range is still restricted, the warmth of thewater will make passive flexion exercises easier.Also, the fingers can be gently bandaged intoflexion prior to immersion in the water. This willnecessitate the wrist being brought into neutralextension while the fingers are passively held inthe flexed position.

Gentle oil massage is performed to soften thescar and to begin the desensitization process. Thelatter is especially important where the digitalnerve repair has also been performed. Massage canbe performed out of the splint by the therapist;however, when the patient is performing themassage, it is safer to keep the hand within thesplint and undo the distal splint strap if necessary.Finger pressure should be very light during the firstfew sessions until increased pressure can betolerated. If hypersensitivity is problematic enoughto interfere with the exercise programme, coveringthe area with Opsite Flexifix will often reducehyperaesthesia significantly.

If Coban wrap is not already being used forswelling control, it should be added to theprogramme for its effectiveness in providing gentlecompression to scar. Unless scar is particularlydense, this modality can be used alone. Whereraised, dense scar restricts passive flexion or ispainful to touch, silicone gel is used under theCoban during the night and intermittently through-out the day.

Day 24 to end of week 6

At 312 weeks gentle active flexion exercises are

begun. Prior to the commencement of activeexercise, the patient must first ‘warm up’ withpassive flexion exercises. Active flexion is onlybegun if the patient is able to passively flex both IPjoints to near-normal flexion range with ease. Thelast few degrees of passive flexion can sometimesbe restricted by dense scarring or residualoedema.

As a tendon glides, it meets a certain degree ofnormal resistance from surrounding tissues. This isreferred to as ‘drag’. Following injury and surgery,this resistance is significantly increased due toswelling, sutures and healing scar. The newlyrepaired tendon must not, therefore, be subjected tothe added stress of overcoming joint stiffness whenactive movement is commenced.

Every 2 h the hand is removed from the splintand rested comfortably on the table in neutral wristextension. From their flexed position, the MCPjoints are actively extended to within 20 or 30degrees of full extension and gently supported.This more extended MCP joint position will helpaccommodate extrinsic finger flexion.

With the wrist in neutral and the MCP jointssupported in 20 to 30 degrees of flexion, the patientis asked to actively extend the IP joints to theirmaximum range as they have been doing in the

Figure 3.13. Patients who heal with dense scarringoften have an increased propensity toward PIP flexiondeformity. This can be managed with a sling thatapplies negligible extension force to the digit. Wherenecessary, the sling is used during sleep. During theday, the sling is removed hourly to perform passive IPjoint flexion exercises.


splint. When maximum IP joint extension range isreached, the patient is then asked to actively flexboth IP joints simultaneously with minimal effort(Fig. 3.14). This position is gently held for severalseconds before the exercise is repeated. Five to tenrepetitions are performed. These early attempts mayyield 30 or 40 degrees of PIP joint flexion and 20 or30 degrees DIP flexion. From the 4th week onward,the MCP joints can be increasingly extended duringIP joint flexion exercises to better facilitate flexortendon pull-through.

Patients who demonstrate marked active flexionrange are considered at greater risk of rupture dueto minimal scar formation. These patients areprotected for a longer period. This means that thecommencement of active movement is delayed byanother week and protective splinting is continuedfor 1 to 2 weeks longer. When active movement isthen initiated, it can be done so with the less-stressful tenodesis manoeuvre described below.Resisted use of the hand will also be delayed byseveral weeks.

Tenodesis manoeuvre

If active flexion range is minimal or where the riskof rupture is considered greater, the patient shouldbe shown ‘place and hold’ exercises as it takes lessforce to maintain an already flexed finger in theflexed position than it does to actively bring thefinger into flexion from the extended position. Thismanoeuvre involves passively flexing the fingers,allowing the wrist to extend to 40 to 45 degrees andthen removing the passive support and askingthe patient to maintain the flexed finger positionwith minimal active muscle-tendon tension(Fig. 3.15(a)). Savage (1988) has shown that thisposition produces the least tension on the repairedtendon during active movement. This position isheld for 3 to 5 seconds. The wrist is then brought

Figure 3.14. Gentle combined active IP joint flexion(i.e. both IP joints simultaneously) is practisedsecond-hourly with 5–10 repetitions at each session.Active range of motion is usually still quite limited atthis early stage. Patients who demonstrate significantactive range with ease are ‘held back’ because theytend to be at greater risk of rupture due to minimalscar formation.

Figure 3.15. (a) The first part of the ‘tenodesismanoeuvre’ involves passively flexing the fingers andallowing the wrist to assume a position of 45 degreesextension. Passive support is then removed and thepatient is asked to maintain the flexed position withminimal active muscle-tendon tension. (b) The wrist isthen brought forward into flexion while the fingersgently extend.

(a)

(b)

Flexor tendons 37

forward into flexion while the fingers gently extend,i.e. the tenodesis effect. This manoeuvre is repeated5 to 10 times second hourly (Fig. 3.15(b)).

The patient may find it helpful to perform theiractive exercises in both of the described ways.

Weeks 6 to 8

The splint is discarded at the end of the 6thpostoperative week unless the nature of the scarindicates that extended protection is necessary. Thehand can be used for light daily functionalactivities that are minimally resistive. The light(sustained) squeezing of a soft bath sponge inwarm water is a suitable exercise at this stage.Patients whose work does not involve heavymanual activity usually return to work at thisstage.

Residual flexion deformity of the PIP joint isaddressed with a neoprene fingerstall (Fig. 3.16). Ifadhesions are affecting tendon glide, the use of anMCP joint blocking splint will facilitate pull-through of the extrinsic flexors (Fig. 3.17).

During activity, the injured finger can be buddy-taped to an adjacent finger with Microfoam tape iflimitation of active flexion range makes grippingobjects difficult. Small handles such as cutlery orrazor can be temporarily built up with insulationtubing (i.e. Bradflex). Light-grade exercise puttycan be added to the programme by the 7th week.Putty squeezing should be carried out in a slow andsustained manner and the patient should take carenot to over-exercise. Three or four short sessions(5 min) each day are sufficient as the patient shouldalso be engaging the hand in regular activity(Fig. 3.18).

Repair in Zones III, IV and V is often accom-panied by tethering of the tendon to skin andsurrounding tissues and some shortening of themuscle-tendon unit. This can be addressed withserial volar splints which exert a gentle correctiveextension force and are worn at night and inter-mittently throughout the day. Occasionally softtissue tightness is quite marked. This may warrantthe use of a dynamic outrigger. Regardless of thesplinting method used, the tension applied shouldbe low and the correction should be gradual toavoid rupturing the repair. The patient should feela gentle stretching sensation that is not painful.

Week 8 onwards

Gentle resistance is added to active flexion exer-cises and activity can be upgraded. Stabilizedexercises are continued; however, they need not be

Figure 3.16. Unresolved flexion deformities of the PIPjoint are managed with a neoprene fingerstall from the6th week onward.

Figure 3.17. An MCP joint blocking splint willfacilitate pull-through of the extrinsic flexor tendons.

Figure 3.18. Light-grade exercise putty is added to theprogramme by the 7th week.


repeated as frequently. Return of function is moreof a priority at this stage in rehabilitation andpatients are encouraged to perform domestic ormechanical tasks as part of their therapy pro-gramme if they have not yet returned to work.

Patients whose work is heavily resistive donot return to work in their normal capacity until theend of the 12th week. This period is extended for afurther 2 weeks where scar formation has beenminimal.

Note: Many patients make steady gains in activeflexion range during the first 3 to 4 postoperativemonths. Patients who heal with dense scar fre-quently show slower progress. Final range ofactive motion may not be achieved for somemonths following cessation of formal therapy.Patients are therefore encouraged to persevere withtheir exercise/activity programme.

Flexor pollicis longus (FPL) repair

Splint position

The splint is applied to the dorsum of the forearmand hand, with the wrist in neutral or very slightflexion. The thumb is held in slight palmarabduction with the MCP in 30 degrees of flexionand the IP joint in neutral extension. The tip of thethumb should be in line with the middle finger(Fig. 3.19).

Exercise protocol

The exercise protocol is the same as for repair of adigital flexor tendon. Some patients find it difficultto isolate FPL function and tend to overuse theintrinsic thenar muscles when active exercises are

begun. This tendency can be overcome with anMCP blocking splint which will restrict movementto the long thumb flexor. This can be appliedbetween the 4th and 5th week (Fig. 3.20).

Tenolysis

Any injury or operation that interferes with thesmooth gliding surface of the tendon systempredisposes the tendon to becoming adherent toadjacent tissues, i.e. skin, retinacular ligament andbone. A tenolysis procedure aims to free the tendonfrom its adhesions and restore its glide. Secondaryjoint changes (capsule or ligament fibrosis) mayalso need correction.

Tenolysis is indicated only when comprehensivetherapy measures, used over a period of at least 3to 6 months following injury or surgery, havefailed to restore a functional range of movement(Fetrow, 1967 and Baker et al., 1996). Patientselection is most important as strong motivationand full co-operation are required in the post-operative phase. Patients are advised that two-stage tendon reconstruction may be necessary ifthe tendon motor and/or flexor pulley system proveinadequate.

Technique

The procedure is performed under local anaestheticusing a zig-zag incision. By using this type ofanaesthesia, the patient is awake and able toparticipate so that the surgeon is able to carry outjust enough dissection and freeing.

Figure 3.19. Postoperative splint used following repairof flexor pollicis longus.

Figure 3.20. To avoid compensatory movements bythe intrinsic thumb muscles during IP joint flexionexercises, a blocking splint is used to isolate the actionof flexor pollicis longus.

Flexor tendons 39


The immediate postoperative exercise regimen willvary from patient to patient and will be determinedby the integrity of the freed tendon. Poor qualitytendons have a greater risk of rupture and shouldbe exercised with some caution. Tendons deemedto be in good condition can be exercised morevigorously. Discussion with the attending surgeonis therefore essential.

The first postoperative week is the most impor-tant (Schneider and Berger-Feldscher, 1995). Theaim of therapy is to reproduce the range ofmovement that was achieved during surgery,before adhesions have an opportunity to becomere-established. The exercise regimen should besufficient to promote maximum tendon glidewithout causing an inflammatory response orincreasing oedema.

Splint

The hand can be rested in the position of safeimmobilization, i.e. wrist comfortable extension,MCP joints in flexion and the IP joints inextension.

Oedema and pain control

The hand is maintained in elevation betweenexercise sessions and ice packs are used every 3 to4 hours prior to exercise during the first 2 to 3 daysto reduce swelling and discomfort. The immediatepostoperative dressing may require de-bulking toensure effectiveness of the ice pack and tofacilitate exercise. Care is taken to keep the wounddry and sterile. Coban wrap can be applied over thedressing to help control swelling. A single layer issufficient and should not interfere with exercise.

Appropriate pain relief should be provided priorto active exercise which is commenced on the dayof surgery.

Exercise protocol (days 0 to 7)

Where the tendon is deemed to be at risk ofrupture, only ‘place and hold’ exercises areperformed during the first week as they requireless tensile loading. The fingers are passivelyflexed to a comfortable range by the therapist orthe patient’s uninvolved hand. This position ofpassive flexion is held for a short period (i.e.30–60 s) after which time the supporting hand isremoved and the patient is asked to maintain the

position with minimal active muscle-tendon ten-sion for several seconds. The digits are thengently extended (actively) and the manoeuvre isrepeated another 3 to 5 times. The exercisesession is repeated every 3 to 4 hours during thefirst day and on an hourly basis from then on.Each session should see a slight increase inflexion range.

Where tendon integrity is considered sound,gentle active unstabilized finger exercises arebegun. They should be preceded by passiveexercises so that the tendon does not have toovercome the resistance of stiffened joints. Theexercises are repeated 3 to 4 times on the firstday and hourly thereafter. Response to exercise ismonitored on an individual basis and the pro-gramme is modified accordingly.

Optimizing tendon glide

To promote optimal tendon glide, the fingers areexercised in a variety of ways:

1. MCP joints are flexed with the IP joints heldin extension, i.e. intrinsic plus position.

2. A hook grip is made, i.e. the IP joints areflexed while the MCP joints are maintained inextension.

3. Composite flexion involves simultaneous flex-ion of all three finger joints. To providefurther differentiation, the fist can be ‘flat’,i.e. with the DIP joints in extension while theMCP and PIP joints are flexed, or ‘tucked’,i.e. with the DIP joints flexed.

Wrist movements are also practised at eachexercise session together with movements of theshoulder, elbow and forearm.

Days 7 to 14

Stabilized (or blocking) exercises are added tothe active exercise programme for ‘low risk’tendons. Splints that block the MCP joints inextension and provide more effective pull-through of the flexor tendon can be used by theend of the 2nd week. For more vulnerabletendons, ‘place and hold’ exercises are replacedwith gentle unstabilized composite flexion exer-cises from a position of digital extension. Stabi-lized exercise for ‘at risk’ tendons is delayeduntil the 3rd postoperative week.


Sutures are removed around the 14th day and oilmassage and scar management are begun. Siliconegel can be used beneath Coban or a silicone-linedfinger sleeve can be worn. Light gripping activitiescan be commenced at this time.

Day 14 onwards

Scar management, active exercise and light activ-ity are continued. Resisted exercise and activitycan commence at week 6 and full resistance can betolerated after the 8th week.

Two-stage tendon reconstruction

Where tendon glide has been compromised byinjury and/or surgery and tenolysis has beenunsuccessful, tendon function can be restored witha two-stage procedure (Hunter et al., 1995).

Patient selection for two-stage tendon recon-struction is even more important than for tenolysisbecause it requires two surgical procedures and apersonal and economic commitment to a protractedaftercare programme.

Preoperative requirements

1. Full or near-normal passive flexion of the IPjoints.

2. Full or near-normal digital extension.3. Soft supple tissues.

Stage 1

The scarred tendon is resected and replaced with asilastic implant or ‘rod’. The implant is attached tothe distal tendon stump. It is then threaded alongthe digit and through the carpal tunnel to lie freelyproximal to the wrist. The muscle motor isanchored to the adjacent muscle-tendon unit ifFDP is involved or to the flexor retinaculum if FPLis involved. Annular pulleys are reconstructed overthe implant around which a fibrous pseudosheathforms during the next 8 to 10 weeks (Fig. 3.21).

This first stage may also involve scar correction,nerve repair/graft or capsulotomy to improve jointrange of motion.

Postoperative aims

1. To regain passive flexion and active extensionrange.

2. To soften scar tissue and restore soft tissuemobility in preparation for the second stage.

3. To maintain mobility of all upper limb joints.4. To encourage use of the hand in suitable light

activity.


Days 1 to 14

For the first 2 weeks the hand is rested on a volarsplint with the wrist in slight extension or neutraland the fingers close to neutral extension. Nopassive IP joint flexion exercises or active wristmovements are performed during this time. Thepurpose of rest is to safeguard against siliconesynovitis which has been associated with earlypostoperative exercise. Adjacent finger joints canbe gently exercised. Oedema is managed withelevation and ice packs.

Day 14 onwards

The sutures are removed and massage to scar iscommenced. Gentle passive IP joint flexion andactive IP extension exercises are begun. Gentleactive wrist movement is also carried out. Theseexercises are to be performed slowly and carefullyand within the limits of pain. Over-vigorous

Figure 3.21. First stage of flexor tendon grafting. Theimplant (silastic rod) is attached to the distal tendonstump and then threaded along the digit and throughthe carpal tunnel to lie freely, proximal to the wrist.

Flexor tendons 41

exercise can easily result in synovitis. Shortsessions (1–2 min duration) every 2 h are sufficientduring the first week of exercise. Early signs ofsynovitis can include:

1. Sudden increased swelling along the volaraspect of the finger.

2. Pain at rest or during passive flexion.3. Loss of passive range.4. Swelling over the proximal end of the implant,

i.e. at the wrist.

Normal residual digital oedema is treated with asingle layer of Coban wrap. Scar is managed witha silicone-lined fingerstall which is worn through-out the night and intermittently during the day.Silicone gel is used over palmar scar.

If the patient has difficulty in regaining flexionrange, the hand is bandaged gently into flexionseveral times a day or a digital flexion strap is used;only the gentlest of pressure is used during thesemanoeuvres. The patient is not permitted to engagethe hand in heavy activity while the implant ispresent. To encourage flexibility of the affecteddigit, it is buddy-strapped to an adjacent digit duringlight activity and exercise (Fig. 3.22).

Stage 2

The second stage of reconstruction is usuallyperformed 8 weeks after the first and involvesremoval of the implant and a tendon graft. Incisionsare made over the distal and proximal juncture sites.The tendon graft (palmaris longus, plantaris or along toe extensor) is harvested and sutured to the

proximal end of the implant. It is then pulledthrough the new tendon bed.

At the distal juncture, the tendon is drawn into thebone with monofilament stainless steel or a non-absorbable suture. The wire is tied over a button onthe dorsum of the fingernail; this remains in placefor a minimum of 6 weeks. The proximal end of thegraft is attached to the motor tendon with aPulvertaft end-weave technique.


The aftercare regimen is as for primary repair withthe proviso that the programme is carried out morecautiously. Because the grafted tendon has a moreprecarious blood supply, there is increased risk ofrupture. For this reason, the various therapy‘milestones’ are all delayed by approximately oneweek (Fig. 3.23).

References

Allen, B. N., Frykman, G. K., Unsell, R. S. and Wood, V. E.(1987). Ruptured flexor tendon tenorrhaphies in Zone II:repair and rehabilitation. J. Hand Surg., 12A, 18–21.

Armenta, E. and Lehrman, A. (1980). The vincula of the flexortendons of the hand. J. Hand Surg., 5, 127–34.

Bainbridge, D. P., Robertson, C., Gillies, D. and Elliot, D. (1994).A comparison of postoperative mobilization of flexor tendonrepairs with ‘passive flexion-active extension’ and ‘controlledactive motion techniques’. J. Hand Surg., 19B, 517–21.

Baker, M. K., Dunn, S. J., Tonkin, M. A. and Eakins, D. F. (1996).Flexor tenolysis: a worthwhile procedure in a select patientpopulation. Hand Surg., 1, 131–40.

Cannon N. (1993). Post flexor tendon repair motion protocol.Indiana Hand Center Newsletter, 1, 13.

Figure 3.22. To maintain interphalangeal jointflexibility of the affected digit, it is ‘buddy-strapped’to an adjacent digit during light activity. Microfoamtape makes an effective buddy-strap as it is soft,flexible and reusable.

Figure 3.23. The aftercare regimen following thesecond stage of reconstruction is as for primary repair;however, the various therapy milestones are delayedby 1 to 2 weeks. Note use of silicone gel to soften thewrist scar.


Chow, S. P., Stephens, M. M., Ngai, W. K., et al. (1990). A splintfor controlled active motion after flexor tendon repair. Design,mechanical testing and preliminary clinical results. J. HandSurg., 15A, 645–51.

Cooney, W. P., Lin, G. T. and An, K. T. (1989). Improved tendonexcursion following flexor tendon repair. J. Hand Surg., 2,102–6.

Cullen, K. W., Tolhurst, P., Lang, D. and Page, R. E. (1989).Flexor tendon repair in zone II followed by controlled activemobilization. J. Hand Surg., 14B, 392–5.

Doyle, J. R. (1989). Anatomy of the flexor tendon sheath andpulley system: a current review. J. Hand Surg., 14A, 349–51.

Duran, R. J. and Houser, R. G. (1975). Controlled passive motionfollowing flexor tendon repair in zones II and III. In AAOSSymposium on Tendon Surgery of the Hand, pp, 105–14,Mosby.

Evans, R. B. and Thompson, D. E. (1993). The application offorce to the healing tendon. J. Hand Ther., 6, 266–84.

Fetrow, K. O. (1967). Tenolysis in the hand and wrist. A clinicalevaluation of two hundred and twenty flexor and extensortenolyses. J. Bone Joint Surg., 49A, 667–85.

Gelberman, R. H., Khabie, V. and Cahill, J. C. (1991a). Therevascularization of healing flexor tendons in the digitalsheath: a vascular injection study in dogs. J. Bone Joint Surg.,73A, 868–81.

Gelberman, R. H., Menon, J., Gonsalves, M. and Akeson, W. H.(1980). The effects of mobilization on the vascularization ofhealing flexor tendons in dogs. Clin. Orthop., 153, 283–89.

Gelberman, R. H., Siegel, D. B., Savio, L., et al. (1991b). Healingof digital flexor tendons: importance of the interval frominjury to repair. J. Bone Joint Surg., 73A(1), 66.

Gelberman, R. H., Woo, S. L. Y., Amiel, D., et al. (1990).Influences of flexor sheath continuity and early motion ontendon healing in dogs. J. Hand Surg., 15A, 69–77.

Hitchcock, T. F., Light, T. R., Bunch, W. H., et al. (1987). Theeffect of immediate constrained digital motion on the strengthof flexor tendon repairs in chickens. J. Hand Surg., 12A,590–5.

Hunter, J. M, Taras, J. S., Mackin, E. J., et al. (1995). Stagedflexor tendon reconstruction using passive and active tendonimplants. In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp.477–514, Mosby.

Kleinert, H. E., Kutz, J. E., Ashbell, T. S. and Martinez, E.Primary repair of lacerated flexor tendons in ‘no-man’s land’(abstract). J. Bone Joint Surg., 49A, 577.

Lundborg, G., Rank, F. and Heinau, B. (1985). Intrinsic tendonhealing: a new experimental model. Scand. J. Plast. Reconstr.Surg., 19, 113–7.

Manske, P. R. and Lesker, P. A. (1983). Palmar aponeurosispulley. J. Hand Surg., 8, 259–63.

Mashadi, Z. B. and Amis, A. A. (1992). Strength of the suture inthe epitenon and within the tendon fibres: development ofstronger peripheral suture technique. J. Hand Surg., 17B(2),172.

McGrouther, D. A. and Ahmed, M. (1981). Flexor tendonexcursions in ‘no man’s land. Hand, 13, 129.

Potenza, A. D. (1964). Prevention of adhesions to healing digitalflexor tendons. J. A. M. A., 187, 187–91.

Savage, R. (1988). The influence of wrist position on theminimum force required for active movement of theinterphalangeal joints. J. Hand Surg., 13B, 262–8.

Schneider, L. H. and Berger-Feldscher, S. (1995). Tenolysis:Dynamic approach to surgery and therapy. In Rehabilitation ofthe Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackinand A. D. Callahan, eds) pp. 463–75, Mosby.

Silverskjoeld, K. L. and May, E. J. (1994). Flexor tendon repairin zone II with a new suture technique and an earlymobilization program combining passive and active motion. J.Hand Surg., 19A, 53–60.

Small, J. O., Brennen, M. D. and Colville, J. (1989). Early activemobilization following flexor tendon repair in zone 2. J. HandSurg., 14B, 383–91.

Strickland, J. W. (1993). Flexor tendon repair: Indiana method.Indiana Hand Center Newsletter, 1, 1.

Strickland, J. W. (1999). Flexor tendons-acute injuries. InGreen’s Operative Hand Surgery (D. P. Green, R. N. Hotchkissand W. C. Pederson, eds) pp. 1851–97, ChurchillLivingstone.

Wagner, W. F., Carroll, C., Strickland, J. W., et al. (1994). Abiomechanical comparison of techniques of flexor tendonrepair. J. Hand Surg., 19A, 979–83.

Further reading

Aoki, M., Kubota, H., Pruitt, D. L. and Manske, P. R. (1997).Biomechanical and histological characteristics of canineflexor repair using early postoperative mobilization. J. HandSurg., 22A, 107–14.

Amadio, P. C., Jaeger, S. H. and Hunter, J. M. (1995). Nutritionalaspects of tendon healing. In Rehabilitation of the Hand:Surgery and Therapy. (J. M. Hunter, E. J. Mackin and A. D.Callahan, eds) pp. 409–16, Mosby.

Callan, P. P. and Morrison, W. A. (1994). A new approach toflexor tendon repair. J. Hand Surg., 19B, 513–6.

Kleinert, H. E., Schepels, S. and Gill, T. (1981). Flexor tendoninjuries. Surg. Clin. North Am. 61, 267–86.

May, E. J., Silverskjoeld, K. L. and Sollerman, C. J. (1992).Controlled mobilization after flexor tendon repair in zone II: aprospective comparison of three methods. J. Hand Surg., 17A,942–52.

Peck, F.H., Bucher, C. A., Watson, S. J. and Roe, A. E. (1996). Anaudit of flexor tendon injuries in zone II and its influence onmanagement. J. Hand Ther., 9, 306–8.

Stewart, K. M. and van Strien, G. (1995). Postoperativemanagement of flexor tendon injuries. In Rehabilitation of theHand: Surgery and Therapy. (J. M. Hunter, E. J. Mackin andA. D. Callahan, eds) pp. 433–62, Mosby.

Strickland, J. W. (1989). Biologic rationale, clinical application,and results of early motion following flexor tendon repair. J.Hand Ther., 2, 71–8.

Taras, J. S., Gray, R. M. and Culp, R. W. (1994). Complicationsof flexor tendon injuries. Hand Clin., 10, 93–109.

Wehbe, M. A. (1987). Tendon gliding exercises. Am. J. Occup.Ther., 41, 164–7.

4

Extensor tendons

The dorsum of the hand has minimal subcutaneoustissue. This means that extensor tendons arevulnerable to injury due to their relatively super-ficial location. Extensor tendon injuries are gen-erally regarded as less significant than thoseinvolving flexor tendons. Postinjury complica-tions, however, are common and can includetendon adhesion, extensor lag and stiffness. Inade-quate management can result in significant func-tional loss.

Anatomy

The extensor mechanism is characterized bynumerous soft tissue attachments and interconnec-tions (e.g. juncturae tendini). Unlike the flexortendons which are surrounded by a synovialsheath, the extensor mechanism in the hand andfingers is covered by paratenon. The tendons inthis region are broad and flat with a significanttendon-bone interface. The soft tissue attachmentsand the support of the paratenon ensure thatretraction of the divided tendon is limited. As aresult, many extensor tendon injuries, particularlythose over the digits, can be treated conservativelywith splinting (Fig. 4.1).

Over the dorsum of the wrist, the extensortendons are considerably more substantial and areoverlain by a wide fibrous band, the extensorretinaculum, the function of which is to preventbowstringing of the tendons.

At this level the tendons are surrounded by asynovial sheath and held in place by five fibro-osseous tunnels (or compartments) and one fibroustunnel, (the fifth dorsal compartment). These six

compartments are separated by septa that arisefrom the retinaculum and insert onto the radius.

Dorsal compartments

The first compartment houses abductor pollicislongus and extensor pollicis brevis; the second,extensor carpi radialis longus and extensor carpiradialis brevis; the third, extensor pollicis longus;the fourth, extensor digitorum communis (EDC)and extensor indicis proprius; the fifth, extensordigiti minimi and the sixth, extensor carpi ulnaris.Just proximal to the MCP joints, the communistendons are joined by fibrous interconnectionsknown as juncturae tendini.

Dorsal hood of MCP joint

The dorsal hood of the finger MCP joints is abroad, fibrous structure combining fibres from thesagittal band, juncturae tendini and the extensortendon. It serves to centre the EDC tendon, theprimary extensor of the MCP joints.

Extensor mechanism of the digit

The extensor mechanism of the digit is a conjointtendinous structure that is formed by the mergingof the following structures (Fig. 4.2):

1. The extrinsic extensor digitorum communis(radial nerve).

2. The intrinsic volar and dorsal interossei (ulnarnerve).

3. The lumbrical muscles (ulnar and mediannerves).


1. Extensor digitorum communis

Distal to the MCP joint, the extensor tendontrifurcates into a central slip and two lateral slips.The central slip inserts into the base of the middlephalanx where it is joined by a medial band ofoblique fibres from the lumbricals and interossei.The two lateral slips of the extensor tendon pass oneither side of the PIP joint and join with the lateralbands of the intrinsic muscles to form the conjoinedlateral bands. These unite distally as the terminaltendon and insert into the distal phalanx.

2. Intrinsic volar and dorsal interossei

The dorsal and volar interossei are separated fromthe lumbricals by the deep transverse metacarpalligament. The interossei are the primary MCP jointflexors. They contribute to IP joint extension onlywhen the MCP joints are simultaneously flexed.

3. The lumbricals

The lumbricals are unique in that they are the onlymuscles that arise from a flexor tendon and insertonto an extensor tendon. They arise from thetendon of flexor digitorum profundus and insertonto the radial lateral band of each finger. Thelumbricals are the prime intrinsic interphalangealjoint extensors.

Retinacular ligaments

1. Transverse retinacular ligament

This ligament arises from the flexor sheath andvolar plate at the PIP joint and passes to the lateralborder of the conjoined lateral band. It preventsdorsal dislocation and bowstringing of the lateralbands during IP joint extension and serves tostabilize the extensor tendon over the PIP joint inthe way that the sagittal band does at the MCPjoint.

2. Oblique retinacular ligament (ORL)

The ORL passes from the flexor sheath of theproximal phalanx and joins the lateral margin of

Figure 4.1. The extensor mechanism of the handdepicting the extensor tendons, the juncturae tendini,the extensor retinaculum, the six dorsal compartmentsand the synovial sheaths. (Copyright, ElizabethRoselius, 1999. Reproduced from Doyle, J. R.Extensor tendons-acute injuries. In Green’s OperativeHand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) p. 1951, Churchill Livingstone,with permission.)

Figure 4.2. The extensor mechanism of the digits.(Copyright, Elizabeth Roselius, 1999. Reproducedfrom Doyle, J. R. Extensor tendons-acute injuries. InGreen’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) p. 1953, ChurchillLivingstone, with permission.)

IX

VIII

VII

VI

V

IV

IIIIII

T IV

T V

T III

T II

T I

Extensor tendons 45

the terminal extensor tendon. Its course is volar tothe axis of the PIP joint but dorsal to the axis of theDIP joint. The ORL is considered to be a retainingligament that centralizes the tendon on the dorsumof the finger (Harris and Rutledge, 1972). It helpsco-ordinate uniform flexion and extension of thePIP and DIP joints.

3. Triangular ligament

This ligament consists of a fascial layer betweenthe conjoined lateral bands and the terminal tendondistal to the insertion of the central slip onto themiddle phalanx. This ligament prevents excessivevolar subluxation of the conjoined lateral bands onflexion of the PIP joint.

Zones of extensor tendon injury

The location of an extensor tendon injury willinfluence the type of treatment. It will alsodetermine the deformity and functional impair-ment. The extensor mechanism can be injured fromthe fingertip (Zone I) to the middle or proximalforearm (Zone IX). The original classification byKleinert and Verdan (1983) included eight zones inthe digital extensor mechanism and five zones forthe thumb. A ninth zone has now been added to theclassification; it covers the muscular area over themiddle and proximal forearm (Fig. 4.3).

Closed injuries

Closed injuries are best managed by splinting.Specific treatment regimens are discussed in eachzone.

Surgery for open injuries

In the case of a tidy wound, primary extensortendon repair is indicated as soon as possible afterinjury. This urgency is not as great as for flexortendons because in Zones I to V the retinacularfibres and juncturae between the tendons preventsignificant retraction of the proximal tendon end.

If the wound is dirty or contaminated, it shouldbe debrided until satisfactory healing has occurred.A delayed primary procedure is then performedunder optimal conditions, with additional skincoverage where required. The suture technique ismodified according to the site of repair as the

extensor mechanism becomes increasingly thin inits distal zones. A study by Newport et al. (1995)concluded that the Kleinert modification of theBunnell suture and the modified Kessler techniqueprovided the greatest strength and were able totolerate controlled active motion protocols. Thehorizontal mattress suture is weaker than theweave sutures but is suitable for broad, flat tendonswith longitudinal fibres.

In complex injuries involving loss of substance(particularly in Zone VI) or where there arefractures and joint injuries, soft tissue cover takespriority over tendon reconstruction. This should beby either a local or distant flap as skin grafts shouldnot be applied over tendons (Fig. 4.4).

Figure 4.3. Zones of extensor tendon injury in thedigits and thumb.


Postoperative management:immobilization vs. early controlledmobilization

Repaired extensor tendons have traditionally beenimmobilized for a period of 3 to 4 weeks prior tothe commencement of active movement. Becauseof the propensity toward tendon adhesion, treat-ment results were frequently disappointing. Theintroduction of controlled mobilization techniquesin the management of extensor tendon injuries hasled to improved results, particularly in the morechallenging Zone III over the PIP joint.

Evans and Burkhalter (1986) reported their6-year experience using controlled motion in thetreatment of untidy extensor injuries. Their treat-ment protocol was developed using knowledge ofextensor tendon excursion as reported by Bunnell(from Boyes, 1970), Elliot and McGrouther (1986)and Brand and Hollister (1993). The effectivenessof early dynamic splinting has been verified byBrowne and Ribik (1989), Hung et al. (1990) andSaldana et al. (1991).

It has been suggested that 3–5 mm of tendonexcursion (Duran and Houser, 1975 and Gelber-man et al., 1986) is sufficient to promote glide andstimulate cellular activity without causing gappingor rupture of the repair. Evans and Burkhalter

(1986) determined that 30 to 40 degrees of MCPjoint motion effected 5 mm of extensor glide inZones III, IV, V, VI and VII. In the case of extensorpollicis (EPL) repair, 60 degrees of IP joint flexioneffected 5 mm of tendon excursion at Lister’stubercle with the wrist in neutral and the thumbMCP joint in extension.

The controlled passive and/or active mobiliza-tion protocol is only used with patients who areable to comply with the regimen. While the firstfew treatments are labour-intensive and time-consuming in terms of splint fabrication andpatient education, the rate of progress and overallresult far outweigh these initial commitments.Where patients being treated with immobilizationare just commencing their active therapy pro-gramme at week 4, most patients being managedwith the controlled mobilization protocol arenearing the end of formal therapy. It is ourexperience that patients involved in this protocolalso benefit psychologically from early activeparticipation.

The treatment programmes described below willinclude conservative management of closed inju-ries together with static and controlled mobiliza-tion protocols following surgical repair of extensortendons. Discussion between surgeon and therapistis essential in determining the protocol mostsuitable for each patient.

Zones I and II

Interruption of the extensor mechanism over theDIP joint and the distal portion of the middlephalanx results in a flexion deformity of the joint,i.e. a mallet finger. The injury can be eitherclosed or open. These injuries are frequentlyassociated with a small avulsion fracture at thebase of the distal phalanx where the tendoninserts (Fig. 4.5).

Conservative management of closedinjury

Closed injuries are treated with a dorsal or volarsplint which maintains the DIP joint in extensionfor a period of 6 to 8 weeks. The position of theDIP joint in the splint needs to be criticallyevaluated as even slight flexion at the joint willcause attenuation of the tendon callus and aresultant extensor lag. Correct positioning withinthe splint is best maintained with taping rather thanstrapping (Fig. 4.6).

Figure 4.4. Technique for extensor tendon repair. Thehorizontal mattress suture is suitable for broad, flattendons with longitudinal fibres.

(a)

(b)

(c)

Extensor tendons 47

A layer of paper tape (e.g. Micropore orHypafix) applied to the skin prior to splintapplication will help prevent maceration. If thedistal joint is swollen, as is often the case with anassociated avulsion fracture, the splint may need tobe adjusted until swelling has stabilized. Cobanused beneath the splint will hasten resolution ofoedema. Full PIP joint mobility should be main-tained throughout this period.

If the patient demonstrates joint hypermobility,the splint can hold the DIP joint in slighthyperextension where this position can be gainedwith ease. Hypermobile joints often require pro-longed splinting, i.e. an additional 3 to 4 weeks.Whether the joint is splinted in neutral extensionor slight hyperextension, care is taken to avoidrestricting the circulation. The patient is instruc-ted in skin and splint care. The splint should beremoved at least once each day to ‘air’ the fingerand to check for adverse effects from the splint.The patient must ensure that the DIP joint issupported in full extension whenever the splint isremoved. While the splint is off, the skin isgently tapped and massaged to stimulate thecirculation.

Following the immobilization period, gentleactive DIP joint flexion exercises are com-menced. Night and intermittent day splinting ismaintained for a further 2 weeks. The patientattempts gentle unforced composite IP joint flex-ion. The finger is then straightened from theflexed position and extension range of the distaljoint is carefully assessed for any sign of lag.Exercise sessions are performed every 2 h with 5to 10 repetitions. A desirable DIP joint flexionrange during the first week is 20 to 30 degrees.The goal is then to achieve a further 10 degreesduring each ensuing week. Patients who demon-strate significant flexion range when the splint isremoved tend to be more prone to a recurrence ofthe deformity. If the DIP joint flexion deformityappears to be recurring, extension splinting isreinstituted for a further 2 weeks when thesituation is reassessed. Resisted activities areavoided until the 10th week.

If the mallet deformity has resulted in asecondary swan-neck deformity (i.e. the PIP jointhas assumed a posture of hyperextension inassociation with the flexion deformity at the DIPjoint), then both IP joints will need to beincluded in the splint. The PIP joint is placed in35 to 45 degrees of flexion to advance the lateralbands, while the DIP joint is held in neutralextension.

Figure 4.5. Types of mallet finger injury: (a) ruptureof distal extensor tendon; (b) avulsion fracture of thebase of the distal phalanx; (c) fracture separation ofepiphysis of distal phalanx.

Figure 4.6. A closed mallet finger injury is treatedwith 6 weeks of immobilization. The DIP joint ismaintained in full extension with a thermoplastic splintthat can be worn volarly or dorsally. The splint shouldallow full PIP joint flexion range.

Centralslip disruption

Oblique retinacular ligament

Joint axisLateral band


Open injury

Open wounds are best treated by repair andinternal fixation of the distal joint with a K-wirewhich is removed 2 to 3 weeks later. An extensionsplint is then applied for a further 3 to 4 weeks.Oedema in the distal segment of the finger ismanaged with Coban wrap (25 mm). Managementis then as for closed mallet injury.

Zones III and IV

Conservative management for closedinjury

Injury to the extensor tendon mechanism over thePIP joint can produce a buttonhole deformitywhich, if untreated, becomes a fixed deformitywith PIP joint flexion contracture and DIP jointhyperextension contracture (Fig. 4.7).

This deformity results when the lateral bandsfall below the axis of the PIP joint. When thisoccurs, the lateral bands become flexors of thejoint while at the same time concentrating theirextension force at the DIP joint. Shortening of theoblique retinacular ligaments quickly ensues. Thisfurther compounds loss of DIP flexion range whichis often the most disabling aspect of thisdeformity.

Suspected closed injuries of the central slip aretreated by splinting which maintains the PIP jointin full extension for a period of 6 weeks. The DIPjoint is left free to move. A variety of splints can beused to achieve this goal, e.g. thermoplastic fingersplint, Capener or a circumferential plaster cast.Because the finger is frequently swollen, a plastercast is the splint of choice (Fig. 4.8). This willprovide gentle even compression and will alleviatejoint discomfort. The cast may need to be changedevery few days until swelling has fully settled. Thecast should not impede DIP joint flexion whichshould be carried out passively and actively on anhourly basis with 10 to 20 repetitions. In mostcases, it can be left in place for about 10 daysbefore it softens and needs replacing.

If the deformity presents late, serial casting isused to overcome the flexion deformity prior to the6-week splinting period which will begin whenneutral extension range has been achieved. Gentledynamic flexion splinting of the DIP joint can beincorporated into the plaster to overcome tightnessof the oblique retinacular ligament.

Gentle unresisted active PIP joint flexion/extension exercises are commenced after 6 weeksof extension splinting. Night splinting in a ther-moplastic finger splint is maintained for a further2 weeks. Flexion of the PIP joint should beregained gradually over a number of weeks.Forced flexion of the joint will result in attenua-tion of the tendon and a recurrence of thedeformity.

Figure 4.7. Buttonhole deformity following injury tothe central slip of the extensor tendon. The lateralbands fall below the axis of the PIP joint and becomeflexors of this joint. Their extension force at the DIPjoint becomes more concentrated, resulting in DIPjoint hyperextension.

Figure 4.8. The PIP joint is plaster-casted to maintainfull extension. In the presence of a flexion contracture,serial casting is undertaken until full extension rangehas been regained. The 6-week splinting period is thencommenced from that time. Passive and active DIPjoint exercises are performed hourly.

Extensor tendons 49

Open injury

The traditional postoperative treatment followingrepair in Zones III and IV has involved immobili-zation of the PIP joint for a 6-week period. Due tothe significant tendon-bone interface and prox-imity to joint structures, this area is particularlyprone to adhesion formation resulting in restrictedtendon excursion, extensor lag and joint stiffness(Newport et al., 1990). Implementation of theactive short arc motion protocol as proposed byEvans (1994) has shown statistically superiorresults when compared with traditional manage-ment of these zones.

The author has now used this protocol forseveral years with good results. Minor modifica-tions to the original protocol have been made.These include:

1. A dorsal finger splint rather than a volar one.2. The use of only one template (instead of two)

during active exercise; the author does not usethe second template used for active DIP jointflexion exercises.

Active short arc motion protocol

Within a day or two of surgery, the inter-phalangeal joints are fitted with a thermoplasticfinger splint that maintains both joints in fullextension (i.e. 0 degrees). Maintenance of thefully extended position between exercise sessionsis most important in avoiding elongation of thetendon (Fig. 4.9).

To help eliminate digital oedema, the finger iswrapped in a single layer of Coban (25 mm)

applied over a non-bulky dressing in a distal toproximal direction. The initial splint may need tobe replaced if postoperative swelling has beensignificant.

A volar template splint is then made which willaccommodate 30 degrees of active PIP jointflexion and 25 degrees of active DIP joint flexion(Fig. 4.10). This splint is used every waking hour.The prescribed exercises are performed with thewrist in 30 degrees of flexion and the MCP joint inneutral extension or slight flexion. With the volartemplate splint held in place, the patient flexesboth IP joints to the limit of the splint and thenactively extends the digit to neutral extension atboth IP joints. The position of extension is held for

Figure 4.9. One or two days following open repair ofthe extensor tendon in Zone III or IV, the digit isfitted with a thermoplastic finger splint that maintainsboth IP joints in full extension. Coban wrap is usedover the dressing to treat postoperative oedema.

Figure 4.10. The volar template splint allows 30 and25 degrees of active flexion at the PIP and DIP joints,respectively. The wrist should be maintained in 30degrees of flexion and the MCP joints maintained inneutral extension during the manoeuvre.

Figure 4.11. Following active flexion to the limit ofthe volar splint, both IP joints are then activelyextended to neutral extension. This extended positionis held for several seconds before the manoeuvre isrepeated.


several seconds prior to again flexing to the limitof the splint (Fig. 4.11). This manoeuvre isrepeated 20 times every hour.

The other component of the hourly exerciseroutine involves active flexion of the DIP jointwith the PIP joint held in full extension. This canbe performed by undoing the distal strap of thesplint and stabilizing the PIP joint during activeflexion of the distal joint (Fig. 4.12). Movement ofthis joint is important in maintaining excursion ofthe lateral bands and the oblique retinacularligaments. If the lateral bands have not beenrepaired, the distal joint is fully flexed andextended. Where they have undergone repair,active DIP joint flexion is limited to 30 degreesand is followed by active DIP joint extension. Thisexercise is repeated 10 to 15 times.

If no extensor lag has developed, the volartemplate splint is modified or replaced after 2weeks to allow 40 degrees of PIP joint flexionduring the described manoeuvre. This is increasedto 50 degrees by week 3, and to 70 or 80 degreesby the end of the 4th week.

Static extension splinting between hourly exer-cise sessions is maintained for 6 weeks. Compositeactive finger flexion can begin at the end of the 5thweek. Return of flexion range should be gradual soas not to jeopardize PIP joint extension range.Fully resisted activity is avoided until the 10thweek.

Zones V and VI

These two zones lie between the MCP joints andthe extensor retinaculum. Closed injuries to thesagittal hood system over the MCP joints can occurwith blunt trauma and result in an extensor lag orulnar drift of the tendon. These injuries are treatedby splinting the involved MCP joint in neutralextension for a period of 4 to 6 weeks.

Tendon glide is more readily restored in theseproximal zones because this area has greater softtissue mobility. Nonetheless, adhesion of therepaired tendon to skin and bone does still occur,particularly if the injury has involved other struc-tures, e.g. bone and intrinsic musculature, follow-ing a crush injury.

Because the dorsum of the hand can accom-modate significant swelling, the propensity towardadhesion formation is great. Prompt managementof postoperative oedema is important in minimiz-ing the risk of these adhesions.


As for Zones III and IV, tendon injuries in thesezones can be managed by:

1. Static splinting and immobilization.2. Dynamic splinting and early controlled

motion.

The controlled motion protocol in these zones wasoriginally devised by Evans to overcome problemsassociated with complex injuries. Because of theundisputed biochemical and biomechanical advan-tages associated with early controlled motion,Evans now also uses the dynamic approach withthe simple tendon injury. Since starting on thedynamic protocol four years ago, this author hasnot used the static splinting method other than forpatients considered unable to cope with theregimen. Both methods of management will bedescribed.

1. Static splint and immobilization

On the 2nd or 3rd postoperative day the plaster isreplaced with a volar thermoplastic splint whichmaintains the wrist in 45 degrees of extension andthe MCP joints in 0 to 20 degrees of flexion. Theinterphalangeal joints are maintained in full exten-sion with a distal splint component that is removedfor IP joint exercises. The maintenance of IP jointextension is important in preventing palmar plate

Figure 4.12. The exercise session is completed withactive stabilized DIP joint flexion/extension exerciseswhich maintain DIP joint mobility and excursion ofthe lateral bands and oblique retinacular ligament. Ifthe lateral bands have been repaired, active DIP jointflexion is limited to 30 degrees for the first twoweeks. The PIP joint must be kept in full extensionduring DIP joint exercises.

Extensor tendons 51

contracture and subsequent flexion deformity. Thesplint extends from two-thirds along the forearm tojust proximal to the PIP joints so IP joint flexioncan be performed (Fig. 4.13).

Days 3 to 24

Because IP joint motion produces only minimalextensor tendon excursion in Zones V and VI(Brand and Hollister, 1993), active IP joint flexionexercises are performed every 2 h with 10 repeti-tions. These are followed by IP joint passiveextension. The distal component of the splint isworn between exercise sessions to maintain fulldigital extension.

When the sutures are removed after about 10days, the hand is bathed in warm, soapy water (withcare taken to maintain the correct position of wristand finger extension) and gentle oil massage isbegun. Scar is managed with silicone gel which isworn beneath Tubigrip elastic stocking. All traces ofoil are removed prior to application of the gel.

Day 24 onwards

At 312 weeks, gentle active motion of the MCP

joints is commenced. The following exercises areperformed:

1. Because wrist flexion is synergistic with fingerextension, active MCP joint extension exercisesare performed with the wrist in 20 to 30 degrees

of flexion. This position reduces the passivetension of the opposing extrinsic digital flexors.‘Place and hold’ exercises are performed withthe wrist supported in 20 to 30 degrees offlexion and the fingers supported in full exten-sion (Fig. 4.14). The supporting hand is thenremoved from the fingers and the patient isasked to maintain active digital extension withminimal exertion for several seconds beforerelaxing. The patient is then asked to activelyflex the MCP joints to 30 degrees, hold thisposition for several seconds, and then activelyextend the MCP joints to neutral extension.This exercise is repeated 10 to 20 times every 1to 2 hours.

2. The wrist is then extended to 45 degrees and thepatient attempts 40 to 60 degrees of MCP jointflexion with the IP joints maintained in exten-sion, i.e. the ‘intrinsic-plus’ position.

3. The third exercise involves active flexion andextension of the IP joints with the wrist in 20 to30 degrees of extension and MCP joints held inneutral extension range.

At week 4, composite flexion (i.e. all three fingerjoints flexing simultaneously), is begun with thewrist held in 45 degrees of extension. Protectivesplinting is maintained between exercise sessionsuntil the end of the 6th week.

At week 6, extrinsic extension exercises areadded to the programme. This involves extendingthe MCP joints while maintaining maximum IP

Figure 4.13. Postoperative splint following extensortendon repair for Zones V and VI using the staticimmobilization protocol. A removable distalcomponent (not shown) is worn at night and betweenexercise sessions to prevent flexion deformity at theinterphalangeal joints. Full active IP joint flexionshould be possible within the splint.

Figure 4.14. ‘Place and hold’ extension exercises areperformed with the wrist in 20 to 30 degrees offlexion while the fingers are supported in fullextension. The supporting hand is then removed andthe patient is asked to maintain active digital extensionfor several seconds.


joint flexion and is performed with the wrist inneutral extension. The patient can engage in lightunresisted daily activity at this stage.

If MCP joint flexion range is still restricted bythe 8th week, a gentle dynamic MCP joint flexionsplint is applied. Fully resisted activity is avoideduntil week 12 when the repair will have sufficienttensile strength.

2. Dynamic splinting and early controlledmotion

A dorsal forearm-based dynamic extension splintis fitted to the patient within the first 3 days ofsurgery. This splint holds the wrist in 40 to 45degrees of extension. Dynamic traction (usingrubber bands that are connected to nylon thread),maintain the MCP and IP joints at 0 degrees (orneutral) extension range. The tension of the rubberbands is checked daily to ensure that neutralextension range is being maintained (Fig. 4.15).

To help maintain IP joint extension at rest andduring active MCP joint flexion exercises, thefinger slings will need to be fairly wide and extenddistal to the PIP joints. Narrow slings that sitbeneath the proximal phalanx only, will allow theIP joints to assume a flexed position. When thepatient then attempts active MCP joint flexionexercises, there will be a strong tendency forflexion to occur at the already flexed IP joints,rather than at the MCP joints. In other words, thepatient will be practising extrinsic IP joint flexionexercises rather than intrinsic MCP joint flexionexercises. If wide finger slings do not prevent theIP joints from assuming a flexed posture, thinthermoplastic finger splints used inside the finger

slings and held on with Microfoam tape willovercome this problem. Alternatively, smallwooden ‘paddle-pop’ sticks can be inserted underthe digit during MCP joint exercise sessions.

On an hourly basis, the patient actively flexesthe MCP joints to a limit of 30 degrees and thenallows the rubber band traction to return the MCPjoints to neutral extension (Fig. 4.16). Thismanoeuvre is repeated 20 times. The author of thisprotocol (Evans, 1989) uses a volar blockingcomponent during exercise to limit active flexionto 30 degrees. Our patients are provided with a linediagram depicting the desired angle. Prior tocommencing the exercise, the manoeuvre is prac-tised on the opposite hand until the patientunderstands what is required. As a departure fromthe original protocol which has the MCP jointsflexing to a limit of 30 degrees for the first 3weeks, our patients are asked to flex to 45 degreesafter 2 weeks and to 60 degrees after 4 weeks.Splinting is maintained for a total of 6 weeks.

Maintenance of interphalangeal joint flexibilityis important throughout the splinting period. Gen-tle active IP joint flexion exercises can be carriedout with the wrist and MCP joints maintained inextension. Flexion of the IP joints in this positioncreates only minimal excursion of the extensortendon in Zones V and VI. Gentle active IP jointflexion exercises are performed 4 to 6 times dailywith 5 to 10 repetitions.

The finger slings are removed for this exerciseand the MCP joints are maintained in full extension.This can be effectively accomplished by holding apen across the base of the proximal phalanges. This

Figure 4.15. A dorsal forearm-based dynamicextension splint is fitted on the 3rd postoperative day.The digital slings maintain the MCP joints in neutralextension range.

Figure 4.16. The patient actively flexes the MCPjoints to a limit of 30 degrees every hour. The jointsare returned to neutral extension by the rubber bandtraction. This manoeuvre is repeated 20 times at eachhourly exercise session.

Extensor tendons 53

will accommodate almost complete IP joint flexionrange while allowing good visualization of the MCPjoints to ensure that they are maintained in fullextension. The IP joints are then passively extendedafter each flexion exercise.

At night, the patient uses either a static volarsplint that maintains the wrist and fingers inextension or a volar finger segment is added to thedynamic splint so that digital extension is main-tained (Fig. 4.17).

The majority of patients are able to demonstratefull composite flexion following removal of thesplint at 6 weeks and extensor lag is rarely seen.Where lag is present, extrinsic extension exercisesare instituted. Patients should avoid fully resistedactivity until 12 weeks following repair (Fig. 4.18).

Minimal active muscle-tendon tension(Evans and Thompson, 1993)

This manoeuvre is the corollary of the ‘place andhold’ exercise used in the early active motionprotocol following flexor tendon repair. It is basedon the tenodesis effect resulting from the syner-gistic action between the wrist extensors and thefinger flexors (Savage, 1988). The converse situa-tion, i.e. that wrist flexion is synergistic with fingerextension, is utilized following extensor tendoninjury.

If minimal active muscle-tendon tension(MAMTT) is to be incorporated into the therapyprogramme, it should be done so within 24 h ofsurgery before collagen bonds, which would limittendon glide, have formed (Gelberman et al., 1985).

It has been experimentally demonstrated that theexpected reduction in tensile strength followingrepair can possibly be prevented if the repair siteundergoes very early stress (Amiel et al., 1991).

Just as full passive IP joint flexion should beachieved prior to the commencement of activeflexion following flexor tendon repair, so too, fullpassive extension of all three digital joints is aprerequisite to the commencement of ‘place andhold’ active extension exercises. Full passivemobility into extension reduces the resistance ofthe antagonistic flexors. Resistance is also createdby dorsal hand oedema. For this reason, a gentlecompression bandage should be used postoper-atively to help control and eliminate oedemapromptly.

MAMTT is practised only in therapy. Thetherapist supports the patient’s wrist in 20 degreesof flexion and all digital joints in 0 degreesextension. Our patients are exercised into slighthyperextension if the opposite hand exhibits anydegree of hypermobility. When the finger jointscan be placed in neutral extension with ease (i.e. noresistance is perceived during passive extension),the therapist removes the supporting hand from thedigits and asks the patient to maintain the extendedposition with minimal active effort for severalseconds. The fingers are then relaxed and the MCPjoints fall into a position of about 30 degrees offlexion. The patient is then asked to actively extendthe MCP joints to neutral (0 degrees) extension andagain, maintain the extended position for severalseconds. This manoeuvre is repeated 20 timesbefore the hand is returned to the splint.

Figure 4.17. A static volar splint can be used at nightif the patient finds the dynamic splint awkward tosleep in.

Figure 4.18. Extrinsic EDC extension exercises areperformed by extending the MCP joints from thefisted position, i.e. interphalangeal joint flexion ismaintained while the patient actively extends the MCPjoints.


Zone VII

At this level the extensor tendons pass beneath theextensor retinaculum. Here the tendons are proneto proximal retraction. Repaired tendons in thisarea have a tendency to adhere to one another aswell as to the adjacent extensor retinaculum.Scarring is usually significant in this zone follow-ing repair. Silicone gel is applied to scar as soon asthe wound has healed.

If wrist extensors alone have been repaired (i.e.ECRL, ECRB or ECU), the wrist is splinted into40 to 45 degrees of extension for a period of 5weeks while the fingers are left free to move.Active wrist flexion exercises are commenced afterthis time.

If finger or thumb extensors are involved, theaftercare is the same as for Zones V and VI in thedigits, and III, IV and V for thumb zones (seebelow).

Injury to the thumb extensors

Zone I

Zone I is the area over the IP joint. Mallet thumbis quite rare. Closed injuries are treated withcontinuous IP joint extension (or slight hyper-extension where possible) splinting for 8 weeks.Tendon laceration in this zone is repaired andfollowed by 6 weeks of extension splinting. Afurther 2 weeks of intermittent splinting is main-tained after IP joint flexion exercises have beencommenced. See ‘Zones I and II’ (fingers) forexercise protocol.

Zone II

This zone involves the proximal phalanx andinjury to the tendon is usually secondary tolaceration or a crush injury rather than avulsion.Because the tendon has increased width in thiszone and curves over the phalanx, it usuallysustains only partial laceration. If the lacerationinvolves less than 50 per cent of the tendon, theinjury is treated conservatively with a dressing andsupport splinting of the IP joint. Gentle activemotion is commenced after 10 days. Supportsplinting between exercises is maintained for 4 to 6weeks.

Surgical repair is carried out for more significantlacerations. The thumb IP joint is then splinted infull extension for 6 weeks. See ‘Zones I and II’(fingers) for exercise protocol.

Zones III, IV and V

Zone III is the area over the MCP joint and mayinvolve one or both of the thumb extensors (i.e.EPL or EPB). The tendons in this area aresufficiently thick to allow the use of standard core-type sutures.

Zone IV is the area over the metacarpal. ZoneV is in the region of the extensor retinaculum andinjury to the EPL in this zone is consideredcomplex because the tendon is synovial at thislevel. Evans (1995) advocates that managementof the tendon in this zone should involve earlycontrolled passive motion and/or MAMTT exer-cises because dense adhesions at this level oftenlimit excursion of the repaired tendon.

1. Static splinting and immobilization

If the immobilization method is used postoper-atively, a static splint is fitted which holds thewrist in 40 degrees of extension and the thumb inradial abduction with the MCP and IP thumbjoints in neutral extension (Fig. 4.19). If only theEPB tendon is involved, the IP joint is left freeto move. A distal component, holding the IP jointin extension at night, is added to the splint toavoid the IP joint developing a flexion deformity.Care should be taken to avoid placing the MCPjoint in hyperextension. The fingers are left freeto move.

Between the 3rd and 4th week, the splint isremoved every 2 h for gentle active thumbexercises. Gentle active thumb joint flexion is

Figure 4.19. The static postoperative splint for EPLrepair holds the wrist in 40 degrees of extension andthe thumb in radial abduction. The thumb MCP and IPjoints are held in neutral extension. In the case ofhypermobile patients, care should be taken to avoidhyperextension of the MCP joint during splint fitting.

Extensor tendons 55

practised with the wrist held in maximum exten-sion. Active thumb extension is not performed withthe wrist held in extension. ‘Place and hold’MAMTT thumb extension exercises are com-menced by allowing the wrist to go into 15 to 20degrees of flexion while holding the thumb in fullextension, see p. 53. The support is then withdrawnfrom the thumb and the patient gently holds theextended thumb position with minimal effort forseveral seconds. These exercises are repeated 5 to10 times during the first week after whichrepetitions are increased.

When the splint is removed after 6 weeks, thethumb can be actively exercised with the wrist inall positions. Due to periarticular thickening,regaining flexion at the MCP joint can sometimesbe difficult. If this is the case, gentle dynamicflexion splinting can be instituted between the 6thand 7th week.

2. Dynamic splinting with controlledmobilization: used for Zones III, IV and Vfollowing EPL repair

The dynamic splint maintains the wrist and thumbin the following position:

1. Wrist in 40 degrees of extension.2. CMC joint in neutral extension.3. MCP joint in 0 degrees extension.4. IP joint at 0 degrees extension.

The dynamic traction sling is applied to thedistal phalanx (Fig. 4.20). The patient performsactive IP joint flexion to a range of 60 degreesevery hour during the day. This results in 5 mmof tendon excursion at Lister’s tubercle. Therubber band traction returns the IP joint toneutral extension. If the patient finds thedynamic splint awkward during sleep, a staticsplint is used at night. Care is taken to avoid aposture of hyperextension at the MCP joint.

The ‘place and hold’ MAMTT exercisesdescribed in the previous section can beemployed after the first day of surgery with thepermission of the treating surgeon.

After the 3rd week, gentle active MCP jointflexion is commenced out of the splint with thewrist maintained in extension. By the 5th week,composite thumb flexion and opposition with thewrist in extension can be begun. After the 6thweek, movements of the thumb can be practisedwith the wrist in all positions. Protective splint-ing between exercise sessions is maintained for 6weeks. The thumb should not be involved infully resisted activity until after the 12th week.

References

Amiel, D., Gelberman, R., Harwood, F. and Siegel, D. (1991).Fibronectin in healing flexor tendons subjected to immobili-zation or early controlled passive motion. Matrix II., 11,184–9.

Boyes, J. H. (1970). Bunnell’s Surgery of the Hand. J. B.Lippincott.

Brand, P. W. and Hollister, A. (1993). Clinical Mechanics of theHand. Mosby Year Book.

Browne, E. Z. and Ribik, C. A. (1989). Early dynamic splintingfor extensor tendon injuries. J. Hand Surg., 14A, 72.

Duran, R. J. and Houser, R. G. (1975). Controlled passivemotion following flexor tendon repair in zones II and III. InThe American Academy of Orthopaedic Surgeons: Sympo-sium on tendon surgery in the hand. Mosby.

Elliot, D. and McGrouther, D. A. (1986). The excursions of thelong extensor tendons of the hand. J. Hand Surg., 11B,77–80.

Evans, R. B. (1994). Early active short arc motion for therepaired central slip. J. Hand Surg., 19A, 991–7.

Evans, R. B. (1995). An update on extensor tendon manage-ment. In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 565–606, Mosby.

Evans, R. B. and Burkhalter, W. E. (1986). A study of thedynamic anatomy of extensor tendons and implications fortreatment. J. Hand Surg., 11A, 774–9.

Evans, R. B. and Thompson, D. E. (1993). The application ofstress to the healing tendon. J. Hand Ther., 6, 262–80.

Figure 4.20. The dynamic splint used following EPLrepair in Zones III, IV and V holds the thumb IP jointis held in a position of neutral extension by rubberband traction. The patient actively flexes the IP jointto 60 degrees every hour with 20 repetitions. Aftereach active flexion exercise, the patient relaxes thethumb and allows the rubber band traction to returnthe joint to neutral extension.


Gelberman, R. H., Vande Berg, J. S., Manske, P. R. and Akeson,W. H. (1985). The early stages of flexor tendon healing: Amorphologic study of the first fourteen days. J. Hand Surg.,10A, 776–84.

Gelberman, R. H., Botte, M., Spiegelman, J. and Akeson, W.(1986). The excursion and deformation of repaired flexortendons treated with protected early motion. J. Hand Surg.,11A, 106–10.

Harris, C. Jr. and Rutledge, G. L. Jr. (1972). The functionalanatomy of the extensor mechanism of the finger. J. BoneJoint Surg., 54A, 713.

Hung, L. K., Chan, A., Chang, J. et al., (1990). Early controlledactive mobilization with dynamic splintage for treatment ofextensor tendon injuries. J. Hand Surg., 15A, 251–7.

Kleinert, H. E. and Verdan, C. (1983). Report of the committeeon tendon injuries. J. Hand Surg., 8A, 794–8.

Newport, M. L., Blair, W. F. and Steyers, C. M. Jr. (1990).Long-term results of extensor tendon repair. J. Hand Surg.,15A, 961–6.

Newport, M. L., Pollack, G. R. and Williams, C. D. (1995).Biomechanical characteristics of suture techniques in exten-sor Zone IV. J. Hand Surg., 20A, 650–6.

Saldana, M. J., Choban, S., Westerbeck, P. and Schacherer, T. G.(1991). Results of acute Zone III extensor tendon injuriestreated with dynamic extension splinting. J. Hand Surg.,16A, 1145–50.

Savage, R. (1988). The influence of wrist position on theminimum force required for active movement of theinterphalangeal joints. J. Hand Surg., 13B, 262–8.

Further reading

Bendz, P. (1985). The functional significance of the obliqueretinacular ligament of Landsmeer. A review and newproposals. J. Hand Surg., 10B, 25.

Chow, J. A., Dovelle, S, Thomas, L. J. and Callahan, D. (1987).Postoperative management of repair of extensor tendons ofthe hand-dynamic splinting versus static splinting. Orthop.Trans., 11, 258–9.

Chow, J. A., Dovelle, S., Thomas, L. J., Ho, P. K. and Saldana,J. (1989). A comparison of results of extensor tendon repairfollowed by early controlled mobilization versus staticimmobilization. J. Hand Surg., 14B, 18–20.

Doyle, J. R. (1999). Extensor tendons-acute injuries. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 1950–87, Mosby.

Eaton, R. G. (1969). The extensor mechanism of the fingers.Bull. Hosp. Joint Dis., 30, 39–47.

Elson, R. A. (1986). Rupture of the central slip of the extensorhood of the finger: a test for early diagnosis. J. Bone JointSurg., 68B, 229.

Evans, R. B. (1986). Therapeutic management of extensortendon injuries. Hand Clin., 2, 157–69.

Evans, R. B. (1989). Clinical application of controlled stress tothe healing extensor tendon: a review of 122 cases. Phys.Ther., 68(12), 1041–9.

Evans, R. B. and Thompson, D. E. (1992). An analysis offactors that support early active short arc motion of therepaired central slip. J. Hand Ther., 5, 187–201.

Ishizuki, M. (1990). Traumatic and spontaneous dislocation ofextensor tendon of the long finger. J. Hand Surg., 15A,967–72.

Kim, P. T., Aoki, M., Tokita, F. and Ishii, S. (1996). Tensilestrength of cross-stitch epitenon suture. J. Hand Surg., 21B,821–3.

Landsmeer, J. M. F. (1949). Anatomy of the dorsal aponeurosisof the human finger and its functional significance. Anat.Rec., 104, 31–44.

Littler, J. W. (1967). The finger extensor mechanism. Surg.Clin. North Am., 47, 415.

Maddy, L. S. and Meyerdierks, E. M. (1997). Dynamicextension assist splinting of acute central slip lacerations.J. Hand Ther., 10, 206–12.

Masson, J. A. (1999). Hand IV: extensor tendons, rheumatoidarthritis and Dupuytren’s disease. Selected Readings in Plast.Surg., 8(35), 1–20.

Miura, T., Nakamura, R. and Torii, S. (1986). Conservativetreatment for a ruptured extensor tendon on the dorsum of theproximal phalanges of the thumb (mallet thumb). J. HandSurg., 11A, 229–33.

Newport, M. L. and Shukla, A. (1992). Electrophysiologic basisof dynamic extensor splinting. J. Hand Surg., 17A, 272.

Patel, M. R., Lipson, L. B. and Desai, S. S. (1986).Conservative treatment of mallet thumb. J. Hand Surg., 11A,45–7.

Rayan, G. M. and Mullins, P. T. (1987). Skin necrosiscomplicating mallet finger splinting and vascularity of thedistal interphalangeal joint overlying skin. J. Hand Surg.,12A, 548–52.

Stern, P. J. and Kastrup, J. J. (1988). Complications andprognosis of treatment of mallet finger. J. Hand Surg., 13A,32.

von Schroeder, H. P. and Botte, M. J. (1993). The functionalsignificance of the long extensors and juncturae tendinum infinger extension. J. Hand Surg., 18A, 641–7.

von Schroeder, H. P. and Botte, M. J. (1995). Anatomy of theextensor tendons of the fingers: variations and multiplicity.J. Hand Surg., 20A, 27–34.

5

Peripheral nerve injuries

Anatomy and pathophysiology

Peripheral nerves are complex composite structurescomprised of nerve fibres, connective tissue andblood vessels. The nerve fibres (or axons) extendfrom the nerve cell body to the receptor organs inthe motor and sensory endplates (Fig. 5.1). Theperipheral nerve carries three types of nerve fibres,i.e. motor, sensory and autonomic. The proportionof fibres in each nerve depends on the function ofthat nerve. In the upper limb, the median nerve hasthe greatest proportion of autonomic fibres. Motornerve fibres originate from cell bodies in the ventralhorn of the spinal cord and terminate at theneuromuscular junction. Sensory fibres originatefrom cell bodies in the dorsal root ganglia andterminate at receptors such as Pacinian corpuscles,Meissner’s corpuscles or as free nerve endings.

Various substances, e.g. proteins, enzymes, freeamino acids, polypeptides, etc., are synthesizedwithin the cell body and are necessary for thenormal function and survival of the axon. Axo-plasmic transport mechanisms move these sub-stances to the periphery (antegrade transport)where breakdown products are then returned in aproximal direction (retrograde transport). The axo-nal transport occurs at speeds that vary from about1–400 mm per day (Weiss and Gorio, 1982).

Most peripheral nerve axons are covered by amyelin sheath which is produced by flattened cellsknown as Schwann cells. Unmyelinated fibres aremainly small sensory fibres that conduct painimpulses from the skin. The unmyelinated gapsbetween the segments of the myelin sheath are

called nodes of Ranvier and are about 1–2 mmapart. This discontinuity in the myelin sheath allowsrapid impulse conduction as the action potentialleaps from one node to the next (Fig. 5.2).

Endoneurium

There are successive layers of connective tissuesurrounding the nerve fibres. The endoneurium isthe supporting collagenous tissue of the individualfibres. It takes part in the formation of the‘endoneurial tube’ which contains the myelinatedaxon and associated Schwann cells.

Perineurium

The nerve fibres with their related endoneuriumform aggregations called bundles, fasciculi orfuniculi which are the smallest units of the nervethat can be surgically manipulated. Fascicles areenclosed by the next connective tissue layer, theperineurium. This thin, lamellated sheath protectsthe contents of the endoneurial tubes, acts as amechanical barrier to external forces and providesa diffusion barrier that keeps certain substances outof the intrafascicular environment (Lundborg,1988). This sheath has great mechanical strengthand strongly resists longitudinal traction.

Epineurium

The epineurium is the outermost layer and islocated between the fascicles and superficially inthe nerve. The epineurium cushions the fasciclesfrom external pressure and allows movement of

Endoneural tissue layer

Schwann cell

Node of Ranvier

Myelin sheath

Axon


one fascicle upon another. The amount of epineur-ial connective tissue can vary enormously(25–75%) among nerves and at different levelswithin the same nerve (Sunderland and Bradley,1949). The epineurium is often more abundant inareas requiring greater protection such as wherethe nerve is in close proximity to bone or a joint(Sunderland, 1978).

Nerve vasculature

The peripheral nerve contains vascular networks inthe epineurium, the perineurium and the endoneu-rium. The blood supply to the peripheral nerve as awhole is provided by large vessels that approach thenerve segmentally along its course. Upon reachingthe nerve, these vessels divide into ascending and

Figure 5.1. Anatomy of a nerve cell showing the cell body and the nerve fibre (axon) with its component parts.(From Grabb, 1970, with permission.)

Figure 5.2. Most peripheral nerves are covered by a myelin sheath. The unmyelinated gaps between the segmentsof the myelin sheath are called nodes of Ranvier.

Peripheral nerve injuries 59

descending branches that run longitudinally andfrequently anastomose with the vessels in theperineurium and epineurium. The microvascularsystem has a large reserve capacity because axonaltransport and impulse propagation depend on a localoxygen supply (Lundborg, 1975).

Types of nerve injury

Nerves can be injured through trauma (laceration,crush or burn), compression (acute or chronic),stretching (traction), ischaemia, electrical current orthe late effects of radiation. The more commonnerve injuries are those involving lacerations whichcan be either partial or complete.

Sir Herbert Seddon has described three levels ofinjury: neurapraxia, axonotmesis and neurotmesis.The classification described by Sir Sidney Sunder-land has five categories of injury, the 1st, 2nd and5th of which correspond to the above three,respectively.

Neurapraxia

Neurapraxia is the mildest form of nerve injury andaxonal continuity is maintained. This injury

involves a localized block to conduction; however,proximally and distally to the lesion, nerve conduc-tion is preserved. A full recovery is expected and isusually complete within weeks or several months.

Axonotmesis

Axonotmesis is a more severe form of nerve injurywith disruption to the continuity of axons within thenerve. Because there has been axonal disruption,Wallerian degeneration of the distal axon will occur.There should, however, be good functional recoverybecause the supportive connective tissue remainsintact so that axonal regeneration is specific to theend organ. Functional recovery can take somemonths depending on the level of the disruption andhow far regeneration needs to occur.

Neurotmesis

Seddon’s last category of nerve injury, i.e. neu-rotmesis, refers to a complete transection of thenerve with loss of integrity of the perineurium andepineurium and corresponds to the 5th categorydescribed by Sunderland. The 3rd and 4th levels ofinjury in the Sunderland classification refer to

Figure 5.3. (a) Nerve degeneration. When there has been axonal disruption, there is degeneration of the axon andmyelin sheath distal to the wound and proximally, as far as the next node of Ranvier. Degeneration is initiated bythe ingrowth of macrophages which, together with the Schwann cells, clear the endoneurial tube of debris inpreparation for axon regeneration. (b) Nerve regeneration. The cell body and proximal axon stump enlarge tosatisfy the metabolic requirements for regeneration. The budding axons grow toward the distal segment andadvance along the Schwann cell columns.


varying degrees of intraneural disruption and loss offascicular integrity that can result from moderate tosevere traction and crushing injuries where theepineurium remains intact. Even if the perineuriumhas remained intact, intraneural haemorrhaging andoedema will often result in scar tissue formation,making nerve regeneration less likely.

Degeneration and regeneration

1. Wallerian degeneration

Degeneration of the distal axon begins at the levelof injury. The interruption to the flow of axoplasmresults in an accumulation of axoplasmic sub-stances at the proximal stump, where degenerationoccurs only as far as the next node of Ranvier.Degeneration is initiated by the ingrowth ofmacrophages which trigger the proliferation ofSchwann cells. The macrophages and Schwanncells clear the Schwann cell tube of myelin andaxoplasm in readiness for subsequent axon regen-eration (Stoll et al., 1989) (Fig. 5.3(a)).

2. Axon regeneration

Severed axons begin to send out a great number ofsprouts within six hours of injury. This occursproximal to the nerve lesion, at the most distalremaining node of Ranvier. These initial sproutsare usually resorbed; however, permanent sproutsare formed a day later. These grow towards thedistal segment and then advance along the endo-neurial tubes (or Schwann cell columns). Theregulation of axon growth and orientation iscomplex and reliant on a variety of biochemicaland biomechanical mechanisms. The maximumrate of axonal outgrowth in humans is about 1 mmper day (Fig. 5.3(b)).

Effect on associated tissues

Muscle changes

Muscle fibres usually undergo moderate tosevere atrophy by three months and moderate tosevere fibrosis after about one year. The degreeof atrophy and fibrosis varies significantlyamong individuals and can be affected by infec-tion, muscle stretching, muscle nutrition or theage of the patient. After a three-year period,muscle fibres exhibit progressive fragmentationand disintegration, with the muscle fibres grad-ually being replaced by fibrotic tissue (Bowdenand Gutmann, 1944).

Sensory loss

A completely severed nerve will result in loss ofsensibility involving the various sensory categories,i.e. light touch, pressure, pain, localization, tem-perature, spatial discrimination (e.g. two-pointdiscrimination) and functional gnosis. Where thenerve lesion is in continuity, the pattern of loss canbe variable, e.g. patients with a compressionneuropathy may show abnormality when testedwith a threshold test such as the Semmes-Weinsteinmonofilaments, but give a normal response tofunctional tests such as moving or static two-pointdiscrimination (Callahan, 1995).

Vasomotor changes

Following complete nerve disruption, the dener-vated hand will be warm to the touch for the first 2 to3 weeks due to vasodilation resulting from paralysisof the vasoconstrictors (Seddon, 1975). After thistime, the hand becomes increasingly cool to thetouch and readily affected by the surroundingtemperature (Sunderland, 1978). Colder weather istroublesome for most patients with nerve injury.

Disruption of sympathetic nerve function affectstissue nutrition, making skin more vulnerable toinjury. When injured, denervated skin usually takeslonger to heal. Nail changes include ridging andfurrowing, slowed growth and hardening. Atrophyof the epidermis results in decreasing prominence ofthe papillary ridges and there may be reduction orabsence of hand sweating. Skin that is smooth anddry is said to have reduced ‘tactile adhesion’(Moberg, 1962). This facility is important inpreventing the slippage of objects when gripping orwhen performing fine manipulative tasks (Clark,1999).

Nerve repair

The nerve is repaired as accurately as possible tofacilitate the regeneration of axons down the distalconnective tissue tubes. The more accurate thematching of sensory to sensory and motor to motornerve fibres, the better is the potential reinnervationof the end organs (Fig. 5.4).

Where possible, primary repair of the nerve isundertaken. In the presence of wound contamina-tion or associated injuries, secondary proceduresare performed when conditions are more favour-able, thereby giving a better result. Where there is agap in the nerve, grafting with a suitable donornerve (e.g. sural nerve, medial cutaneous nerve ofthe forearm) is undertaken to avoid tension at the


repair site which will encourage proliferation ofscar tissue. It is more difficult to match like axonswith a nerve graft; however, because there iscomplete absence of tension, joint mobilization cancommence earlier.

Technique

The proximal and distal nerve stumps are isolatedand every attempt is made to preserve the vascularattachments. Epineurial repair is the most commontechnique and is used for the completely transectednerve. This is the simplest type of repair, requiringminimal magnification and a minimum number ofsutures.

Perineurial (or fascicular) repair is the secondmost commonly used technique of nerve repair.Higher magnification is required to identify andbetter align the fascicular groups which should berepaired without tension. This technique allows forgreater accuracy in matching fascicles of similarsize. Individual fascicular repair is only rarelyperformed.

Healing of nerve repair

The repaired nerve sheath, whether epineurium orperineurium, takes 3 weeks to gain sufficienttensile strength to withstand stress. The repair issplinted without tension during this time.

Factors affecting nerve regeneration

Factors that can affect regeneration of nervefollowing injury or repair include:

1. The age of the patient (with increasing age thereis a reduction in receptor populations, e.g.Meissner corpuscles).

2. The level of injury (the more proximal thelesion, the less likelihood there is of a favour-able outcome).

3. Associated injuries, i.e. soft tissue loss, frac-tures, tendon injuries.

4. Degree of scar tissue.5. Accuracy of fascicular alignment.

Digital nerve repair

The digital nerves are the most frequently severedperipheral nerves (Clark, 1999). To avoid tensionat the repair site, digital nerve repairs are pro-tected for three weeks with a dorsal hand-basedsplint that maintains the MCP joints in 50 to 70degrees of flexion. The finger portion of thesplint should allow full IP joint extension. GentleIP joint exercises can be performed within thesplint. The patient should aim for full intrinsic IPjoint extension to the limit of the splint to avoidthe development of a PIP joint flexiondeformity.

Figure 5.4. Nerve suture techniques. (a) Laceration; (b) Epineurial suture; (c) Group fascicular suture; (d)Individual fascicular suture. (Reproduced from Brushart, T. M. Nerve repair and grafting. 1999. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) p. 1387, Churchill Livingstone,with permission.)


In the case of the thumb, a small hand-basedthumb post can be fitted which holds the MCP jointin 35 to 40 degrees of flexion while permittingmotion at the IP joint. Following the 3-weeksplinting period, the patient should avoid digitalhyperextension for the next 1 to 2 weeks.

Scar massage is begun following sutureremoval. The patient is instructed in skin care andhow to avoid injury to anaesthetic skin. Desensiti-zation exercises are performed at the repair site.Nerve regeneration is often accompanied byunpleasant paraesthesia or hyperaesthesia. A layerof Opsite Flexifix over the affected area oftenhelps ‘dampen’ these unpleasant sensations(Boscheinen-Morrin and Shannon, 2000). Sensoryretraining is begun when moving-touch can beperceived in the fingertip (see p. 68).

Early postoperative managementfollowing nerve repair at the wrist

After a median or ulnar nerve repair at wrist level,the hand is rested in a dorsal splint whichmaintains the wrist in slight flexion to avoid stresson the repair. The splint extends just beyond thetips of the fingers with the thumb remaining free.The splint is worn for 3 to 4 weeks by which timethere is sufficient connective tissue strength towithstand wrist movement (Fig. 5.5).

Nerve injuries at the wrist are frequently asso-ciated with tendon injuries. In the absence oftendon injuries, gentle active finger and thumbmovements can be commenced within the splint 1to 2 days after surgery when the inflammatoryresponse has subsided. Where there has been flexortendon involvement, the flexor tendon protocol is

used unless the surgeon advises that gentle earlyactive movement is allowed. To minimize stress onthe tendon repair, full passive finger flexion rangeshould be established prior to the commencementof active motion.

Scar management and desensitization

Sutures are removed 10 to 14 days after surgery.Scar softening and desensitization at the repair siteare commenced. Gentle oil massage should becarried out four to six times a day as part of a homeprogramme. Initially, massage is light otherwise itcannot be tolerated due to hypersensitivity. Astolerance to touch improves, pressure is graduallyincreased. Extreme hypersensitivity is managedwith transcutaneous electrical nerve stimulation(TENS).

Scar tissue that is dense and/or raised ismanaged with silicone scar gel which is applied toclean, dry, oil-free skin. The gel is also helpful inacting as a ‘shock absorber’ over the repairednerve.

Patient education

Patient education is an important aspect of man-agement following a peripheral nerve lesion.Patients should be informed of the following:

1. That muscle wasting increases in the earlystages following nerve injury.

2. How to avoid injury and take care of anaes-thetic skin; the patient will need to compensatevisually until protective sensation hasreturned.

3. How to avoid deformity due to muscle imbal-ance by corrective splinting and maintainingmobility of joint and soft tissue structures.

4. That the average rate of nerve regeneration isapproximately 1 mm per day.

5. That paraesthesia (tingling or pins and needles)and hyperaesthesia (painful hypersensitivity)are normal manifestations of nerve regenerationand will diminish with time and use of thehand.

Later stage postoperative management(4 to 6 weeks)

Gentle active wrist movements are commenced after4 weeks. Active wrist extension is initially carriedout with the fingers held flexed as there is oftenconsiderable tethering of structures, i.e. skin, nerveand tendons, resulting in soft tissue tightness.

Figure 5.5. Following repair of the median or ulnarnerve at the wrist, the hand is rested in a dorsal splintwhich maintains the wrist in slight flexion.


Overcoming soft tissue tightness

A mild flexion deformity of the wrist can bemanaged with a cock-up wrist splint which holdsthe wrist in neutral or slight extension. If theflexion deformity involves the wrist and fingers,serial extension casting is commenced between the4th and 5th weeks. The wrist and fingers are castedin a position of correction that provides only anegligible stretch. The initial cast should hold thewrist and fingers in the position achieved by thepatient when asked to actively extend to maximumrange (Fig. 5.6).

This position should not cause pain and thefingertips are checked for signs of skin blanchingthat indicate excessive pressure. The skin, partic-ularly areas of altered or absent sensibility, arechecked regularly for signs of pressure areas. Thesplint is used during the night and intermittentlythroughout the day. Wearing time may need to beincreased slowly from initial periods of 1 to 2hours. Hand oedema is managed with a lycrapressure glove which will also exert a gentleextension force to the digits.

Tendon adherence

Due to adherence of soft tissue structures at therepair site, active movement of the fingers andthumb occurs as a ‘mass’ action. To promoteeffective tendon glide, active finger and thumbexercises should be performed individually withstabilization of more proximal joints (Fig. 5.7).The patient is advised to perform short exercisesessions on an hourly basis with at least 10 to 15repetitions of movement. Finger movements are

more effectively performed when the wrist issupported in slight extension with a brace orthermoplastic splint.

Protection in cold weather

As the nerve-injured hand is vulnerable to theeffects of the cold, the use of a thermal glove forprotection in winter is recommended. Prior toexercise, the hand can be soaked in warm water for10 to 15 minutes to improve comfort and mobility.

Week 6 onwards

Gentle resistance is added to flexion and extensionexercises. The patient can attempt to activelyextend the fingers and wrist simultaneously ifflexor tightness has been overcome. Where softtissue tightness remains, serial casting is continueduntil full simultaneous wrist/digital extension hasbeen achieved. This process can sometimes takeseveral months.

The patient is encouraged to use the hand forlight daily activity. This may require functionalsplinting to oppose the thumb in a median nervelesion or the use of an anti-claw splint in an ulnarnerve lesion. Where gripping is a problem, utensilscan be ‘built-up’ with Handitube.

Figure 5.6. Serial plaster casts are used to overcomesoft tissue tightness on the volar aspect of the wristand/or fingers.

Figure 5.7. To promote tendon glide, interphalangealjoints should be exercised with stabilization of themore proximal joints.


Care of denervated skin

Denervated skin becomes smooth, shiny, fragileand prone to injury. Skin should be nourishedregularly to maintain suppleness. Apart from thepotential danger of heat and sharp implements,patients should be alert to pressure areas that canarise from friction during activity or pressure areasresulting from prolonged contact of the denervatedarea with splints or simply resting against a hardsurface. Frequently used utensils and tools can bepadded to avoid these problems.

Specific nerve lesions

Median nerve

In a median nerve lesion, the hand is referred to asa ‘simian’ or monkey hand because of the flatappearance of the thenar musculature and theinability to rotate the thumb to oppose the digits.The thumb tends to lie beside the index fingerbecause of the unopposed action of extensorpollicis longus and adductor pollicis (Fig. 5.8).

Low lesion

In a low lesion (i.e. at wrist level), the followingmuscles are affected: abductor pollicis brevis,flexor pollicis brevis and opponens pollicis (thesethree muscles comprise the thenar eminence) andthe 1st and 2nd lumbricals.

This results in:

1. Loss of thumb opposition.2. Hyperextension of the MCP joints of the index

and middle fingers from overaction of theextensor digitorum communis (EDC).

High lesion

A high lesion (elbow or neck) involves thefollowing muscles in addition to the above-mentioned: flexor pollicis longus (anterior inter-osseous branch of median nerve), flexor digitorumprofundus (FDP) to index and middle fingers(anterior interosseous branch), pronator quadratus(anterior interosseous branch), pronator teres(main branch of median nerve), flexor carpiradialis (main branch), palmaris longus (mainbranch) and flexor digitorum superficialis to alldigits (main branch) (Fig. 5.9).

This results in:

1. Loss of flexion to the thumb IP joint and fingerflexion (other than FDP action to the ring andlittle fingers).

2. Loss of forearm pronation.3. Weak radial deviation of the wrist.

The combined loss of sensibility and thumbopposition significantly affects hand function.Power grip is also affected because of the loss ofthe stabilizing action of the thumb. Loss of thumbpalmar abduction results in an inability to grasplarger objects such as a glass.

Figure 5.8. In a median nerve lesion the thenareminence has a flat appearance and the thumb liesbeside the index finger because of the unopposedaction of extensor pollicis longus and abductorpollicis.

Figure 5.9. This median nerve lesion was sustainedduring a crush injury to the forearm. Note the anteriorinterosseous syndrome with loss of function of FPLand FDP to the index finger. Note also the blister onthe tip of the index finger from contact with a kettle.


Trick movement

In a low-level median nerve lesion, pinch grip isachieved by the action of flexor pollicis longus andadductor pollicis against the radial side of theindex finger.

Lively splint

A rotation strap made from neoprene or stretchtape (e.g. Microfoam) is used to bring the thumb

into palmar abduction and opposition to facilitatepinch grip (Fig. 5.10).

Associated problems

1. Injury to skin (Fig. 5.11).2. Contracted thumb web space; this can be

overcome with serial C-splints that gentlystretch the web space (Fig. 5.12).

Figure 5.10. A rotation strap will elevate the thumbfrom its adducted posture and reposition it inopposition to the index and middle fingers.

Figure 5.11. Anaesthetic skin is very vulnerable toinjury from contact with hot surfaces, prolongedcontact with hard surfaces or friction ‘burns’ duringprolonged activity.

Figure 5.12. Serial C-splints are used to overcome atight thumb web that can develop following a mediannerve lesion.

Figure 5.13. An ulnar nerve lesion results in a clawdeformity of the ring and little fingers regardless ofthe lesion level.


Ulnar nerve

An ulnar nerve lesion results in a claw handregardless of the level of the nerve lesion. TheMCP joints of the ring and little fingers assume aposition of hyperextension and IP joint flexion(Fig. 5.13).

Low lesion (wrist level)

The following muscles are affected: abductor digitiminimi, flexor digiti minimi, opponens digitiminimi (these three muscles comprise the hypo-thenar eminence); adductor pollicis, all dorsalinterossei, all palmar interossei and the medialtwo lumbricals, i.e. the lumbricals to the ring andlittle fingers.

This results in:

1. Loss of finger abduction and adduction.2. Loss of thumb adduction.3. Clawing of the ring and little fingers – this is

due to loss of the interossei and the unopposedaction of extensor digitorum communis andextensor digiti minimi; this posture is known asDuchenne’s sign.

4. Inability to elevate the 5th metacarpal to enableeffective opposition between the thumb andlittle finger.

High lesion (above the elbow)

Together with the muscles involved in a low lesion,only two other muscles are affected: flexor carpiulnaris and flexor digitorum profundus to the ringand little fingers. This results in:

1. Weakened ulnar deviation of the wrist becauseof unopposed action of extensor carpi ulnaris.

2. Loss of flexion at the DIP joints of the little andring fingers; this is known as Pollock’s sign.

Power grip is significantly diminished in an ulnarnerve lesion. Pinch grip is also affected throughloss of the first dorsal interosseous muscle andadductor pollicis. This loss results in instability inpinching the thumb against the index finger(Froment’s sign).

Trick movements

1. In the absence of adductor pollicis, adduction ofthe thumb to the index finger is achievedthrough the combined action of flexor pollicislongus and extensor pollicis longus.

2. In the absence of the 3rd and 4th lumbricals,attempts to flex the MCP joints of the ring andlittle fingers will result in acute flexion of the IPjoints of these digits.

3. In the absence of the dorsal interossei function,finger abduction is mimicked by the digitalextensors, particularly in the case of the indexand little fingers which have a second extensor,i.e. extensor indicis proprius and extensor digitiminimi, respectively.

4. In the absence of volar interossei function,finger adduction is mimicked by relaxation ofthe digital extensors and contraction of theextrinsic finger flexors.

5. On attempting to oppose the little finger to thethumb, the IP joints of the little finger willmarkedly flex to compensate for the lack of 5thmetacarpal elevation owing to loss of opponensdigiti minimi function.

Associated problems

1. Abduction deformity of the little fingerThe abductor digiti minimi is the first muscle torecover following an ulnar nerve lesion at thewrist. As recovery proceeds, the little fingerbecomes progressively abducted. This posture cansometimes interfere with function. To overcomethis, the little finger can be buddy-strapped to theadjacent ring finger during activity.

2. Hyperaesthesia along the ulnar borderof the handNerve regeneration can be accompanied by hyper-sensitivity. This can be troublesome during writ-ing. Patients are encouraged to practise desensiti-zation exercises frequently throughout the day.Covering the affected area with a layer of OpsiteFlexifix can often help to reduce sensitivity.

3. Claw deformityThis deformity can be controlled with a variety ofanti-claw splints. The principle of these splints is tosupport the MCP joints in flexion thus allowing thelong extensors to act on the IP joints in the absenceof the ulnar-innervated intrinsics. This is known asBouvier’s manoeuvre (Fig. 5.14).

Radial nerve

A radial nerve lesion results in a wrist dropdeformity. The wrist falls into approximately 45degrees of flexion because the wrist flexors areunopposed by the wrist extensors. The thumb falls


into flexion and palmar abduction because thethumb intrinsics are unopposed by abductor polli-cis longus, extensor pollicis longus and extensorpollicis brevis (Fig. 5.15).

The MCP joints of the fingers fall into slightflexion because the intrinsic hand muscles, i.e. theinterossei and lumbricals, are unopposed by exten-sor digitorum communis.

The most common site of radial nerve injury is atthe radial groove of the humerus. Where this is thecase, the following muscles are affected: triceps,brachioradialis, extensor carpi radialis longus,extensor carpi radialis brevis, extensor carpi ulnaris,extensor digitorum communis, extensor pollicis

longus, extensor pollicis brevis and abductorpollicis longus.

This results in loss of:

1. Elbow extension (high lesion).2. Flexion of the elbow with the forearm in

midposition (i.e. brachioradialis function).3. Wrist extension.4. Digital MCP joint extension.5. Thumb extension.

Patients with a radial nerve palsy have poor gripfunction owing to a lack of stabilizing action of thewrist extensors.

Trick movements

1. There may appear to be contraction of the wristextensors following strong finger and wristflexion; this is purely due to relaxation of theflexors.

2. When the patient attempts to extend the fingers,flexion of the MCP joints will be observed dueto compensatory efforts by the intrinsic muscleswhose action is to flex the MCP joints andsimultaneously extend the IP joints.

3. Thumb IP extension is achieved during palmarabduction owing to the accessory insertion ofabductor pollicis brevis into the extensorapparatus.

Figure 5.14. (a) The static ‘spaghetti’ splint controls the hyperextension deformity of the MCP joints andfacilitates full interphalangeal joint extension by maintaining the MCP joints in slight flexion. (b) The splint doesnot hamper finger flexion and therefore allows the hand to function.

(a) (b)

Figure 5.15. This wrist drop deformity resulted frominjury to the radial nerve following a crush injury.Note that the thumb has not fallen into palmarabduction because the median nerve was also affected.Note also that the MCP joints have not fallen intoflexion because of skin contracture following extensivegrafting.

Splinting

A lively radial palsy splint can restore the recipro-cal tenodesis action of finger extension-wrist


flexion and finger flexion-wrist extension. Thissplint employs a static suspension line (nylonthread) (Fig. 5.16).

Hand function can also be significantlyenhanced with a simple cock-up wrist bracewhich places the wrist in 30 to 40 degrees of

extension. Patients achieve a functional degree ofdigital extension using the intrinsic musculatureto extend the IP joints (Fig. 5.17). It is theexperience of this author that most patients rejectthe lively splint in favour of the static wristbrace when provided with both splints. Regard-less of the type of splint used, it is important tomaintain wrist support to prevent stretching ofthe dorsal hand structures.

Sensory retraining after median nerverepair

Patients with a sensibility deficit have the ability toadapt and compensate for this loss if they are wellmotivated and prepared to engage the hand in day-to-day activities (Onne, 1962). A formal sensoryre-education programme can utilize learning prin-ciples such as attention, feedback, memory andreinforcement, and thereby expedite this process.These higher cortical functions, whilst not able tospeed up axonal regeneration or create the forma-tion of receptors, will help patients to interpret thealtered sensory impulses that reach the brain fromthe peripheral nerves.

The best known of these re-education pro-grammes are those described by Wynn Parry andSlater (1976) and Dellon et al. (1974). The aim ofretraining is to improve stereognostic ability, i.e.the recognition of an object by assessing its shape,weight, size and texture. This results in improvedfunctional dexterity even though two-point dis-crimination may be sub-optimal.

Figure 5.16. (a) In a radial nerve palsy a lively splint can restore the reciprocal tenodesis action of fingerextension-wrist flexion and finger flexion-wrist extension. When the hand is relaxed, the splint maintains the wristand fingers in neutral extension. (b) When the patient actively flexes the fingers, the wrist is brought into afunctional range of extension. This splint utilizes static tension by way of nylon monofilament.

(a) (b)

Figure 5.17. Surprisingly good function can beachieved with a simple wrist cock-up splint. Theslightly extended wrist accommodates optimal functionof the finger flexors and enables grasp. To releaseobjects, sufficient digital extension is usually gainedthrough the intrinsic musculature which extends theinterphalangeal joints.


Timing of programme commencement

When the patient is able to discern moving-touchin the fingertips, sensory retraining is begun.Moving-touch precedes light touch which, in turn,precedes discriminative touch (Callahan, 1995).Moving-touch can be assessed with the examiner’sfingertip or with Semmes-Weinstein monofila-ments which should record 4.31 or lower to qualifyfor retraining.

Formal sensibility testing for nerve regenerationcan be carried out every 6 to 8 weeks (See Chapter1 – ‘Assessment’).

Treatment parameters

Sensory retraining sessions should ideally beperformed four times each day. Sessions should bekept short and should take place in a quietenvironment to eliminate distraction.

Localization

While the patient may be able to perceive themonofilament or fingertip, localization of thestimulus may be inaccurate. Retraining incorpor-ates both moving- and constant-touch. Moving-touch perception returns ahead of constant-touchperception.

With the eyes closed, the stimulus is applied tothe skin. The patient is then asked to identify thearea with eyes opened. If localization is incorrect,the stimulus is again applied with the patientobserving the manoeuvre and integrating both thevisual and sensory impressions. Different areas ofthe palm and fingertips are then tested andretrained. Progress can be recorded on a gridpattern. Reinforcement by repetition is integral totraining.

Discrimination training using textures,shapes and everyday objects

With vision occluded, the patient is asked todescribe a variety of textures. These shouldinitially be quite different to allow for easydiscrimination and can include textures such as:sandpaper, sheepskin, velvet, pimple rubber, car-pet, leather, towelling and silk. The patient isencouraged to describe his sensory impressions,e.g. ‘rough’, ‘smooth’, ‘prickly’ or ‘spongy’, asthis description will often help the patient deducethe texture. In this way, the patient is reproducing

in slow motion what the normal hand doesautomatically and with great speed. Where distinc-tion is poor or inaccurate, the patient moves thetexture over the affected area again while watchingthe manoeuvre so that the tactile-visual image canbe reinforced.

The process is then repeated using differentshaped blocks. Larger sizes are used initially. Thepatient is encouraged to slowly move the blocks inthe hand, thereby gaining impressions of smoothsurfaces and corners. When these have beenmastered, the patient progresses to smaller sizes.

The final stage of retraining involves the use ofeveryday objects. Larger objects are used beforesmaller objects are introduced. The types of objectsused in testing and training should reflect theeveryday experience of the patient. Again, thepatient is encouraged to explore the object slowly,gleaning information regarding its size, shape,density, temperature and texture. More texturesand objects are added to the programme as thepatient demonstrates progress (Fig. 5.18).

Retraining sessions can be curtailed when thepatient has attained the desired level of functionaldexterity. The maintenance of this dexterity, how-ever, relies on the hand being engaged in daily useso that the training effect is not lost.

References

Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix:an effective adjunct in the management of pain andhypersensitivity in the hand. Aust. Occup. Ther. J., (submittedfor publication September, 2000).

Figure 5.18. The final stage of sensory retraininginvolves trying to identify everyday objects.


Bowden, R. E. M. and Gutmann, E. (1944). Denervation andreinnervation of human voluntary muscle. Brain, 67,273–313.

Callahan, A. D. (1995). Sensibility assessment: prerequisitesand techniques for nerve lesions in continuity and nervelacerations. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 129–52, Mosby.

Clark, T. (1999). Digital nerve repair: The relationship betweensensibility and dexterity. Thesis. (MSc – coursework). CurtinUniversity of Technology, Perth, Australia.

Dellon, A. L., Curtis, R. M. and Edgerton, M. T. (1974). Re-education of sensation in the hand after nerve injury andrepair. Plast. Reconstr. Surg., 53, 297–305.

Lundborg, G. (1975). Structure and function of the intraneuralmicrovessels as related to trauma, edema formation andnerve function. J. Bone Joint Surg., 57A, 938.

Lundborg, G. (1988). Nerve Injury and Repair. ChurchillLivingstone.

Moberg, E. (1962). Criticism and study of methods forexamining sensibility in the hand. Neurology, 12, 8–19.

Onne, L. (1962). Recovery of sensibility and sudomotor activityin the hand after nerve suture. Acta Chir. Scand. (Suppl.) 300,1–69.

Seddon, H. J. (1975). Surgical Disorders of the PeripheralNerves. Churchill Livingstone.

Stoll, G., Griffin, J. W., Li, C. Y. and Trapp, B. D. (1989).Wallerian degeneration in the peripheral nervous system:participation of both Schwann cells and macrophages inmyelin degradation. J. Neurocytol., 18, 671–83.

Sunderland, S. (1978). Nerves and Nerve Injuries. ChurchillLivingstone.

Sunderland, S. and Bradley, K. C. (1949). The cross-sectionalarea of peripheral nerve trunks devoted to nerve fibers. Brain,72, 428–49.

Weiss, D. G. and Gorio, A. (eds) (1982). Axoplasmic Transportin Physiology and Pathology. Springer-Verlag.

Wynn Parry, C. B. and Salter, M. (1976). Sensory re-educationafter median nerve lesions. Hand, 8, 250–7.

Further reading

Bell-Krotoski, J. (1995). Sensibility testing: current concepts. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 109–28,Mosby.

Birch, R. and Raji, A. R. M. (1991). Repair of median and ulnarnerves. Primary suture is best. J. Bone Joint Surg., 73B,154–7.

Brushart, T. M. (1994). Peripheral nerve regeneration: strategiesto augment specificity. Adv. Operat. Orthop. 2(Suppl.), 20.

Brushart, T. M. (1999). Nerve repair and grafting. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 1381–403, Churchill Livingstone.

Butler, D. S. (1991). Mobilisation of the Nervous System.Churchill Livingstone.

Chassard, M., Pham, E. and Comtet, J. J. (1993). Two-pointdiscrimination tests versus functional sensory recovery inboth median and ulnar nerve complete transections. J. HandSurg., 18B, 790–6.

Colditz, J. C. (1995). Splinting the hand with a peripheral nerveinjury. In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp.679–92, Mosby.

Conolly, W. B. and Morrin, J. (1981). Sensory rehabilitation inthe hand. Lancet, i, 135.

Curtis, R. M. and Dellon, A. L. (1980). Sensory re-educationafter peripheral nerve injury. In Management of PeripheralNerve Injuries (G. Omer and M. Spinner, eds) pp. 769–78,W. B. Saunders.

Dellon, A. L. Reinnervation of denervated Meissner corpuscles:a sequential histologic study in the monkey followingfascicular repair. J. Hand Surg., 1, 98.

Dellon, A. L. and Jabaley, M. E. (1982). Re-education ofsensation in the hand following nerve suture. Clin. Orthop.,163, 75.

Efstathopoulos, D., Gerostathopoulos, N., Misitzis, et al.(1995). Clinical assessment of primary digital nerve repair.Acta Orthop. Scand. Suppl., 264, 45–7.

Jerosch-Herold, C. (1993). Measuring outcome in median nerveinjuries. J. Hand Surg., 18B, 624–8.

Kallio, P. K. and Vastamaeki, M. (1993). An analysis of theresults of late reconstruction of 132 median nerves. J. HandSurg., 18B, 97–105.

Kendall, F. P. (1983). Muscles – Testing and Function. Williams& Wilkins.

Lundborg, G. (1993). Peripheral nerve injuries: pathophysiol-ogy and strategies for treatment. J. Hand Ther., 6, 179.

Millesi, H. (1985). Peripheral nerve repair. Terminology,questions and facts. J. Reconstr. Microsurg., 2, 21–31.

Moran, C. A. and Callahan, A. D. (1986). Sensibility measure-ment and management. In Hand Rehabilitation (Clinics inPhysical Therapy Series) (C. A. Moran, ed.) pp. 45–68,Churchill Livingstone.

Smith, K. L. (1995). Nerve response to injury and repair. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 609–626,Mosby.

Sunderland, S. (1990). The anatomy and physiology of nerveinjury. Muscle Nerve, 13, 771–84.

6

Tendon transfers

Where muscle function has been lost throughinjury or disease, hand function can be improvedby the transfer of an expendable muscle-tendonunit with the aim of restoring balance to the hand.Selected early transfers can optimize sensibility re-education when performed in the dominant hand(Citron and Taylor, 1987).

Prerequisites for tendon transfer

1. The patient must be a suitable candidate forreconstructive surgery.

2. All joints that will be affected either directly orindirectly by the transfer must be fully pas-sively mobile as transferred tendons cannotmove or correct stiffened or contracted joints.

3. All skin and soft tissue in the vicinity of thetransfer must be pliable and mobile. Any pre-existing soft tissue adherence will preventeffective tendon glide of the transferred tendon.Also, any soft tissue tightness, e.g. a contractedthumb web, will require correction prior tosurgery.

4. The muscle-tendon unit to be transferred mustbe sufficiently strong to perform its newfunction in its altered position.

Contraindications

1. Contracture of joints or skin that would limitmovement.

2. Lack of a suitable muscle or muscles fortransfer.

3. A progressive neuropathy, e.g. nerve damagefollowing radiation therapy.

4. Complicating medical conditions, e.g. musclespasm or circulatory inadequacy.

Preoperative preparation

A full muscle assessment of the arm is undertakento determine precisely which muscles are affectedand to ascertain which muscles can be used fortransfer. A muscle-strengthening programme isdevised for the patient to carry out independentlyso that motivation and commitment to therapy canbe evaluated (Warren, 1997).

All surgical stages must be planned prior to thefirst procedure. When choosing transfers, it isimportant to know the strength of the muscle andits excursion. The strength of a muscle is propor-tional to its cross-sectional area and is expressed asa tension fraction. The excursion of a muscle isdetermined by the length of its fibres. Because thisis constantly changing, the resting fibre length isrecorded. These measurements have been deter-mined by Brand et al. (1981) and abstracts fromtheir charts are given in the table below.

Surgical considerations

Choice of transfer tendon

The retraining of muscle function following trans-fer is easier when there is synergism between themuscle’s original function and its new action


(Davis and Barton, 1999). The use of superficialistendons may be an exception to this because thereis more independent cortical control compared toother muscles in the hand (Green, 1999).

Expendability of the donor

The removal of a tendon for transfer should notleave an unacceptable loss of function, e.g. onlyone of the two main wrist flexors (i.e. FCR orFCU) should be used as palmaris longus is aninadequate substitute for their loss.

Incision sites

The suturing of skin directly over tendon suturesshould be avoided, as should incisions along thenew line of the transferred tendon.

The transfer pathway

The most efficient transfer is one that passes in adirect line from its origin to the insertion of thetendon that it is substituting. If the transfer cannotperform its new function with a straight line of

pull, it should pass through no more than onepulley. Acute angulation of the transfer at thepulley should be avoided.

Where possible, natural ‘tracks’ should be used.If a new one is needed, there should be no forceused when tunneling through tissues such as scar,fascia or muscle. Tunnels need to be wide enoughto permit free passage of the tendon. If passagethrough a sheet of fascia is necessary, there shouldbe sufficient excision to minimize obstructingadhesions. The creation of a tunnel by force islikely to result in adhesions.

Single or dual insertion techniques

Tendon transfers are most efficient when theyperform only one active function. The effectivenessof a tendon transfer is reduced when it is expected toproduce two dissimilar functions even when theyare not directly opposed (Green, 1999).

Tension of transfers

The proper tension in a transfer is critical to theoutcome of the procedure. For some transfer

Table 6.1. Alphabetic list of the main muscles of the forearm with resting fibre length and tension fraction

Muscle Resting fibre length(cm)

Tension fraction(%)

Abductor digiti minimi 4.0 1.4Abductor pollicis brevis 3.7 1.1Abductor pollicis longus 4.6 3.1Brachioradialis 16.1 (average) 2.4Extensor carpi radialis brevis 6.1 4.2Extensor carpi radialis longus 9.3 3.5Extensor carpi ulnaris 4.5 4.5Extensor digitorum communis 5.6 (average) 1.4Extensor digiti minimi 5.9 1.0Extensor indicis proprius 5.5 1.0Extensor pollicis brevis 4.3 0.8Extensor pollicis longus 5.7 1.3Flexor carpi radialis 5.2 4.1Flexor carpi ulnaris 4.2 6.7Flexor digitorum profundus 6.5 (average) 2.9Flexor digitorum superficialis 7.1 (average) 2.1Flexor pollicis brevis 3.6 1.3Flexor pollicis longus 5.9 2.7Opponens pollicis 2.4 1.9Palmaris longus 5.0 1.0Pronator teres 5.1 5.5

Tendon transfers 73

procedures, e.g. the standard thumb opponensreplacement, tensions have been determined. Forothers, tension must be carefully estimated and acertain level of experience is necessary before thesurgeon develops the ‘feel’ for proper tension.Most tendon junctions stretch in the first threemonths and it is better to err on the side of slightlytoo much tension than not enough.

Tendon junctions

Where grafts are used to extend tendons or wherethere are mid-tendon junctions, tidy suturing isrequired. Loose tendon ends, long threads, promi-nent knots or potentially irritating non-absorbablesutures, e.g. silk, should not be left exposed as theymay irritate and/or cause adhesions.

Healing times

The repair is either tendon to tendon or tendon tobone and requires about 4 weeks of healing beforeit is safe to subject it to the stress of activemovement. Healing also occurs along the course ofthe transferred tendon and can result in adhesionsto surrounding tissues.

Opponensplasty for median nervepalsy

Abductor pollicis brevis is the prime muscle ofthumb opposition. Some opposition is also pro-duced by opponens pollicis and flexor pollicisbrevis (Cooney and Linscheid, 1984). Following acomplete lesion of the median nerve, thumbabduction and opposition are frequently retainedbecause of the variability of thenar muscle innerva-tion. The flexor pollicis brevis muscle frequentlyhas dual median and ulnar nerve innervation(Rowntree, 1949).

The success of opponensplasty will be deter-mined by the quality of sensibility. In the case of ahigh median nerve lesion in adults, sensoryrecovery is usually poor and the benefit of thisprocedure is doubtful.

Requirements prior to opponensplasty forlow level lesion (wrist)

1. Normal or maximal thumb web span.2. Mobile thumb joints.3. Full mobility of the unaffected digits.

4. Supple skin so that the tendon transfer is notlimited by subdermal scarring.

The basic requirements for restoring thumb oppo-sition were established by Bunnell (1938) whoidentified the pisiform as the best location for afixed pulley because this keeps the transfer in linewith the abductor pollicis brevis muscle.

Opponensplasty using superficialis of thering finger

Technique

The superficialis tendon of the ring finger isharvested through an incision in the distal palm toavoid injury to the flexor sheath at the level of thePIP joint. Where patients exhibit joint hyper-mobility, tenodesis of the PIP joint is performed toprevent a secondary hyperextension deformity.

About 3–4 cm proximal to the wrist, a flap israised using the anterior half of the flexor carpiulnaris tendon. The flap is elevated as far as 1 cmproximal to the tendon’s insertion into the pisi-form. It is then fashioned into a loop with a 1 cmcentral diameter and serves as a pulley (Bunnell,1938). To prevent migration of the pulley, the

Figure 6.1. Opponensplasty for low median nervepalsy using FDS of the ring finger as motor.


distally based slip of FCU can be attached to thetendon of extensor carpi ulnaris (Sakellarides,1970) (Fig. 6.1).

The flexor retinaculum and ulnar border of thepalmar aponeurosis can provide an alternativepulley to the one described (Thompson–Royletransfer, 1942). The superficialis tendon is dividedinto two slips. One slip is attached as far distally aspossible to the abductor pollicis brevis tendon andthe other, more distally, into the extensorapparatus.


The wrist is immobilized in neutral extension withthe thumb held in full opposition and the IP joint ofthe thumb held in extension to protect the attach-ment to the extensor mechanism (Fig. 6.2). Thefingers are left free to move. If the PIP joint has

been tenodesed to prevent hyperextension deform-ity, it should be splinted in about 45 degrees offlexion during the immobilization period.

Weeks 0 to 4

During the first 3 to 4 postoperative weeks, thetransfer is completely immobilized to protect thetendon junctions. Gentle active finger movementscan be performed. If the postoperative plaster iscomfortable and maintains the correct position, itneed not be replaced. During this period, however,the splint should be checked regularly to ensurethat it is comfortable and that the correct position isbeing maintained.

Weeks 4 to 6

The hand is taken out of the splint and active use ofthe transferred tendon is commenced. Throughoutthis fortnight, the splint is worn between exercisesessions and during sleep. With the wrist held inmild flexion and the other digits trapped inextension, the patient is asked to flex the donorfinger, i.e. the ring finger. This action shouldproduce some thumb abduction and opposition. Ifthis is not occurring, it may be necessary to slightly‘straighten’ the wrist so that a little tension isplaced on the transfer to help facilitate its action.This action is repeated until the patient is able todemonstrate spontaneous movement of thethumb.

To help facilitate this spontaneity, the patient canbe asked to touch the thumb to the little finger or topick up a light object. Non-resistive activity, suchas playing board games, should be encouraged. Assensory recovery may still be suboptimal, the gamepieces should not be too small and can be coveredwith a textured fabric to enhance grip. Exerciseand activity sessions are kept short at this stage toavoid fatigue of the transferred muscle. The patientshould perform 6 daily sessions with each sessionlasting between 5 and 10 minutes (Stanley,1995).

From the 5th week onward, active abduction andopposition are practised with the hand in allpositions. It is important to emphasize wristmovements as these alternately relax and tightenthe opponensplasty (Davis and Barton, 1999). Ifthe patient is overusing flexor pollicis longusduring active exercise, the thumb IP joint can beimmobilized in extension with a small thermo-plastic splint to isolate the action of the transfer.

Figure 6.2. The position of immobilization followingopponensplasty has the wrist in neutral extension andthe thumb in full opposition with the IP joint held inextension.

Tendon transfers 75

Scar softening is an important part of the homeprogramme during this time. Oil massage along thescar line should be carried out 4 to 6 times daily.Silicone gel is used at night and in betweenexercise sessions.

Week 6 onwards

Graded resistance is applied to the transferredtendon by way of exercise and activity. Massageand pressure therapy are continued until scarresolution has been achieved. The transfer shouldbe able to withstand normal loading 12 to 14 weeksafter surgery.

Alternative procedures

1. Extensor indicis propriusopponensplasty

This transfer has an advantage over the superficialistransfer in that it does not compromise gross gripstrength through the loss of a digital flexor(Burkhalter et al., 1973). The ulnar border of thewrist is used as a natural pulley and the transfer isinserted into the tendon of abductor pollicis brevis.

Because extensor indicis proprius has a rela-tively short excursion, the wrist should be immobi-lized in 30 degrees of flexion so as to relax thetransfer during the immobilization period (Davisand Barton, 1999).

2. Camitz palmaris longusopponensplasty

This procedure is used for patients with a func-tional disability related to severe carpal tunnelsyndrome and can be performed at the same timeas carpal tunnel release. The palmaris longustransfer is usually attached to the insertion ofabductor pollicis brevis (Terrono et al., 1993) andrestores palmar abduction rather than opposition(Fig. 6.3).

The wrist is maintained in neutral extension withthe thumb in opposition and the MCP joint inextension. The splint is maintained for 4 weeks andformal therapy is rarely required following thisprocedure.

3. Less commonly used transfers

These include: abductor digiti minimi (Huber),extensor carpi ulnaris, extensor carpi radialislongus and extensor digiti minimi.

Ulnar nerve palsy

The classic ulnar claw deformity is not alwaysapparent following injury to this nerve. There canbe several anomalous neural patterns of the ulnarnerve in the forearm and hand. This may result inall of the lumbricals being innervated by themedian nerve in which case there would be noclawing of the digits.

In 50 per cent of upper limbs, there is dualinnervation to the third lumbrical and this wouldresult in clawing of the little finger only in a lowlevel palsy. In 10 per cent of hands, the mediannerve partially or completely innervates the firstdorsal interosseous muscle with rare innervationby the radial nerve also occurring (Kaplan andSpinner, 1980).

Figure 6.3. The Camitz opponensplasty utilizes thepalmaris longus tendon which is lengthened with astrip of palmar aponeurosis and attached to theabductor pollicis brevis insertion. (Reproduced fromDavis, T. R. C. and Barton, N. J. Median nerve palsy.1999. In Green’s Operative Hand Surgery(D. P. Green, R. N. Hotchkiss and W. C. Pederson,eds) p. 1509, Churchill Livingstone, with permission.)


Preoperative requirements for low levelulnar nerve lesion

1. The PIP joints must be fully mobile in passiveextension and the MCP joints fully mobile inpassive flexion.

2. Soft tissues should be free of contracting scarand have adequate circulation.

Available donors

Tendon transfers in an ulnar nerve palsy aim torestore flexion of the MCP joints and thumbadduction. Almost any tendon that crosses the wristcan be used. Suitable muscle-tendon units include:flexor digitorum superficialis, extensor carpi radia-lis longus, extensor carpi radialis brevis, flexor carpiradialis, brachioradialis and palmaris longus. Thesmaller extensors, i.e. extensor indicis proprius andextensor digiti minimi (quinti) can provide intrinsicfunction with the transfer of a muscle to two fingerseach (original Fowler technique) (Fig. 6.4).

Superficialis transfers are designed to integrateMCP joint and IP joint motion. They do not,however, result in increased grip strength (Hast-ings and McCollam, 1994). The use of a wrist

extensor to flex the MCP joints will improve grosspower grip.

Intrinsic transfer using extensor carpiradialis longus

The extensor carpi radialis longus tendon islengthened with a free tendon graft using palmarislongus (or plantaris). The graft is split into twoslips that are passed through the intermetacarpalspaces between the long/ring and ring/little fingersrespectively (Fig. 6.5).

Each slip is then passed volar to the deeptransverse metacarpal ligament and inserted into adrill hole, on the radial aspect of the proximalphalanges of the ring and little fingers. Manysurgeons transfer to all four fingers.


The hand is splinted in the following position:

1. Wrist in 45 degrees of extension.2. MCP joints in 70 degrees of flexion.3. IP joints in full extension.4. The thumb remains free (Fig. 6.6).

Figure 6.4. The Fowler transfer for ulnar nerve palsy uses the EIPand EDQ (or EDM) tendons, each divided into two slips.

Figure 6.5. Intrinsic transfer using extensor carpi radialis longus.The tendon is lengthened with a free graft using palmaris longus (orplantaris). The graft is split into two slips which attach to the radial

sides of the proximal phalanges of the ring and little fingers.

Tendon transfers 77

Weeks 0 to 4

The hand and forearm are maintained in thedescribed position for the first postoperativemonth. If postoperative swelling has been sig-nificant, it may be necessary to change the castafter several days so that the position of immobili-zation is not lost.

Weeks 4 to 6

When the hand is removed from the splint andplaced on the table, there will be a slight relaxationof the positions of wrist extension and MCP jointflexion. To prevent further extension of the MCPjoints, the therapist places light pressure over thePIP joints. The patient is then asked to activelyextend the wrist which should result in some MCPjoint flexion. Extension of the IP joints should be

maintained during this manoeuvre. The hand isreturned to the splint after each exercise sessionuntil the end of the 6th week.

The patient should perform this exercise on a 1 to2 hourly basis with 5 to 10 repetitions during the 1stweek of active exercise. By the 2nd week, the patientlearns to localize the action of MCP joint flexionwithout having to extend the wrist and practises themovement with the hand in all positions, i.e. palm upand with the hand on the side.

By the 5th week, emphasis is placed on activeflexion and extension of the fingers while main-taining MCP joint flexion. Gentle active wristflexion is also begun.

Weeks 6 to 12

Light gripping activities are commenced. If activefinger flexion is incomplete, the handles of every-day utensils, e.g. cutlery, can be temporarilyenlarged to encourage function.

Graded resistance is applied to MCP jointflexion with the IP joints extended, i.e. intrinsicflexion. The activity programme is upgraded torestore maximum power grip. Workers involved inmanual work can return to employment after the14th week.

Alternative dynamic procedure

Superficialis transfer

The superficialis tendon of the middle (long) orring finger is divided into 2 slips (for the ring/littlefingers only) or 4 slips for all digits. Each slip isattached in one of three ways (Fig. 6.7):

1. To the lateral band of the dorsal apparatus (thisinsertion is associated with a high incidence ofswan-neck deformity).

2. Into the A1 or A2 pulley of the flexor sheath.3. Into a drill hole in the proximal phalanx.

The position of immobilization is: wrist in slightflexion (15 to 20 degrees), MCP flexion of 60 to70 degrees and full extension of the IP joints(Fig. 6.8).

Static procedures

1. Capsulodesis of the MCP joints

A short flap of the MCP joint volar plate is drawnproximally and sutured into the neck of themetacarpal, thereby holding the MCP joints in 20

Figure 6.6. The position of immobilization followingintrinsic transfer using ECRL is as follows: wrist in 45degrees of extension, MCP joints in 70 degrees offlexion, IP joints in full extension and the thumbremaining free.


degrees of flexion (Zancolli, 1957). Postoper-atively, this position must be maintained for atleast 6 weeks.

2. Flexor pulley advancement(Bunnell, 1942)

The A2 pulley is split on each side for 1.5 to 2.5 cmto the middle of the proximal phalanx. This resultsin ‘bowstringing’ of the flexors, thereby increasingmovement across the MCP joint.

3. Static tenodesis

A free tendon graft (e.g., ECRL, ECU) is passedfrom the lateral band of the dorsal extensorapparatus to the deep transverse metacarpal liga-ment in the palm where it is sutured with theMCP joint in 45 degrees of flexion. Each graftedfinger functions independently (Parkes, 1973).

The thumb in ulnar nerve palsy

Patients with ulnar nerve palsy lose 75 to 80 percent of pinch grip power (Mannerfelt, 1966). Theadduction force in key pinch comes primarilyfrom adductor pollicis and the radial head of thefirst dorsal interosseous muscle (Omer, 1999).Restoration of pinch grip power following tendontransfer ranges between 25 and 50 per cent ofnormal.

Figure 6.7. The superficialis transfer for ulnar nervepalsy using the FDS tendon of the middle (long) orring finger. The tendon is hatched back to the level ofthe flexor retinaculum and divided into four slips(coloured black) which are rerouted volar to the deeptransverse metacarpal ligament. The slips are attachedeither to the lateral band of the dorsal apparatus, intothe A1 or A2 pulley or into a drill hole in theproximal phalanx.

Figure 6.8. The position of immobilization following a superficialis transfer holds the wrist in slight flexionbecause of the flexor route of the transfer.

Tendon transfers 79

Corrective procedures

1. Thumb adduction

The restoration of thumb adduction can be ach-ieved with a variety of transfers using the fol-lowing donors: extensor carpi radialis brevis,extensor carpi radialis longus, brachioradialis,extensor indicis proprius, extensor carpi ulnarisand flexor digitorum superficialis. The wristextensors and brachioradialis require lengtheningwith free grafts.

2. Index abduction

Tendon transfers to improve abduction of theindex finger give some stability during pinch,but provide only modest improvement inpower. The following transfers are used to insertinto the tendon of the first dorsal interosseous:abductor pollicis longus (extended with a freegraft), extensor indicis proprius, palmaris longus(lengthened with palmar fascia), brachioradialis,extensor pollicis brevis and flexor digitorumsuperficialis.

Postoperatively, the index finger is held inabduction and extension with the wrist in slightflexion for a period of 3 weeks after whichactive movement is commenced.

3. Arthrodesis

Fusion of either the MCP or IP joint of thethumb is an alternative to tendon transfer andcan provide greater stability for pinch gripfunction.

Radial nerve palsy

The classic ‘wrist drop’ resulting from a radialnerve palsy has significant consequences forhand function. When the wrist cannot be stabi-lized in extension, the power of the long flexorsis minimized, thereby seriously impairing gripfunction (Reynolds, 1995). Where the radialnerve is irreparable, the following functions willneed to be restored:

1. Wrist extension.2. Finger extension (at the MCP joints).3. Thumb extension and abduction.

In the absence of associated injury to the medianand ulnar nerves, there are many transfer options

available. Early tendon transfer is an option forproviding an ‘internal splint’ to enhance functionwhile awaiting nerve regeneration. The earlytransfer of pronator teres to extensor carpi radia-lis brevis significantly improves hand function(Burkhalter, 1974).

Preoperative requirements

1. The wrist must be passively mobile inextension.

2. The MCP joints must be passively mobile inextension.

3. The thumb web space must be normal.4. There must be a full range of forearm supina-

tion/pronation.5. There must be full range of elbow flexion and

extension.

Tendon transfer for radial nerve palsy

The most commonly used transfers to restoreextension to the wrist, MCP joints and thumbjoints include:

1. The FCU transfer

Pronator teres to extensor carpi radialis brevis.Flexor carpi ulnaris to extensor digitorumcommunis.Palmaris longus to rerouted extensor pollicislongus.

2. The superficialis transfer

Pronator teres to extensor carpi radialis longusand brevis.Flexor digitorum superficialis (middle finger) toextensor digitorum communis.Flexor digitorum superficialis (ring finger) toextensor indicis proprius and abductor pollicislongus.Flexor carpi radialis to abductor pollicis longusand extensor pollicis brevis.

3. The FCR transfer

Pronator teres to extensor carpi radialis brevis.Flexor carpi radialis to extensor digitorumcommunis.Palmaris longus to rerouted extensor pollicislongus.

EPL

PL

APL

PT

EDC

FCU

ECRL and ECRB


Radial nerve palsy correction with FCUtransfer

Technique

1. Pronator teres is stripped with its periostealinsertion from the radius, rerouted superficial tothe brachioradialis and extensor carpi radialislongus, and then sutured as distally as possibleto the extensor carpi radialis brevis.

2. Flexor carpi ulnaris is freed extensively tocreate a direct line of pull from its origin to itsnew insertion into the tendons of extensordigitorum communis (using an end-to-sidejunction) just proximal to the extensorretinaculum.

3. Extensor pollicis longus is rerouted out of theextensor retinaculum. The palmaris longus isdivided at the flexor retinaculum and sutured tothe rerouted EPL, creating a combined abduc-tion-extension force to the thumb (Fig. 6.9).


Splint position (Fig. 6.10)

1. Elbow in 90 degrees of flexion.2. Forearm in about 30 degrees of pronation.

3. Wrist in 45 degrees of extension.4. MCP joints in 10 to 15 degrees of flexion; the

splint extends just proximal to the PIP jointswhich are left free to move.

5. Thumb in maximum extension and abduction.

Note: An alternative to the long arm splint is asugar tong splint which allows limited elbowmotion, however does not cause undue tension onthe suture lines.

Weeks 0 to 4

Active IP joint flexion and passive IP jointextension exercises are carried out regularlythroughout the day. Sutures are removed 10 to 14days after surgery.

Weeks 4 to 6

The long arm splint is replaced with a short armversion that is worn for another 2 weeks andmaintains the wrist, MCP joints and thumb inextension. The splint is removed every 2 h and the

Figure 6.9. Flexor carpi ulnaris (FCU) transfer forradial nerve palsy using pronator teres (PT), FCU andpalmaris longus (PL) as motors.

Figure 6.10. The position of immobilization after FCUtransfer for radial nerve palsy is as follows: elbow in90 degrees of flexion, forearm in about 30 degrees ofpronation, wrist in 45 degrees of extension and MCPjoints in 10 to 15 degrees of flexion. The splintextends just proximal to the PIP joints to allow themfull flexion range. The thumb is held in maximumextension and abduction.

Tendon transfers 81

following active exercises are performed insequence and repeated 5 to 10 times.

1. With the arm held in the same position that ismaintained in the splint, the patient is asked togently pronate the forearm. This will result inslight wrist extension.

2. The patient is then asked to gently flex thewrist. This action will result in simultaneousfinger and thumb extension. These man-oeuvres are repeated until the patient is ableto demonstrate spontaneous use of thetransfers.

Following this procedure, there is a high inci-dence of tendon adhesion along the course of thetransfers. Firm oil massage and silicone gelcompression are therefore important aspects ofmanagement.

Week 6 onwards

The patient can now discard the splint. Com-bined flexion (i.e. simultaneous flexion of allthree finger joints) can be commenced. Activewrist flexion exercises are emphasized to over-come soft tissue tightness on the dorsum of theforearm and hand.

The patient can use the hand for light dailyactivities which will encourage spontaneousmuscle action and improve finger flexibility.Activities are gradually upgraded to provideincreasing resistance with the aim of restoringpower to the hand.

A well-motivated patient should have goodcontrol of function by the 3rd month althoughmany patients take as long as 6 months to gainoptimal recovery.

References

Brand, P. W., Beach, R. B. and Thompson, D. E. (1981).Relative tension and potential excursion of muscles in theforearm and hand. J. Hand Surg., 6, 209–19.

Bunnell, S. (1938). Opposition of the thumb. J. Bone JointSurg., 20, 269–84.

Bunnell, S. (1942). Surgery of the intrinsic muscles of thehand other than those producing opposition of the thumb.J. Bone Joint Surg., 24, 1–3.

Burkhalter, W. E. (1974). Early tendon transfer in upperextremity peripheral nerve injury. Clin. Orthop., 104,68–79.

Burkhalter, W., Christensen, R. C. and Brown, P. (1973).Extensor indicis proprius opponensplasty. J. Bone JointSurg., 55A, 725–32.

Citron, N. and Taylor, J. (1987). Tendon transfer in partiallyanaesthetic hands. J. Hand Surg., 12B, 14–18.

Cooney, W. P. and Linscheid, R. L. (1984). Opposition of thethumb: an anatomic and biomechanical study of tendontransfers. J. Hand Surg., 9A, 777–86.

Davis, T. R. C. and Barton, N. J. (1999). Median nerve palsy.In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) pp. 1497–525,Churchill Livingstone.

Green, D. P. (1999). Radial nerve palsy. In Green’s OperativeHand Surgery (D. P. Green, R. N. Hotchkiss and W. C.Pederson, eds) pp. 1481–96, Churchill Livingstone.

Hastings, H. II and McCollam, S. M. (1994). Flexor dig-itorum superficialis lasso tendon transfer in isolated ulnarnerve palsy: a functional evaluation. J. Hand Surg., 19A,275–80.

Kaplan, E. B. and Spinner, M. (1980). Normal and anom-alous innervation patterns in the upper extremity. In Man-agement of Peripheral Nerve Problems (G. E. Omer Jr. andM. Spinner, eds) pp. 75–99, W. B. Saunders.

Mannerfelt, L. (1966). Studies on the hand in ulnar nerveparalysis. A clinical-experimental investigation in normaland anomalous innervation. Acta Orthop. Scand. Suppl.,87, 89–97.

Omer, G. E. Jr. (1999). Ulnar nerve palsy. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 1526–41, Churchill Livingstone.

Parkes, A. (1973). Paralytic claw fingers – A graft tenodesisoperation. Hand, 5, 192–9.

Reynolds, C. C. (1995). Preoperative and postoperative man-agement of tendon transfers after radial nerve injury. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 753–63,Mosby.

Rowntree, T. (1949). Anomalous innervation of the handmuscles. J. Bone Joint Surg., 31B, 505–10.

Sakellarides, H. T. (1970). Modified pulley for opponenstendon transfer. J. Bone Joint Surg., 52A, 178–9.

Stanley, B. G. (1995). Preoperative and postoperative man-agement of tendon transfers after median nerve injury. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 765–78,Mosby.

Terrono, A. L., Rose, J. H., Mulroy, J. and Millender, L. H.(1993). Camitz palmaris longus abductorplasty for severethenar atrophy secondary to carpal tunnel sundrome.J. Hand Surg., 18A, 204–6.

Thompson, T. C. (1942). A modified operation for opponensparalysis. J. Bone Joint Surg., 26, 632–40.

Warren, G. (1997). Tendon transfers. In Atlas of HandSurgery (W. B. Conolly, ed.) pp. 215–249, ChurchillLivingstone.

Zancolli, E. A. (1957). Claw-hand caused by paralysis of theintrinsic muscles. A simple surgical procedure for itscorrection. J. Bone Joint Surg., 39A, 1076–80.


Further reading

Bell-Krotoski, J. (1995). Preoperative and postoperative man-agement of tendon transfers after ulnar nerve injury. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 729–51,Mosby.

Brand, P. W. (1970). Tendon transfers for median and ulnarnerve paralysis. Orthop. Clin. North Am., 1, 447–454.

Brand, P. W. (1975). Tendon transfers in the forearm. InHand Surgery (J. E. Flynn, ed.) pp. 189–200, Williams &Wilkins.

Brand, P. W. (1995). Mechanics of tendon transfers. InRehabilitation of the Hand: Surgery and Therapy (J. M.Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 715–28,Mosby.

Omer, G. E. Jr. (1974). The technique and timing of tendontransfers. Orthop. Clin. North Am., 5, 243–52.

Omer, G. E. Jr. (1980). Tendon transfers for reconstruction ofthe forearm and hand following peripheral nerve injuries.In Management of Peripheral Nerve Problems (G. E. OmerJr. and M. Spiner, eds) pp. 817–46, W. B. Saunders.

Pulvertaft, R. G. (1960). Techniques in hand surgery(abstract). J. Bone Joint Surg., 42A, 907.

7

Peripheral nerve entrapment

This chapter deals with compression neuropathiesat and below the elbow that have been deemedexclusive of more proximal causes such as cervicalnerve root compression or thoracic outlet syn-drome. A brachial plexus screening test shouldtherefore form part of the routine examination forperipheral nerve compression in the upper extrem-ity, e.g. ‘Elvey’s test’ (Elvey, 1985).

As the peripheral nerves course from theirrespective cervical roots to the hand, they can besubject to compression in a number of specificanatomical tunnels and spaces.

Double crush phenomenon

The various substances synthesized by the nervecell body, e.g. enzymes, polypeptides, free aminoacids, etc., are necessary for the normal functionand survival of the axon. These substances travelalong the axon in a distal direction. Axoplasmictransport mechanisms are then responsible forreturning breakdown products in a proximaldirection.

Where synthesis or transport of these substancesis disrupted, the axons will be more vulnerable tocompression. This disruption of axoplasmic flowwill increase the susceptibility of the nerve tocompression at sites proximal and distal to theoriginal site. This is referred to as ‘double’ (Uptonand McComas, 1973) or ‘multiple crush’syndrome.

Even minor nerve injury will affect the qualityof the axoplasm and the rate of its flow. A co-existent cervical lesion is one of the reasons forpersistent residual symptoms following carpal

tunnel release and some patients may require aproximal as well as distal decompression (Mac-kinnon and Dellon, 1988).

Causes of nerve compression

1. Change in tunnel dimensions

Compression may be due to an increase in thecontents of the tunnel e.g. a space-occupyinglesion such as a ganglion or tumour, or there maybe a narrowing of the tunnel from post-traumaticfibrosis or osteoarthritis. Congenital anomalies,e.g. aberrant muscles in the carpal tunnel, cancause nerve compression (Lakey and Aulicino,1986).

2. Medical conditions

Compression neuropathies can be associated with anumber of medical conditions which influenceperipheral nerves and thus render them moresusceptible to compression syndromes. Theseinclude: diabetes, which raises the intrafascicularpressure throughout the body (Myers and Powell,1981), alcoholism, hypothyroidism and exposureto industrial solvents. Hormonal changes relatingto pregnancy and menopause can predispose tocarpal tunnel syndrome.

3. Cumulative trauma

Repetitive muscle contraction and poor bodyposture can contribute to nerve injury (Lundborgand Dahlin, 1989). A thorough assessment of the

Transversecarpalligament

Palmarislongus

Mediannerve

Volarcarpal

ligament

Carpal tunnel

Flexorpollicis longus

Flexorcarpiradialis

Guyon’sspace


work environment and postural habits may helpdetermine the cause(s) of symptoms.

Clinical features

The clinical features of nerve compression caninclude the following:

1. Sensory – pain, paraesthesia, numbness.2. Motor – weakness, clumsiness.3. Autonomic – changes to colour, temperature or

texture of the skin or nails.

Diagnosis of peripheral nervecompression

Assessment of peripheral nerve pathology includesthe following:

1. History of the condition – and the activities thatcause or aggravate symptoms; a thoroughassessment of work habits is especially impor-tant if an occupational aetiology is suspected.

2. Clinical examination including provocativetests, e.g. Phalen’s test for carpal tunnel syn-drome, the elbow flexion test for cubital tunnelsyndrome.

3. Electrodiagnostic tests – while not alwaysentirely reliable, electrical studies may be theonly objective means of assessing nerve entrap-ment. These tests include electromyography(EMG) and nerve conduction velocity (NCV)studies. They can also help confirm the exist-ence of more proximal sites of entrapment.

4. X-ray examination – to exclude osteoarthritis ofthe carpal tunnel or deformity followingtrauma.

5. Imaging – such as ultrasound, MRI or CTscan.

6. Sensory evaluation – using the Semmes–Wein-stein monofilaments. This is a threshold testwhich is more likely to determine a gradualdeterioration in nerve function where corticalorganization remains intact. It must be borne inmind that light touch perception can be normalwhen paraesthesia is present.

Median nerve compression

Carpal tunnel syndrome

Compression of the median nerve in the carpaltunnel, i.e. carpal tunnel syndrome (CTS), is by farthe commonest of all peripheral nerveentrapments.

Anatomy

The carpal tunnel is a rigid osteoligamentouscanal. The flexor retinaculum (FR) forms the roofof the carpal tunnel and extends from the distalradius to the bases of the metacarpals. It is overlainwith the proximal antebrachial fascia, the tendonof palmaris longus and the distal palmar fascia.The dorsum (or floor) of the tunnel is bounded bythe bones of the carpus.

The FR has three components:

1. Proximally, the deep forearm fascia.2. The transverse carpal ligament (TCL).3. Distally, the thick aponeurosis between the

thenar and hypothenar muscles.

The TCL is a thick (2–4 mm), rigid fibrous sheetwhich is attached ulnarly to the pisiform bone andhook of hamate, and radially to the scaphoidtubercle and the beak of the trapezium.

At the wrist, there are two tunnels (or canals)and one space. The carpal tunnel proper contains:

(i) the median nerve,(ii) flexor pollicis longus tendon and (iii) the eight flexor tendons of the four digits.

The second canal contains the tendon of flexorcarpi radialis. Guyon’s space contains the ulnarartery and ulnar nerve (Fig. 7.1).

The median nerve is the softest and most volarstructure in the carpal tunnel. It lies directlybeneath the TCL and is superficial to the ninedigital flexor tendons. At the distal edge of theTCL, the median nerve normally divides into 6branches:

Figure 7.1. Diagrammatic transverse section throughthe midcarpus showing the transverse carpal ligament,the two tunnels (or canals) and Guyon’s spacecontaining the ulnar nerve and artery.

Three properdigital nerves

Recurrentmotorbranch

Palmarcutaneousbranch

Mediannerve

Two commondigital nerves

Ulnar nerveTransversecarpal ligament

Peripheral nerve entrapment 85

1. The recurrent motor branch.2. Three proper digital nerves (two to the thumb

and one to the index finger).3. Two common digital nerves (one to index/

middle and one to middle/ring) (Fig. 7.2).

Median nerve anomalies are common, e.g. themotor branch may be extraligamentous, trans-ligamentous or subligamentous and may arise fromthe volar, radial or ulnar side of the median nerve.The most common pattern of the motor branch isextraligamentous and recurrent. Variations in thepalmar cutaneous branch are also common (Siegelet al., 1993).

There are also variations in the course of themedian nerve itself. It occasionally has a high orlow division into its various branches and theremay be a persisting median artery.

Patient presentation

The patient usually presents with numbness, painand paraesthesia in the median nerve distributionof the hand. Because of communication betweenthe median and ulnar nerves, symptoms may alsoinvolve the ring and little fingers. There is oftenassociated clumsiness and weakness of pinch.Sensory changes, both subjective and objective,

usually precede weakness and wasting by weeks ormonths.

Characteristically, pain and paraesthesia aremost distressing at night. This is related to vascularstasis caused by inactivity and pressure on themedian nerve from wrist flexion or lying on thearm. The painful burning, numbness or tinglingsensations may radiate up the arm to the shoulderor neck where there may be restriction to longitudi-nal glide of the nerve. The fingers may feel swollenand the whole arm heavy. The patient usuallyattempts to relieve these symptoms by hanging thearm over the side of the bed or shaking the hand.This is referred to as ‘waking numbness’.

Clinical assessment

Two commonly used provocative tests to help inthe clinical diagnosis of CTS are Phalen’s test andTinel’s sign. While these tests are not absolutelydiagnostic, they are positive in about two-thirds ofpatients with this syndrome.

1. Phalen’s test (wrist flexion test)

This test is performed with the patient holding theforearm vertically in the air and allowing the wrist

Figure 7.2. The transverse carpal ligament is a thickfibrous sheet attached ulnarly to the pisiform and hookof hamate, and radially, to the scaphoid tubercle andbeak of trapezium. The median nerve lies directlybeneath the TCL and normally divides into sixbranches at the distal edge of this ligament.

Figure 7.3. Phalen’s (wrist flexion) test is performedwith the forearm held vertically in the air whilemaintaining the wrist in flexion for a period of 60seconds.


to fall into full flexion. The fingers and thumbremain relaxed. This position is held for 60 s and isconsidered positive if numbness and paraesthesiaare elicited during this time (Fig. 7.3).

The reverse Phalen’s test may be positive whenthe wrist flexion test is negative. The palms of thehands are placed together with the elbows raised,thus extending the wrists and placing the mediannerve on the stretch (Fig. 7.4).

2. Tinel’s sign

The Tinel’s manoeuvre involves gentle tappingover the median nerve at wrist level. Again, if thisproduces symptoms, the test is considered to bepositive.

3. Semmes–Weinstein monofilaments

Sensory impairment, which is not always presentin CTS, can be assessed with monofilaments whichmay detect loss of light touch or, in moreestablished cases, loss of protective sensation.

4. Assessment of motor function

Abnormal motor signs include weakness of thethenar muscles, especially abductor pollicis brevis.This can be tested by forcible tip-to-tip pinchbetween the thumb and ring finger. Weakness oflumbrical action to the middle finger may occa-sionally be seen.

5. Autonomic findings

As the median nerve transmits most of thesympathetic nerve supply to the hand, there mayalso be abnormal autonomic findings. These mayinclude: discoloration of the skin, disorder ofsweating in the hand and fingers or nail changessuch as fragility, brittleness or shedding.

Causes of carpal tunnel syndrome

The causes of CTS are many and varied. Metabolicand endocrinal causes can include: pregnancy,menopause, Raynaud’s disease, rheumatoid dis-ease, diabetes, myxoedema and acromegaly. Therecan be an acute onset of CTS following wristtrauma, infection within the tunnel, thrombosis ofan anomalous median artery or iatrogenic injectioninjury of the median nerve.

Occupational factors can include repetitive force(particularly where fingers and wrist are flexedsimultaneously), posture, vibration and tempera-ture of work environment.

Lifestyle factors are also believed to play animportant role in the incidence of CTS. Thesefactors include: obesity (Nathan et al., 1992),excessive alcohol consumption and tobacco use.

There is an ischaemic factor in many compres-sion neuropathies (Gelberman and Szabo, 1986).The reduced epineurial blood flow leads toimpaired axonal transport. Whilst these effects canbe reversed in the early stages, prolonged endo-neurial swelling with resultant fibrosis can result inpermanent sensory and motor loss.

Stages of compression

1. Early

These patients have a history of recent onset andintermittent symptoms of numbness and paraes-thesia. This category of patients shows the bestresponse to conservative treatment measures whichinclude:

1. Wrist splinting in neutral or slight extension(the carpal tunnel has maximum capacity inthese positions).

2. Corticosteroid injection into the carpal tunnel(this helps reduce inflammatory oedema aroundthe nerve).

3. Nerve gliding exercises.4. Postural assessment in relation to the work

environment or leisure activities.5. Modification of work practices and work envi-

ronment where indicated.

Wrist splinting

The wrist support is used only at night if there areno day symptoms. Intermittent day use is recom-mended for patients whose symptoms are alsopresent during the day. For patients who have had

Figure 7.4. The reverse Phalen’s test places themedian nerve on the stretch and may elicit a positiveresponse when the wrist flexion test is negative.

1 2 3

4 5


a corticosteroid injection, the wrist is restedcontinuously for a period of 2 weeks (Fig. 7.5).

Nerve gliding exercises

Totten and Hunter (1991) have developed a seriesof nerve gliding exercises for the brachial plexusand the median nerve at the carpal tunnel. A studyby Wilgis and Murphy (1986) on the longitudinalexcursion of peripheral nerves, determined that thegreatest excursion occurred proximal to the carpaltunnel at the wrist.

The median nerve gliding exercises can be usedfor conservative management of CTS or post-operatively, to minimize nerve-tendon adhesions.The exercises can be performed with the patientsitting or lying supine. The head is in the midlineposition, the shoulder is adducted and the elbow isflexed to 90 degrees (Fig. 7.6).

The exercise sequence is performed in a slow,methodical manner with 5 to 10 repetitions every1 to 2 hours. The manoeuvre is performed to thepoint where slight tension is produced, thisusually manifesting as a slight pull or somechange to sensibility. When this point is reached,the patient is asked to back off slightly to easethese symptoms. Some trial and error is usuallynecessary to establish the appropriate level ofexercise. It is preferable to ‘underperform’ theexercises rather than to perform them too vigor-ously and exacerbate symptoms. Symptoms oftingling, numbness or pain following the glidingexercises should not take more than a few hoursto resolve.

Brachial plexus gliding exercises

These gliding exercises address the entire length ofthe nerves, from proximal to distal. This manoeuvreis far more likely to produce an irritable responseand should therefore be performed very cautiously.Symptoms are often not evident for several hoursafter the exercise and, as with the above exercises,should resolve after several hours (Fig. 7.7).

Gentle brachial plexus gliding exercises can beused in the workplace as part of a prevention/treatment strategy that also incorporates assess-ment/modification of postural and work habits.

2. Intermediate

Patients in this category report almost constantnumbness and paraesthesia and are candidates fornerve decompression.

Figure 7.5. Early symptoms of CTS are managed withconservative measures that include a wrist splint tomaintain the wrist in neutral or slight extension.

Figure 7.6. Median nerve gliding exercises can beperformed as part of a conservative treatmentprogramme or following open or endoscopic carpaltunnel decompression. Position 1: the forearm is inneutral rotation, the wrist in neutral extension and thefingers and thumb are flexed. Position 2: the wristremains in neutral, the fingers extend and the thumb liesin neutral beside the index finger. Position 3: while thethumb remains in the neutral position, the wrist isextended while finger extension is maintained. Position4: the wrist is returned to neutral extension and with thefingers and thumb also in neutral extension, the forearmis supinated. Position 5: with the forearm still insupination, a gentle stretch is applied to the thumb.(Redrawn with permission from Totten, P. A. and Hunter,J. M. 1991. Therapeutic techniques to enhance nervegliding in the thoracic outlet and carpal tunnelsyndromes. Hand Clin., 7(3), 505.)

1 2 3 4

5 6 7


3. Late

These patients have usually had longstandingsymptoms. Even after decompression, there maybe permanent sensory impairment and thenarwasting because of the degree of neural fibrosis.Where appropriate, these patients are offeredan opposition transfer to enhance pinch gripfunction.

Surgery

Surgery to decompress the tunnel is indicatedwhere conservative measures have failed to relievesymptoms. The aim of surgery is to increase thedimensions of the carpal tunnel by releasing thetransverse carpal ligament and its fascialextensions.

Studies have shown that the average increase involume of the tunnel following decompression is24 per cent and that the tunnel is converted from anoval to a circular shape (Richman et al., 1989).

1. Open decompression

Decompression of the carpal tunnel has tradition-ally been performed as an open procedure. Theobvious advantage of the open technique is goodvisualization which allows identification of ana-tomical anomalies. This means a reduced risk ofiatrogenic injury.

The skin incision is made 2–3 mm ulnar to andparallel with the thenar crease and extends fromjust proximal to the wrist crease proximally, and asfar as the level of the thumb web space, distally(Fig. 7.8). During incision, care is taken topreserve the small cutaneous nerves to avoidincisional tenderness. The TCL and related fasciaare divided. The division is not complete until themedian nerve can be seen throughout its course inthe canal. Any adhesions of the median nerve tosurrounding flexor tenosynovium are freed bycareful dissection. The carpal tunnel floor isinspected for ganglia or bony spurs. The skin isclosed with interrupted fine sutures.

Figure 7.7. The brachial plexus programme is as follows: Position 1: the head is laterally flexed to the affectedside with the elbow, wrist and fingers of the affected side in flexion. Position 2: the head comes to the neutralposition. Position 3: the hand is moved across the chest and down to the hip level. Position 4: the patientgradually extends the elbow and increasingly abducts the shoulder into positions 5 and 6. Position 7: Lateralcervical flexion to the opposite side is the final component of this manoeuvre. (Redrawn with permission fromTotten, P. A. and Hunter, J. M. 1991. Therapeutic techniques to enhance nerve gliding in thoracic outlet and carpaltunnel syndromes. Hand Clin., 7(3), 505.)


2. Endoscopic carpal tunneldecompression

The past decade has seen the introduction ofendoscopic carpal tunnel release as an alternativesurgical procedure to open carpal tunnel release.The two best known techniques are the two-portaltechnique of Chow (1994) and the single portaltechnique of Agee et al. (1995).

The advantages of endoscopic release over opendecompression include a faster return to activityand more rapid return of grip strength. Theprocedure does, however, carry a greater risk ofiatrogenic injury because the median nerve is notactually seen during the procedure.

Pillar pain remains a problem that is associatedwith both the open and endoscopic techniques ofdecompression. Palm tenderness, usually asso-ciated with the open technique, has not been fullyeliminated with endoscopic decompression.

Results

Relief of pain following surgery should beimmediate; however, relief of numbness or weak-ness may be slow and incomplete. Nerve con-ductivity improves slowly over 1 to 2 years.

Complications of surgery

Intraoperative complications include injury to themedian nerve trunk or its branches. Immediate

postoperative complications include: haematoma(from damage to the superficial palmar arch),oedema or infection.

Later complications can include: persistinghand weakness, palmar pain/hypersensitivityfrom the entrapment of cutaneous nerves withinthe scar, pillar pain, hypertrophic scarring, pal-mar fasciitis and chronic regional pain syndromeresulting from injury to the palmar cutaneousbranch of the nerve. This complication can leadto disability far greater than the originaldisorder.


Exercise

The wound is dressed and supported with a lightcompression bandage. The hand is rested inneutral extension for the first 1 to 2 post-operative days. Neck, shoulder and elbow move-ments are commenced immediately to maintainlongitudinal glide of the median nerve. Thumband finger movements are performed within thepostoperative cast.

Gentle active wrist movements are commencedon the 2nd or 3rd postoperative day. Specificmedian nerve gliding exercises are performed asfor conservative management of CTS. All exer-cises are performed gently and slowly every 2 hwithin the limits of discomfort. Earlier concernsregarding the risk of tendon bowstringing withearly mobilization have been dispelled (Nathan etal., 1993). Nonetheless, simultaneous wrist andfinger flexion is avoided as this position makesthe tendons most vulnerable to bowstringing.

Scar management

Sutures are usually removed about 10 days aftersurgery. Scar management is then commenced.Light massage, using oil or cream, is usuallywell tolerated and should be performed 4 to 6times a day by the patient as part of a homeprogramme.

Most postoperative scars resolve uneventfullywithin 4 to 6 weeks after surgery. Raised orpersisting scar is managed with silicone gel. Thearea should be washed and dried thoroughly andbe free of oily residue prior to application of thegel. The gel is held in place with Tubigripstockinette of appropriate tension (Fig. 7.9).

Figure 7.8. Skin incision for open carpal tunneldecompression.


Hypersensitivity

Where scar sensitivity is a problem, a layer ofOpsite Flexifix is applied over the sensitive area.Silicone gel can be applied over the Opsite wherenecessary (Fig. 7.10).

Hypersensitivity that is troublesome enough tointerfere with the exercise programme is managedwith transcutaneous electrical nerve stimulation(TENS). The therapist should remain alert to asudden increase in pain and hypersensitivity whichmay herald the onset of chronic regional painsyndrome. Other signs and symptoms associatedwith this condition include persisting handoedema, colour changes (mottling) and excessivesweating.

Pillar pain

Some patients are troubled by pillar pain forseveral months following decompression (Ludlowet al., 1997). This usually manifests as an ache inthe area of decompression, i.e. between the thenarand hypothenar eminences, and can significantlyhamper hand function. It is addressed with sup-portive wrist strapping or splinting which usuallyalleviates discomfort and gives the patient greaterconfidence in using the hand (Fig. 7.11).

Return to activity

Light daily activity can be commenced 2 to 3weeks after surgery. Heavier activities are avoidedfor 2 to 3 months. Patients are advised that thereturn of maximum grip strength can take somemonths to achieve.

Compression of the median nerve atmore proximal locations

Pronator syndrome

The median nerve can be constricted just above theelbow by the ligament of Struthers, at the elbow bythe lacertus fibrosis and in the upper forearm,between the two heads of pronator teres and underthe fibrous arch of flexor superficialis.

Pronator syndrome is rare (representing lessthan 1 per cent of peripheral neuropathies) and canresult from repetitive use of the arm. It should besuspected if pain and paraesthesia in the cutaneousdistribution of the median nerve are associatedwith forearm pronation rather than the usual night

Figure 7.9. Persisting scar is managed with siliconegel that is held in place with Tubigrip supportstocking.

Figure 7.10. Hypersensitive scar is covered withOpsite Flexifix film to reduce discomfort. The area ofapplication has been dotted for identification. Siliconegel can be used over the film.

Figure 7.11. Pillar pain following carpal tunneldecompression (open or endoscopic) can be relievedwith supportive wrist strapping.


manifestations of carpal tunnel syndrome. Palpa-tion of the median nerve in the proximal forearmproduces pain. Percussion of the median nerve atthis level may cause tingling and paraesthesia. Thepronator teres muscle can be tender, firm orenlarged.

Fifty per cent of patients with pronator syn-drome will respond to conservative treatmentincluding modification or cessation of aggravatingactivities and the use of a removable long armsplint which maintains the elbow in 90 degrees offlexion, the forearm in slight pronation and thewrist in slight flexion. This position relievespressure and traction on the median nerve. Whereconservative measures fail, the median nerve isexplored and released.

Anterior interosseous syndrome

This syndrome also represents less than 1 per centof all peripheral neuropathies. Anterior inter-osseous syndrome is characterized by loss offunction of FPL and FDP to the index (sometimesFDP to the middle finger and pronator quadratus).An incomplete syndrome can manifest as weak-ness of FPL and FDP to the index withoutinvolvement of pronator quadratus. Sensibility isunaffected.

The most frequent cause of this syndrome is afibrous band(s) in the pronator teres muscle.Outcome following decompression for completelesions is superior to that for partial lesionsinvolving only the thumb and index finger(Werner, 1989).

Ulnar nerve compression

The commonest sites for compression of the ulnarnerve are at the elbow (cubital tunnel syndrome) orin Guyon’s canal at the wrist (ulnar tunnelsyndrome).

Anatomy

The ulnar nerve passes from the flexor to theextensor compartment in the upper arm through anopening in the intermuscular septum. It then passesthrough the cubital tunnel at the elbow, posterior tothe medial epicondyle of the humerus (where it canbe palpated with ease) and into the forearmbetween the heads of the flexor carpi ulnarismuscle.

It enters the hand by passing over the flexorretinaculum, lateral to the pisiform bone and medialto the hook of hamate. In the palm, it divides intosuperficial and deep terminal branches.


The patient usually presents with paraesthesia ornumbness in the little finger and the ulnar half ofthe ring finger. While there is rarely wasting of theintrinsic hand musculature in the early stages ofcompression, the sensory symptoms are oftenaccompanied by a weak grip.

Clinical assessment

1. Percussion test at the cubital tunnel

A positive Tinel’s test when the nerve is percussedover the medial epicondyle can indicate entrap-ment at this level. This test on its own is notdiagnostic as almost a quarter of asymptomaticpeople have a positive response to this test.

2. Elbow flexion test (Wadsworth, 1977)

This test is analogous to Phalen’s wrist flexion testfor carpal tunnel syndrome. It involves holding theelbow in maximum flexion with the forearm insupination and the wrist in neutral to avoidconfusion with Phalen’s wrist flexion test forcarpal tunnel syndrome. The position is held fortwo minutes and the test is considered positive ifsymptoms of numbness and paraesthesia in theulnar nerve distribution are elicited during thistimeframe. False positives can occur in 25 per centof the population (Fig. 7.12).

Figure 7.12. The elbow flexion test is used in theassessment of cubital tunnel syndrome.


3. Semmes–Weinstein monofilament test

Decreased sensibility over the dorsal ulnar aspectof the hand would indicate that the lesion isproximal to the wrist as the dorsal cutaneousbranch of the ulnar nerve branches proximal toGuyon’s canal.

4. Muscle assessment

Flexor carpi ulnaris, flexor digitorum profundus tothe ring and little fingers and the intrinsics shouldbe assessed. It must be remembered that themedian nerve can contribute to innervation of theintrinsics via a Martin–Gruber anastomosis andthat FCU and FDP are spared if their innervation isproximal to the cubital tunnel.

5. X-ray of the elbow

This is useful for patients with arthritis or a historyof trauma to the elbow.

6. Electrodiagnostic studies

These will help establish the diagnosis and willhelp determine the level of the lesion.

Cubital tunnel syndrome

Cubital tunnel syndrome is the second mostcommon nerve compression after carpal tunnelsyndrome. At this level, the ulnar nerve is predis-posed to compression because of anatomicalpeculiarities in the region of the elbow (Feindeland Stratford, 1958). Cubital tunnel syndrome maybe caused by: bony abnormalities, e.g. spurs orcubitus valgus, constricting fascial bands, softtissue structures, e.g. tumour or ganglion, orsubluxation of the nerve over the medial epi-condyle during elbow flexion.

In patients under 40 years of age, the mostcommon cause of cubital tunnel syndrome (withthe exclusion of trauma), is a shallow canal withpartial anterior subluxation of the ulnar nerveduring elbow flexion.

Activities involving repeated elbow flexion andextension can aggravate cubital tunnel syndrome,although there are no data pointing to work as arisk factor.

Conservative management

Approximately half of all patients with cubitaltunnel syndrome will improve spontaneously.Mild, intermittent sensory symptoms (i.e. in theabsence of motor changes) can be managed withnight splinting that holds the elbow joint in 30 to45 degrees of flexion. This will prevent acuteelbow flexion when the cubital tunnel is at itsnarrowest. Prolonged elbow flexion during the dayshould also be avoided (Fig. 7.13).

Oral anti-inflammatory medication is sometimesused in conjunction with splinting. Patients areinstructed in ulnar nerve gliding exercises (Tottenand Hunter, 1991). These exercises are performedevery 1 to 2 hours with 5 to 10 repetitions. Somerelief of symptoms should be apparent within 3weeks if conservative management is having anyeffect. Where this is not the case, surgical optionsare considered (Fig. 7.14).

Surgical procedures for cubital tunnelsyndrome

There are a number of surgical options for themanagement of this syndrome. Choice of proce-dure will depend upon the patient’s age (in theolder patient, the nerve is vulnerable to iatrogenicinjury during transposition), pathology, and pres-ence or absence of nerve subluxation.

Procedures include:

1. Simple decompression

This procedure involves releasing the arch of theFCU origin so that unrestricted movement of the

Figure 7.13. Mild, intermittent sensory symptoms ofcubital tunnel syndrome can be managed with nightsplinting that prevents acute elbow flexion duringsleep.

1 2 3

4 5 6


nerve can occur during elbow flexion. In thisprocedure the ulnar nerve is not disturbed in its bedand does not undergo neurolysis. The ulnar nervemay sublux following this procedure.

The elbow is protected in flexion with a bulkydressing with plaster reinforcement for the first 10postoperative days. Early gentle active elbowmovement is commenced following thisprocedure.

2. Medial epicondylectomy

The medial epicondyle is removed and the bone issmoothed. This allows the nerve to migrateanteriorly and lie free. To maintain the integrity ofthe anterior medial collateral ligament, removal ofthe epicondyle should be restricted to 1–4 mm, i.e.about one fifth of the width of the epicondyle. Asoft compressive dressing is applied and earlyactive elbow motion is encouraged following thisprocedure.

3. Anterior subcutaneous transposition

This procedure is indicated for anatomic lesionsthat interfere with or compress the ulnar nerve

along its course, e.g. tumour, ganglion orosteophyte.

The ulnar nerve is decompressed as for simpledecompression. The medial intermuscular septumis then resected and the nerve is placed in thesubcutaneous tissue, anterior to the medial epi-condyle. Sometimes a flap of antebrachial fascia isused to create a fasciodermal sling around thetransposed nerve. The elbow is protected witha bulky dressing and light plaster for about 1 week.Early gentle elbow movements can then becommenced.

4. Anterior submuscular transposition

This procedure is indicated for more severeneuropathy and is the best salvage procedure forprevious procedures that have failed, as it placesthe nerve in an unscarred bed. The procedureinvolves unroofing of the cubital tunnel andelevation of the flexor-pronator muscle mass at itsorigin. The nerve is moved anterior to the medialepicondyle and the muscle mass is returned to itsorigin and now overlies the ulnar nerve.

To protect the reattachment of the muscle massfor 2 to 3 weeks, the elbow is protected in asugar tong splint which immobilizes the forearm

Figure 7.14. Ulnar nerve gliding exercises used in conservative management of cubital tunnel syndrome. Thesequence is performed only to the point where slight tension is produced. When this point is reached, the patientis asked to back off slightly. The first three positions emphasize the distal ulnar nerve and begin with a position ofminimal stress. Position 1: the head is in the midline and the shoulder is forward flexed and adducted. The elbowis extended and the wrist and fingers are flexed. Position 2: the wrist and fingers are extended. Position 3: theelbow is flexed. The final three positions in the sequence focus on the proximal ulnar nerve with the distalsegment in a more neutral position. Position 4: the shoulder is abducted, the elbow extended and the wrist broughtto neutral. Position 5: external rotation of the shoulder is added to the previous posture. Position 6: this positionincorporates lateral cervical flexion to maximize tension. (Redrawn with permission from Philadelphia HandCentre, PC, 901 Walnut St., Philadelphia, Pennsylvania.)

1 2 3

4 5 6


and wrist but permits a short arc of elbowmovement.

5. Anterior intramuscular transposition

This procedure resembles the above procedure;however, the ulnar nerve is placed within the flexor-pronator muscle mass rather than beneath it.

Following surgery, the elbow is maintained in 90degrees of flexion, the forearm in 30 to 45 degreesof pronation and the wrist in 30 degrees of flexionfor a period of 3 weeks. Gentle active elbow,forearm and wrist movements are commencedafter 3 weeks; however, intermittent use of the longarm splint is maintained for another week or two.If passive range of motion exercises are required,they are commenced after 6 weeks together withstrengthening exercises.

Regaining movement

When active and passive movements are com-menced, they are done so gently and carefully so asnot to exacerbate neurological symptoms. These

symptoms will be present if axonal regeneration isoccurring and will subside with time. End range ofelbow movement is not a priority in the first fewweeks following surgery.

Nerve gliding exercises

Postoperative ulnar nerve gliding exercises areinstituted as soon as active motion is allowed(Fig. 7.15).

Scar and oedema management

Scar is treated with gentle oil massage which willalso serve to desensitize the area. Raised scar ismanaged with silicone gel. This is held in placewith Tubigrip stockinette and will control oedemaaround the elbow.

Pain or tenderness over the medial elbowfollowing epicondylectomy can be addressed witha soft elbow pad if silicone gel does not providesufficient relief. Patients should avoid leaning onthe elbow until tenderness has subsided.

Figure 7.15. Postoperative ulnar nerve gliding exercises. Position 1: the shoulder is adducted and flexed to 90degrees, the elbow is flexed to 90 degrees and the wrist and fingers are in gentle flexion. Position 2: the wrist andfingers are extended. Position 3: the elbow is extended. Position 4: the shoulder is abducted, the elbow is flexed to90 degrees and the wrist and fingers are flexed. Position 5: the arm is externally rotated. Position 6: lateralcervical flexion is added to the previous position. (Used with permission from the Philadelphia Hand Centre, PC,901 Walnut St., Philadelphia, Pennsylvania).


Hypersensitivity

Hypersensitivity resulting from scar or axonalregeneration is addressed with a layer of OpsiteFlexifix. Silicone gel can be used over theOpsite.

Ulnar tunnel syndrome

The ulnar nerve courses through Guyon’s canalbetween the volar carpal ligament and the trans-verse carpal ligament. Depending on the preciselocation of the compression, entrapment at thislevel may manifest as purely sensory, motor ormixed.

Causes

The commonest non-traumatic cause of ulnarcarpal syndrome is a ganglion arising from thetriquetrohamate joint. Other causes include bonylesions, e.g. fractures of the hook of hamate, ormuscle anomalies.


The patient may present with wrist pain andassociated numbness, tingling or burning thatradiates into the ring and little fingers. Weakness ofthe intrinsic musculature can occur and canprogress to atrophy if the compression is notrelieved.

Clinical assessment

This includes palpation of tender areas (e.g. overhook of hamate) and checking for the presence ofswelling or a soft tissue mass. The nerve ispercussed for presence of Tinel’s sign and sensi-bility is assessed with Semmes–Weinstein mono-filaments. Symptoms of ulnar carpal syndrome cansometimes be provoked by sustained wrist hyper-flexion or hyperextension. Muscle testing of theintrinsic hand musculature is carried out.


Where an obvious cause of compression cannotbe found, conservative management is trialled.This involves wrist splinting in neutral or slightextension, modification of work activities whereindicated, and non-steroidal anti-inflammatorymedication. If conservative measures fail toprovide relief of symptoms, the ulnar nerve is

released within Guyon’s canal and is exploredfrom the distal forearm into the palm.

Aftercare

The wrist is supported for the first 10 postoperativedays. Where there has been excision of the hook ofhamate, palmar tenderness may persist and shouldbe managed with silicone gel compression.

Radial nerve compression

Two distinct syndromes are seen at the elbow levelwhere the posterior interosseous nerve (PIN)passes deep to the fibrous arch (arcade of Frohse)and then between the two heads of the supinatormuscle itself. As the PIN is purely a motor nerve,weakness is the main feature of these syndromes.

1. Posterior interosseous nerve syndrome

This syndrome may have an acute presentationfollowing trauma or there may be a gradual andpainless loss of function due to a lipoma organglion at the elbow.

The patient complains of a weakness of fingerand wrist extension and some associated pain.Investigative tests include: EMG, X-ray of theelbow to rule out dislocations or fractures, MRI orultrasound to exclude ganglia.

Treatment

Exploration of the nerve is indicated in the case ofa space-occupying lesion or long-standing weak-ness. If the syndrome appears to be a postoperativeneurapraxia, it is observed for 2 to 3 monthsprovided that there are no signs of deterioration.Forceful forearm rotation is avoided during thistime. Radial nerve gliding exercises can be per-formed as part of the conservative management(Fig. 7.16).

If surgical decompression is considered neces-sary, it should not be delayed for too long becauseof the risk of permanent muscle weakness. Recov-ery following surgery can take 12 to 18 months.

2. Radial tunnel syndrome

This syndrome is a pain condition where weaknessfeatures secondarily. The patient typically com-plains of a deep, aching pain on the lateral aspectof the elbow. Night pain is not uncommon. Thissyndrome is often related to work activities that

1 2 3 4 5


involve repetitive forceful elbow extension orforearm rotation. Radial tunnel syndrome cancoexist with lateral epicondylitis with which it canbe confused. In the case of radial tunnel syndrome,tenderness will be distal to the lateral epicondyle.

Symptoms are aggravated by passive forearmpronation with the wrist flexed and active forearmsupination with the elbow extended. These man-oeuvres are performed against resistance. Anotherprovocative manoeuvre involves extending theelbow and digits fully with the wrist in neutral andapplying firm pressure to the dorsal aspect of theproximal phalanx of the middle finger. If thisresults in pain in the proximal forearm, the test isconsidered positive. The diagnosis is confirmed ifthere is relief of symptoms following a localanaesthetic into the radial tunnel.

Treatment

Conservative treatment is always trialled firstbecause this syndrome, unlike the PIN syndrome,does not progress to muscle palsy. Conservativetreatment involves rest, anti-inflammatory medica-tion, radial nerve gliding exercises and a splint thatmaintains a position of forearm supination andwrist extension.

Wartenburg syndrome (or superficialradial nerve compression syndrome)

Neuritis of the superficial branch of the radialnerve can result from compression by watchbands,bracelets or sporting straps or from repetitiveactivity. The sensory nerve can be compressed inthe forearm between the tendons of extensor carpiradialis longus and brachioradialis as the forearmis pronated.

Patients complain of pain, numbness or tin-gling over the dorsal radial aspect of the hand.Symptoms are exacerbated by wrist movement ortightly pinching the thumb and index fingertogether. This syndrome can be difficult to dis-tinguish from de Quervain’s syndrome which ischaracterized by pain at the radial styloid processwhich radiates down the thumb and proximally,into the forearm. This latter syndrome is alsousually associated with swelling over the firstdorsal compartment.

Treatment

Conservative measures such as local steroid injec-tion, splinting and work modification are trialledprior to surgical neurolysis.

Figure 7.16. Radial nerve gliding exercises. Position 1: the patient stands with the body in a relaxed posture.Position 2: the shoulder is depressed. Position 3: the arm is internally rotated and the wrist is flexed. Position 4:the patient adds lateral cervical flexion to the previous posture. Position 5: the shoulder is extended while wristflexion is maintained. (Redrawn with permission from a home programme form used by Spectrum HealthRehabilitation and Sports Medicine Services, Grand Rapids, Michigan.)


References

Agee, J. M., Peimer, C. A., Pyrek, J. D. and Walsh, W. E.(1995). Endoscopic carpal tunnel release: A prospectivestudy of complications and surgical experience. J. HandSurg., 20A, 165–72.

Chow, J. C. (1994). Endoscopic carpal tunnel release. Two-portal technique. Hand Clin., 10, 637–46.

Elvey, R. (1985). Brachial plexus tension tests and thepathoanatomical origin of arm pain. In Aspects of Manip-ulative Therapy (E. Glasgow et al., eds) ChurchillLivingstone.

Feindel, W. and Stratford, J. (1958). The role of the cubitaltunnel in tardy ulnar nerve palsy. Can. J. Surg., 1,287–300.

Gelberman, R. H. and Szabo, R. M. (1986). Pressure effectson human peripheral nerve function. In Tissue Nutrition andViability (A. R. Hargens, ed.) pp. 161–83, Springer-Verlag.

Lakey, M. D. and Aulicino, P. L. (1986). Anomalous musclesassociated with compression neuropathies. Orthopaedic Rev.,15(4), 19–28.

Ludlow, K. S., Merla, J. L., Cox, J. A. and Hurst, L. N. (1997).Pillar pain as a postoperative complication of carpal tunnelrelease. J. Hand Ther., 10(4), 277–82.

Lundborg, G. and Dahlin, L. B. (1989). Pathophysiology ofnerve compression. In Nerve Compression Syndromes (R. M.Szabo, ed.) Slack.

Mackinnon, S. E. and Dellon, A. L. (1988). Surgery of thePeripheral Nerve. Thieme.

Myers, R. and Powell, H. (1981). Endoneurial fluid pressure inperipheral neuropathies. In Tissue Fluid Pressure andComposition (A. Hargens, ed.) Williams & Wilkins.

Nathan, P. A., Keniston, R. C., Myers, L. D. and Meadows,K. D. (1992). Obesity as a risk factor for slowing of sensoryconduction of the median nerve in industry. A cross-sectionaland longitudinal study involving 429 workers. J. Occup.Med., 34, 379–83.

Nathan, P. A., Meadows, K. D. and Keniston, R. C. (1993).Rehabilitation of carpal tunnel surgery patients using a shortsurgical incision and an early program of physical therapy.J. Hand Surg., 18A, 1044–1050.

Richman, J. A., Gelberman, R. H., Rydevik, B. L., et al. (1989).Carpal tunnel syndrome: morphologic changes after releaseof the transverse carpal ligament. J. Hand Surg., 14A,852–7.

Siegel, J. L., Davlin, L. B. and Aulicino, P. L. (1993). Ananatomical variation of the palmar cutaneous branch of themedian nerve. J. Hand Surg., 18B, 182.

Totten, P. A. and Hunter, J. H. (1991). Therapeutic techniques toenhance nerve gliding in thoracic outlet syndrome and carpaltunnel syndrome. Hand Clin., 7, 505.

Upton, A. R. M. and McComas, A. J. (1973). The double crushin entrapment syndromes. Lancet, 2, 359–62.

Wadsworth, T. G. (1977). The external compression syndromeof the ulnar nerve at the cubital tunnel. Clin. Orthop., 124,189.

Werner, C. O. (1989). The anterior interosseous nerve syn-drome. Int. Orthop., 13, 193–7.

Wilgis, E. F. S. and Murphy, R. (1986). The significance oflongitudinal excursion in peripheral nerves. Hand Clin., 2(4),761–6.

Further reading

Amadio, P. C. (1995). The first carpal tunnel release? J. HandSurg., 20B, 40–1.

Barton, N. (1989). Repetitive strain disorder. Br. Med. J., 229,405–6.

Bell-Krotoski, K. (1991). Advances in sensibility evaluation.Hand Clin., 7, 527–46.

Butler, D. S. (1991). Mobilization of the Nervous System.Churchill Livingstone.

Dellon, A. L. (1992). Patient evaluation and managementconsiderations in nerve compression. Hand Clin., 8(2),229.

Dellon, A. L. and Mackinnon, S. E. (1986). Radial sensorynerve entrapment in the forearm. J. Hand Surg., 11A,199–205.

Fry, J. H. (1986). Overuse syndrome in the upper limb inmusicians. Med. J. Aust., 144, 182–5.

Gelberman, R. H., Eaton, R. and Urbaniak, J. R. (1993).Peripheral nerve compression. Instructional course lectures,The American Academy of Orthopaedic Surgeons. J. BoneJoint Surg., 75(A), 1854–78.

Johnson, E. W. (1993). Diagnosis of carpal tunnel syndrome.The gold standard (editorial). Am. J. Phys. Med. Rehabil.,72, 1.

Kenneally, M., Rubenach, H. and Elvey, R. (1988). The upperlimb tension test: the SLR test of the arm. In PhysicalTherapy of the Cervical and Thoracic Spine, Clinics inPhysical Therapy 17 (R. Grant, ed.) pp. 167–94. ChurchillLivingstone.

Kerr, C. D., Gittins, M. E. and Sybert, D. R. (1994). Endoscopicversus open carpal tunnel release. Clinical results. Arthro-scopy, 10, 266–9.

Lundborg, G. (1988). Nerve Injury and Repair. ChurchillLivingstone.

Mackinnon, S. (1992). Double and multiple crush syndromes.Hand Clin., 8, 369.

Maitland, G. (1977). Peripheral Mobilization. Butterworth.Martin, C. H., Seiler, J. G. and Lessne, J. S. (1996). The

cutaneous innervation of the palm: An anatomic study of theulnar and median nerves. J. Hand Surg., 21A, 634–8.

Millesi, H., Zoch, G. and Rath, T. (1990). The gliding apparatusof peripheral nerve and its clinical significance. Ann HandSurg., 9(2), 87.

Osterman, A. L. (1991). Double crush and multiple compres-sion neuropathy. In Operative Nerve Repair and Reconstruc-tion (R. H. Gelberman, ed.) pp. 1211–29, J. B. Lippincott.

Phalen, G. S. (1970). Reflections on 21 years experience withcarpal tunnel syndrome. J. Am. Med. Assoc., 212(8),1365–7.

Rozmaryn, L. M., Dovelle, S., Rothman, E. R., et al. (1998).Nerve and tendon gliding exercises and the conservativemanagement of carpal tunnel syndrome. J. Hand Ther., 11(3),171–9.


Simpson, R. L. and Fern, S. A. (1996). Multiple compressionneuropathies and the double crush syndrome. Orthop. Clin.North Am., 27(2), 381–8.

Szabo, R. and Madison, M. (1995). Carpal tunnel syndrome as awork-related disorder. In Repetitive Motion Disorders of theUpper Extremity (S. L. Gordon, S. J. Blair and L. J. Fine, eds)pp. 421–34, American Academy of Orthopaedic Surgery.

Terrono, A. L., Belsky, M. R., Feldon, P. G. and Nalebuff, E.A. (1993). Injury to the deep motor branch of the ulnarnerve during carpal tunnel release. J. Hand Surg., 18A,1038–40.

Weiss, A. P., Sachar, K. and Gendreau, M. (1994). Conservativemanagement of carpal tunnel syndrome. J. Hand Surg., 19A,410–5.

8

Conditions of the wrist and fingertendons

Introduction

The tendons of the wrist and hand are subject to anumber of disorders and conditions. As withperipheral nerve compression, these conditions canhave a number of causes: anatomic anomalies,systemic/metabolic disorders (e.g. diabetes,Dupuytren’s disease, thyroid conditions) or occu-pational factors.

Inflammatory conditions

Inflammatory-type conditions can be specific tocertain diseases such as: rheumatoid arthritis(proliferative tenosynovitis), amyloidosis, calcifictenosynovitis (e.g. flexor carpi ulnaris tendon) orgout. An acute inflammatory response is charac-terized by redness, swelling, intense local pain andsometimes crepitus. Infective (or septic) tenosyno-vitis can have a bacterial, mycobacterial, e.g.tuberculosis (Kozin and Bishop, 1994), or viralcause.

Constrictive conditions

‘Stenosing tendovaginitis’ and ‘reactive tenosyno-vitis’ are two of the terms used to describeconstriction of tendons at the wrist and in thefingers (Wolfe, 1999). These conditions commonlyinvolve:

1. The flexor tendons of the digits and thumb(triggering).

2. The tendons of the first dorsal compartment (deQuervain’s disease) (Fig. 8.1).

3. Flexor carpi radialis (Fig. 8.2).4. Extensor carpi ulnaris.

Extensor pollicis longus is much less frequentlyinvolved.

Constrictive tenosynovitis is more likely to berelated to intrinsic anatomic and degenerativechanges rather than being an inflammatory condi-tion. These conditions occur in the region of thefibro-osseous tunnels which act as fulcrums for thefinger and wrist tendons. Repeated movement of atendon through such a confined passage can resultin swelling and bunching of the tendon fibres(Hueston et al., 1973) and interfere with tendonglide. With time, the retinacular sheaths canthicken considerably and the tendon will showsigns of attrition (Keon-Cohen, 1951).

Trigger finger/thumb and de Quervain’s diseaseoften co-exist with carpal tunnel syndrome andepicondylitis and are far more common in womenthan men. Whilst trauma and repetitive work canexacerbate these conditions, it is thought that thereis a predisposition to their development (Weilby,1970).

1. Triggering of the digits or thumb

Constriction at the level of the metacarpal headresults from the disproportionate size of the flexortendon in relation to its overlying retinacularpulley (i.e. the A1 pulley) which can undergomarked hypertrophy (Bunnell, 1944) (Fig. 8.3).

ECUtendonitis

EDM

EIP

APL

EPB

Site ofintersectionsyndrome

ECRLECRB

FPL

FCR tendonitis

Triggeringat AI pulleysover metacarpalheads

Calcific tendonitisof FCUFCU tendonitis

Thickened tendon

AI pulley



The incidence of trigger finger peaks in the sixthdecade of life. The thumb is most commonlyaffected, followed by the ring, middle, little andindex fingers (Weilby, 1970). Several digits can beaffected at once. Multiple digit involvement ismore common in insulin-dependent diabetics whosometimes present with a mild PIP joint flexiondeformity of the middle finger. Non-diabeticpatients with longstanding triggering may alsopresent with a PIP joint flexion deformity which issometimes mistaken for Dupuytren’s disease orjoint dislocation.

The patient may complain of tenderness over theA1 pulley, pain on active flexion and/or ‘catching’or ‘clicking’ of the PIP joint as the finger movesfrom extension to flexion or from flexion to fullextension. The digit may actually ‘lock’ intoflexion and require passive correction to restoredigital extension. The thickened flexor sheath cangenerally be palpated.


1. Corticosteroid injectionPrimary triggering of the digits can often betreated successfully with corticosteroid injectioninto the tendon sheath. Success of this treatmentis greater in patients with involvement of only

Figure 8.1. The more common tendon disorders onthe dorsum of the hand involve the 1st and 6thcompartments, i.e. the tendons of abductor pollicislongus (APL)/extensor pollicis brevis (EPB) andextensor carpi ulnaris (ECU) respectively. Lesscommon entrapment disorders involve the tendons ofextensor indicis proprius (EIP) and extensor digitiminimi (EDM).

Figure 8.2. Common tendon disorders on the volaraspect of the hand include triggering of the thumband/or digital flexor tendons and tendonitis of flexorcarpi radialis (FCR) and flexor carpi ulnaris (FCU).The FCU tendon can be the site for calcific depositsnear the tendon’s junction with the pisiform. Inrheumatoid disease, flexor pollicis longus (FPL) canundergo attrition rupture due to bony spicules on thescaphoid.

Figure 8.3. The disproportionate size of the flexortendon in relation to its overlying retinacular pulleycan result in pain on active flexion and cause thefinger to ‘trigger’ or, in severe cases, lock into theflexed position.

Conditions of the wrist and finger tendons 101

one digit and where duration of symptoms is lessthan four months (Newport et al., 1990). Ifsymptoms persist, the injection can be repeatedon two more occasions without the risk ofpossible complications such as skin depigmenta-tion, skin atrophy or tendon rupture (Marks andGunther, 1989).

2. SplintingPatients who do not wish to undergo injection orsurgical release can be managed with a hand-basedsplint which immobilizes the MCP joint(s) of theaffected digit(s) in neutral extension. This treatmentprotocol was devised by Evans et al. (1988) and itsaim is to rest the proximal pulley system by alteringthe biomechanics of the flexor tendons (Fig. 8.4).The outcomes of splinting have been compared withthose of injection at follow-up after one year andresults have been encouraging. Sixty-six per cent ofsplinted digits were symptom-free compared to 84per cent in the case of injected digits (Patel andBassini, 1992).

The patient is asked to wear the splint duringwaking hours for an initial period of 3 weeks. Thesplint prevents flexion at the MCP joint(s) ofaffected digit(s), however is ‘stepped down’ toallow MCP flexion of uninvolved digits. Every2 hours during the day, the patient actively flexes

the fingers into a ‘hook fist’ and then activelyextends the digits to full range. This exercisemaintains the differential glide of the flexortendons within the sheath and is repeated 20 timesat each session (Fig. 8.5).

At the completion of this set of exercises, ‘placeand hold’ flexion exercises are performed in thefull-fist position, i.e. the fingers are passivelyplaced into full flexion at all three digital joints andthe patient is then asked to gently maintain thisfully flexed position for several seconds. Thismanoeuvre maintains mobility of the MCP jointsand avoids the ‘triggering’ that can occur withactive digital flexion from the fully extendedposition.

If the patient has shown some improvementduring the 3-week period, a further 3 weeks oftreatment can be trialled. If there has been noimprovement during this time, steroid injection orpulley release are indicated.

Surgery

The pulley is generally divided through an openprocedure; however, percutaneous trigger fingerrelease is an alternative procedure (Stothard andKumar, 1994). The percutaneous method is contra-indicated in patients with rheumatoid disease,diabetes or those with excessive subcutaneoustissue (Froimson, 1993) (Fig. 8.6).

Early active movement is begun within a day ofsurgery and scar management is commenced uponremoval of sutures.

Figure 8.4. Conservative management of triggerfinger(s) involves a hand-based splint that immobilizesthe MCP joint(s) of the affected digit(s) in neutralextension.

Figure 8.5. On a 2-hourly basis, the patient fullyflexes and extends the digits 20 times. The purpose ofthis exercise is to maintain the differential glide of theflexor tendons.

Branches ofsuperficial

radial nerve EPL

1st Dorsalcompartmenthousing APL

and EPB tendons

Open release ofthe AI pulley


2. de Quervain’s disease

de Quervain’s disease is stenosing tendovaginitisof the first dorsal compartment (Fig. 8.7). This isthe most radial of the six dorsal extensor compart-ments and houses the sheaths of abductor pollicislongus (APL) and extensor pollicis brevis (EPB) atthe radial styloid process. APL (which often hasseveral slips) and EPB can share a tunnel or, moreoften, lie in separate tunnels. It has been suggested

these anatomic anomalies may account for thepoor response of some patients to conservativemanagement (Minamikawa et al., 1991). Theremay be thickening of the retinacular roof, anassociated ganglion and/or there may be radialnerve neuritis.

Aetiology

This condition can result from activities thatrequire frequent thumb abduction in combinationwith ulnar deviation of the wrist. Occasionally, deQuervain’s disease can present acutely from alocal blunt injury to the styloid process.


The patient generally presents with pain andswelling on the radial aspect of the wrist. Thepatient may complain of an ache in the thumband this may radiate proximally into the forearm.Pain is aggravated by movement of the thumb.On palpation, there is tenderness over the radialstyloid. If there is also involvement of thesuperficial branch of the radial nerve, sensitivityin this region can be quite marked.

Diagnostic manoeuvre

To help establish the diagnosis of de Quervain’sdisease, the following test is performed (Finkel-stein, 1930). The patient is asked to flex the MCPand IP joints of the thumb across the palm. Thefingers are then flexed over the thumb and thepatient is asked to ulnar deviate the wrist. Wherethis manoeuvre elicits intense pain, the test issaid to be positive. This manoeuvre can beuncomfortable in the normal wrist so comparisonwith the non-involved side should always bemade (Fig. 8.8).

Resistance given to thumb extension at thelevel of the MCP joint can also be suggestive ofEPB inflammation (Kirkpatrick and Lisser, 1995).This is referred to as the ‘hitch-hiker’s’ test.

Differential diagnosis

Conditions that can present similarly to de Quer-vain’s disease include arthritis of the first(CMC) joint (which may coexist with this condi-tion) and, rarely, intersection syndrome wheresymptoms of pain and swelling of the APL andEPB muscle bellies occur 4–6 cm proximal to the

Figure 8.6. Open release of the A1 pulley.

Figure 8.7. Stenosing tendovaginitis of the tendons inthe first dorsal compartment (i.e. de Quervain’sdisease) involves the tendons of abductor pollicislongus (APL) and extensor pollicis brevis (EPB). Notethe superficial branches of the radial nerve which arevulnerable to injury during decompression.


wrist rather than 1–2 cm as in the case of deQuervain’s disease.


In the first instance, there should be cessation ormodification of the precipitating activities. Splint-ing involves resting the wrist and thumb for aperiod of 3 to 4 weeks. The wrist is held in neutralor slight extension and the thumb is held incomfortable palmar abduction. The terminal jointof the thumb is left free to move (Fig. 8.9).

To expedite progress, splinting can be used inassociation with steroid injection into the synovialsheath of the first dorsal compartment. As in thecase of triggering, conservative management of deQuervain’s disease has a higher success rate incases that are relatively acute. Success rate withsteroid injection, given once or twice, ranges from50 to 80 per cent (Harvey et al., 1990).

At the completion of the immobilization period,the patient can be fitted with a soft neoprene wrist/thumb wrap that provides elastic support withouthindering movement. This support is particularlyhelpful for patients who are returning to work(Fig. 8.10).

Surgery

Surgical treatment involves decompression of thefirst dorsal compartment through either a trans-verse or longitudinal incision (Fig. 8.11). While atransverse incision leaves a more cosmetic scar,

exposure is compromised and the risk of injury tothe superficial branch of the radial nerve istherefore greater. To avoid injury, the subcutaneousfat is incised by using gentle blunt longitudinaldissection. Under direct vision, the thickenedcompartment sheath is longitudinally incised on itsdorsal surface. A volar lip of retinaculum ismaintained to minimize the risk of volar disloca-tion of the APL tendon.

The compartment is explored for the presence ofintervening septa which will require completedivision. The tendons are decompressed from theirmusculotendinous junctions proximally, to about1 cm distal to the retinaculum. The function of eachtendon is tested for independent movement.

Figure 8.8. A positive Finkelstein test helps confirmthe diagnosis for de Quervain’s disease. This testinvolves flexing the thumb across the palm, thenflexing the fingers over the thumb and ulnar deviatingthe wrist. While this manoeuvre is uncomfortable inthe normal wrist, it usually elicits intense pain inpatients with de Quervain’s disease.

Figure 8.9. Conservative management of deQuervains’s disease includes temporary immobilizationin a thermoplastic splint that maintains the wrist inneutral or slight extension and the thumb in afunctional degree of palmar abduction. The IP joint ofthe thumb is left free to move.

Figure 8.10. A soft neoprene thumb/wrist wrapprovides support while allowing movement whenactivity is resumed.

Decompressionof the 1st dorsalcompartment


Aftercare

The wound is covered with a soft bulky dressingthat restricts movement of the thumb for the firstfew postoperative days. Gentle active movementand light use of the hand is then begun.

Raised and/or sensitive scar is managed withOpsite Flexifix and silicone gel. Patients whodevelop problems of marked hypersensitivity fromirritation of the radial nerve are also treated withtranscutaneous electrical nerve stimulation.

3. Flexor carpi radialis

The tendon of flexor carpi radialis lies in its owntight fibrous canal and is anchored rigidly to thewall of the trapezium. This appears to render thetendon vulnerable to both primary tendovaginitisand to the secondary effects of carpal degeneration(Bishop et al., 1994).


The patient is typically a middle-aged female whopresents with pain over the scaphoid tubercle.There may be some local swelling and an over-lying ganglion. When the patient is asked toactively flex and radially deviate the wrist againstresistance, increased pain will help suggest thediagnosis (Fitton et al., 1968).

Treatment

This condition usually responds to a combinationof rest in a wrist splint, non-steroidal anti-inflammatory medication and corticosteroid injec-tion. Most cases settle within 2 to 3 weeks.

Where tendovaginitis is secondary to arthriticlesions, decompression of the tendon may beindicated to avoid attrition rupture.

4. Extensor carpi ulnaris

The tendon of extensor carpi ulnaris can becomeinflamed following a twisting injury of the wrist orrepetitive hypersupination with wrist ulnar devia-tion. This condition, which presents with pain andswelling on the ulnar side of the wrist, can bedifficult to distinguish from other pathology in thisarea, e.g. arthritis of the distal radioulnar joint ortears of the triangular fibrocartilage.

A provocative manoeuvre that points to thediagnosis involves giving resistance to wrist exten-sion and ulnar deviation. This results in increasedpain which may be accompanied by crepitus withinthe swollen sheath.

Treatment

Conservative treatment includes ice (in theimmediate postinjury phase), wrist splinting inextension, anti-inflammatory medication and corti-costeroid injection.

Where symptoms persist, decompression of thesixth dorsal compartment is carried out.

References

Bishop, A. T., Gabel, G. and Carmichael, S. W. (1994). Flexorcarpi radialis tendinitis. Part 1: Operative anatomy. J. BoneJoint Surg., 76A, 1009–14.

Bunnell, S. (1944). Injuries of the hand. In Surgery of the Hand.pp. 496–9, Lippincott.

Evans, R. B., Hunter, J. M. and Burkhalter, W. E. (1988).Conservative management of the trigger finger: a newapproach. J. Hand Ther., 1, 59.

Finkelstein, H. (1930). Stenosing tendovaginitis at the radialstyloid process. J. Bone Joint Surg., 12, 509.

Fitton, J. M., Shea, W. F. and Goldie, W. (1968). Lesions of theflexor carpi radialis tendon and sheath causing pain at thewrist. J. Bone Joint Surg., 50B, 359–63.

Froimson, A. I. (1993). Tenosynovitis and tennis elbow. InGreen’s Operative Hand Surgery (D. P. Green, ed.), ChurchillLivingstone.

Harvey, F. J., Harvey, P. M. and Horsley, M. W. (1990). DeQuervain’s disease: surgical or nonsurgical treatment.J. Hand Surg., 15A, 83–7.

Hueston, J. T., Wilson, W. F. and Soin, K. (1973). Triggerthumb. Med. J. Aust., 2, 1044–5.

Keon-Cohen, B. (1951). De Quervain’s disease. J. Bone JointSurg., 33B, 96–9.

Kirkpatrick, W. H. and Lisser, S. (1995). Soft tissue conditions:Trigger fingers and De Quervain’s disease. In Rehabilitation

Figure 8.11. The sheath of the 1st dorsal compartmentis incised longitudinally on its dorsal surface. A volarlip of retinaculum is maintained to minimize the riskof volar dislocation of the APL tendon.


of the Hand: Surgery and Therapy (J. M. Hunter, E. J.Mackin and A. D. Callahan, eds) pp. 1007–15.

Kozin, S. H. and Bishop, A. T. (1994). Atypical Mycobacteriuminfections of the upper extremity. J. Hand Surg., 19A,480–7.

Marks, M. R. and Gunther, S. F. (1989). Efficacy of cortisoneinjection in treatment of trigger fingers and thumbs. J. HandSurg., 14A, 722–7.

Minamikawa, Y., Peimer, C. A., Cox, W. L. and Sherwin, F. S.(1991). De Quervain’s syndrome: surgical and anatomicalstudies of the fibro-osseous canal. Orthopaedics, 14,545–9.

Newport, M. L., Lane, L. B. and Stuchin, S. A. (1990).Treatment of trigger finger by steroid injection. J. HandSurg., 15A, 748–50.

Patel, M. R. and Bassini, L. (1992). Trigger fingers and thumb:when to splint, inject or operate. J. Hand Surg., 17A, 110–3.

Stothard, J. and Kumar, A. (1994). A safe percutaneousprocedure for trigger finger release. J. R. Coll. Surg. Edinb.,39, 116–7.

Weilby, A. (1970). Trigger finger. Incidence in children andadults and the possibility of a predisposition in certain agegroups. Acta Orthop. Scand., 41, 419–27.

Wolfe, S. W. (1999). Tenosynovitis. In Green’s Operative HandSurgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson,eds) pp. 2022–44, Churchill Livingstone.

Further reading

Arons, M. S. (1987). De Quervain’s release in working women:a report of failures, complications and associated diagnoses.J. Hand Surg., 12A, 540–4.

Carroll, R. E., Sinton, W. and Garcia, A. (1955). Acute calciumdeposits in the hand. JAMA, 157, 422–6.

Phalen, G. S. (1991). Stenosing tenosynovitis: Trigger fingers,trigger thumb and De Quervain’s disease. Acute calcificationin wrist and hand. In Flynn’s Hand Surgery (J. P. Jupiter, ed.)pp. 439–47, Williams & Wilkins.

Sampson, S. P., Badalamente, M. A., Hurst, L. C. and Seidman,J. (1991). Pathobiology of the human A1 pulley in triggerfinger. J. Hand Surg., 16A, 714–21.

Sampson, S. P., Wisch, D. and Badalamente, M. A. (1994).Complications of conservative and surgical treatment of DeQuervain’s disease and trigger fingers. Hand Clin., 10,73–82.

Secretan, H. (1901). Oedema dur et hyperplasie traumatique dumetacarpe dorsal. Rev. Med. Suisse Romande., 21, 409.

Shaw, J. A. (1986). Acute calcific tendonitis in the hand.Orthop. Rev., 15, 482–5.

Witt, J., Pess, G. and Gelberman, R. H. (1991). Treatment of DeQuervain’s tenosynovitis. A prospective study of the resultsof injection of steroids and immobilization in a splint. J. BoneJoint Surg., 73A, 219–22.

9

Dupuytren’s contracture

Definition

Dupuytren’s disease is a condition in whichnodules and cords form in the palmar-digital fasciaof the hand (Luck, 1959). The fascia undergoespathological change which converts the normalbands and ligaments into diseased cords. Thesecords can displace neurovascular bundles and maycause soft tissue and joint contractures (Fig. 9.1).The pathologic tissue is comprised of immaturecollagen and fibroblasts.

Aetiology

The aetiology of this condition remains unknown.Current evidence points to a genetic predisposi-tion. The disease is seen most frequently in thepopulations of northern Europe. It is rare amongstOriental and black races.

The significance of injury or occupation aspredisposing factors in the development ofDupuytren’s disease remains controversial(Meagher, 1990). The disease is associated withcertain medical conditions, e.g. diabetes and rheu-matoid arthritis. Earlier associations with epilepsypoint to the drugs used in treatment, rather than thecondition itself, to account for the relationship(Hurst and Badalamente, 1990).


The patient with Dupuytren’s disease may presentwith a palmar or digital nodule, a cord or both(Fig. 9.2). The skin may or may not be involved.There may be contracture of a single digitinvolving one or all three joints or there may beinvolvement of multiple digits and one or moreweb spaces. Where the disease is present on theradial aspect of the hand, it is often moreaggressive and difficult to treat. It is also usuallymore aggressive in the younger patient.

There may be extrapalmar ectopic depositsmanifesting as knuckle pads, plantar nodules andPeyronie’s disease. Unless associated with acutepalmar fasciitis or carpal tunnel syndrome,Dupuytren’s disease is usually painless.

The presenting hand may be supple and mobile orthick with joints that are prone to stiffness. The stiff,

Figure 9.1. Features of the Dupuytren’s hand caninclude: palmar cords and nodules, interdigital webcontracture, flexion deformity at the MCP and/or PIPjoints, hyperextension deformity of the DIP joint andknuckle pads. (Note the skip area where the skin isnot tethered by the disease. Fat lying between the skinand the disease in this skip area will often contain theneurovascular bundle.)

Natatory ligament

Cleland’sligament

Lateraldigital sheet

Spiral bandNeuravascularbundle

Pretendinousband

Superficialtransverseligament

Grayson’s ligament

(a)

Spiral cord

Intrinsic muscle

Central cord

Lateral cord

Pretendinous cord

(b)


arthritic or sweaty hand is prone to post-surgicalcomplications. There can be associated triggering ofthe finger or carpal tunnel syndrome. Theseconditions are more likely in diabetic patients.

The average age of onset in men is about 48years, while in women it is 59 years. Although thedisease appears later in women, and is usually lesssevere, the postoperative complication of chronicregional pain syndrome is double that of men. Theoverall incidence of this complication is approx-imately 5 per cent.

Structures involved in contracture

MCP joint

Contracture of the metacarpophalangeal joint iscaused primarily by involvement of the pre-tendinous band (Fig. 9.3). Contracture can also

result from diseased fascia of the intrinsic muscu-lature. Disease of the natatory ligament causes webspace contracture which will limit finger span.

PIP joint

The bands and ligaments which become diseased,resulting in contracture of the PIP joint, are severalin number. Surgical correction of this joint istherefore more difficult. Of the various cords thatcan develop in the digit (i.e. lateral, central,natatory or spiral), it is contracture of the spiralcord that can significantly displace the neuro-vascular bundle, rendering it susceptible to injuryduring surgery (Umlas et al., 1994). The spiral cordis comprised of: the pretendinous band, the spiralband, the lateral digital sheet and Grayson’sligament (Fig. 9.4).

Figure 9.2. This little finger demonstrates a palmarnodule, a palmar-digital cord and a marked PIP jointflexion deformity. Note the skin excoriation.

Figure 9.3. Contracture of the MCP joint is causedprimarily by involvement of the pretendinous band.

Figure 9.4. (a) Normal components of the finger fascia. (b) When diseased, the normal components of the digitalfascia are converted into the spiral, lateral and central cords which result in flexion contracture of the PIP joint.

Thumb rayincision

Longitudinalincision

Mid-plamarincision

Dupuytren’s contracture 109

Indications for surgery

Surgery is indicated if the patient presents with afunctional disability or where there has been rapidprogression of the disease. Contractures of the PIPjoint of 30 degrees or less are generally not treatedby surgery (McFarlane and Botz, 1990). Suchcases of mild deformity with slow progression aremonitored on a 6 to 12 monthly basis (Fig. 9.5).

Limited surgery is advisable for the elderlypatient. In the younger patient with a strongDupuytren’s diathesis and progressive contracture,more radical surgery is advised.

Patients who request surgical treatment forcosmetic reasons should be warned of the possiblerisk of losing some hand function. Most patientswith Dupuytren’s contracture can make a normalfist before surgery, but some may have difficultyregaining full flexion after surgery.

Biologically, the disease can extend beyond thefield of surgical clearance. Cure of the disease bycomplete fasciectomy, therefore, is not possible.Because of the potential for a number of post-operative complications, e.g. ischaemia and infec-tion, it is prudent to inform the patient of theirpossible occurrence.

Results

Approximately 80 per cent of patients can expectto gain a near-normal range of extension followingsurgery. Return of maximum flexion range cantake some months, particularly in the older patient

with coexisting problems, e.g. osteoarthritis ordiabetes.

Long-term results show a recurrence rate rang-ing from 25 to 80 per cent. Studies suggest thatthis rate is influenced not so much by thesurgical technique as by the disease processitself. Full-thickness skin grafting alone has beenshown by Hueston (1984a) to decrease recur-rence rate.

Contraindications for surgery

These include the following:

1. Skin excoriation, maceration or infection, par-ticularly in the web space.

2. Arthritis in the hand which is likely to beexacerbated by surgery.

3. A patient who is unable to comply with thepostoperative therapy regimen.

4. Poor general health.

Types of incision

Palmar-digital contractures are approachedthrough a longitudinal incision which is con-verted to a Z-plasty at closure. Transverse dis-ease in the palm can be approached by a mid-palmar incision. A combined thumb and thumbweb contracture is approached by an incisionboth along the thumb ray and the thumb web.Both incisions are converted to a single ordouble Z-plasty at closure (Fig. 9.6).

Figure 9.5. Surgery is indicated where the patientpresents with a functional disability or where there hasbeen rapid progression of the disease.

Figure 9.6. Types of incision.


Types of operation

1. Fasciotomy

This procedure involves simple division of aDupuytren’s cord. It may be performed eitherclosed (i.e. percutaneously) or by open technique.The open technique involves dissection of theneurovascular bundle. Fasciotomy is a less inva-sive procedure than fasciectomy and recovery istherefore faster. Recurrence of the deformity,however, is more likely. Indications for thisprocedure include:

(i) An MCP joint contracture that is due to adiscrete palmar pretendinous cord withmobile overlying skin.

(ii) The elderly patient.(iii) As a first-stage procedure for advanced dis-

ease where there may be skin excor-iation.

2. Regional (or limited) fasciectomy

In this procedure, only the diseased fascia isremoved. It is commonly performed in the palmwhere results are more satisfactory than thosegained in the finger, where recurrence rate ishigher. This is the most commonly performedoperation and in experienced hands gives the bestresults (Fig. 9.7).

3. Extensive (or radical) fasciectomy

This procedure involves resection of all palmarfascia but only digital fascia that is involved in thedisease process. It carries a high complication ratewith questionable reduction of recurrence.

4. Dermofasciectomy

Where skin is also involved in the disease process,it is resected and a full-thickness skin graft is usedto cover the defect. The skin is also removed if it isrendered non-viable through the dissectionprocess.

Prophylactic dermofasciectomy is indicated forrecurrent and advanced disease, particularly in theyounger patient. Theoretically, skin grafting inter-rupts the contracting force, preventing recurrencedeep to the grafted ‘firebreak’ (Hueston, 1984b).

Associated procedures

1. Release of PIP joint flexion contracture. Afterremoval of the involved fascia, the PIP jointmay remain contracted. Gentle manipulation isattempted. If this is unsuccessful, formal surgi-cal division of the flexor tendon sheath, palmarplate and sometimes the accessory collateralligament is required. A longstanding con-tracture may have caused attenuation of theextensor apparatus.

2. Release of DIP joint extension contracture. Asevere longstanding PIP joint contracture isoften associated with hyperextension of the DIPjoint. This results from involvement of theoblique retinacular ligament which requiressurgical division. Capsulotomy of this joint mayneed to be performed in association withdivision of the extensor tendon to allow DIPjoint flexion (Belusa et al., 1997).

3. Microscopic repair of the digital nerve andartery may be necessary if intraoperative dam-age has occurred.

Figure 9.7. Regional (or limited) fasciectomy is themost commonly performed operation and gives thebest results in experienced hands.


4. If the contracture is irreversible, the patient mayopt for joint fusion in a functional position. Ifthe contracture is associated with severeinvolvement of the digital nerves and arteries,elective amputation at the PIP or MCP jointlevel may be a better option.

Types of skin closure

1. Direct suture

Where incisions are made along neutral lines, i.e.where there is no skin tension in any position in thepalm or digit, the wounds can be directly sutured.The same applies to the Bruner zigzag incision.

2. Local flaps

Local flaps include single Z-plasty, multipleZ-plasties or four-times Z-plasty. Longitudinalwounds are best closed by Z-plasty over the mid-portion of the pulps and that part of the palm wherethe local skin is most mobile. Areas with optimalblood supply are chosen.

The Z-plasty interrupts the line of potential skincontracture and gains skin length after release ofthe contracture.

3. Skin graft

A full-thickness skin graft is preferable to a split-thickness skin graft because it has considerablyless tendency to contract.

4. Open wound (McCash, 1964) technique

Transverse wounds in the palm and digits will healby spontaneous wound contraction over a period of3 to 5 weeks depending on the size of the wound.Such a wound drains freely and haematoma istherefore avoided and infection is rare. As the skinis not sutured, pain is minimal and active move-ment is begun early. Because the healing processinvolves a contraction, rather than a contracture,the eventual scar line is negligible. This method ofwound management does, however, require fre-quent dressing change.

Complications of surgery and healing

A combination of the following factors predisposesto wound and other hand complications (Prosserand Conolly, 1996):

1. Older age of patient.2. The presence of diabetes.3. The surgical raising of extensive thin flaps.4. Involvement of the skin in the disease

process.5. Extensive dissection involving the blood sup-

ply to the skin and deeper structures.6. Excision of scar tissue involving the flexor

tendon sheath and IP joints.

Complications include:

1. Ischaemia of the digit from digital arteryspasm, thrombosis or laceration duringsurgery.

2. Division of the digital nerve.3. Haematoma: this manifests postoperatively

as throbbing pain and is not relieved byanalgesics.

4. Oedema.5. Infection.6. Skin necrosis from inadequate circulation to

skin flaps.7. Tendon adhesions.8. Joint adhesions and stiffness, especially at

the PIP joint level.9. Palmar fasciitis.

10. Hypertrophic/contracting scar.11. Slow healing of the operative wound due to

poor circulation following months or yearsof fibrosis.

12. Chronic regional pain syndrome (formerlyreferred to as reflex sympathetic dystrophy).The incidence of this is approximately 5 percent and it is seen twice as often in womenas in men.

13. Recurrence of the deformity as the diseaseinevitably extends beyond the field of surgi-cal clearance.

Principles of postoperativemanagement

1. Early diagnosis and prevention of woundcomplications, e.g. removal of sutures fromany area of skin with poor circulation.

2. Treatment of oedema.3. Maintenance of surgical correction.4. Scar management.5. Restoration of flexion range and hand

function.


Monitoring of the hand

The appearance and condition of the hand ismonitored closely during the first few weeks aftersurgery as changes in hand circulation and oedemacan be quite marked from one therapy session tothe next. The therapist should remain alert to anysigns that may herald the onset of chronic regionalpain syndrome. These signs include:

1. Oedema that worsens rather than improvesduring the course of the day.

2. Pain that progressively worsens rather thaneases.

3. Lack of progress in regaining flexibility (in theabsence of arthritic changes).

4. Autonomic signs such as excessive sweating ormottling of the skin.

Occasionally following surgery, the patient willpresent with a ‘flare’ reaction which can have asimilar appearance to CRPS. It is distinguishedfrom this condition by the fact that it is usuallyconfined to the area of surgery, rather than thewhole hand, and tends to settle within a fewdays.

Refer to the chapter on ‘Chronic regional painsyndrome’ for management.

Wound care

The hand therapy programme is commenced 2 to 3days following surgery. Ideally, the patient is seenat least 2 to 3 times a week for the first fortnight.If skin grafting has been carried out, exercise isdeferred for 7 to 10 days during which time thehand usually remains in its postoperative plaster.

Patients who have undergone regional fasciect-omy will have had primary closure of theirwounds. Dressings should be renewed at eachtreatment session so that the wound can beassessed for any signs of infection or haematoma.The replacement dressing should be minimal sothat exercises can be performed in an unimpededmanner.

When the open-palm technique is used, thewound can be soaked once or twice a day for 5 minin a solution of warm water (1200 ml) to which20 g of salt has been added. This is prepared byboiling the water, adding the salt and allowing thesolution to cool until tepid. The patient is encour-aged to perform gentle active exercises while thewound is soaking (Fietti and Mackin, 1995).Following this procedure, the wound is redressed

with a non-adherent dressing, e.g. Adaptic), layerof gauze and a layer or two of bandage or Tubigripstockinette.

Treatment of oedema

Because surgery for Dupuytren’s disease is oftenquite extensive, postoperative hand oedema shouldbe anticipated. Persisting oedema can result infibrosis of the joints and soft tissues which leadsinevitably to stiffness. Oedema can be managedby:

1. Elevation (for at least the 1st postoperativeweek).

2. Ice therapy.3. Commencement of early active exercise in the

absence of grafting.4. Compression wrap, e.g. gentle application of a

crepe bandage, Coban wrap or Tubigrip supportfor palmar or dorsal hand swelling. Whenapplying Coban wrap to the digits, tensionshould be negligible and application is in adistal to proximal direction.

If hand swelling persists beyond wound healing, alycra compression glove is applied (Fig. 9.8). Thepatient should be fitted with the appropriate size toavoid compromising circulation. The glove shouldfit snugly but should not cause throbbing ornumbness. It should be pointed out to the patientthat active flexion exercises are a little more‘challenging’ to perform with the glove in placedue to the gentle extension force exerted by theelasticity in the material. If flexion range is

Figure 9.8. Where hand oedema persists beyond thewound healing stage, a lycra compression glove isapplied. Silicone scar gel can be used beneath thecompression glove.


significantly restricted, removal of the glove priorto exercise may be advisable. Many patients areable to demonstrate improved flexion range whilewearing the glove because the support it providescan reduce discomfort during exercise.

Maintenance of surgical correction

The postoperative splint is most important inmaintaining the extension range achieved at sur-gery. The plaster applied in theatre is replaced witha thermoplastic splint on the 3rd day. This splint isusually a static one and can be applied either on thevolar or dorsal aspect of the hand and forearm. Thesplint should extend from just distal to thefingertips to two thirds along the forearm andextend mid-laterally on the ulnar and radial aspectsof the forearm (Fig. 9.9).

To accommodate a comfortable finger extensionrange in the immediate postoperative phase, it issometimes necessary to place the wrist into slightflexion to avoid undue tension on the palmartissues. The splint is worn continuously for the first3 to 4 weeks, being removed only for dressingchanges and 2-hourly exercise sessions. After thistime, the splint is left off for increasing periodsthroughout the day so that flexion range can beregained.

Where there has been correction of a single digitcontracture or where correction has been localizedto the PIP joint, a dorsal hand-based outriggersplint can be fitted (Rives et al., 1992). Thisdynamic splint has the advantage of allowingactive motion while the splint is being worn.Wearing of the splint at night is continued for 6months after surgery (Fig. 9.10).

Scar management

When the wound has healed, usually between 10 to14 days, oil massage is commenced. This serves todesensitize as well as soften the scar. If there areareas of diminished sensation, the patient is givenadvice regarding protection from injury.

Grafted areas are massaged very lightly at firstto avoid blistering of the skin. The linear scarresulting from the open-palm technique is usuallyminimal, requiring little or no therapyintervention.

To assist scar resolution, adhesive silicone gel(Cica-Care) is applied to the scar and used inconjunction with the extension splint. It can beheld in place with a compression glove or a layerof Tubigrip. The gel is used only on clean, dry andoil-free skin. The gel is washed on a daily basis andis left off the skin for at least 4 h each day to avoidskin maceration. On the first day, the skin ischecked every few hours for irritation or signs ofallergy which are rare. When present, allergyusually manifests as small red dots.

Although the gel is quite costly, one piece isusually sufficient for the duration of scar treatmentwhich is generally 4 to 6 weeks.

Regaining movement

All joints proximal to the hand should be exercisedregularly throughout the day to prevent stiffness.

Figure 9.9. Surgical correction is maintained with astatic volar extension splint. To avoid placing unduetension on the palmar tissues following surgery, thewrist may need to be placed in slight flexion.

Figure 9.10. A dorsal hand-based outrigger can beused to maintain correction following a single digitPIP joint release. This splint has the advantage ofallowing active PIP joint flexion against the rubberband traction.


This applies particularly to the shoulder joint of theolder patient.

Gentle passive and active wrist and fingermovements are commenced on the 2nd post-operative day unless there has been skin grafting,in which case movement of the grafted area isdelayed for 7 to 10 days. Movements should notcause pain and they should be performed with thehand is slight elevation to assist resolution ofoedema.

Each digit is exercised individually with thetherapist passively flexing the digit at the MCP,PIP and DIP joints simultaneously until maximumpassive flexion is achieved without undue dis-comfort. This position is held for a short time(30–60 s) after which the patient actively extendsthe digit. When reasonable passive flexion rangehas been achieved, 10 active stabilized IP jointflexion exercises are practised. Individual fingerexercises are followed by 10 global flexion (or fist-making) exercises.

Because patients with Dupuytren’s disease tendto be in the older age group and because surgery isfrequently quite extensive, the propensity toward

stiffness is great. Exercise sessions should there-fore be repeated at least 2-hourly during the earlypostoperative phase.

As soon as allowed (usually after the 1stpostoperative week), warm water soaks are com-menced. A mild cleansing agent can be added tothe water. The effectiveness of these soaks cannotbe overemphasized. The advantages include:

1. Debridement of the wound.2. Reduction of pain.3. Increased movement.

Soaking the hand in warm soapy water has asoothing effect and helps facilitate movement. Thisis particularly the case in colder weather. Squeez-ing a soft sponge improves mobility and helps toreduce hand swelling. Where interphalangeal jointsare quite stiff, the fingers are gently bandaged intoflexion for 15-min periods several times a day. Forextra effectiveness, this manoeuvre should becombined with the warm water soaks. An IP jointflexion strap will help gain the final degrees offlexion range (Fig. 9.11).

Some patients regain flexion range quitequickly. Others must persevere with their homeprogrammes for several months before regaining aflexion range that is consistent with good function.The patient should be informed that grip strengthcan take many months to return and that activitylevels should be gradually increased commensu-rate with improvement.

References

Belusa, L., Buck-Gramcko, D. and Partecke, B. D. (1997).Results of interphalangeal joint arthrolysis in patients withDupuytren’s disease. Handchir. Mikrochir. Plast. Chir., 29,158–63.

Fietti Jr., V. G. and Mackin, E. J. (1995). Open-palm techniquein Dupuytren’s disease. In Rehabilitation of the Hand:Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D.Callahan, eds) pp. 995–1006, Mosby.

Hueston, J. T. (1984a). Dermofasciectomy for Dupuytren’sdisease. Bull Hosp. Joint Dis. Orthop. Inst., 44, 224.

Hueston, J. T. (1984b). ‘Firebreak grafts’ in Dupuytren’scontracture. Aust. N. Z. J. Surg., 54, 277–81.

Hurst, L. C. and Badalamente, M. (1990). Associated diseases.In Dupuytren’s Disease. Biology and Treatment. The Handand Upper Limb Series (R. M. McFarlane, D. A. McGroutherand M. H. Flint, eds) pp. 253–60, Churchill Livingstone.

Luck, J. V. (1959). Dupuytren’s contracture: A new concept ofthe pathogenesis correlated with surgical management.J. Bone Joint Surg., 41A, 635–64.

Figure 9.11. To help overcome interphalangeal jointstiffness, the fingers can be bandaged into flexionseveral times a day for a period of 10 to 15 minutes.The effect of this stretching manoeuvre is augmentedif the hand is immersed in warm water.


McCash, C. R. (1964). The open palm technique in Dupuytren’scontracture. Br. J. Plast. Surg., 17, 271.

McFarlane, R. M. and Botz, J. S. (1990). The results oftreatment. In Dupuytren’s Disease. Biology and Treatment.The Hand and Upper Limb Series. Vol. 5 (R. M. McFarlane,D. A. McGrouther and M. H. Flint, eds) pp. 387–412,Churchill Livingstone.

Meagher, S. W. (1990). Manual work and industrial injury: Apersonal commentary. In Dupuytren’s Disease. Biology andTreatment. The Hand and Upper Limb Series. Vol. 5 (R. M.McFarlane, D. A. McGrouther and M. H. Flint, eds) pp. 261–4, Churchill Livingstone.

Prosser, R. and Conolly, W. B. (1996). Complications followingsurgical treatment for Dupuytren’s contracture. J. HandTher., 9, 344–8.

Rives, K., Gelberman, R., Smith, B. and Carney, K. (1992).Severe contractures of the proximal interphalangeal joint inDupuytren’s disease. Results of a prospective trial ofoperative correction and dynamic extension splinting.J. Hand Surg., 17A, 1153–9.

Umlas, M. E., Bischoff, R. J. and Gelberman, R. H. (1994).Predictors of neurovascular displacement in hands withDupuytren’s contracture. J. Hand Surg., 19B, 664–6.

Further reading

Andrew, J. G., Andrew, S. M., Ash, A. and Turner, B. (1991).An investigation into the role of inflammatory cells inDupuytren’s disease. J. Hand Surg., 16B, 267–71.

Breed, C. M. and Smith, P. J. (1996). A comparison of methodsof treatment of PIP contractures in Dupuytren’s disease.J. Hand Surg., 21B, 246–51.

Foucher, G., Cornil, C. and Lenoble, E. (1992). Open palmtechnique for Dupuytren’s disease. A five-year follow-up.Ann. Chir. Main Memb. Super., 11, 362–6.

Hall, P. N., Fitzgerald, A., Sterne, G. D. and Logan, A. M.(1997). Skin replacement in Dupuytren’s disease. J. HandSurg., 22, 193–7.

Hueston, J. T. (1963). Dupuytren’s contracture. E & SLivingstone.

Lanzetta, M. and Morrison, W. A. (1996). Dupuytren’s diseaseoccurring after a surgical injury of the hand. J. Hand Surg.,21B, 481–3.

McFarlane, R. M. (1991). Dupuytren’s disease: relation to workand injury. J. Hand Surg., 16A, 775.

McFarlane, R. M. and MacDermid, J. C. (1995). Dupuytren’sdisease. In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 981–94, Mosby.

McGrouther, D. A. (1999). Dupuytren’s contracture. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 563–91, Churchill Livingstone.

Moermans, J. P. (1996). Long-term results after segmentalaponeurectomy for Dupuytren’s disease. J. Hand Surg., 21B,797–800.

Schneider, L. H. (1991). The open palm technique. Hand Clin.,7, 723.

Skoog, T. (1967). The transverse elements of the palmaraponeurosis in Dupuytren’s contracture. Scand. J. Plast.Surg. 1, 51–63.

Starkweather, K. D., Lattuga, S., Hurst, L. C., et al. (1996).Collagenase in the treatment of Dupuytren’s disease: An invitro study. J. Hand Surg., 21A, 490–5.

Tonkin, M. A., Burke, F. D. and Varian, J. P. W. (1984).Dupuytren’s contracture: A comparative study of fasciectomyand dermofasciectomy in one hundred patients. J. HandSurg., 9B, 156–62.

Weinzweig, N., Culver, J. E. and Fleegler, E. J. (1996). Severecontractures of the proximal interphalangeal joint in Dupuyt-ren’s disease: Combined fasciectomy with capsuloliga-mentous release versus fasciectomy alone. Plast. Reconstr.Surg., 97, 560–6.

10

Fractures of the handJacki Shannon-Johnstone

Fractures to the hand are common and most can betreated conservatively by simple closed reduction,protective splinting and early mobilization (Pun etal., 1989). Non-operative treatment is preferredwherever possible to avoid further trauma to thesoft tissues, thus ensuring a more favourableoutcome.

The most commonly fractured bone in the handis the distal phalanx, accounting for nearly 50per cent of all hand fractures. Metacarpal fracturesaccount for approximately 30 per cent of fractures.The remaining 20 per cent occur in the proximaland middle phalanges (Meyer and Wilson, 1995).

Assessment

1. Mechanism of injury

The mechanism of injury will determine the typeof fracture. A direct blow will usually result in atransverse fracture. These tend to produce angula-tory deformities which can be seen in both lateraland frontal radiographic views. A spiral or obliquefracture results from a twisting injury. Obliquefractures result in rotatory deformities but may alsoangulate or shorten. Crushing injuries producecomminuted fractures which nearly always shortenand may rotate or angulate. The degree of softtissue injury associated with the fracture has adirect correlation to the final range of motion(Duncan et al., 1993).

Rotational deformity can be assessed by notingthe position of the fingernails when the digits areextended. They generally lie in the same plane asone another. Orientation of the fingers should be

compared with the opposite hand. During flexion,fingers are checked for a tendency to cross overone another, i.e. ‘scissor’.

2. Radiological examination

Good quality X-rays are essential for accuratediagnosis. Three views are required: anteropos-terior (AP), oblique and lateral. Oblique views areparticularly important for the assessment of intra-articular fractures.

3. Soft tissue injury

Because stress testing for ligament damage has thepotential to displace a fracture, it should be carriedout after fracture evaluation. Local anaestheticshould be administered prior to the test to eliminatepain.

Classification of fractures

Fractures of the metacarpals and phalanges can beclassified in the following way (Fig. 10.1):

1. Closed or open.2. Stable or unstable.3. According to fracture geometry, i.e. transverse,

oblique, spiral or comminuted.4. According to site, i.e. base, shaft, neck or

head.5. According to fracture deformity, i.e. rotational,

angular or shortening.

(a)

(b)

(c)

Collateralligament

(a) (b)

Palmarplate


6. Intra-articular or extra-articular.7. By the presence or absence of associated

ligament, tendon or neurovascular injuries.

Stable fractures

A fracture is considered stable if the bone frag-ments do not displace when stress is applied.Stable fractures may require temporary splinting tosupport the soft tissue and to relieve pain. Gentleactive range of movement can usually be com-menced several days following injury.

Displaced metacarpal and phalangeal fracturescan often undergo closed reduction. Appropriateanalgesia will be required and an X-ray should betaken prior to and post reduction to ensure bonyalignment has been achieved.

Position of safe immobilization

Following reduction the hand is rested in theposition of safe immobilization, i.e. in a POSIsplint (Fig. 10.2). This position is also referred toas the ‘intrinsic plus’ or ‘clam-digger’ position andis as follows:

1. Wrist extension of 30 to 40 degrees.2. Maximum MCP joint flexion (usually 80 to 90

degrees).3. Maximum interphalangeal joint extension

(ideally 0 degrees).

The position of safe immobilization maintains thecollateral ligaments of all finger joints at optimallength thereby avoiding the tendency towardextension contracture of the MCP joints andflexion contracture of the PIP joints. Both thesecontractures are commonly associated with frac-tures of the hand (Fig. 10.3).

Figure 10.1. Classification of fractures. (a) Stable;(b) potentially unstable; (c) unstable.

Figure 10.2. The hand is placed in the ‘position ofsafe immobilization’ following fracture reduction.

Figure 10.3. The collateral ligaments of the MCPjoints are (a) relaxed and short when the joints areextended and (b) stretched when the joints are flexed.

Fractures of the hand 119

Unstable fractures

In an unstable fracture, bony alignment is easilylost. Internal fixation is needed to restore andmaintain normal bony anatomy.

Open reduction and internal fixation

Approximately 10 per cent of phalangeal andmetacarpal fractures require open reduction andinternal fixation (Melone, 1986). Open reductionhas gained greater acceptance over the past twodecades due to increased understanding of thebiomechanical principles of internal fixation,improved materials, increasing specialization insurgery of the hand and antibiotic availability tominimize the risk of infection.

Indications for open reduction and internalfixation are:

1. Unstable fracture where closed reduction can-not be achieved or maintained.

2. Intra-articular fractures.3. Multiple fractures.4. Open fractures, particularly where there is

bone loss.5. Fractures associated with soft tissue damage

requiring surgery, e.g. tendon and/or nervedamage.

6. Rotational malalignment, usually seen in spi-ral and oblique fractures.

7. Pathological fractures (e.g. enchondroma).8. Malunion or non-union.9. Reconstruction, e.g. rotation osteotomy for

malunion.

The advantages of open reduction and internalfixation of hand fractures are:

1. Screws and plates provide more stability.2. The reduction is more accurate.3. Movement can be commenced within a day or

two of surgery.

Fixation methods (Fig. 10.4)

1. Kirschner wires

Kirschner wires (K-wires) offer the simplest tech-nique for fracture fixation and because they can beinserted percutaneously, they can be placed withminimal soft tissue dissection. They can be used fornearly all types of fracture. Crossed K-wires aremost suited for transverse fractures. In long obliquefractures the wire is placed perpendicular to thebone. In spiral fractures they are placed in parallel.Some surgeons prefer to bury the pin while othersprefer to let it protrude through the skin.

While a simple and relatively cheap technique,K-wires often require support splinting or supple-mentary techniques as they do not provide rigidinternal fixation. They are unsuitable for commi-nuted or open fractures or in association withsignificant soft tissue injury. The complication rateassociated with the use of K-wires in the hand andwrist is 18 per cent (Botte et al., 1992).

2. Wiring

Because K-wires on their own do not provide rigidfixation or rotational stability, they are often

Figure 10.4. Fixation methods. (a) Crossed Kirschner wires are most suited for transverse fractures; (b) compositewiring converts distraction forces into compression forces; (c) lag (or compression) screws can provide rigidfixation; (d) plating provides longitudinal stability that can resist bending as well as torsional forces.


supplemented by wiring (composite wiring).This combined technique allows early activemovement.

Composite wiring converts distraction forcesinto compression forces at the fracture site and isparticularly suitable for unstable transverse orshort oblique phalangeal fractures. The inter-osseous tension band wire is passed as a figure ofeight, with the crossover lying external to the twofracture fragments.

Interosseous wiring requires minimal exposureand is less prominent than plates or screws. It isuseful for transverse shaft fractures. Because thisform of fixation does not interfere with mobility ofadjacent joints, it is particularly suited to replanta-tion and fusion.

3. Lag (or compression) screw

The lag or compression screw allows two frag-ments to be compressed together. Compression ofthe fracture surfaces gives rigid fixation. This formof fixation is best suited to long oblique and spiralshaft fractures when the fracture length is at leasttwice the diameter of the bone. Maximum com-pression is achieved with the screw at right anglesto the fracture plane. A single lag screw is ideal fora small fracture fragment such as a unicondylarfracture of the head of the proximal phalanx.

4. Plates

Plating provides longitudinal stability that canresist bending as well as torsional forces. Plating isparticularly suitable for multiple fractures, espe-cially those associated with soft tissue injury or forbone loss requiring grafting (Simonetta, 1970).They are also appropriate for unstable transversefractures in a single digit. Compression screwsmay be inserted through the plate’s holes if theyare at suitable angles or they may be inserted awayfrom the plate. Micro-plates from maxillofacialsets (Luhr Microfixation system) are now beingutilized. These plates are low profile, thus allowingthe periosteum to be closed with less tendencytoward adhesion formation.

5. Intramedullary fixation

Open reduction and intramedullary fixation can beachieved in transverse metacarpal shaft fracturesusing a Steinmann pin. Early active movement canbe commenced with this form of fixation. Thistechnique is not suitable for long oblique or spiralmetacarpal fractures.

A closed technique of intramedullary fixation isnow available. This technique involves the use ofthree blunt and pre-bent flexible K-wires thatensure rotational control through 3-point fixation.This technique has been described by Foucher(1995) in the management of displaced fractures ofthe fifth metacarpal neck and is known as ‘bouquetosteosynthesis’.

6. External fixation

External fixation is reserved for severe fractureswhere restoration of the skeletal anatomy is notpossible. These include comminuted open fractureswhich are often associated with bone loss and/ordamage to soft tissues, i.e. tendon and nerve.External fixators can function either statically ordynamically.

(i) Static fixatorA static fixator can be used across the MCP joint ofthe thumb for a comminuted intra-articular frac-ture. Stiffness at this joint can be compensated forby the mobility of the basal thumb joint, i.e. theCMC joint.

(ii) Dynamic fixatorDynamic traction combines the old method oftraction with motion and can be used for unstableintra-articular PIP joint fractures, e.g. pilon frac-tures. The two types of dynamic traction include thearcuate splint and the low profile lateral hingetraction splint (Dennys et al., 1992). The distaldistraction produces several effects. The articularfragments are reduced and the joint surfacesrealigned by traction on their ligamentous and volarplate attachments. This process is termed liga-mentotaxis. Maintenance of traction throughout thehealing process prevents collapse of the fracturefragments. Furthermore, the distal distraction forceprevents contracture of the joint ligaments and otherperiarticular structures. Joint motion enhancescartilage regeneration and healing (see ‘Jointinjuries of the fingers and thumb’).

Complications associated withfractures

1. Delayed union or non-union caused by infec-tion, poor blood supply, interspersed fragmentsof tissue such as muscle, or movement of thefractured parts.

2. Malunion, rotation of a spiral fracture orangulation of a transverse fracture.

Thick cortex with almostno cancellous bone

(a) (b) (c)

(a)First phase

(b)Reparative phase

(c)Last phase


3. Adherence of the closely allied flexor/extensortendons resulting from postinjury oedema and/or surgery.

4. Joint stiffness and contracture, i.e. extensioncontracture of the MCP joints after metacarpalfractures or flexion contracture of the PIP jointfollowing phalangeal fracture.

5. Occasionally, development of chronic regionalpain syndrome.

Phases of bone healing (Fig. 10.5)

Following a fracture, bone healing occurs in threeoverlapping phases:

1. Inflammatory phase

This phase occurs in the 3 to 4 days following afracture. The gap in the bone is bridged with ablood clot which coagulates to form a haematoma.An inflammatory response is triggered by media-tors released from dead and injured cells. Thisresults in vasodilation, plasma exudation andmigration of inflammatory cells to the fracture site.Osteoclasts resorb dead bone and fibroblasts startproducing a new matrix (Fig. 10.6(a)).

2. Reparative phase

The fracture haematoma begins to organize. Fibrinin the haematoma provides a framework for

migration of fibroblasts and undifferentiatedmesenchymal cells. There is ingrowth of capillarybuds. The cells increase in number and differ-entiate into what is known as fracture callus. Thecentre of the inflammatory reaction is made up ofmostly cartilage, called soft callus. This soft callusis gradually replaced by bone. The immature bonebeing formed at the periphery of this reaction iscalled hard callus.

By the end of this phase, which usually lasts 4 to6 weeks, a fracture may be considered clinicallyhealed, i.e. there is no motion at the fracture sitewhen stressed and no pain with active movement

Figure 10.5. Healing timetable for bone. Fractureconsolidation varies within each segment of the handand is slowest where the ratio of cortical to cancellousbone is highest. (a) 3–5 weeks; (b) 5–7 weeks; (c) 10–14weeks. (From Moberg, 1950, with permission).

Figure 10.6. Diagrammatic representation of the threephases of fracture healing. (Reproduced from Meyer,F. N. and Wilson, R. L. 1995. Management ofnonarticular fractures of the hand. In Rehabilitation ofthe Hand: Surgery and Therapy (J. M. Hunter, E. J.Mackin and A. D. Callahan, eds) p. 354, Mosby, withpermission.)

Interosseousmuscle


of nearby joints. At this stage there is usually littleradiographic evidence of fracture healing. Clinicalhealing occurs in about a quarter of the time ittakes for complete bony healing to occur (Smithand Rider, 1935) (Fig. 10.6(b)).

3. Remodelling phase

During this phase lamellar bone replaces wovenbone and callus is resorbed. Much of this phaseoccurs in the first few months after injury;however, this phase can continue for several years(Fig. 10.6(c)).

Primary bone healing

When the fractured bone ends are brought intodirect contact with one another, i.e. with openreduction and internal fixation, primary bonehealing occurs in two phases: gap healing andhaversian remodelling.

Lamellar bone forms directly across the fracturesite. Osteoclasts bridge the fracture line followedby osteoblasts, which form new bone. Osteoblastsare followed by new capillaries. This forms newhaversian systems called primary osteons.

Metacarpal fractures

1. Shaft fractures

(i) Transverse (Fig. 10.7)

In a transverse fracture, the interosseous musclesare responsible for dorsal angulation at the fracturesite. Where angulation results in shortening of themetacarpal, compensatory hyperextension of theMCP joint will be present, i.e. a pseudo-claw. Mildangulation in the ring and little fingers is consideredacceptable (20 and 30 degrees, respectively)because of compensatory mobility of the CMCjoints in these two digits. Angulation of the lessmobile index and middle fingers, however, is anindication for reduction and percutaneous pinning.

(ii) Oblique and spiral

Oblique metacarpal fractures have a tendency toshorten. Where this exceeds 3–5 mm, an imbal-ance between the extrinsic and intrinsic musclescan result. Spiral fractures can result in rotationalmalalignment. Even a minor rotational deformitycan be quite disabling as it will result in ‘scissor-ing’ of the digits during finger flexion (Opgrandeand Westphal, 1983). This problem is best man-aged with open reduction (Fig. 10.8).

Conservative treatment and therapy

Splint position and oedema control

Most shaft fractures can be successfully managedclosed. After fracture reduction, the hand ismaintained for 3 to 4 weeks in the position of safeimmobilization, i.e. wrist in 30 to 40 degrees ofextension, MCP joints in maximum flexion and IPjoints in maximum extension. A half-plaster applied

Figure 10.7. In a transverse metacarpal fracture, theinterosseous muscles are responsible for dorsalangulation at the fracture site.

Figure 10.8. Metacarpal spiral fractures can result inrotational malalignment causing ‘scissoring’ of thedigits during flexion.


to the dorsum of the forearm and hand will applygentle compression to hand oedema and will allowunimpeded finger flexion and intrinsic IP jointextension to the limit of the cast (Fig. 10.9).

Because dorsal hand oedema is often marked, itmay be difficult to place the MCP joints inmaximum flexion (usually 80–90 degrees) at theinitial cast application. The cast will therefore needto be replaced after several days when swelling hassubsided. Coban wrap (50 mm width) or tubularsupport stocking (of appropriate tension) can beapplied to the hand prior to moulding to assist withoedema resolution. The hand should be keptelevated for at least the 1st week.

Finger alignment

Alignment of the fingernails is assessed to checkany tendency toward rotation of the affected digit.During interphalangeal flexion, the digit isobserved for any tendency to cross over anadjacent digit. If the fracture has not been satisfac-torily reduced, open reduction may be necessary.

Exercises

The patient should perform active shoulder andelbow exercises on an hourly basis during the 3 to4 week splinting period. These proximal jointexercises are followed by gentle active combined(i.e. simultaneous PIP and DIP joint) inter-phalangeal joint flexion. Intrinsic extension of theIP joints should follow each flexion exercise andthe patient should aim to reach the level of the

splint, i.e. full IP joint extension. These exercisesare repeated 6 to 10 times at each session. To helpmaintain digital alignment, the affected digit canbe buddy-strapped to an adjacent digit duringactive exercise.

At the completion of the splinting period, a lycracompression glove is fitted if dorsal hand oedemapersists. The patient is taught to initiate fist-makingat the MCP joints otherwise the natural tendency,in the presence of persisting oedema, will be toassume a hook grip where flexion is initiated at theIP joints whilst the MCP joints remain in exten-sion. Light activity is commenced following plas-ter removal. Heavy use of the hand is avoided until12 weeks post fracture.

Therapy following open reduction andinternal fixation (ORIF)

Therapy following ORIF is much the same as forconservative management (Fig. 10.10). The maindifference is that the postoperative splint can beremoved for exercise sessions every few hours andcan be discarded after 10 to 14 days when suturesare removed.

Oedema

Postoperative oedema is often marked, makingflexion of the MCP joints difficult. Oedema shouldbe managed with Coban wrap initially. Followingsuture removal, a lycra glove is fitted. If gentlepassive/active exercise does not overcome MCPjoint stiffness within the first 2 weeks, a dynamicMCP joint flexion splint should be applied(Fig. 10.11).

Extensor lag

Extensor tendon adhesion following surgery isquite common and can result in a temporary laguntil tethering of the tendon to skin and bone isovercome. Scar massage, silicone gel compressionand extrinsic extension exercises should beemployed to address this problem.

Corrective procedures

(i) Wedge osteotomy

Dorsal angulation following transverse shaft frac-tures can result in prominence of the metacarpalhead in the palm that causes pain when gripping.This deformity is also associated with a pseudo-claw due to shortening of the metacarpal. This

Figure 10.9. The hand is placed in the ‘clam-digger’position (also known as the ‘intrinsic plus’ position or‘position of safe immobilization’) with a dorsalhalf-plaster which will allow finger flexion andintrinsic IP joint extension to the limit of the splint.


problem can be addressed with an opening orclosing wedge osteotomy.

(ii) Rotation osteotomy

Rotational malunion following spiral or obliquefractures can be addressed with a correctiveosteotomy through the base of the metacarpal.

2. Neck fractures

Metacarpal neck fractures usually involve the ringand little finger metacarpals and result from theforceful impact of the clenched fist with a solidobject.

There is not universal agreement on the manage-ment of these fractures. Treatment strategiesvary considerably from centre to centre andinclude:

(i) Crepe bandage support with immediate com-mencement of active movement.

(ii) Closed reduction and transverse percutaneousK-wire fixation of the fractured metacarpal tothe adjacent metacarpal. Support splinting inthe position of safe immobilization is used for3 to 4 weeks, however the splint is removedevery 2 to 3 hours during the day and gentleactive exercise of all digits is carried out.

(iii) ‘Bouquet osteosynthesis’, i.e. closed intra-medullary fixation using three pre-bent flex-ible K-wires (Foucher, 1995).

(iv) Open reduction, e.g. lateral application of aminicondylar plate.

Figure 10.10. (a) Oblique fracture of the middle finger metacarpal; (b) Open reduction and internal fixation withcompression screws.

(a) (b)

Figure 10.11. Stiffness of the MCP joints that is notreadily overcome with passive/active exercise, ismanaged with a dynamic flexion splint.


Whatever treatment method is used, non-union israrely a problem. Some patients are unhappy overthe loss of prominence of the metacarpal headalthough this is more a cosmetic rather than afunctional consideration.

Some surgeons believe that in the case of thelittle finger, significant angulation (up to 70degrees) can be accepted without compromisingfunction (Holst-Nielsen, 1976).

Metacarpal head and base fractures

1. Head

A fracture to the head of a metacarpal is rare andusually intra-articular. Comminuted intra-articularfractures can be difficult to treat with ORIF and insome cases immediate arthroplasty may be con-sidered. An alternative option is an osteochondralautograft taken from a toe.

2. Base

Base fractures of the index and middle fingermetacarpals are rare. Fracture dislocation of thelittle finger CMC joint is more common. Treatmentoptions include closed reduction with percutaneousK-wire fixation or open reduction and internalfixation.

Fractures of the proximal andmiddle phalanges

1. Stable – conservative treatment

Fractures that are stable, closed and non-displacedare treated with a finger splint holding theinterphalangeal joints in extension for 3 weeks.The splint is removed every few hours for gentleactive IP joint flexion and extension exercises.Digital oedema is managed with a single layer ofCoban wrap (25 mm) which is applied in a distal toproximal direction. A buddy strap can be usedduring active movement. A short section of narrowCoban can be used for this purpose (Fig. 10.12).

(i) Transverse fractures

Displaced fractures that are stable following reduc-tion are splinted in the position of safe immobiliza-tion for 3 weeks. Transverse fractures of theproximal and middle phalanx are particularlyamenable to closed reduction. Full extension of theinterphalangeal joints may not be achievable when

the splint is first fitted. It should therefore beremoulded or replaced 3 to 5 days later. When theimmediate soft tissue response of pain and swell-ing has subsided after the first 2 to 3 days, gentleactive interphalangeal joint movement is begun.

To help control fracture alignment, the digit isbuddy-strapped to an adjacent digit with nonstickstrapping such as Velcro or a section of Coban. Thesplint is removed every 2 to 3 hours during the dayand 5 to 10 repetitions of combined IP joint flexionand extension movements are performed. Theseexercises are carried out slowly within the limits ofdiscomfort. Blocking the MCP joints in extensionwill help facilitate extrinsic flexor tendon pull-through. Following splint removal, buddy-strap-ping is maintained for a further 2 weeks.

(ii) Spiral fractures (Fig. 10.17)

Closed reduction of spiral fractures of the proximaland middle phalanges is often lost through earlymovement. For this reason, these fractures areimmobilized in a POSI splint for 3 weeks (SeeFigure 10.2). Gentle active movement is thenbegun.

Associated problems

Flexion deformity of the PIP joint

As with any injury to the digits, the commonestcomplication after phalangeal fracture is a PIPjoint flexion deformity. Coban wrap, with its gentleextension force, goes some way toward counter-acting this problem. Maintenance of the digit inextension during splinting also helps avoid aflexion deformity. When the support splint isdiscarded after the 3rd week, a neoprene fingerstallwill effectively maintain extension while at thesame time allowing IP joint flexion (Fig. 10.13). ACapener splint is used if the flexion deformity isunresponsive to the neoprene stall.

Stiffness

If interphalangeal joint flexion range is slow toimprove or has plateaued, flexion splinting can beinstituted when clinical union has been achieved,usually 3 to 5 weeks following fracture (Fig. 10.14).Confirmation of skeletal integrity by the treatingsurgeon should be sought prior to the commence-ment of flexion splinting. This can involve gentleflexion bandaging, a hand-based dynamic flexionsplint or an IP joint flexion strap to gain the end


Figure 10.12. (a) This midshaft fracture of the middlephalanx of the middle finger is stable, non-displacedand was treated conservatively. (b) This fracture wasassociated with soft tissue injury. (c) Stable proximaland middle phalangeal fractures are protected with afinger splint for 3 weeks. Digital oedema is treatedwith Coban wrap (25 mm). (d) Gentle activeinterphalangeal joint flexion and extension exercisesare performed every few hours.

(a)

(b)

(c)

(d)


Figure 10.13. A neoprene fingerstall is an effectivemeasure for controlling and overcoming flexiondeformity of the PIP joint.

Figure 10.14. Stiffness of the PIP/DIP joint(s) isaddressed with a hand-based dynamic flexion splint.

Figure 10.15. The end range of flexion is achievedwith an IP joint flexion strap. Coban wrap (25 mm)was used in this instance.

range of flexion (Fig. 10.15). Whatever method isused, care must be taken to apply only a gentlestretch which does not result in pain or swelling.

Functional outcome

The final range of motion achieved will bedetermined by a number of factors. Theseinclude:

1. Age of the patient.2. The nature of the fracture and associated soft

tissue injury, i.e. tendon, nerve and vessel injuryor skin loss.

3. Length of immobilization.4. Patient compliance and associated conditions,

e.g. arthritis.

Of these various factors, the most significant one isthe age of the patient. Patients in the first twodecades of life achieve significantly greater mobil-ity than those beyond the fourth or fifth decades.The patient with an underlying arthritic conditionwill be considerably more prone to stiffness.Excessive immobilization following fracture, i.e.beyond 4 weeks, is also responsible for a pooroutcome (Strickland et al., 1982).

2. Unstable

(i) Closed reduction and percutaneousK-wire fixation

Shaft fractures that are potentially unstable can beaddressed with percutaneous K-wire fixation for 3weeks (Belsky and Eaton, 1985). These include

Interosseousmuscle

Lumbricalmuscle


spiral and oblique fractures that tend to rotate,angulate or shorten. Most fractures needing percu-taneous pinning will require two pins for stabilityand to control rotation.

This form of fixation is augmented with asupport splint holding the hand in the position ofsafe immobilization. Ideally the fixation will bestable enough to allow early active movementseveral days after surgery. The splint is wornbetween exercise periods.

(ii) Rigid internal fixation

Irreducible spiral, oblique or transverse shaftfractures of the proximal and middle phalanges arebest treated with rigid internal fixation. Thepotential problem of postoperative scarring follow-ing extensive soft tissue dissection is offset by thecommencement of early active movement. Use ofthe lower profile Luhr microfixation system hasallowed easier wound closure and less interferencewith extensor tendon excursion (Fig. 10.18).

Therapy

(a) Splinting and early movementThe hand is rested in a POSI splint for the first 3 to5 postoperative days. Elevation is maintained andmovement of the shoulder and elbow jointsencouraged. If pain and swelling allow, the fore-arm-based splint can be replaced with a fingersplint after about 5 days.

Gentle, active stabilized movement of the inter-phalangeal joints is begun 2 to 3 days following

Figure 10.16. The lumbricals and interossei are thedeforming forces in a transverse proximal phalangealfracture.

Figure 10.17. This potentially unstable proximalphalangeal fracture was treated conservatively withsplinting in the ‘position of safe immobilization’.

Figure 10.18. Irreducible fractures are treated withrigid internal fixation. The Luhr microfixation systemwas used to manage this unstable proximal phalangealfracture.


surgery. Coban wrap (25 mm) can be applied overthe dressing to reduce oedema. The finger splint ismoulded over the Coban which is liberally coatedwith powder to prevent the heated material fromsticking to the wrap. If maximum extension of theIP joints cannot be achieved at the initial splintingsession, the finger splint should be replaced orremoulded several days later when swelling hasfurther subsided. Support splinting is maintainedfor 3 to 5 weeks.

(b) Scar managementFollowing suture removal, soft tissue scarring isaddressed with oil massage. Scar compression isalso provided by Coban wrap, a neoprene finger-stall or silicone-lined fingerstalls. All these materi-als allow interphalangeal joint flexion.

(c) StiffnessStiffness of the PIP and DIP joints can beaddressed with gentle flexion bandaging after thefirst two weeks. The tension of the bandage shouldbe low and not result in pain. The effectiveness offlexion bandaging is augmented by immersing thehand in warm water for the 15 min that thisposition is maintained. This manoeuvre is repeatedevery few hours throughout the day. Wherenecessary, a hand-based dynamic flexion splint canbe applied with the permission of the treatingsurgeon.

Fractures of the distal phalanx

The thumb and middle finger distal phalanges arethe most common fracture sites in the hand. Mostof these fractures are sustained in the workplace.Fractures of the distal phalanx can occur at threelevels:

1. Tuft

These fractures invariably result from a crush injuryand are often associated with laceration to the pulpand/or nail matrix. Closed injuries often result in asubungual haematoma which should be decom-pressed to provide relief of pain (Fig. 10.19).

Treatment

Treatment of these fractures involves repair of thenail matrix together with a short period of DIPjoint support (7 to 10 days) to provide symptomaticrelief. Dressings should be nonstick, e.g. Adaptic,

and can be held in place with gentle Cobancompression. Movement of the more proximaljoints is commenced immediately. On healing ofthe pulp, desensitization exercises are begun. Tohelp alleviate hypersensitivity, Opsite Flexifix isapplied over the sensitive area.

2. Shaft

Shaft fractures are either transverse or longitudi-nal. Unless displaced, these fractures can be treatedconservatively for 2 to 3 weeks with a smallthermoplastic splint which allows motion of thePIP joint.

Displaced fractures are stabilized with a Herbertscrew or K-wire.

3. Base

Fractures to the base of the distal phalanx are oftenunstable and may require fixation, particularly ifthe injury is an open one. A stable fracture can besplinted in a mallet-type splint for 3 to 4 weeks.

Figure 10.19. The distal phalanges of the thumb andmiddle finger are the most common fracture sites inthe hand.


Fractures of the distal phalanx are frequentlyassociated with some long-term problems whichinclude: numbness, cold sensitivity, hypersensitiv-ity and abnormal nail growth.

Fractures to the thumb

Thumb fractures tend to be much more forgivingthan finger fractures because of the compensatorymovements afforded by the mobility of the thumb atits basal joint. The surfaces of the trapezium andthumb metacarpal resemble two interlocking sad-dles. This configuration allows motion in twoplanes. When the integrity of this joint is lostthrough injury or degenerative arthritis, thumbfunction is compromised. The thumb metacarpal isthe second most commonly fractured metacarpalwith 80 per cent of fractures occurring at its base.

1. Bennett’s fracture

This intra-articular fracture was first described in1882 by E. H. Bennett and is really a fracturesubluxation. It usually involves less than a third ofthe articular surface. The fracture occurs at themedial volar lip which remains attached to themetacarpotrapezial ligament while the metacarpalshaft is subluxed radially and dorsally by thetendon of abductor pollicis longus. A true lateralview of the CMC joint must be obtained toestablish joint congruity (Billing and Gedda,1952).

(i). Closed reduction

In general, closed reduction alone is difficultbecause the pull of abductor pollicis longus tendsto cause the base of the metacarpal to slide downthe inclined plane of the trapezium.

In a low demand patient, particularly if thefragment is less than 15 to 20 per cent of thearticular surface, percutaneous K-wire fixation andplaster immobilization for one month may beindicated. Pin fixation can be intermetacarpal, i.e.inserted between the thumb and index metacarpals,or through the metacarpal shaft and into thefractured fragment.

Aftercare

The thumb is immobilized in a forearm-basedthumb spica for one month. A temporary plaster is

fitted for the first few days after which the plasteris remade or a thermoplastic splint fitted toaccommodate reduction of oedema. The thumb IPjoint should be left free to move.

Following K-wire removal after 4 weeks, aremovable splint is used for a further month ofprotection in between exercise sessions.

(ii) Open reduction and internal fixation

Where the patient has greater demand placed onthe hand, e.g. a professional athlete, or where thefragment is greater than 25 to 30 per cent of thearticular surface, open reduction and internalfixation with lag screws is preferred.

Aftercare

The thumb is protected in a forearm-based thumbspica for the first 10 to 14 days following surgery.The splint should maintain the first web space andthe thumb should be aligned with the index andmiddle fingers. The splint is worn in ‘at risk’situations for a further 2 to 3 weeks.

Gentle active movement of all thumb joints isbegun 2 to 3 days after surgery. Contact sports canusually be resumed after 1 month.

2. Rolando’s fracture (Fig. 10.20)

The Rolando fracture is also an intra-articularfracture and appears Y- or T-shaped. Anatomic

Figure 10.20. Rolando’s fracture is a comminutedintra-articular fracture of the base of the thumbmetacarpal.


reduction is usually not achievable with thisfracture which is usually managed by openreduction and internal fixation. Techniques ofopen reduction include: multiple K-wires, tensionband wiring or plate fixation, using an L- orT-plate (Fig. 10.21).

Aftercare is as for ORIF following a Bennett’sfracture.

References

Belsky, M. R. and Eaton, R. G. (1985). Closed percutaneouswiring of metacarpal and phalangeal fractures. In TheHand (R. Tubiana, ed.) pp. 790–5, W. B. Saunders.

Billing, L. and Gedda, K. O. (1952). Roentgen examinationof Bennett’s fracture. Acta Radiol., 38, 471–6.

Botte, M. J., Davis, J. L. W., Rose, B. A., von Schroeder, H.,Gellman, H., Zinberg, E. M. and Abrams, R. A. (1992).Complications of smooth pin fixation of fractures anddislocations in the hand and wrist. Clin. Orthop., 276,194–201.

Dennys, L. J., Hurst, L. N. and Cox, J. (1992). Managementof proximal interphalangeal joint fractures using a newdynamic traction splint and early active movement.J. Hand Ther., 5, 16–24.

Duncan, R. W., Freeland, A. E., Jabaley, M. E. and Mey-drech, E. F. (1993). Open hand fractures: an analysis of therecovery of active motion and of complications. J. HandSurg., 18A, 387–94.

Foucher, G. (1995). ‘Bouquet’ osteosynthesis in metacarpalneck fractures: a series of 66 patients. J. Hand Surg., 20A(Suppl.), 86–90.

Holst-Nielsen, F. (1976). Subcapital fractures of the fourulnar metacarpal bones. Hand, 8, 290–3.

Melone, C. P. Jr. (1986). Rigid fixation of phalangeal andmetacarpal fractures. Orthop. Clin. North Am., 17,421–35.

Meyer, F. N. and Wilson, R. L. (1995). Management ofnonarticular fractures of the hand. In Rehabilitation of theHand: Surgery and Therapy (J. M. Hunter, E. J. Mackinand A. D. Callahan, eds) pp. 353–75, Mosby.

Opgrande, J. D. and Westphal, S. A. (1983). Fractures of thehand. Orthop. Clin. North Am., 14, 779–92.

Pun, W. K., Chow, S. P., So, Y. C., Luk, K. D., Ip, F. K.,Chan, K. C., Ngai, W. K., Crosby, C. and Ng, C. A.(1989). A prospective study on 284 digital fractures of thehand. J. Hand Surg., 14A, 474–81.

Simonetta, C. (1970). The use of ‘A. O.’ plates in the hand.Hand, 2, 43–5.

Smith, F. L. and Rider, D. L. (1935). A study of the healingof one hundred consecutive phalangeal fractures. J. BoneJoint Surg., 17, 91–109.

Strickland, J. W., Steichen, J. B., Kleinman, W. B., Hastings,H. I. and Flynn, N. (1982). Phalangeal fractures: factorsinfluencing digital performance. Orthop. Rev., 11, 39–50.

Further reading

Breen, T. F., Gelberman, R. H. and Jupiter, J. B. (1988).Intra-articular fractures of the basilar joint of the thumb.Hand Clin. 4, 491–501.

Butt, W. D. (1962). Fractures of the hand. II. Statisticalreview. Can. Med. Assoc. J., 86, 775.

DeBartolo, T. F. (1996). Screw fixation of Bennett’s fracture.In Techniques in Hand Surgery (W. F. Blair, ed.) pp. 265–73, Williams & Wilkins.

Freeland, A. E. and Benoist, L. A. (1994). Open reductionand internal fixation method for fractures at the proximalinterphalangeal joint. Hand Clin., 10, 239–50.

Gonzalez, M. H., Igram, C. M. and Hall, R. F. (1995).Intramedullary nailing of proximal phalangeal fractures.J. Hand Surg., 20A, 808–812.

Hargreaves, I. C. (1997). Open reduction and internal fixationof metacarpals and phalanges. In Atlas of Hand Surgery(W. Bruce Conolly, ed.) pp. 99–113, ChurchillLivingstone.

Howe, L. M. (1993). Fractures of the hand. Scand. J. Plast.Reconstr. Hand Surg., 27, 317–9.

Figure 10.21. Rolando’s fracture requires openreduction and internal fixation.


Jupiter, J. B., and Silver, M. A. (1988). Fractures of themetacarpals and phalangeals. In Operative Orthopaedics(M. W. Chapman, ed.) pp. 1235–50, Lippincott.

Moberg, E. (1950). The use of traction treatment for fracturesof phalanges and metacarpals. Acta Chir. Scand., 99,341–52.

Ouellette, E. A. and Freeland, A. E. (1996). Use of theminicondylar plate in metacarpal and phalangeal fractures.Clin. Orthop., 327, 38–46.

Stern, P. J. (1999) Fractures of the metacarpals and pha-langes. In Green’s Operative Hand Surgery. (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) pp. 711–71,Churchill Livingstone.

Collateralligament proper

Accessorycomponent

Volar (palmer) plate

Check-rein ligaments

Accessorycomponent

Volar (palmer) plate

Collateral ligament proper

11

Joint injuries of the fingers and thumb

Joint and ligament injuries occur most frequentlyin the proximal interphalangeal (PIP) joints of thefingers and the metacarpophalangeal (MCP) jointof the thumb. Joint injuries are incurred frequentlyduring sporting activities. They are often regardedas trivial and by the time treatment is soughtseveral weeks or months later, the sequalae of pain,deformity and stiffness have become entrenched.

Anatomy of the PIP joint

The PIP joint is a ginglymus (or hinged) joint whichmoves in the sagittal plane and has a flexion rangeof approximately 100 degrees (Eaton, 1995). Thejoint is comprised of three main anatomic compo-nents: bone, ligament and tendon (Fig. 11.1).

The head of the proximal phalanx is a convexbicondylar surface with an intercondylar groovethat articulates with the biconcave base andintercondylar ridge of the middle phalanx. Thearticular surface extends further palmarly thandorsally, thereby favouring flexion. The width ofthe joint is twice its vertical height and thiscontributes significantly to joint stability.

The articular surfaces, whilst mirroring oneanother, are not fully congruous. This lack ofcomplete congruity allows slight lateral and rota-tional motion. When the PIP joint is flexed to 90degrees and the proximal phalanx is viewed end-on, it is noted to have a trapezoidal shape; thisshape varies from digit to digit. Combined with theaccessory movements, these slight variations inshape allow the digits to adapt to irregular shapeswhen power grip is applied (Fig. 11.2).

The support system of the PIP joint

Capsular support for the PIP joint consists of toughcollateral-accessory ligaments on the lateral aspectof the joint and a fibrous plate on the volar aspect.The collateral ligaments are 2–3 mm thick and are

Figure 11.1. The PIP joint is a hinged joint with aflexion range of approximately 100 degrees. The thickcollateral ligaments have a proper and an accessorycomponent that are distinguished by their points ofinsertion. The collateral ligaments are the primaryrestraints to radial and ulnar joint deviation. The volarplate forms the floor of the joint and is suspendedlaterally by the collateral ligaments.

III

III

IV


the major restraint to lateral stress (Kiefhaber et al.,1986). They arise from the condyles of theproximal phalanx and pass in an oblique and volardirection. The collateral ligament proper inserts onthe volar base of the middle phalanx while theaccessory portion of the ligament attaches to andsuspends the volar plate and tendon sheath. Thislatter portion is the more flexible and concertinasin the end range of flexion.

The volar plate forms the floor of the joint.Distally it is a dense fibrocartilaginous structurewith periosteal attachment at the central base ofthe middle phalanx and dense lateral attachmentsat the corners. The thickness of the distal volarplate increases the mechanical advantage of theflexor tendons in the initiation of interphalangealjoint flexion. Proximally the volar plate is muchlike an inverted ‘U’ and resembles a swallow’stail. The two ‘tails’ are check-rein ligaments andare firmly anchored to the volar periosteum ofthe proximal phalanx. They prevent hyperexten-sion of the joint yet are sufficiently flexible tofold upon themselves during maximum jointflexion.

The proximal end of the volar plate has a centralmembranous portion which bridges the retro-condylar recess. It is here that the major vincularsystems to the flexor tendons originate. When thePIP joint is fully flexed, the base of the middlephalanx sits firmly in this recess, providingmaximum stability. Obliteration of this space by

scar, bone spur, adherence of the volar plate orprolonged immobilization will produce a majorrestriction to joint motion.

Support to the dorsum of the joint is minimal,consisting mostly of the thin, semi-elastic extensormechanism as it blends with the delicate dorsalcapsule. Supplementary joint stability is providedby the lateral bands, the transverse retinacularligament and the oblique retinacular ligament.

Signs and symptoms of PIP joint injury

1. Swelling.2. Deformity (usually PIP joint flexion deformity)

(Fig. 11.3).3. Stiffness of interphalangeal joints.4. Pain.

Assessment

1. History

The history should include the mechanism andrecency of injury, e.g. did the joint dislocatelaterally or dorsally and was it reduced at thetime?

2. Physical examination

Observations during the physical examinationshould include: degree of swelling, type of deform-ity and restriction of joint motion. Acute swellingis usually soft and easily indented. When presentfor weeks or months it becomes fibrotic and resultsin periarticular thickening that gives the joint afusiform appearance. The joint is gently palpatedfor specific areas of tenderness (Fig. 11.4).

Figure 11.2. When the PIP joint is flexed to 90degrees and the proximal phalanx is viewed end-on, itis noted to have a trapezoidal shape. This shape variesfrom digit to digit. This variation, combined with theslight lack of joint congruity that facilitates lateral androtational motion, allows the digits to adapt toirregular shapes when power grip is applied.

Figure 11.3. Injury to the PIP joint is invariablyaccompanied by a flexion deformity.

Joint injuries of the fingers and thumb 135

3. X-ray examinations

Posteroanterior (PA) and true lateral views of thehand should include views of the digit alone toavoid superimposition of the other digits.

4. Joint stability

If a serious fracture has been excluded, active andpassive joint stability is assessed. Where the injuryis acute and accompanied by pain, a metacarpalblock will be required prior to this assessment.

Dislocation of the PIP joint

The PIP joint can dislocate dorsally, laterally orvolarly. Most dislocations can be treated con-servatively, the exception being an unstable frac-ture-dislocation.

Lateral injury to the PIP joint

Injuries to the collateral ligaments occur morefrequently on the radial aspect of the joint andoften have some involvement of the volar plate.They result from unilateral stress applied to the

extended digit. A ligament injury can be regardedas a sprain if the injured joint has sufficientcapsular support to prevent displacement underappropriate stress. If the lateral stress test producesa deformity of greater than 20 degrees, this willindicate complete disruption of the collateralligament. These injuries are managed conserva-tively following reduction.

In the acute phase, these injuries are painful andaccompanied by significant oedema which effec-tively ‘splints’ the joint in a semi-flexed position.While the oedema has some protective role, itsprolonged presence will prevent movement andwill result in adherence of joint structures.

Treatment

Oedema control and protective splinting

A single layer of 2.5 cm Coban wrap is applied tothe digit in a distal to proximal direction. This isapplied with great care to avoid lateral stress to thePIP joint. The finger is then rested in a thermoplasticfinger splint in slight PIP joint flexion, i.e about 20degrees if volar plate involvement is suspected or inmaximum extension if the injury is regarded as asprain of the collateral ligaments. The splint is wornfor the first 3 to 7 days following injury to allow

Figure 11.4. The injured PIP joint usually presentswith soft swelling in the early stages after injury, andlater with fibrotic periarticular thickening. Note theabsence of skin creases over the PIP joint. Stiffness ofboth IP joints is common.

Figure 11.5. A single layer of Coban is applied to theswollen digit. A dorsal finger splint provides supportduring the first few postinjury days. If involvement ofthe volar plate is suspected, the PIP joint is placed inslight flexion, otherwise the IP joints are splinted inmaximum extension. This may not be achievable onthe first visit.


pain and swelling to settle. This period may beextended if there has been complete rupture andsignificant pain and swelling (Fig. 11.5).

Exercises

Gentle active stabilized IP joint flexion/extensionexercises are then commenced through the Cobanwrap. These exercises are performed on an hourlybasis with 5 to 10 movements initially. Astolerance to exercise improves, the number ofmovements is increased. Movements are carriedout gently and slowly and the end range positionshould be held for several seconds before themovement is repeated (Fig. 11.6).

Buddy-strapping

After the splinting period, the injured finger istaped to an adjacent digit to provide lateral supportduring activity. Coban wrap and Micropore tapeare both suitable for this purpose. A buddy-strapfashioned from Velcro can be used if the joints ofthe two adjoining fingers are relatively level.

Intrinsic stretches

Adherence of the lateral bands or oblique reti-nacular ligament can occur following injury to thecollateral ligaments. To help prevent contracture,

intrinsic stretches are incorporated into the exer-cise programme. The intrinsic muscles are stret-ched by holding the MCP joints in the extendedposition while passively flexing the IP joints (Fig.11.7). This is followed by stabilized active DIPflexion exercises with the PIP joint held inextension; this manoeuvre places the obliqueretinacular ligament on maximum stretch.

Overcoming PIP joint flexion deformity

The first line of defence in correcting and control-ling a PIP joint flexion deformity is a neoprenefingerstall. The stall can be sewn in minutes and iseasily applied and removed. It controls oedema,allows flexion and frequently reduces joint pain(Fig. 11.8). To gain the last 20 degrees or so ofextension range, a Capener splint may be required(Fig. 11.9). Efforts to overcome the flexiondeformity need to be balanced with consistentattention to regaining passive/active flexion rangeat both IP joints. The patient is advised to wear theneoprene stall around the clock other than whenperforming hourly flexion exercises.

Flexion strapping of interphalangeal joints

Where IP joint stiffness is marked, gentle flexionbandaging prior to active exercise is recommended.An IP joint flexion strap made from neoprene isused when the patient has achieved sufficientflexion range to hold the strap in place. Coban wrap(25 mm) or Microfoam tape also make effectiveflexion straps (Fig. 11.10). The tension of the strap

Figure 11.6. Hourly active stabilized IP jointflexion/extension exercises are performed through theCoban wrap.

Figure 11.7. Intrinsic stretches are performed byholding the MCP joints in the extended position andgently passively flexing the IP joints. This manoeuvremaintains the length of the lateral bands and obliqueretinacular ligament.

Accessoryligament

Collateral ligament proper

Rupturedvolar plate


should be sufficient to provide a gentle stretchwithout causing pain or restricting circulation. It isleft in place for 10 to 15 min every few hours duringthe day. Resisted exercises and activities aredelayed until at least 6 weeks after injury.

Maintenance of home programme

Ligaments are notoriously slow to heal. Persistingpain, stiffness and recurrent joint swelling arecommon. The patient is therefore encouraged tomaintain the exercise and splinting programme forsome months following injury. Even when flexionrange has been restored, the propensity for recur-rent flexion deformity is great. Intermittent exten-sion splinting by way of a neoprene fingerstall,Capener or static finger splint should be main-tained until the joint no longer ‘relapses’ when

these devices are left off for several consecutivedays. Use of the neoprene stall during the dayallows unimpeded use of the digit. A Capener orstatic splint can then be used at night.

Dorsal dislocation of the PIP joint

Dorsal dislocation of the PIP joint is the mostcommon dislocation in the hand. It results fromhyperextension of the joint and is usually asso-ciated with a distal rupture of the volar plate fromthe base of the middle phalanx with or without anavulsed bone fragment (Fig. 11.11).

Figure 11.8. A neoprene fingerstall is the first line ofdefence in overcoming a PIP joint flexion deformity.As well as exerting a gentle extension force, the stallwill reduce oedema and frequently relieve joint pain.Active flexion exercises can be carried out with thestall in place.

Figure 11.9. A dynamic Capener splint may be neededto overcome the last 20 to 25 degrees of deformity.

Figure 11.10. Frequent use of an IP joint flexion strapthroughout the day will help restore flexion range. Thestrap can be made from neoprene/velcro, oralternatively, Coban wrap or Microfoam tape which isshown here.

Figure 11.11. Dorsal dislocation of PIP joint. Thecollateral ligament proper remains attached and intactand usually provides stability after joint reduction. Theaccessory portion of the collateral ligament remainswith the volar plate which ruptures from the base ofthe middle phalanx, either on its own or with a smallavulsion fragment.


Treatment

The majority of these hyperextension and dorsaldislocations injuries can be reduced satisfactorilyand treated conservatively. The PIP joint is splintedin 25 to 30 degrees of flexion for 1 to 2 weeks.Gentle active exercise is commenced 2 to 3 daysafter injury when the initial swelling and oedemahave subsided. Oedema is managed with Cobanwrap. Following removal of the splint, the digit isbuddy-strapped to an adjacent finger for support.Extension splinting is delayed until the 5th weekand consists of the same regimen as that which hasbeen described for lateral joint injury.

Unstable fracture-dislocation ofthe PIP joint

Unstable fracture-dislocations are those where jointcongruity has not been established following closedreduction or where more than 40 per cent of thevolar articular surface is fractured (Fig. 11.12).

Surgery

Volar plate advancement (Bilos et al., 1994) restoresa smooth fibrocartilaginous surface to the base ofthe middle phalanx. The joint is exposed andassessment is made regarding the possibility ofreduction and fragment fixation. A single, largefragment can be reduced and held with one or twoK-wires. Where the fracture is significantly commi-nuted, the fragments are debrided and the distalportion of the palmar plate is advanced 4–6 mm andsutured to the base of the middle phalanx using apull-out suture. A K-wire holds the reduced joint in25 to 30 degrees of flexion for 3 weeks (Fig.11.13).

Aftercare

Gentle DIP exercises are practised throughoutthis period. Following removal of the K-wire, thejoint is maintained in the same degree of PIPjoint flexion with a dorsal blocking splint foranother week and gentle active PIP joint flexionexercises are begun. Unforced active PIP jointextension is then commenced at week 4. Anyresidual flexion deformity is overcome withgentle extension splinting from the 5th weekonward.

Intra-articular fractures

Apart from hyperextension injuries, intra-articularfractures of the PIP joint (Morgan et al., 1995) canresult from impaction injuries where the base ofthe middle phalanx is driven over the head of theproximal phalanx or pilon fractures where there isdisruption of both the dorsal and volar articular

Figure 11.12. Radiograph showing dorsal dislocationof the PIP joint of the index finger with a significantarticular fracture of the base of the middle phalanx.

Figure 11.13. Volar plate advancement restores asmooth fibrocartilaginous surface to the base of themiddle phalanx. The volar plate is sutured to the baseof the middle phalanx using a pull-out suture. AK-wire holds the reduced joint in 25 to 30 degrees offlexion for three weeks.

Figure 11.14. Pilon fracture of the left little fingersustained whilst playing cricket.


margins and depression of the central articularsurface (Stern, 1991) (Fig. 11.14).

Surgical management of these can includeskeletal traction using an external fixateur or openreduction and internal fixation (Dennys et al.,1992) (Fig. 11.15). Treatment of these complexinjuries has a significant failure rate and PIP jointfusion, implant arthroplasty or elective amputationmay be indicated.

Corrective surgical procedures ofthe PIP joint

The most common complication of injury to thePIP joint is stiffness. Where adequate functionalmotion in either flexion or extension range has notbeen achieved despite a protracted splinting regi-men, surgical release (arthrolysis) is considered.

Technique

This procedure is performed under selectiveperipheral nerve block. The joint is approachedthrough a midaxial incision and the collateralligaments and/or volar plate are released. Ifnecessary, limited extensor and flexor tenolysis isperformed.

Aftercare

Postoperatively the joint is splinted into thecorrected position and active movement is begunwithin a day of surgery. Exercise sessions shouldbe short and performed 1 to 2 hourly. Analgesiamay be required for the first few days. Cobancompression is used to control digital oedema.

Dynamic splinting is reinstituted after the firstweek when the postoperative soft tissue response

Figure 11.15. (a) The arcuate splint provides dynamic traction whilst allowing early movement. (b) Exercises areperformed by the patient on an hourly basis. (c) Radiological appearance of the PIP joint at completion of tractionperiod, i.e. at 6 weeks. (d) Active flexion range at completion of traction period.

(a) (b)

(c) (d)


has subsided. The tension of the splint shouldinitially be low to gauge joint response.Dynamic splinting may need to be maintainedfor several months to prevent recurrence of thecontracture.

Alternative salvage procedures include PIPjoint arthroplasty or fusion. These proceduresand their aftercare are discussed in the chapteron ‘Arthritis’.

Thumb joint injuries

Anatomy of the thumb MCP joint

The MCP joint of the thumb has features of botha condyloid and ginglymus joint (Eaton, 1971).Its main movement is flexion-extension but it isalso capable of some abduction-adduction androtational movement. The thumb MCP joint dif-fers from the finger MCP joints by having aradial and an ulnar sesamoid in the volar platebetween which passes the FPL tendon. Unlikethe finger PIP joints, the MCP joint of thethumb has no flexor sheath proximal to the volarplate and also has no check-rein ligaments.

Lateral stability of the joint comes from col-lateral and accessory ligaments. Volar stability isprovided by the volar plate together with thethenar intrinsic muscles. Flexor pollicis brevisand abductor pollicis brevis insert into the radialsesamoid. Adductor pollicis and the first palmarinterosseous insert into the ulnar sesamoid(Kaplan and Riordan, 1984).

Ulnar collateral ligament injury

This injury is commonly referred to as ‘skier’sthumb’ and results from forced abduction of theMCP joint. The ulnar collateral ligament (UCL)is injured 10 times more frequently than theradial collateral ligament (Moberg and Stener,1953). Distal tears at the insertion of the liga-ment are more common than proximal tears.Injury to UCL may be associated with an avul-sion fracture where the ligament inserts onto theulnar base of the proximal phalanx. It is impor-tant to distinguish between a partial and com-plete ligament rupture (Stener lesion). Where therupture is complete, interposition of the adductorexpansion will prevent the avulsed ligamentfrom making contact with the rupture site,thereby impeding ligament healing.

Diagnosis

Diagnosis is generally made on a clinical basis,although diagnostic ultrasound and MRI (Har-ammati et al., 1995) can help confirm the diagnosiswhere necessary. Signs and symptoms of UCLinjury include bruising, tenderness and swellingalong the ulnar border of the joint. Where 30degrees or more of joint laxity is present, it isusually assumed that there has been a completeligament rupture. Paradoxically, a complete rup-ture will often be less painful than an incompleteone. Radiographs are taken in 3 planes to assessthe base of the proximal phalanx for avulsionfracture. Significant displacement will indicateretraction of the ligament and a large displacedfragment involving the articular surface willrequire open reduction and internal fixation.

Treatment of stable ligament injury

Partial tears are splinted continuously for 4 weeks ina hand-based thumb splint which holds the MCPjoint in slight ulnar deviation and flexion (Campbellet al., 1992) (Fig. 11.16). Full mobility of the distalthumb joint is maintained during this time. Inter-mittent use of the splint is maintained for a further 2weeks with the splint being removed every fewhours for gentle active motion. Normal unrestraineduse of the thumb is delayed until 12 weeksfollowing injury.

Treatment for complete rupture of UCL

Because the results of conservative treatment forcomplete rupture are unpredictable, surgical repairis indicated.

Figure 11.16. Partial tears of the ulnar collateralligament are managed with a hand-based thumb splintwhich holds the MCP joint in slight ulnar deviationand flexion.


Surgery

A ‘lazy-S’ incision is made over the dorsum ofthe joint. Care is taken to protect the superficialradial nerve. The adductor aponeurosis is identi-fied and incised parallel to EPL. The articularsurface of the joint is examined. If there hasbeen a midsubstance rupture, a direct repair ismade with interrupted non-absorbable sutures.Some distal ruptures can be attached directly tothe remaining tissue on the proximal phalanx.Where there has been a small bony avulsionfracture, this is best excised and the ligamentadvanced to bone and anchored with non-absorb-able thread or wire. A temporary transarticularK-wire is used if the repair seems a littletenuous. A large bone fragment is anatomicallyreduced and attached by pull-out suture, inter-osseous wire, K-wires or a small screw.

Aftercare

The joint is protected with a hand-based thumbsplint for a total period of 6 weeks. The distalthumb joint is mobilized throughout this periodto avoid adherence of the extensor mechanism.Splinting of the MCP joint is continuous for thefirst 4 weeks of immobilization. During the next2 weeks, the splint is removed every few hoursand gentle MCP joint exercises are carried out.

Unrestrained use of the thumb is delayed until12 to 16 weeks following repair.

References

Bilos, Z. J., Vender, M. I., Bonavolonta M. and Knutson, K.(1994). Fracture subluxation of the proximal interpha-langeal joint by palmar plate advancement. J. Hand Surg.,19A, 189–96.

Campbell, J. D., Feagin, J. A., King, P., et al. (1992). Ulnarcollateral ligament injury of the thumb. Treatment withglove spica cast. Am. J. Sports Med., 20, 29–30.

Dennys, L. J., Hurst, L. N. and Cox, J. (1992). Managementof proximal interphalangeal joint fractures using a newdynamic traction splint and early active movement. J.Hand Ther., 5, 16–24.

Eaton, R. G. (1971). Joint Injuries of the Hand. pp. 51–66,Charles C. Thomas.

Eaton, R. G. (1995). The Founders Lecture: The narrowesthinge of my hand. J. Hand Surg., 20A, 149–54.

Harammati, N., Hiller, N., Dowdle, J., Jacobson. M., et al.(1995). MRI of the Stener lesion. Skeletal Radiol., 24,515–8.

Kaplan, E. B. and Riordan, D. C. (1984). The thumb. InKaplan’s Functional and Surgical Anatomy of the Hand(M. Spinner, ed.) pp. 116–7, J. B. Lippincott.

Kiefhaber, T. R., Stern, P. J. and Grood, E. S. (1986). Lateralstability of the proximal interphalangeal joint. J. HandSurg., 11A, 661–9.

Moberg, E. and Stener, B. (1953). Injuries to the ligaments ofthe thumb and fingers. Diagnosis, treatment and prognosis.Acta Chir. Scand., 106, 166–86.

Morgan, J. P., Gordon, D. A., Klug, M. S., et al. (1995)Dynamic digital traction for unstable comminuted intra-articular fracture-dislocation of the proximal interphalan-geal joint. J. Hand Surg., 20A, 565–73.

Stern, P. J. (1991). Pilon fractures of the proximal inter-phalangeal joint, J. Hand Surg., 16A, 844–50.

Further reading

Abbiati, G., Delaria, G. E., Saporiti, E., et al. (1995). Thetreatment of chronic flexion contractures of the proximalinterphalangeal joint. J. Hand Surg., 20B, 385–9.

Arnold, D. M., Cooney, W. P. and Wood, M. B. (1992).Surgical management of chronic ulnar collateral ligamentinsufficiency of the thumb metacarpophalangeal joint.Orthop. Rev., 21, 583–8.

Bowers, W. H. (1981). The proximal interphalangeal jointvolar plate. II. A clinical study of hyperextension injury. J.Hand Surg., 6, 77–81.

Dobyns, J. H. and McElfresh, E. C. (1994). Extension blocksplinting. Hand Clin., 10, 229–37.

Frykman, G. and Johansson, O. (1956). Surgical repair ofrupture of the ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb. Acta Chir. Scand., 112,58–64.

Glickel, S. Z., Alton Barron, O. and Eaton, R. G. (1999).Dislocations and ligament injuries in the digits. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 772–808, Churchill Livingstone.

Green, A., Smith, J., Redding, M. and Akelman, E. (1992).Acute open reduction and internal fixation of proximalinterphalangeal joint fracture dislocation. J. Hand Surg.,17A, 512–7.

Green, D. P. (1990). Dislocations and ligamentous injuries ofthe hand. In Surgery of the Musculoskeletal System (C. M.Evarts, ed.) pp. 385–448, Churchill Livingstone.

Heyman, P., Gelberman, R. H., Duncan, K. and Hipp, J. A.(1993). Injuries of the ulnar collateral ligament of thethumb metacarpophalangeal joint–biomechanical and pro-spective clinical studies on the usefulness of valgus stresstesting. Clin. Orthop., 292, 165–71.

Inanami, H., Ninomiya, S., Okutsu, I., et al. (1993). Dynamicexternal finger fixator for fracture dislocation of the prox-imal interphalangeal joint. J. Hand Surg., 18A, 160–4.

Jobe, M. T. ( 1993). Fractures and dislocations of the hand.In Fractures and Dislocations (R. B. Gustilo, ed.) pp.625–30, Mosby.


Mansat, M. and Delprat, J. (1992). Contractures of theproximal interphalangeal joint. Hand Clin., 8, 777–86.

Minamikawa, Y., Horii, E., Amadio, P. C., et al. (1993).Stability and constraint of the proximal interphalangealjoint. J. Hand Surg., 18A, 198–204.

Noszian, I. M., Dinkhauser, L. M., Orthner, E., et al. (1995).Ulnar collateral ligament: differentiation of displaced andnondisplaced tears with US. Radiology, 194, 61–3.

Tonkin, M. A., Beard. A. J., Kemp, S. J. and Eakins, D. F.(1995). Sesamoid arthrodesis for hyperextension of thethumb metacarpophalangeal joint. J. Hand Surg., 20A,334–8.

Wilson, R. L. and Hazen, J. (1995). Management of jointinjuries and intra-articular fractures of the hand. In Reha-bilitation of the Hand: Surgery and Therapy (J. M. Hunter,E. J. Mackin and A. D. Callahan, eds) pp. 377–94,Mosby.

Hamate

PisiformTriquetrumLunate

TrapezoidTrapeziumCapitateScaphoid

DRUJ

12

The wristPeter Scougall

The wrist is comprised of several articulations, theanatomy and biomechanics of which are complex.Biomechanical interpretation has undergone somemodification recently and continues to evolve.

Anatomy

The wrist is comprised of (Fig. 12.1):

1. The radiocarpal joint

At this joint the distal radius articulates with thescaphoid and lunate bones. This joint carries 80 percent of the axial load of the forearm.

2. The midcarpal joint

The proximal carpal row, i.e. the scaphoid, lunateand triquetrum, articulates with the distal carpalrow, i.e. the trapezium, trapezoid, capitate andhamate bones. The pisiform is a sesamoid bonethat enhances the mechanical advantage of themost powerful motor in the wrist, i.e. flexor carpiulnaris. The pisiform articulates with thetriquetrum.

3. The distal radioulnar joint (DRUJ)

The head of the ulna articulates with the shallowconcavity of the sigmoid notch at the distal radius.Twenty per cent of the axial load of the forearm iscarried through the ulnar carpus via the triangularfibrocartilage complex (TFCC).

Radial tilt and inclination

In the sagittal plane, the radius has a palmar tilt ofapproximately 11 degrees. In the frontal plane, theulnar inclination of the distal radial articular surfaceis approximately 23 degrees (Fig. 12.2(a)).

Ulnar variance

Ulnar variance (also known as Hulten’s variance)refers to the length of the ulna relative to theradius. In ulna neutral (or zero) variance, the distalmargin of the ulnar head articular surface is levelwith the medial corner of the radius. In ulna plus(or positive) variance, the ulna is 1–5 mm longerthan the radius; in ulna minus (or negative)variance the ulna is 1–6 mm shorter than the

Figure 12.1. Schematic drawing of the volar aspect ofthe wrist showing the radiocarpal joint, the midcarpaljoint, the eight carpal bones and the distal radioulnarjoint.

(a)

Ulnar inclinationof distal radius

Ulna neutralvariance

(b)

RCL

ECU sheath

UT

UL

TFC

TFCCRC

RT

RSL

T

C


radius. Ulna positive variance is associated withdegenerative changes in the ulnolunate joint.Kienboeck’s disease is more common in peoplewith an ulna minus variance (Fig. 12.2(b)).

The carpus

The carpus does not move as a solid block. It is alabyrinth of small bones and is flexible andcompliant. Movement occurs not only between thecarpal rows but also between the individual bones.There is more play between the bones of theproximal row than the distal, this row being arelatively immobile unit that articulates with themetacarpals to form the carpometacarpal joints.

Range and direction of movement of the carpalbones is determined by their articular arrangementsand ligamentous attachments. The scaphoid bonespans both carpal rows anatomically and function-ally, acting as a restraining link that contributes tocarpal stability. In transverse section, the carpusforms an arc which is the floor of the carpal tunnel.

Carpal ligaments

The relative importance of the carpal ligamentsystem becomes apparent when it is rememberedthat all wrist tendons, with the exception of flexorcarpi ulnaris, insert beyond the carpus onto themetacarpals, thereby depriving the wrist joint oftheir stabilizing influence.

Carpal stability is provided by a complexintrinsic and extrinsic ligament system. Intrinsiccarpal ligaments connect the carpal bones to eachother. Clinically, the most important of these is the

Figure 12.2. (a) Palmar tilt of the radius. (b) Ulnaneutral (or zero) variance and ulnar inclination ofdistal radius.

Figure 12.3. Volar wrist ligaments: RCL, radial collateral ligament; RC, radiocapitate, RT, radiotriquetral; C, capitate;T, triquetrum; RSL, radioschapholunate; ECU, extensor carpi ulnaris; UT, ulnotriquetral; UL, ulnolunate; TFC,triangular fibrocartilage; TFCC, triangular fibrocartilage complex. (Copyright, Elizabeth Roselius, 1999 withpermission. Reproduced from Fernandez, D. L. and Palmer, A. K. 1999. Fractures of the distal radius. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) p. 932, Churchill Livingstone).

The wrist 145

scapholunate (S-L) ligament. Extrinsic ligamentsconnect the carpal bones to the radius and ulnaproximally and the metacarpals distally.

The palmar wrist ligaments are thicker and moreplentiful than the thinner dorsal ones. It wouldappear that a strong palmar system is necessary tostabilize against wrist extension while less supportis needed dorsally to stabilize against wrist flexion(Figs. 12.3 and 12.4).

The distal radioulnar joint

Forearm rotation involves movement of the radiusand hand about the ulnar head. Static stability ofthe DRUJ is provided by:

1. Congruent articular surfaces.2. The triangular fibrocartilage complex (TFCC).3. The interosseous membrane.4. The dorsal wrist retinaculum.

Dynamic stability is provided by the pronatorquadratus, extensor carpi ulnaris and flexor carpiulnaris.

The triangular fibrocartilage complex(TFCC)

This complex is comprised of:

1. The triangular fibrocartilage proper (TFC).2. The ulnocarpal complex, i.e. the extrinsic

ulnolunate and ulnotriquetral ligaments.3. The extensor carpi ulnaris sheath.

The TFC proper passes from the sigmoid notchon the radius to the base of the ulnar styloidprocess. As the name implies, it is triangular inshape. The peripheral margins of the TFC arethick, vascular and structurally adapted to beartensile loading. The central portion is thin, avas-cular and more suited to bearing compressive loads(Fig. 12.5).

Wrist movements

Wrist movement, excluding motion at the DRUJ,occurs in two planes:

1. Flexion/extension in the sagittal plane.2. Radial/ulnar deviation in the frontal plane.

Figure 12.4. Dorsal wrist ligaments: DIC, dorsalintercarpal ligaments; RS, radioscaphoid; RT,radiotriquetral; TFCC, triangular fibrocartilagecomplex. (Copyright, Elizabeth Roselius withpermission. Reproduced from Fernandez, D. L. andPalmer, A. K. 1999. Fractures of the distal radius. InGreen’s Operative Hand Surgery (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) p. 931,Churchill Livingstone.)

Figure 12.5. Triangular fibrocartilage and ulnocarpal Vligament (Copyright, Elizabeth Roselius with permission.Reproduced from Bowers, W. H. The distal radioulnar joint.1999. In Green’s Operative Hand Surgery (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) p. 991, ChurchillLivingstone.)


When these movements are combined, a consider-able range of motion occurs from radial deviationand extension to ulnar deviation and flexion. Rangeof motion can vary considerably among individuals.Wrist flexion usually ranges between 75 and 90degrees, extension between 70 and 80 degrees,radial deviation between 15 and 20 degrees andulnar deviation between 35 and 40 degrees.

Total range of forearm rotation is 150 to 190degrees at the DRUJ proper and 260 degrees at thehand. Forearm supination and pronation rangesbetween 80 to 90 degrees when assessed from themidrange position with the elbow flexed to 90degrees.

During wrist extension, the first two thirds ofmovement occur at the radiocarpal joint, theremaining third at the midcarpal joint. During wristflexion, the first half of motion occurs at themidcarpal joint and the second half at the radio-carpal joint. Radial and ulnar deviation occurprimarily at the radiocarpal joint.

Assessment of the wrist

1. History

Assessment is made of the mechanism of injury andthe force involved. Was the injury associated with a‘snapping’ or ‘popping’ sound or sensation? Doesthe wrist ‘give way’ during activity? Where andwhen is pain present? What factors aggravate orrelieve pain? Note should be taken of the patient’sexpectations and physical demands in relation tooccupation, sporting and leisure pursuits.

2. Examination

Look for swelling or deformity. Ask the patient topoint to the most painful area; this area is palpatedlast. Compare range of motion and grip strengthwith the contralateral side. Check for generalizedligamentous laxity and perform specific tests toassess stability, e.g. the Watson scaphoid shift test,where appropriate.

3. Investigations

(i) X-raysMany injuries can be diagnosed by plain X-rays.Special views may need to be requested, depend-ing on the suspected pathology (see each sectionfor details). If the diagnosis remains unclear afterthorough clinical assessment and plain X-ray, otherinvestigations can be useful.

(ii) Bone scanThis is a sensitive although non-specific investiga-tion for suspected bone injury. Two days afterinjury, plain X-rays can appear normal while a bonescan will be positive, e.g. fracture of the scaphoid.

(iii) TomographyTomography can define the anatomy of the injurymore accurately than plain X-ray. Bone healing andfracture non-union is more apparent than on plainX-ray, particularly where the scaphoid or hook ofhamate are involved.

(iv) Magnetic resonance imaging (MRI)Magnetic resonance imaging can be used to assesscertain ligament injuries and is the best investiga-tion for the assessment of bone vascularity, e.g.Kienboeck’s disease.

(v) ArthroscopyArthroscopy has become an increasingly useful toolin recent years for the assessment and treatment ofmany wrist conditions including ligament injuries,articular cartilage defects and intra-articularfractures.

Fractures of the distal radius

Fracture of the distal radius is a common and oftencomplex injury. The ultimate functional result willdepend on accurate anatomic reduction. Unless thiscan be achieved and maintained, problems such asmalunion, angulation, shortening and loss of radialtilt will result in wrist pain, stiffness, weakness andfinally, post-traumatic arthritis. Incongruity orinstability of the DRUJ or ulnar impaction syn-drome are other potential problems.

Factors affecting outcome

Outcome will also be influenced by the patient’s ageand health status. A low velocity fracture in anelderly person with osteoporosis is a completelydifferent injury to a high speed, comminutedfracture involving young, strong bone. Over-enthusiastic treatment of the first can be just asdetrimental as ‘under-treatment’ of the second. Thechoice of treatment will depend on the individualrequirements of the patient and the complexity ofthe injury. Fractures in older patients are generallytreated less ‘aggressively’ than those in youngadults although treatment decisions should be basedon the physical requirements of the patient rather

The wrist 147

than simply on age. Severe osteoporosis and seriousillness do, however, mitigate against an enthusiasticoperative approach.

Assessment of distal radial fractures

1. History

How did the injury occur and what force wasinvolved? High velocity injuries, e.g. falls from aheight or from a motorbike at speed, involve greatersoft tissue swelling and a higher risk of associatedinjuries.

2. Soft tissues

Open fractures require urgent surgical debridement.Acute carpal tunnel syndrome may occur andoccasionally, the median nerve may even bedivided. Ulnar nerve injury is rare. Tendon injuriesare possible. Vascular injuries are rare after distalradial fractures, as is compartment syndrome(although this can be caused by a cast which is tootight).

3. The fracture

Adequate X-ray views are essential (posterior-anterior, lateral and oblique views). The oppositewrist is X-rayed for comparison. A CT scan maydefine the anatomy of intra-articular fractures betterthan plain films.

4. The patient

The treatment plan must take into consideration theage, general health, occupation, activity level,expectations and hobbies of the patient.

Classification of distal radial fractures

The more commonly used eponyms for the classifi-cation of distal radial fractures include:

1. Colles’ fracture

This describes a transverse extra-articular fractureof the distal radius less than 2.5 cm from the wrist.The distal fragment is shifted and tilted dorsally andradially. It is usually impacted. The ulnar styloidprocess may be avulsed (Fig. 12.6).

2. Smith’s fracture

This is a true reversed Colles’ fracture, i.e. extra-articular distal radial fracture with volar shift and tilt(Fig. 12.7).

Figure 12.6. Colles’ fracture with dorsal tilt of thedistal fragment (Frykman, G. K. and Kropp, W. E.Fractures and traumatic conditions of the wrist. 1995.In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)p. 320, Mosby, with permission.)

Figure 12.7. Smith’s fracture with volar tilt of thedistal fragment (Frykman, G. K. and Kropp, W. E.Fractures and traumatic conditions of the wrist. 1995.In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)p. 322, Mosby, with permission.)

Figure 12.8. Barton’s fracture-dislocation (dorsal).This is an intra-articular unstable fracture with eithervolar or dorsal fragment displacement. (Frykman,G. K. and Kropp, W. E. Fractures and traumaticconditions of the wrist. 1995. In Rehabilitation of theHand: Surgery and Therapy (J. M. Hunter, E. J.Mackin and A. D. Callahan, eds) p. 322, Mosby, withpermission.)

Type I Type II

Type III Type IV A

Type IV B Type IV C


3. Barton’s fracture-dislocation

This is an intra-articular unstable injury. Thecarpus displaces with the articular fracture frag-ment. This fracture can be volar or dorsal.

Numerical classification

Contemporary authors prefer to classify fracturesof the distal radius numerically. The higher thenumerical rating, the more serious the injury and

the more uncertain the outcome. These classifica-tions are determined by whether:

(i) The fracture is open or closed.(ii) It is displaced or undisplaced.(iii) It is comminuted or non-comminuted.(iv) It is extra-articular or intra-articular.(v) The patient is an adult or a child.

Unlike earlier descriptions of radial fractures, theseclassifications include the ulna and DRUJ.

Some of the authors who have described classi-fication systems include: Frykman, Melone, Ray-hack, Fernandez and Cooney et al. (1990) whoseclassification is shown below:

Type I – non-articular, undisplaced.Type II – non-articular displaced.Type III – intra-articular, undisplaced.Type IVA – intra-articular, displaced, reducible,stable.Type IVB – intra-articular, displaced, reducible,unstable.Type IVC – intra-articular, irreducible (Fig.12.9).

Treatment of distal radial fractures

1. Closed reduction and plasterimmobilization

Many fractures of the distal radius can be treatedby closed reduction and plaster, particularly thosethat are low velocity, relatively stable and extra-articular, i.e. Types 1, 2 and 3.

A well-moulded plaster slab is applied initially.A short arm plaster is usually adequate. It shouldfinish just proximal to the distal palmar crease toallow unimpeded flexion of the MCP joints. Thelimb is elevated and finger, thumb, elbow andshoulder movements are commenced. The cast isreinforced or tightened as needed and is completedwhen swelling has settled. The position is checkedwith regular X-rays. Gentle wrist movements arecommenced when the plaster is removed; this isusually at 6 weeks (see p. 152 for therapy).

2. Closed reduction and percutaneousK-wire fixation (Fig. 12.10)

Oblique or comminuted fractures are unstable andlikely to redisplace unless internally fixed. Closedreduction and percutaneous K-wire fixation isuseful for extra-articular, incomplete articular andradial shear fractures if an acceptable reduction isachieved following closed manipulation. Great

Figure 12.9. The universal classification of distalradial fractures as proposed by Cooney et al. (Cooney,W. P., Agee, J. M., Hastings, H., et al. Symposium:Management of intra-articular fractures of the distalradius. Contemp. Orthop. 21, 71–104, 1990, BobitPublishing Co., with permission).

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Figure 12.10. (a) This 63-year-old female sustained a low velocity Colles’ fracture resulting from a fall whileplaying tennis. (b) Lateral view of fracture. (c) This fracture was treated with closed reduction and percutaneousK-wire fixation. Note restoration of the distal radioulnar joint. (d) Lateral view following closed reduction andpercutaneous K-wire fixation.

(a) (b)

(c) (d)


care is taken to avoid damage to tendons, sensorynerves and vessels when inserting the wires.

The plaster is removed at 6 weeks and wristmovements are begun. The wires are removed 6 to8 weeks following removal of plaster.

3. Open reduction and internal fixation

Open reduction and internal fixation (ORIF) isachieved with plates and screws and is indicated inthe following circumstances:

(i) A satisfactory position has not been achievedwith closed reduction.

(ii) There is an unstable fracture pattern, e.g.Barton’s intra-articular fracture-dislocation.

(iii) Displaced radial styloid fractures; these maybe associated with scapholunate ligamentinjuries which should also be repaired.

(iv) Displaced or depressed intra-articular frac-tures, e.g. die-punch fracture (involving theradiolunate joint) (Fig. 12.11).

Metaphyseal bone loss should be grafted toprevent loss of reduction and non-union. Iliac crestbone graft is the graft of choice although variousbone substitutes are available.

AftercareOpen reduction and rigid internal fixation of thefracture allows early movement of the wrist whichis protected initially with a plaster slab and then athermoplastic wrist splint. The splint is removedevery few hours so that gentle active wristmovements can be carried out. (See p. 153 forgreater detail.)

4. External fixation

External fixation can be used to treat complexcomminuted fractures or those with extensive softtissue injury. Skeletal fixation via pins through thesecond metacarpal and distal radius allows precise,firm distraction of the fracture fragments (Fig.12.12).

The technique is excellent for restoring lengthand radial inclination. Palmar tilt may be moredifficult to restore and often requires an extra pinor K-wire. Displaced or depressed articular frag-ments may require open reduction via a smallincision.

Associated soft tissue injuries, i.e. vessels,nerves and tendons, should be repaired at the sametime as fracture fixation. Carpal tunnel decompres-sion is frequently required.

Figure 12.11. (a) This unstable comminuted fracture of the distalradius was sustained by a 28-year-old female who fell at highspeed from a snowboard. (b) Treatment of this fracture requiredopen reduction, cancellous bone grafting from the iliac crest andplate fixation.

(a)

(b)

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Comminuted high velocity fractures of the distalradius can be difficult to treat and complicationrates are high. Nevertheless, new fixation devicesand better surgical techniques have improved theresults of these complex injuries.

Therapy during fixator immobilizationperiod

A thermoplastic wrist splint can be mouldedaround the frame of the fixator to provide volarsupport to the hand. Oedema, particularly on thedorsum of the hand, is often marked and can beaddressed with light application of 2-inch Cobanwrap. The arm should be elevated regularly andexercise of the proximal upper limb joints shouldbe carried out frequently during the day.

The combination of oedema, wrist posture andrestriction of finger movement due to the frame,can make finger flexion difficult. Compositeflexion is usually not possible. The patient shouldtherefore perform active intrinsic MCP joint flex-ion exercises separately to extrinsic stabilizedinterphalangeal joint flexion exercises with theMCP joints held in neutral extension (Figs. 12.13and 12.14). Active exercises usually need to bepreceded by passive flexion exercises.

Active finger extension is also restricted byoedema and tethering of the extensors. To helpovercome this, ‘place and hold’ exercises are

Figure 12.12. External fixation was used to treat this32-year-old man’s intra-articular comminuted distalradial fracture following a crush injury. Note thepostoperative hand oedema which, if not treatedpromptly, will rapidly lead to stiffness of the fingerjoints.

Figure 12.13. Active intrinsic MCP joint flexion.

Figure 12.14. Stabilized extrinsic interphalangeal jointflexion exercises.


performed 1 to 2 hourly. The fingers and thumb arepassively extended to a comfortable maximumrange and held in this position for a short period,i.e. 1 to 2 minutes. Support is then withdrawnwhile the patient attempts to maintain the extendedposition actively. This manoeuvre is repeated untilthe patient is able to demonstrate active finger andthumb extension with ease. (See ‘Therapy follow-ing cast removal after closed reduction’ for therapymanagement following removal of fixator.)

5. Arthroscopy

It can be difficult to assess the position of thearticular surface, even after good plain X-rays andtomography. Arthroscopy offers an excellent viewof the joint and may assist with reduction andpercutaneous fixation of some fractures. Thetechnique facilitates accurate diagnoses of asso-ciated intra-articular injuries, e.g. scapholunateligament tear, triangular fibrocartilage tear andosteochondral fractures.

Complications of distal radialfractures

Complications following a fracture of the distalradius are relatively common and can result fromthe fracture itself or as a consequence of treatment.

1. Stiffness

Stiffness can involve any joint in the upper limb,particularly the shoulder in the elderly patient. Therisk is minimized by elevation of the injured wrist,careful cast application and early movement of allunsplinted joints.

2. Carpal tunnel syndrome

Symptoms of median nerve compression, i.e. pinsand needles, numbness or pain, may settle afterfracture reduction. If symptoms persist post-operatively and are not relieved by dressingrelease, urgent carpal tunnel decompression isindicated.

3. Malunion

Malunion is common; non-union is rare. The riskof malunion is minimized by appropriate anatom-ical reduction via internal fixation of unstablefractures.

4. Chronic regional pain syndrome (CRPS)

This may be triggered by carpal tunnel syndrome,radial neuritis or a tight plaster. Changes such as

increased pain, swelling, hand sweating or discol-oration may be an indication of CRPS.

5. Loss of grip strength

Weakness inevitably follows prolonged immobili-zation. Grip strength will gradually be restored aspain subsides and wrist motion, particularly exten-sion range, improves.

6. Tendon adherence

The soft tissue response associated with fracturesfrequently results in adherence of adjacent ten-dons. The tendons become adherent to one anotheras well as to bone. The extensor tendons areparticularly prone to tethering following complexfractures which require open reduction and internalfixation.

7. Delayed rupture of extensor pollicislongus

This is more common after minimally displacedfractures and usually occurs 4 to 6 weeks afterinjury. Rupture of the EPL can sometimes bedifficult to distinguish from adherence of thetendon as this too can result in a flexed IP thumbjoint posture. This situation is not an emergencyand is overcome by tendon transfer using extensorindicis proprius.

8. Palmar fasciitis

This manifests as thickened, red, tender bands inthe palm. Fasciitis can be present on its own or issometimes present with other signs and symptomsof CRPS.

9. Post-traumatic arthritis

This is a late complication, the symptoms of whichmay not manifest themselves for several years.

Therapy during immobilizationperiod after closed reduction

Postoperatively the injured limb is elevated.Active, active-assisted or passive movement of allunsplinted joints is commenced. Elevation usingpillows is preferred to the use of a sling which cancontribute to shoulder stiffness. When the patient isambulant, collar-and-cuff support is a comfortablealternative.

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Patients are encouraged to exercise for severalminutes each hour when awake. Active and passivemovements should be performed in a systematicfashion, beginning with the shoulder and workingdistally. Active finger exercises should be per-formed in elevation to assist resolution of handoedema. In the case of patients who are frail or thosewith memory problems, a family member should beinstructed in the home programme and ideally beavailable to supervise on a regular basis.

Increased pain, swelling, altered sensation,numbness or hand discoloration should be reportedpromptly as these could indicate a tight cast, carpaltunnel syndrome or herald the onset of chronicregional pain syndrome (CRPS).

Active movement should be preceded by passiveexercises to help facilitate tendon pull-through,particularly of the weaker extensors which are oftentethered to adjacent tissue. ‘Place-and-hold’ man-oeuvres are often easier in the initial exercisesessions.

To ensure effective flexor tendon pull-through,each joint is exercised individually with stabiliza-tion of the more proximal joint. Global flexion (i.e.fist-making) should follow individual finger flexionexercises.

Particular attention is given to MCP joint flexion.Unless instructed, most patients will assume a‘hook’ grip when asked to make a fist. This issometimes due to restrictive dorsal hand oedema,but is more often habitual because it requires lesseffort. A manoeuvre that the patients find difficult,but which is effective, is to passively flex the MCPjoints to their maximum comfortable limit andwhile holding this position, perform active inter-phalangeal joint flexion exercises. Active intrinsicMCP joint flexion exercises are added to theexercises when the patient can demonstrate asatisfactory passive range of MCP joint flexion.This manoeuvre should be repeated 5 to 10 timeseach session and continued until the patient initiatesfist-making with the MCP joints rather than the IPjoints.

Attention also needs to be given to the web spacesof the digits and thumb. Small wads of gauze, cottonwool or foam can be inserted between the fingers forshort periods (i.e. 10 to 15 minutes) several times aday. These are made bulkier as finger abductionimproves. Larger pieces of foam are used for thethumb web and can be bandaged into position.Active range of finger abduction readily followsimprovement in the passive range.

Where finger stiffness persists, as is often thecase in the older patient with degenerative arthritis,

the fingers can be lightly bandaged into a ‘mitten’by using a light crepe bandage. This manoeuvreshould provide a gentle stretch only, i.e. should notresult in pain. The bandage is left in place for 15 to20 minutes and the process can be repeated everyfew hours during the day. When the bandage isremoved, the patient should unfurl the fingersslowly to avoid the pain that can be associated withsudden extension following prolonged flexion.

Therapy following cast removalafter closed reduction

Most limb fractures, including closed/stable ones,are accompanied by a significant soft tissueresponse, i.e. oedema. When a fracture requiresORIF and/or is associated with injury to othertissues, e.g. skin, tendons, nerves or blood vessels,the soft tissue manifestations will be more com-plex. Their recognition and treatment are importantin the management of distal radial fractures.

Effects of fracture and prolongedimmobilization

A wrist that has been immobilized for 6 to 8 weeksusually presents with the following features uponcast removal (Fig. 12.15):

1. It is considerably thickened in appearance; thisresults from a combination of residual oedema,bony callus and soft tissue scar (fibrosis).

2. The skin is frequently dry, flaky and/orscabby.

3. The wrist will in most cases have a restrictedpassive/active range of movement. This is duenot only to joint pathology but also to flexor

Figure 12.15. Residual oedema, bony callus and softtissue adhesions are commonly observed followingprolonged wrist immobilization.


muscle-tendon shortening after protractedimmobilization in a position of wrist flexion.Supination/pronation range is often quitelimited.

4. Extensor tendon lag is common. Open reduc-tion and internal fixation frequently results intendon adherence (also known as tethering).The tendons can become adherent to oneanother, to adjacent bone or overlying skin.Rupture of the extensor pollicis longus tendoncan be an associated complication.

5. The unsupported wrist is painful for manypatients. This normal postinjury wrist pain issometimes complicated by nerve involvement,e.g. an associated carpal tunnel syndrome orirritation of the radial nerve superficial branchduring injury or surgery.

Hand bathing

Following cast removal, the hand and forearmshould be given a prolonged soak in warm soapywater. The benefits of this are skin cleansing andpain reduction, particularly in the older patient.When the hand is removed from the water, theentire forearm is supported on a table, as suspend-ing the hand in the air at this early stage causesdiscomfort to many patients. A rolled towel can beplaced beneath the wrist in whatever position thepatient finds most comfortable.

Oil massage

Gentle oil massage will help relax the patient,begin the desensitization process, soften the scarand assist with elimination of swelling whencarried out in a distal-to-proximal direction. Warmwater soaks and oil massage should be repeatedseveral times a day as part of the home programmeuntil the skin has returned to its pre-injury state.

Exercise

Exercise sessions during the first 2 weeks shouldbe short but frequent, i.e. 1 to 2 hourly, and shouldnot exacerbate pain. Before commencing wristexercises, shoulder and elbow motion is assessed.The patient is reminded to incorporate all upperlimb joints into their exercise regimen. Gentleactive wrist movements including flexion/exten-sion and ulnar/radial deviation are begun withgravity eliminated at this early stage. Activepronation and supination exercises should beperformed with the elbow joint held in 90° of

flexion; this position eliminates compensatorymovements of the shoulder. To help isolate move-ment at the DRUJ, the patient should grasp a lightobject, e.g. a pen, to avoid using the finger andwrist tendons as a substitute for true forearmrotation.

Passive manoeuvres are used judiciously. Resid-ual stiffness of the interphalangeal joints is over-come by bandaging the fingers into flexion everyfew hours to augment the exercise programme.

Hypersensitivity

Hypersensitivity that persists beyond the first 2weeks or which interferes with the patient’s abilityto carry out their exercise programme is treatedwith transcutaneous electrical nerve stimulation(TENS). The patient should be issued with a unitfor home use until hypersensitivity has resolved.This is usually achieved after 7 to 10 days.

Wrist support

The wrist may be splinted between exercisesessions and during light daily activity. This isparticularly appropriate for patients who find itdifficult to lift their hand out of the flexed posturebecause of pain, marked stiffness and/or lack ofconfidence. Serial extension splinting is institutedwith these patients (Fig. 12.16). Intermittent sup-port of the wrist has the following advantages:

1. Pain relief.2. Helps resolve residual wrist oedema.3. Overcomes stiffness when used serially.

While support splinting may appear to be aretrograde step following prolonged immobiliza-tion, the author believes that progress is expeditedas the patient is more likely to use the hand whenpain is reduced or eliminated. The patient isnonetheless monitored for a tendency to overusethe support.

Serial extension splinting of the wrist

The preferred material for serial wrist splinting isplaster as it gives a more contiguous fit andprovides greater rigidity than thermoplastic materi-als. It is more comfortable in hot weather and ismore economical where a series of splints isindicated. The close fit of the plaster, in combina-tion with the compressive effect of the retainingbandage, provides good scar compression and

The wrist 155

assists with the resolution of residual swelling. Ifsilicone gel is indicated for scar management, theplaster is moulded over the covered gel.

The plaster cast should extend midlaterally oneither side of the forearm and should attempt tohold the wrist in a slightly corrected position.Gains at each plaster change may only be modest;however, improvement in extension range over a 2to 3 week period is often quite marked. Thecorrected position should cause only mild dis-comfort that usually settles quickly; it should notcause pain. The plaster is renewed every few dayscommensurate with improvement. The frequencyof plaster change usually decreases after the first 2to 3 weeks and is continued until a plateau hasbeen reached, this generally occurring after 2 to 3months. Progress is influenced by the complexityof the injury and the age of the patient. Discussionwith the treating surgeon regarding realistic expec-

tations is advisable. It is also important to stress tothe patient that the splinting programme is com-plementary to their exercise and activity regimenand is not a substitute for it.

When a functional degree of wrist extension hasbeen achieved, i.e. 20 to 30 degrees, a soft elasticwrist support can be used as an alternative duringactivity (Fig. 12.17).

Figure 12.16. Serial plaster casting of a stiff, painfulwrist will hasten progress by providing pain relief andincreasing range of motion.

Figure 12.17. Where pain threshold is low or thepatient is not confident enough to use the hand, theintermittent use of a soft wrist splint during activitycan expedite progress.

Dynamic wrist splinting

Dynamic splinting of the waist is another optionfor overcoming stiffness; however, the outriggerportion of the splint can be impractical duringactivity. In the experience of the authors, theresults of static splinting are equal to those gainedwith dynamic splinting.

Overcoming tendon adherence

Silicone gel compression and scar massage aremaintained until scar has softened and tendon glidehas been re-established.

Active wrist extension is synergistic with fingerflexion. As wrist extension improves, there is acorresponding improvement in finger flexion. Thisis referred to as the ‘tenodesis effect’. Conversely,active finger extension becomes more difficult aswrist extension improves, particularly when ten-don adhesions are also present. To utilize thesynergistic relationship between active wrist flex-ion and finger extension, early active finger/thumbextension exercises are best performed with thewrist in neutral extension or even slight flexion totake advantage of this tenodesis effect until theextensor tendons are less adherent and stronger.The wrist can then be brought into greater degreesof wrist extension during active finger extensionexercises.

Tethering of the extensor pollicis longus tendonfollowing ORIF can result in a lag at the IP joint.A mallet splint can be worn intermittently toprevent a flexion deformity at this joint. The splintwill also assist in active thumb extension exercises.Where there is an extensor lag at the MCP joints,‘place and hold’ extension exercises are preferableto actively extending the MCP joints from theirrelaxed posture of slight flexion.

Forearm rotation exercises

Patients often find it more difficult to regainforearm supination than pronation. Passive andactive rotation exercises need to be practised as


frequently as wrist exercises. Gentle stretches intosupination should be maintained for short periodsoften throughout the day. Holding a hammer forshort periods will assist forearm supination orpronation range by utilizing the weight of thehammer’s head. The weight can be readily adjustedby moving the hand proximally or distally alongthe handle (Fig. 12.18).

Dynamic forearm rotation splint

If a satisfactory range of forearm rotation has notbeen achieved with passive and active exercise bythe 6th week of therapy, application of a dynamicrotation splint should be considered. Approval bythe treating surgeon should be sought beforeapplying this splint as there may be contra-indications. The force exerted by the splint shouldalways be gentle but prolonged. It is better to erron the side of caution and use too little forceinitially, rather than too much. The author has usedthe Colello–Abraham splint and the kit availablefrom Smith and Nephew and has found both to beeffective (Fig. 12.19).

Upgrading of treatment programme

Gentle resistance is added to the programme aftera month and gradually increased over the ensuingweeks. Graded weights can be used to strengthenwrist flexors and extensors and the patient’sactivity programme is upgraded. The patient isstrongly encouraged to use the hand and upperlimb in suitable home and leisure activities. Wherepossible, return to the work environment isencouraged.

Cessation of therapy programme

It can be difficult to know just how long topersevere with the home splinting/exercise pro-gramme. A minimum of 3 months is usuallyrequired to attain a functional wrist range andreasonable grip strength. By this time the patientshould have been weaned from formal therapyvisits. Normal use of the hand will engenderfurther mobility and strength. As a guide, formalexercise and splinting can be discontinued whenactive range of movement is equal to passive rangeand when there has been no increase in movementfor several weeks.

Patients who are tentative about loading anunsupported wrist when they return to work arefitted with a neoprene wrist wrap. This allowsunrestricted movement while providing supportduring activity (Fig. 12.20). Manual workers whoplace high demands upon their wrists can usuallyreturn to work at about 8 weeks following castremoval if good radiological and clinical union hasbeen confirmed by the surgeon.

Figure 12.18. A hammer can be used as a passiveweight stretch to increase forearm rotation. The weightof the hammer is readily adjusted by moving the handalong the handle of the hammer.

Figure 12.19. A dynamic forearm rotation splint isindicated if the exercise programme does not yieldadequate progress in forearm supination/pronationrange after a period of several weeks.

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Carpal fractures

Carpal fractures are common and often result froma fall on the outstretched hand. Their order offrequency is as follows: scaphoid, triquetrum,trapezium, hamate, lunate, pisiform, capitate,trapezoid.

Scaphoid

Fractures of the scaphoid represent just under 80per cent of all carpal fractures. The scaphoid is theonly bone to cross both carpal rows. Stress istherefore concentrated in its waist and fracturescan occur with forced hyperextension. These areoften high velocity injuries. The appearance of theX-ray will frequently belie the seriousness of thefracture. A fracture of the scaphoid waist requirestwice the force necessary to fracture the distalradius. There may be other carpal fractures andassociated ligament tears, creating instability andincreasing the risk of non-union.

Blood supply to the scaphoid

Two thirds of the scaphoid surface is covered byarticular cartilage through which blood vesselscannot pass. Scaphoid vascularity is thereforeprecarious and the bone can become ischaemicafter injury. Eighty per cent of the scaphoid’sarterial supply enters via soft tissue attachmentsalong the dorsal ridge, derived from a dorsal

branch of the radial artery; 20 per cent enters thevolar aspect via the tubercle.

Clinical presentation

Patients with scaphoid injuries frequently presentwith wrist pain and swelling after a fall. Clini-cally, there is periscaphoid tenderness, partic-ularly in the anatomical snuffbox. Range ofmovement and grip strength are reduced.

Diagnosis

The fracture may not be visible on initial X-rays,even when appropriate views are taken, i.e. PAview in ulnar and radial deviation (with the fistclenched), 45 degree oblique and lateral. Theopposite wrist is X-rayed for comparison. Ifthere is any doubt about the diagnosis, the wristshould be rested in a splint and reassessed at 2weeks with repeat clinical examination and fur-ther investigations (Fig. 12.21). Due to boneresorption at the fracture site, the fracture willbecome visible on plain X-rays at that time. Ifearly diagnosis is needed, a bone scan 48 hoursafter injury will accurately identify occult frac-tures. False positives occur with a 10 per centfrequency (Fig. 12.22).

A CT scan may be useful for more accuratedefinition of the fracture anatomy (Fig. 12.23). Itwill also assess union and detect subtle injuries.An MRI scan is very sensitive in detectingscaphoid fractures and for assessing bone vascu-larity. These scans are, however, expensive andnot usually necessary.

The diagnosis of ‘wrist sprain’ should beavoided. The injury should be regarded as afracture until proven otherwise. A missed diag-nosis and delay in treatment increases the risk ofnon-union, carpal collapse and secondaryosteoarthritis of the wrist. Ninety-seven per centof patients with established scaphoid non-uniondevelop wrist arthritis within 5 years. This stat-istic becomes important when one recalls thatthe majority of people with this injury areyoung, healthy adults who are frequently athletesor manual workers. In these patients, inadequatetreatment of a scaphoid injury may result indisabling wrist arthritis before the age of 30(Fig. 12.24). Early diagnosis and appropriatetreatment are therefore important.

Treatment

Conservative treatment is indicated for:

Figure 12.20. A neoprene wrist wrap allows fullmotion while providing firm elastic support to patientswho are to return to heavy work.


Figure 12.21. (a) This 19-year-old female presented with acute wrist pain after a fall. The scaphoid fracture isdifficult, if not impossible, to see on this initial X-ray. (b) The scaphoid fracture is clearly visible on repeat filmstaken 2 weeks later.

(a) (b)

Figure 12.22. A bone scan can identify occultfractures 48 hours after injury if early diagnosis isrequired. This scan shows increased uptake in thescaphoid consistent with an acute fracture.

Figure 12.23. A CT scan can more accurately definethe fracture anatomy as in the case of this scaphoidfracture.

The wrist 159

1. Stable, undisplaced fracture of thewaist

Stable waist fractures can be treated in a short armcast including the thumb in a position of oppositionto the index and middle fingers and the wrist inslight radial deviation and flexion (Fig. 12.25). Useof a long arm cast has been recommended by someto eliminate scaphoid motion due to forearmrotation. Recent experimental studies have shown,however, that such motion does not occur provided

that the wrist and thumb are immobilized. Averagehealing time is 6 to 12 weeks, although this isfrequently longer. Reported union rates vary sig-nificantly from 60 to 90 per cent.

2. Tubercle fractures

Tubercle fractures are rested in a wrist splint for 3to 4 weeks. Waist movements are thencommenced.

Indications for open reduction andinternal fixation

1. Unstable, displaced waist fractures.2. Proximal pole fractures.3. Scaphoid injuries associated with carpal insta-

bility, e.g. trans-scaphoid perilunate dis-location.

4. Non-union.5. Pathological fracture (Fig. 12.26).

The scaphoid is the most important bone in thewrist. The only acceptable result following acutefracture is solid bony union in an anatomicposition. This is best achieved by treating unstablescaphoid fractures with early internal fixation.

Figure 12.24. Post-traumatic osteoarthritis of the wristdue to an untreated scaphoid non-union.

Figure 12.25. Short arm cast used to treat a stablescaphoid waist fracture.

Figure 12.26. Pathological scaphoid fracture due to abenign enchondroma.


Advantages of early internal fixation include:

1. Increased union rate (90–95 per cent).2. The avoidance of problems associated with

prolonged immobilization, e.g. muscle wasting,joint stiffness, osteoporosis.

3. Rapid functional recovery with early return towork and leisure activities.

Technique

Fixation is achieved via a volar approach for waistfractures and a dorsal approach for proximal poleinjuries. There are various fixation devices. Thebest, in the opinion of the author, is the Herbertscrew.

The principles of surgical treatment are:

1. Debridement of the non-union to healthybone.

2. Assessment of bone vascularity.3. Correction of the deformity with a cortico-

cancellous block of iliac crest bone graft.4. Addition of a vascularized bone graft if

indicated.5. Rigid fixation using a Herbert compression

screw (Fig. 12.27).


Following surgery the arm is elevated for 24 to 48hours. Finger exercises are commenced within aday of surgery. The wrist is immobilized in a softbulky dressing or plaster splint for 7 days. Gentleactive unresisted wrist exercises are thencommenced.

Most patients regain good wrist motion within afew weeks of surgery and require little formaltherapy once they are shown a home programme ofactive wrist exercises. Residual scar is managedwith silicone gel.

The patient should refrain from heavy activitiesand contact sport until the fracture has united. Thisusually takes between 6 and 12 weeks dependingon the size of the graft.

Salvage procedures

If the scaphoid cannot be reconstructed or the wristhas already developed secondary osteoarthritis,bone grafting and internal fixation are notappropriate.

Pain can often be controlled with non-operativemeasures such as support splinting and/or activitymodification. If required, surgical optionsinclude:

1. Radial styloidectomy.2. Wrist denervation.3. Scaphoid excision and four-corner fusion (i.e.

capitate, hamate, lunate and triquetrum).4. Costochondral grafting (rib).5. Proximal row carpectomy.6. Total fusion.

Note: Prosthetic replacement is no longer used dueto the risk of silicone synovitis.

Triquetrum

The triquetrum is the second most commonlyfractured carpal bone, representing approximately14 per cent of carpal bone fractures. Triquetralfractures are often associated with other carpalinjuries and usually result from a fall on theoutstretched hand.


The patient presents with pain, swelling andtenderness over the dorso-ulnar aspect of thewrist.

Figure 12.27. Scaphoid union following excision,bone grafting and Herbert screw fixation.

The wrist 161

Diagnosis

Triquetral fractures may be small avulsions, frac-tures through the body or impaction injuries, thelast being the most common. The ulnar styloid isfrequently longer in these patients than in thegeneral population, i.e. there is an ulna positivevariance. Diagnosis of these fractures can bedifficult. Oblique X-ray views, CT or bone scansmay be necessary (Fig. 12.28).

Treatment

These injuries will often heal if the wrist isimmobilized in a splint or cast for 4 to 6 weeks incomfortable extension. If symptoms persist follow-ing non-operative treatment, arthroscopy may beindicated. This will often reveal an area of cartilagedamage which can be debrided arthroscopically.Painful, un-united fracture fragments may requireexcision.

Lunate

Lunate fractures represent less than 2 per cent ofcarpal bone fractures and are usually associatedwith Kienboeck’s disease (avascular necrosis).They are rare otherwise. The cause of thiscondition is unknown, although various vascularand mechanical predisposing factors have beenimplicated. Kienboeck’s disease is more commonin people with an ulna minus variance, i.e. thedistal articular surface of the ulna is proximal tothe distal articular surface of the radius.

The natural history of Kienboeck’s disease isunpredictable and poorly understood. Ischaemiaweakens the bone and allows it to collapse. Whilethe ischaemia is reversible, collapse of the lunateand carpus is not. The purpose of treatment,therefore, is to correct lunate ischaemia early inorder to prevent collapse.


The patient, usually a young adult, presents withwrist pain and stiffness often associated withswelling. Occasionally there are symptoms ofcarpal tunnel syndrome.

The onset of symptoms is frequently triggeredby trauma. They may result from minor repeatedtrauma or occasionally, in a predisposed individ-ual, from a single traumatic episode.

Diagnosis

The diagnosis is usually made on plain X-ray (Fig.12.29). This will show lunate sclerosis. In the laterstages there may be fragmentation and secondarywrist osteoarthritis.

Bone scan is useful for early detection and maybe positive when plain X-ray is still normal. AnMRI scan will also detect ischaemia early and maybe used to assess the extent of the disease and theeffect of treatment (Fig. 12.30).

Classification

Lichtmann’s classification for Kienboeck’s diseaseis widely used:

Stage 1 – normal lunate density; a linear orcompression fracture may be visible.Stage 2 – density is abnormal, i.e. the bone issclerotic; no lunate or carpal collapse.

Figure 12.28. This 21-year-old man presented withulnar-sided wrist pain due to a fall while skate-boarding. Clinically there was local tenderness overthe triquetrum. Plain X-ray had shown a large ulnarstyloid process. This bone scan shows increaseduptake in the triquetrum consistent with an impactionfracture.


Stage 3 – lunate collapse is present.Stage 3(a) – carpal height is normal.Stage 3(b) – carpal height is diminished.Stage 4 – osteoarthritis is present.

Treatment

Treatment for Kienboeck’s disease is influenced bythe following factors:

1. The stage of the disease.2. Ulnar variance.3. Age and activity level of the patient.4. The presence of arthritis.


Mild symptoms can be managed with intermittentwrist splinting, analgesia and activity modification.These conservative measures can often be usedindefinitely. While there will be radiographicevidence of deterioration over time, more oftenthan not, this will be unaccompanied by worseningsymptoms.

The principles of surgical treatment

1. Reconstruct and revascularize the ischaemiclunate using a bone graft and vascular pedicleimplantation (e.g. second metacarpal artery,posterior interosseous artery at the wrist).

2. Unload the lunate to facilitate healing.(i) In patients with ulna minus variance (Stage

1, 2 or 3), this is achieved by a jointlevelling procedure such as radial short-ening or ulnar lengthening.

(ii) In patients with ulna neutral or positivevariance (Stage 1, 2 or 3), midcarpalprocedures such as scapho-trapezial-trape-zoid (STT) fusion or capitate shorteningare performed. Other techniques includedorsal capsulorrhaphy and radial wedgeosteotomy.

Salvage procedures

If there is lunate fragmentation, carpal collapse orsecondary arthritis, a salvage procedure may beindicated, e.g. proximal row carpectomy (if cap-itate and radial surfaces permit), wrist denervationor partial or total wrist fusion.

Hamate

Fractures of the hook of hamate are rare andrepresent less than 2 per cent of carpal bonefractures. This injury is associated with sports that

Figure 12.29. Kienboeck’s disease showing advancedcollapse and lunate fragmentation. Note the ulnaminus variance.

Figure 12.30. MRI scan showing Kienboeck’s disease(avascular necrosis of the lunate). MRI is moresensitive for early diagnosis of Kienboeck’s diseaseand can show ischaemia when a plain X-ray is normal.

The wrist 163

involve gripping a club or racket (golf, tennis,squash, baseball or hockey) and is more commonin athletes who grip the end of the handle in thepalm.

Even when clinically suspected, this fracturemay be missed as it is difficult to demonstrate onplain X-rays. Carpal tunnel views or CT scan arerequired to make the diagnosis (Fig. 12.31). Abone scan will show increased tracer uptake in thehamate.


The patient presents with deep, ill-defined painover the hypothenar eminence. Symptoms areaggravated by gripping. There is local tendernessover the hook of hamate in the palm (2 cm distaland 1 cm radial to the pisiform). There may beulnar nerve symptoms due to irritation in Guyon’scanal. Active flexion of the little finger may beuncomfortable and flexor tendon attrition rupturecan occur.


If the diagnosis is made early, the fracture may healwith rest and a trial of wrist immobilization for 4 to6 weeks. This bone has a poor blood supplyhowever and risk of non-union is high.

Surgical management and aftercare

Symptomatic non-union is treated by excision ofthe un-united fragment through a palmar incision,taking care to avoid damage to the motor branch of

the ulnar nerve. The bone surface is smoothed offto avoid irritation of the overlying tendons andulnar nerve.

Postoperatively the wrist is immobilized for twoweeks. A removable splint is then used and activewrist movements are begun.

Capitate

Capitate fractures represent 1 per cent of carpalbone fractures. These fractures may be associatedwith other carpal injuries, in particular, scaphoidwaist fractures (scaphocapitate syndrome). Thisrepresents an incomplete form of trans-scaphoidperilunate dislocation. The treatment of choice isearly internal fixation of one or both injuries.

The capitate is at risk of avascular necrosisbecause the proximal pole is entirely intra-articu-lar. As with Kienboeck’s disease, revascularizationprocedures have been used with variable success.

Postoperative treatment is the same as forscaphoid fracture following ORIF.

Carpal dislocations

Most major carpal dislocations result from a highenergy hyperextension injury, e.g. falling from aheight or a motorbike accident.

The two commonest patterns are:

1. Perilunate dislocation (Fig. 12.32).2. Trans-scaphoid perilunate dislocation.

These injuries require prompt reduction. Bothclosed and open techniques have been used. In the

Figure 12.31. This 28-year-old golfer presented withpain on the ulnar side of the palm. Plain X-rayincluding carpal tunnel views appeared normal. Thefractured hook of hamate is demonstrated by this CTscan.

Figure 12.32. This 28-year-old man sustained aperilunate dislocation due to a heavy fall while playingrugby union. The scaphoid and capitate are displaceddorsal to the lunate.


opinion of the author, closed reduction and plasterimmobilization are unreliable in maintaining ana-tomical alignment of the carpus. Open reduction istherefore preferred.

Surgery for perilunate dislocations

Perilunate dislocations are reduced through acombined dorsal and volar approach. The carpaltunnel is released, the carpus is reduced andruptured ligaments are repaired. The reduction isheld with K-wires.


Postoperatively the wrist is immobilized in neutralfor 8 weeks at which time the K-wires areremoved. Gentle active wrist motion is thencommenced and a removable splint is used for anadditional 4 weeks.

These are major carpal injuries. The final rangeof wrist motion is approximately 50 per cent ofnormal and usually takes some months to achieve.It will take most patients at least 6 months (andoften longer) to return to heavy manual work.

Surgery for trans-scaphoid perilunatedislocation

Open reduction is indicated for this injury and, atthe very least, the scaphoid fracture should beinternally fixed. Bone grafting may also berequired if the fracture is comminuted.

Aftercare is similar to that for perilunatedislocation.

Carpal instability

Increased or altered carpal motion may occur as aresult of:

1. Ligament tears.2. Bony abnormality.3. Ligamentous laxity.

If this altered motion causes symptoms, the wrist issaid to be ‘unstable’ and treatment may beindicated.

Carpal instability can occur:

1. Between the bones of the same carpal row, e.g.scapholunate dissociation, lunotriquetraldissociation.

2. Between the proximal and distal rows (mid-carpal instability).

3. Between the radius and proximal carpal row(radiocarpal instability). This is often associatedwith rheumatoid disease (ulnar translocation ofthe carpus) or developmental Madelung’sdeformity.

Most midcarpal instabilities have involvement ofboth the radiocarpal and midcarpal ligaments.

1. Scapholunate dissociation

Scapholunate ligament injuries are a commoncause of wrist pain and the diagnosis is frequentlymissed (Fig. 12.33). Untreated scapholunate dis-sociation will result in wrist osteoarthritis due toabnormal loading of articular surfaces, i.e. scapho-lunate advanced collapse deformity (the SLACwrist).

Figure 12.33. This 55-year-old man has along-standing scapholunate injury. Note the increasedscapholunate gap (‘Terry Thomas’ sign) andforeshortened appearance of the scaphoid giving a‘signet ring’ appearance as a result of scaphoidflexion. Note also the early loss of joint space in theradioscaphoid joint. Arthritis begins here beforeinvolving the midcarpal joint. The radiolunate joint isusually spared (SLAC pattern).

The wrist 165


The patient presents with wrist pain and weakness,sometimes associated with a click or a feeling of‘giving way’. There may or may not be a history oftrauma (usually a hyperextension injury). Instabil-ity may be associated with a dorsal wrist ganglion.Generalized ligamentous laxity is sometimes apredisposing factor. Patients with hypermobilejoints are usually able to demonstrate thefollowing:

1. Passive extension of the little finger MCP jointbeyond 90 degrees.

2. Passive opposition of the thumb to the flexoraspect of the forearm.

3. Elbow hyperextension beyond 10 degrees.4. Knee hyperextension beyond 10 degrees.5. Forward flexion of the trunk with straight knees

so that the palms of the hand rest easily on thefloor.

Clinical assessment

There is periscaphoid tenderness, particularly dor-sally over the scapholunate joint. Wrist motionmay be normal although there is pain on fullextension. Grip strength is often reduced comparedwith the opposite side. Generalized ligamentouslaxity should be looked for.

The Watson scaphoid shift test(Fig. 12.34)

The Watson scaphoid shift test may be positive.This test can be difficult to perform and may bepositive in normal wrists. Place the examiningthumb on the tubercle of the scaphoid and theindex finger adjacent to the proximal pole dorsally.As the wrist moves from ulnar to radial deviation,the examiner feels the scaphoid flex. Dorsalpressure is applied with the thumb on the scaphoidtubercle. If the S-L ligament is lax or torn, thescaphoid may sublux dorsally. This can be felt andmay be associated with a painful click. Alwayscompare with the opposite side.

Radiological examination

A thorough history and clinical examination willusually suggest the diagnosis which is best con-firmed by arthroscopy. Plain X-rays are frequentlynormal, even if appropriate views are taken. Theseare: PA in radial and ulnar deviation, PA and lateral

views in neutral. A clenched fist view may behelpful. The opposite wrist should be X-rayed forcomparison.

X-ray signs that are consistent with scapho-lunate ligament instability include:

1. Increased scapholunate gap (‘Terry Thomas’sign).

2. Increased scapholunate angle on lateral view(greater than 60 degrees); compare with theopposite side (Fig. 12.35).

3. DISI pattern (dorsal intercalated segment disa-bility), i.e. the lunate is extended and thescaphoid is flexed (Fig. 12.36).

4. Foreshortened appearance of the scaphoid inthe PA view due to increased scaphoid flexion;the scaphoid may resemble a signet ring.

The radiological features of scapholunate insta-bility are frequently discussed but it is important toremember that instability, by definition, is adynamic condition. Radiographs, even if ‘motion’or ‘stress’ views are taken, are merely a staticrecord of the wrist position at the time the picturewas taken. Imaging studies frequently record fixeddeformity, not instability. The instability gradingsystem suggested by Herbert (1991) acknowledgesthe importance of clinical assessment.

Figure 12.34. The Watson scaphoid shift test.(Reproduced from Garcia-Elias, M. Carpal instabilitiesand dislocations. 1999. In Green’s Operative HandSurgery (D. P. Green, R. N. Hotchkiss and W. C.Pederson, eds) p. 884, Churchill Livingstone, withpermission.)

Lunate

Scaphoid

30 – 60

(a) NORMAL

(b) DORSIFLEXIONINSTABILITY(DISI)

< 60

< 30

(c) PALMARFLEXIONINSTABILITY(VISI)


Instability grading

1. Symptomatic wrist with no demonstrable clin-ical instability.

2. Clinically subluxable scaphoid.3. Subluxed scaphoid, reducible.4. Subluxed scaphoid, irreducible.5. Secondary osteoarthritis.

Diagnostic assessment

An MRI scan can demonstrate partial or completescapholunate tears. Dynamic ultrasound can showabnormal scapholunate motion when comparedwith the opposite wrist and will demonstrate anassociated ganglion when present.

Figure 12.35. (a) When the normal wrist is viewed inneutral extension on a lateral X-ray, the normalscapholunate angle is from 30 to 60 degrees. Notehow the long axis of the distal radius, lunate, capitateand metacarpal bones are collinear. Note also how thearticular surfaces of the distal radius, lunate andcapitate fit together like multiple Cs facing in thesame direction. (b) When the lunate faces dorsally, thescapholunate angle is greater than 60 degrees (usuallyabout 100 degrees). This angle indicates a dorsalintercalated segment instability (DISI). The capitate isdisplaced dorsally in relation to the radius. (c) Whenthe lunate faces palmarly and the scapholunate angle isless than 30 degrees, this demonstrates a volarintercalated segment disability (VISI). (Reproducedfrom Frykman, G. K. and Kropp, W. E. Fractures andtraumatic conditions of the wrist. 1995. InRehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)p. 329, Mosby, with permission.)

Figure 12.36. (a) This is the lateral view of thenormal right wrist of a 22-year-old professionalfootballer. (b) Note the DISI (dorsal intercalatedsegmental instability) pattern on the injured left sidewhere the lunate is extended and the scaphoid isflexed.

(a)

(b)

The wrist 167

Bone scan is unreliable in diagnosing scapho-lunate dissociation.

Arthroscopy is the most accurate way to confirmthe diagnosis. The ligament tear and abnormalmotion are clearly visible.

Conservative treatment

Conservative treatment can be trialled with Grades1 and 2. If the symptoms are mild or the ligamenttear is partial, non-operative treatment is appro-priate. A resting wrist splint is applied and resistedactivities are avoided until symptoms settle. Gentleisometric wrist strengthening exercises are thengradually increased as comfortable. When thepatient returns to heavy activities and/or sport,protective strapping or a splint is applied.

Surgical treatment and aftercare

For complete ligament tears, surgical repair isindicated. The malrotated scaphoid and lunatebones are reduced via a dorsal approach and theligament is repaired with transosseous sutures. Thereduction and ligament repair are protected withtemporary K-wires (Fig. 12.37).

The wrist is immobilized in 10 to 15 degrees ofextension for a period of 6 to 8 weeks. The K-wiresare then removed and active wrist movements arecommenced. A removable wrist splint is appliedfor a further month. Heavy physical activities areavoided for 3 months postoperatively.

Maximum wrist motion may not be achieved forat least a year. Wrist flexion range will be restrictedto about 60 per cent of its former range.

Other surgical options include:

(i) Partial wrist fusion, e.g. scapho-trapezial-trapezoid (STT).

(ii) Ligament reconstruction using tendon or reti-nacular grafts.

As yet, no single technique has been universallysuccessful in treating this difficult clinicalproblem.

Late presentation with establishedarthritis

Untreated scapholunate dissociation leads toarthritis resulting from the abnormal loading ofarticular surfaces. Cartilage wear begins in the

Figure 12.37. (a) Acute scapholunate ligament disruption. Note the widening of the S-L interval. (b) Ligamentrepair and reduction of malrotation. The reduction and repair are protected with temporary K-wire fixation (6 to 8weeks).

(a) (b)


radioscaphoid joint and goes on to involve themidcarpus. The radiolunate joint is almost alwaysspared.

Non-operative treatment involves activity mod-ification and intermittent splinting.

Surgical options include:

(i) Radial styloidectomy.(ii) Proximal row carpectomy.(iii) Partial fusion (four-corner fusion, i.e. fusion

of the capitate, hamate, lunate and trique-trum with excision of the scaphoid).

(iv) Total fusion.

2. Lunotriquetral dissociation

As with scapholunate instability, there may be ahistory of trauma (hyperextension). This diagnosiscan often be confused with TFCC injury orulnocarpal impaction.


The patient presents with ulnar-sided wrist pain,sometimes associated with a click or clunk thataccompanies active ulnar deviation of the wrist andforearm supination. There is local tenderness overthe lunotriquetral joint. The distal ulna may beprominent.

Diagnosis

The ‘shear’ (or ballottement) testStability can be assessed by ballotting the joint.Stabilize the lunate with one thumb; grasp thetriquetrum and pisiform between the index fingerand thumb of the opposite hand. Applying shear tothe joint may cause abnormal motion, pain orcrepitus. Comparison should be made with theother wrist.

Investigations

Lateral X-rays may show a volar intercalatedsegment instability (VISI), i.e. the unrestrainedlunate assumes a flexed posture and the triquetrumis distal in relation to the hamate. Note should betaken of the ulnar variance as this instability maybe difficult to distinguish from ulnar carpalimpingement due to a long ulna.

A bone scan is locally hot. Abnormal luno-triquetral motion may be confirmed byarthroscopy.


Mild symptoms may be managed with splinting,non-steroidal medication, injections and activitymodification.

Prosser (1995) has described a programmefor ulnar carpal instability that involves thefollowing:

1. Eccentric ECU exercises.2. A soft splint which attempts to ‘relocate’ the

subluxed carpus from its supinated position.3. Grip strengthening exercises which provide

the isometric component of the programme.

The ECU exercises are carried out 3 times a daywith 10 repetitions using a 500 g weight andprogressing to 1 kg in weight. Grip strengtheningexercises are performed with the forearm in thesupinated, pronated and neutral positions.

The splint is comprised of a snugly fitting elasticwrist brace which has a strap sewn into the ulnaraspect of the midpalmar area. The section of thestrap which passes beneath the ulna is firm whilethe section over the ulnar aspect of the wrist iselasticized. As the strap is drawn around the ulnarcarpus and onto the dorsum of the hand, thesubluxed carpus is elevated (or ‘relocated’). Thiscorrection gives most patients significant relief ofpain (Fig. 12.38).

The splinting/exercise programme is maintainedfor a minimum of 6 weeks. Grip strength is re-examined. If there has been improvement, thesplint is gradually withdrawn.

Figure 12.38. Soft splint used in the early manage-ment of ulnar carpal instability.

The wrist 169

Surgery

If non-operative measures fail, the most reliablesurgical treatment is a four-corner fusion (trique-trum, hamate, capitate and lunate). Various liga-ment reconstructions have been tried with limitedsuccess.

3. Midcarpal instability

Midcarpal instability includes a diverse group ofconditions. Most midcarpal instabilities involveboth the radiocarpal and midcarpal joints, the latterof these predominating. Congenital ligamentouslaxity is frequently associated with these condi-tions. Ulna minus variance or an increased slope ofthe distal radius may also be present.

(i) The capitate-lunate instability pattern(CLIP)

This appears to result from attenuation of theradiocapitate ligament which allows dorsal sub-luxation of the capitate during movement of thewrist into ulnar deviation.

(ii) Triquetro-hamate-capitate ligamentlaxity

This will result in a VISI deformity. The ligamentssupporting these bones prevent midcarpal collapseand ensure a smooth transition of the proximalcarpal row from flexion to extension as the wristulnar deviates. Where this restraint is lacking, theproximal row stays flexed for too long, thisresulting in a catch-up clunk when the wristreaches the end range of ulnar deviation.


The patient is frequently a young female present-ing with a painful click that is associated with ulnardeviation and pronation of the wrist. There may bea supination deformity of the distal carpal rowrelative to the forearm bones. Symptoms are oftenprecipitated by minor trauma or repetitive activity.Wrist movement is sometimes restricted and gripstrength is often reduced.


Conservative management includes splinting andstrengthening of extensor carpi ulnaris (see ‘Luno-triquetral dissociation’), non-steroidal medicationand modification of work and leisure activities.

Surgery

Where conservative measures prove ineffective,the following surgical options can be considered:soft tissue reconstruction (e.g. tenodesis using aslip of ECRB), a triquetro-hamate or four-cornerfusion, or levelling of the DRUJ where there isulna minus variance.

The distal radioulnar joint

1. Fractures

Fractures of the distal radius often involve the distalradioulnar joint (DRUJ). Anatomic reduction willusually restore the integrity of the joint and, in themajority of cases, no further treatment is required.

Distal radial fractures are sometimes associatedwith fractures of the ulnar styloid. These areligamentous avulsion injuries. If the ulnar styloidfragment is large, internal fixation with tensionband wiring is carried out. If the fragment is small orthere is no fracture, the TFCC is repaired with heavynon-absorbable sutures which are passed throughbone.

Aftercare

The forearm is immobilized in neutral rotation in asugar tong splint with the wrist in slight flexion andulnar deviation for 4 to 6 weeks. Gentle activemovements are then commenced (Fig. 12.39).

2. Dislocation

Dislocation of the DRUJ is treated with a sugartong splint for 6 weeks. Volar dislocation of the

Figure 12.39. Sugar tong splint used to immobilizethe forearm following fractures involving the distalradioulnar joint. (Reproduced from Fernandez, D. L.and Palmar, A. K. Fractures of the distal radius. 1999.In Green’s Operative Hand Surgery (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) p. 949,Churchill Livingstone, with permission.)


ulna requires immobilization with the forearm inpronation. Dorsal dislocation of the ulna requiresimmobilization of the forearm in supination.

Stability of the DRUJ also depends on normalalignment of both forearm bones and integrity ofthe proximal radioulnar joint. The entire forearmshould therefore be X-rayed. Instability associatedwith radial or ulnar shaft deformity should betreated by corrective osteotomy at the site of thedeformity.

3. Triangular fibrocartilage (TFC) injury

Triangular fibrocartilage (TFC) tears may bedegenerative or traumatic. Degenerative tearsoccur with an ulna positive variance and may beassociated with other lesions such as articularsurface wear on the lunate, triquetrum and distalulna (ulnar carpal impingement syndrome).


Patients with TFC tears usually present with ulnar-sided wrist pain that is often associated with aclick. There may be history of a fall or twistinginjury. Pain is aggravated by ulnar deviation andforearm rotation.

Diagnosis

The DRUJ is assessed for instability and increasedcarpal supination; comparison is made with theother side.

PA and lateral X-ray views are taken with theforearm in neutral rotation. Note is taken of theulnar variance. An ulna positive variance may beassociated with an impaction type cystic lesion onthe ulnar side of the lunate.

Magnetic resonance imaging has an accuracy of90 per cent in diagnosing TFC tears. Arthroscopyhas the advantage of enabling treatment at thesame time.


Initial treatment involves rest, immobilization andanti-inflammatory medications. If symptoms per-sist, arthroscopy is indicated.

Arthroscopic debridement

Central TFC tears are debrided arthroscopically.The unstable portion is excised and any associated

articular cartilage wear on the lunate or ulnar headis also debrided.

Aftercare

Postoperatively the wrist is immobilized in a bulkysoft dressing for 1 to 2 weeks. Gentle active wristmovements within comfortable limits are thenbegun.

(Note: Patients who have an ulna positivevariance often require an ulnar shortening osteot-omy in addition to arthroscopic debridement.)

4. Subluxation of the extensor carpiulnaris tendon

Peripheral TFC tears may be associated withDRUJ instability and subluxation of the ECUtendon. Treatment for this involves arthroscop-ically assisted TFC repair and open reconstructionof the ECU tendon sheath if indicated.

Aftercare

The forearm is immobilized for 6 weeks in a sugartong splint which holds the elbow in flexion andboth the forearm and wrist in neutral. Gentle activeforearm rotation and wrist movements are begunupon removal of the splint.

5. Ulnar carpal impingement


The patient presents with ulnar-sided wrist painwhich is aggravated by ulnar deviation.

Diagnosis

A plain X-ray (PA view) with the forearm inneutral rotation shows a long ulna relative to theradius. There may be cystic changes or sclerosis onthe ulnar aspect of the lunate. The ulna positivevariance may be developmental or acquired (e.g.radial shortening due to a malunited fracture,excision of radial head or premature closure of theradial epiphysis). The condition is frequentlyasymptomatic. Trauma, either a single episode orrepeated minor trauma, may precipitate symptomsin a susceptible individual (Fig. 12.40).

A bone scan will show uptake on the ulnaraspect of the wrist. An associated TFC tear mayalso be demonstrated with MRI although thisinvestigation is rarely required (Fig. 12.41).

The wrist 171


Conservative treatment involves a resting wristsplint and activity modification.

Surgery

Surgical options include:

(i) Ulnar shortening osteotomy.(ii) Corrective osteotomy of radial malunion.(iii) Wafer resection of the distal ulna.

6. Osteoarthritis of the distal radioulnarjoint (DRUJ)

The patient presents with ulnar-sided wrist painwhich is aggravated by forearm rotation. TheDRUJ is tender and irritable. The diagnosis isconfirmed by plain X-ray.


Non-operative treatment involves splinting, non-steroidal anti-inflammatory medication and activ-ity modification.

Surgical treatment options include:

(i) The Darrach procedure (Fig. 12.42(a))

This procedure involves subperiosteal resection ofthe distal end of the ulna (2 cm). Care is taken toprotect the dorsal cutaneous branch of the ulnarnerve. The soft tissues, including the TFCC and

Figure 12.40. (a) This 52-year-old female had ulnar carpal impingement following radial shortening due to amalunited fracture. Note the ulna positive variance. (b) Correction was achieved by ulnar shortening osteotomywhich restored the integrity of the DRUJ.

(a) (b)

Figure 12.41. MRI showing cysts within the lunateand triquetrum of a 39-year-old female with ulnarcarpal impingement due to ulna positive variance. Thiswas also treated with ulnar shortening osteotomy.

(a) (b) (c)


other ligament attachments are repaired. Instabilityof the ulnar stump is a common problem.

Aftercare

The wrist is supported in slight extension for 3 to4 weeks. Gentle active forearm rotation and wristmovements are begun 2 weeks postoperatively.

(ii) Sauve-Kapandji procedure(Fig. 12.42(b))

The distal radioulnar joint is arthrodesed and apseudoarthrosis is created by excising a distalportion of the ulnar shaft (about 2 cm). Thisexcision includes the periosteum and interosseousmembrane. The pronator quadratus is brought intothe pseudoarthrosis gap and sutured to the ECUsheath. As with the Darrach procedure, instabilityof the ulnar stump can occur.

Aftercare

The fusion is protected with a short arm cast for 4to 6 weeks. Gentle active movement is then begun;however, a removable splint is used for a further 6weeks.

(iii) Bower’s hemiresection interpositionarthroplasty (Fig. 12.42(c))

This procedure involves hemiresection of thearticular surface of the distal ulna with an inter-position ‘anchovy’ of tendon, muscle or capsule tofill the vacant cavity. The clinical results of thistechnique are unpredictable and frequentlydisappointing.

Aftercare

The wrist is immobilized for 2 weeks. A removablesplint is then applied and gentle active movementsare commenced.

(iv) Joint replacement (Herbert ceramiculnar head prosthesis and Swansonsilicone capping)

(a) Herbert ceramic ulnar headThis is an uncemented prosthesis with a titaniumporous coated stem and a ceramic head. Thisimplant is combined with a simple soft tissuerepair and restores DRUJ function more accuratelythan other surgical options. Early clinical resultshave been promising.

Aftercare

The wrist is rested in an ulnar gutter for 2 weeks.Gentle active forearm and wrist movements arethen begun.

(b) Swanson silicone elastomer cappingThe silastic prosthesis is no longer recommendeddue to the risk of silicone synovitis.

References

Cooney, W. P., Agee, J. M., Hastings, H. II., et al. (1990).Management of intra-articular fractures of the distal radius.Contemp. Orthop., 21, 71–104.

Herbert, T. J. (1991). Carpal instability. Proceedings of theSydney Hospital Hand Symposium: Update on the WristJoint. pp. 2–6.

Figure 12.42. (a) The Darrach procedure. This involves excision of the distal ulna. The TFCC is preserved. (b)Sauve-Kapandji procedure. The distal ulnar head is stabilized against the distal radius by a screw. (c) Bower’sprocedure. The ulnar head articular surface is resected and the vacant cavity is filled with tendon, muscle or acapsular flap.

The wrist 173

Prosser, R. (1995). Conservative management of ulnar carpalinstability. Aust. J. Physiother., 41(1), 41–6.

Further reading

Bowers, W. H. (1999) The distal radioulnar joint. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. D. Pederson, eds) pp. 986–1032, Churchill Livingstone.

Byl, N. N., Kohlhase, W. and Engel, G. (1999). Functionallimitation immediately after cast immobilization and closedreduction of distal radial fractures: Preliminary report. J.Hand Ther., 12(3), 201–11.

Contesti, L. A. (1999). The radioulnar joints and forearm axis:Therapist’s commentary. J. Hand Ther., 12(2), 85–91.

Feinberg, N. R. (1999). The carpus: therapist’s commentary. J.Hand Surg., 12(2), 108–10.

Fernandez, D. L. (1995). Nonunion of the scaphoid. Revascu-larization of the proximal pole with implantation of avascular bundle and bone grafting. J. Bone Joint Surg., 6A,883–93.

Fernandez, D. L. and Jupiter, J. B. (1996). Fractures of theDistal Radius. A Practical Approach to Management.Springer.

Fernandez, D. L. and Palmer, A. K. (1999). Fractures of thedistal radius. In Green’s Operative Hand Surgery (D. P.Green, R. N. Hotchkiss and W. D. Pederson, eds) pp.929–85, Churchill Livingstone.

Flowers, K. R. and Schultz-Johnson, K. (1992). Static-progressive splints. J. Hand Ther., 5(1), 36–7.

Frykman, G. K. and Kropp, W. E. (1995). Fractures andtraumatic conditions of the wrist. In Rehabilitation of theHand: Surgery and Therapy (J. M. Hunter, E. J. Mackin andA. D. Callahan, eds) pp. 315–36, Mosby.

Garcia-Elias, M. (1999). Carpal instabilities and dislocations. InGreen’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. D. Pederson, eds) pp. 865–928, ChurchillLivingstone.

Herbert, T. J. (1990). The Fractured Scaphoid. Quality MedicalPublishing.

Jupiter, J. B. and Lipton, H. (1993). The operative treatment ofintra-articular fractures of the distal radius. Clin. Orthop.,292, 48–61.

LaStayo, P. and Howell, J. (1995). Clinical provocative testsused in evaluating wrist pain: A descriptive study. J. HandTher., 8(1), 10–7.

Linscheid, R. L., Dobyns, J. H., Beabout J. W. and Bryan, R. S.(1972). Traumatic instability of the wrist: diagnosis, classifi-cation and pathomechanics. J. Bone Joint Surg., 54A,1612–32.

Palmer, A. K. and Werner, F. W. (1981). The triangularfibrocartilage complex of the wrist: anatomy and function. J.Hand Surg., 6, 153.

Prosser, R. and Herbert, T. (1996). The management of carpalfractures and dislocations. J. Hand Ther., 9(2), 139–47.

Reiss, B. (1995). Therapist’s management of distal radialfractures. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 337–51, Mosby.

Schultz-Johnson, K. (1996). Splinting the wrist: mobilizationand protection. J. Hand Ther., 9(2), 165–77.

Skirven, T. (1996). Clinical examination of the wrist. J. HandTher., 9(2), 96–107.

Taleisnik, J. (1985). The Wrist. Churchill Livingstone.Taleisnik, J. (1988). Carpal instability. J. Bone Joint Surg., 70A,

1262–7.Taleisnik, J. (1988). Pain on the ulnar side of the wrist. Hand

Clin., 3, 51–68.Watson, H. K., Ashmead, D. IV. and Makhlouf, M. V. (1988).

Examination of the scaphoid. J. Hand Surg., 13A, 657–60.Watson, H. K. and Ballet, F. L. (1984). The SLAC wrist:

scapholunate advanced pattern of degenerative arthritis. J.Hand Surg., 9A, 358–65.

Weinstock, T. B. (1999). Management of fractures of the distalradius: therapist’s commentary. J. Hand Ther., 12(2),99–102.

Weiss, A. (1999). The carpus: surgeon’s perspective. J. HandTher., 12(2), 103–7.

13

Amputations – digital and partial hand

Amputations involving the hand or digits can occuras a result of trauma or elective surgery for thefollowing reasons:

1. Irretrievable circulation.2. Malignancy or severe infection.3. Congenital abnormality.4. Digits that are dystrophic, permanently stiff

and/or painful.

Classification

1. Single or multiple digits at various levels.2. Thumb.3. Combination of fingers and thumb, i.e. radial or

ulnar hemiamputation or ‘mitten’ hand involv-ing loss of all the rays of the hand (Figs. 13.1and 13.2).

4. The entire hand.

Function and significance of thumband digits

Thumb

The thumb is the most mobile and important digitof the hand, representing 40 per cent of handfunction. Together with the index and middlefingers, the thumb is the primary digit for explora-tion. Because the hand is an organ of touch,

Figure 13.1. The ‘radial hand’ has loss of all fourfingers with the thumb remaining.

Figure 13.2. The ‘ulnar hand’ has loss of the radialthree digits (thumb, index and middle finger).


sensation to the thumb is as important to functionas is movement.

Other requisites of normal thumb function are:

1. Opposibility.2. Stability.3. Length.

Index finger

This digit represents 20 per cent of hand functionand plays a vital role in precision pulp-to-pulphandling and lateral pinch. The musculature of theindex finger is relatively independent and thishelps contribute to its strength.

This digit provides stability and balance indelicate everyday activities such as writing anddrawing. Length is vital to the index finger. As thelevel of amputation approaches the PIP joint, pinchgrip function is automatically transferred to themiddle finger (Fig. 13.3). Because of the impact onpower grip associated with total loss of the indexfinger, every effort is made to conserve the proximalphalanx in manual workers (Murray et al., 1977).

Middle finger

The middle finger represents 20 per cent of handfunction. In flexion, this digit has greater strengththan the index finger. It is the longest of the digitsand its central position enables it to participate inprecision as well as power grip. Loss of the middlefinger constitutes a greater aesthetic loss than that

associated with the index finger, as the adjacentdigits tend to converge toward the residual gap.

Ring finger

The ring finger represents 10 per cent of handfunction. This digit, together with the little finger,participates in strong digital-palmar grip. The ringfinger is rarely used in precision grip. Loss of thisdigit results in the least functional deficit whencompared to the other digits (Fig. 13.4).

Little finger

The little finger accounts for the remaining 10 percent of hand function. The ability of this digit toabduct widely is of great functional significance ingrasping larger objects. The gripping ability of thelittle finger is enhanced by its greater range ofmotion at the MCP joint where strength isreinforced by the powerful hypothenar muscles.

Psychological aspects

Wherever circumstances allow, the patient’s emo-tional attitude toward amputation should be takeninto account. Individual reaction to amputation isby no means always proportional to the extent ofthe loss. A patient who has lost the tip of a singledigit may be as traumatized as another patientwhose loss involves multiple digits. Pre-injury

Figure 13.3. When the level of amputation approachesthe PIP joint of the index finger, pinch function willautomatically be transferred to the middle finger. Inthe case of this patient who has undergone elective rayamputation of his index finger and has a middle fingerstump, pinch grip is transferred to the adjacent ringfinger.

Figure 13.4. Loss of the ring finger allows smallobjects to fall through the hand.

Amputations – digital and partial hand 177

personality, attitudes and motivation will stronglyinfluence a patient’s coping mechanism (Grant,1980).

Self-esteem relating to body image can beseriously damaged following loss of a part.Religious and cultural factors will often play animportant role in the patient’s reaction. Potentialloss of employment as a result of the injury willhave major emotional and psychosocial con-sequences. Financial consequences for workerswith dependent families will be enormous if theindividual is unable to return to pre-injuryemployment.

Whatever the psychological manifestation, it isimportant to afford it the same attention as theinjured part. If there is any concern regarding thepatient’s ability to cope with the aftermath ofthe injury, referral to a social worker, psychologistor psychiatrist should be considered. Signs andsymptoms of impending depression may include:loss of appetite, the development of sleepingproblems, loss of interest in personal appearance,conversation that dwells on only negative aspectsof the person’s life or withdrawal from socialactivities.

Fingertip injuries

Digital tip amputations are the most common typeof amputation in the upper limb. Management of

these injuries includes: primary closure, split-thickness and full-thickness skin grafting, oradvancement flaps, e.g. V-Y, volar or local rota-tion. Cross-finger pedicle or thenar flaps may beindicated for the younger patient with no pre-existing degenerative arthritis and in whom thedevelopment of stiffness is not considered to be arisk. Choice of treatment will depend on the degreeof tissue loss, the presence of exposed bone and thepersonal preference of the treating surgeon (Fig.13.5).

Problems associated with fingertipinjuries

1. Hypersensitivity.2. Altered sensibility.3. Cold intolerance.

These problems are a result of the injury ratherthan the treatment and their incidence is significantin the adult patient with loss of pulp (Conolly andGoulston, 1973).

Therapy programme

Desensitization is not commenced until woundhealing is complete. To help reduce pulp oedemaand for the provision of comfort, dressings can beheld in place with a lightly applied layer of Cobanwrap (25 mm).

Figure 13.5. V-Y advancement flap following a crush injury to the tip of the index finger.


The patient is instructed in gentle passive/activeinterphalangeal joint exercises which should beperformed frequently throughout the day. Whensufficient healing has occurred, usually at 10 to 14days, warm water soaks are commenced to debridethe area in preparation for skin management anddesensitization. Skin is then massaged lightly withoil. Massage pressure used can be graduallyincreased commensurate with the patient’s prog-ress. Short gentle percussion exercises are per-formed on an hourly basis. Most patients requirevery little formal therapy once they are shown ahome programme of exercises. Patients are remin-ded to make every effort to incorporate the injureddigit during activity.

Persisting hypersensitivity

Where fingertip hypersensitivity is extreme orpersistent, the area can be covered with OpsiteFlexifix. This usually reduces discomfort sub-stantially whilst still allowing full sensory input.The film can be worn continuously and is reason-ably water-resistant. It is simply replaced when itbegins to lift at the edges. Opsite Flexifix can beused on its own or in conjunction with Coban wrapor a silicone-tipped fingerstall if scar managementor shaping of the pulp are required (Fig. 13.6).

Surgical considerations for electivedigital amputation

The requisites of a satisfactory stump include:

1. Adequate length.2. Sufficient soft tissue cover.3. Sensibility.

Surgical technique

1. Skin flaps of sufficient size are raised to exposethe underlying bone, flexor and extensor ten-dons, and neurovascular bundles.

2. If the amputation is through an IP joint, thearticular cartilage is not removed, but thecondyles and any rough projections of bone arenibbled away.

3. Flexor and extensor tendons are cut so that theylie away from the stump. If they are suturedover the stump, they will interfere with themovements of the other fingers.

4. Digital nerves are dissected and cleanly dividedabout 1 cm proximal to the stump, so that anyneuroma that forms is not at the scar line.

5. Skin is closed accurately and a non-adherentcompression bandage is applied.

6. The wrist and digit are splinted in elevation forat least 48 h.

Possible complications

1. Poor skin cover.2. Poor circulation.3. Neuroma formation.4. Stiff joints of the injured or adjacent digits.5. Inadequate length for function.6. Phantom pain (Jensen et al., 1985).7. Dystrophy.

Postoperative therapy of digitalamputations

The aim of treatment is to regain movement andfunction as quickly as possible. This is accom-plished by a combination of passive and activeexercise and desensitization techniques. Earlyfunction is also encouraged (Fig. 13.7).

The hand is rested in a light plaster and keptelevated for the first few postoperative days. Threedays after surgery, gentle active stabilized flexion/extension exercises are begun. Full range ofmovement is maintained at all upper limb joints.Stump dressings should be minimal so that IP jointmotion can be performed without the restriction ofa too-bulky dressing. Coban wrap (25 mm) is usedto hold the dressing in place, to treat pulp oedemaand to help shape the stump (Fig. 13.8).

Figure 13.6. Opsite Flexifix applied to thisskin-grafted middle finger tip significantly reducedhypersensitivity and allowed the patient to use thedigit.


The hand should be used for light self-careactivities as soon as possible. Early use of the handimproves mobility, assists with the desensitizationprocess and has a positive psychological effect.Sutures are usually removed between 10 and 14days at which time warm water soaks (containing amild cleansing agent) are carried out several timesa day. These will assist with wound debridementand help facilitate movement if stiffness is still aproblem. Light sponge squeezing in the water willalso promote movement and help with desensitiza-

tion. Light massage with cream or oil will softenthe scar and plays an important part in thedesensitization process (Fig. 13.9).

Opsite Flexifix is applied to the stump to reducesensitivity at this early stage (Boscheinen-Morrinand Shannon, 2000). Patients generally find theirdesensitization exercises much easier to performthrough the Opsite layer. They are also moreinclined to use the stump during activity when thefilm is in place (Fig. 13.10). Coban wrap orsilicone-lined fingerstalls can be used in conjunc-tion with the Opsite for scar management andstump shaping (Fig. 13.11).

In preparation for return to work, patients areencouraged to use the hand for normal domesticand house maintenance activities. Carrying lightshopping bags, hanging out washing, window

Figure 13.7. Following amputation, early function isencouraged.

Figure 13.8. Coban wrap (25 mm) is used to hold thedressing in place, reduce pulp oedema and shape thestump.

Figure 13.9. Oil or cream massage softens the scarline and is an important part of the desensitizationprocess.

Figure 13.10. Opsite Flexifix applied to the stumpsignificantly alleviates hypersensitivity. This makesdesensitization exercises easier and encourages earlyfunction. The area of application is highlighted.


washing, etc., will all help encourage normal useof the hand and entire upper limb. Attempting touse equipment such as vacuum cleaners or lawnmowers for short periods will help acclimatizethe hand to vibration. Gardening activities willpromote gross gripping and general fitness.Most patients are able to resume manual workwithin 4 to 6 weeks after amputation.

Reconstruction

Where replantation was not possible, reconstruc-tive procedures can be considered. The patient’ssuitability is assessed in terms of age, occupation,leisure pursuits and hobbies, hand dominance,general health and the psychological ability to copewith sometimes numerous surgical procedures andaftercare programmes.

Reconstruction is most often used for restorationof pinch grip function. This can involve rearrange-ment of hand remnants or reconstruction of thethumb itself.

Local rearrangement of hand remnants

1. Deepening of the interdigital cleft, e.g. thethumb web, by Z-plasty lengthening of the skinand sliding the thenar muscle attachments downthe shaft of the first metacarpal (Fig. 13.12).

2. Transfer of a digit, i.e. pollicization, when themetacarpal of the donor digit (e.g. index finger)is divided and transferred to the recipientstump; internal fixation is used to stabilize thetransferred digit.

Toe to thumb reconstruction

Complete or partial toe transfer has proved effec-tive in reconstructing the absent or deficientthumb. The toe has strong skeletal support, a nail,glabrous skin that can be reinnervated and mobilejoints. Problems of size discrepancy (the large toeis about 20 per cent larger than the thumb) havebeen partly addressed with the ‘wraparound’ and‘trimmed toe’ procedures.

While toe transplantation has the disadvantageof toe loss, the transplanted toe mimics thestructure and function of a thumb more closelythan any other thumb reconstruction procedure.

The five toe transplant options for thumbreconstruction include:

1. Whole great toe transfer (Fig. 13.13).2. Second toe transfer.3. The ‘wraparound’ procedure (Morrison et al.,

1980) – this procedure is suitable for thumb lossdistal to the MCP joint and involves transfer ofa soft tissue flap and nail from the great toe;bony support is supplied by an iliac bone graftrather than the phalanges of the great toe. Thistransfer does not provide motion.

4. The ‘trimmed toe’ technique – the great toe istrimmed to the dimensions of the oppositethumb. Like the ‘wraparound’ technique, thisprocedure is used primarily for thumb lossdistal to the MCP joint. Unlike the ‘wrap-around’ technique, this procedure does providemotion.

5. Partial toe transplant.

Figure 13.11. Silicone-lined mesh fingerstalls can beused over the Opsite film where hypersensitivity issevere or where scar management is still indicated.

Figure 13.12. This 18-year-old apprentice carpenterwas left with a ‘mitten’ hand following a circular sawinjury at work. The re-creation of a thumb webrestored gross grasp and enabled him to complete hisapprenticeship.


Sensation in the new thumb is anticipated inapproximately 4 to 6 months.

Distraction lengthening of themetacarpals and phalanges (callotasis)

Distraction lengthening is a means of restoringfunctional length to a hand that is skeletallydeficient through trauma or congenital absence(Seitz, 1999). This technique was first used forelongation of the long bones in the lower limbs.Although this procedure improves hand cosmesis,its primary goal is to enhance mechanical advan-tage and thereby function. This procedure requireshigh patient compliance; patient selection is there-fore crucial.

Distraction lengthening can be applied to thethumb or multiple digital rays. A midshaft osteot-omy is made through the metacarpals or phalangesand the distraction device is applied. The lengthen-ing process begins on the 5th postoperative day forchildren and the 7th postoperative day in the caseof adults. The process involves four daily incre-ments of 0.25 mm each. About 2–2.5 cm oflengthening can be obtained through remodellingof the fracture callus. Following the lengtheningperiod, the device needs to be worn for an

additional period to allow complete bony con-solidation. The extended period needs to be 2 to 3times the duration of the lengthening period andthe device is not removed until there is radiologicalevidence of consolidation of at least threecortices.

Partial hand prostheses

Where replantation or reconstruction are inap-propriate or rejected by the patient, a prostheticaid, for function and/or cosmesis, should beoffered to the patient. Immediately after surgery,the cosmetic appearance of the hand is of majorimportance to some patients, especially to women.Many will demand immediate fitting of a cosmeticdigit. By the time fitting of the device can bearranged (i.e. often weeks postinjury when the size

Figure 13.13. Transfer of the great toe to the thumbtwo weeks after surgery.

Figure 13.14. Some patients with significant hand losswear a cosmetic prosthesis when in public.

Figure 13.15. The most common types of functionalhand prostheses are those which provide an opposition‘post’ to enable gross pinch grip.


of the stump is stable), preoccupation with cosme-sis has usually subsided and most patients nolonger wish to proceed with the visit to theprosthetist.

It has been our experience that preoccupationwith the stump lessens as patients become involvedin their therapy programme and begin to use theirhand normally. They realize that the hand appearsmost normal when it is being used.

The most common types of functional handprostheses are those which provide an opposition‘post’ against which the remaining digit(s), be theyradial or ulnar, can be opposed for gross pinch gripfunction (Figs. 13.14 and 13.15).

References

Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix:an effective adjunct in the management of pain andhypersensitivity in the hand. Aust. J. Occup. Ther., (submittedSeptember 2000).

Conolly, W. B. and Goulston, E. (1973). Problems of digitalamputations: a clinical review of 260 patients and 301amputations. Aust. N. Z. J. Surg., 43, 118–23.

Grant, G. H. (1980). The hand and the psyche. J. Hand Surg., 5,417–9.

Jensen, T. S., Krebs, B., Nielsen, J. and Rasmussen, P. (1985).Immediate and long-term phantom limb pain in amputees:incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain, 21, 267–78.

Morrison, W. A., O’Brien, B. M. and MacLeod, A. M. Thumbreconstruction with a free neurovascular wrap-around flapfrom the big toe. J. Hand Surg., 5, 575–83.

Murray, J. F., Carman, W. and MacKenzie, J. K. (1977).Transmetacarpal amputation of the index finger: a clinicalassessment of hand strength and complications. J. HandSurg., 2, 471–81.

Seitz, W. H. Jr. (1999). Distraction lengthening in the hand andupper extremity. In Green’s Operative Hand Surgery (D. P.Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 619–35,Churchill Livingstone.

Further reading

Barber, L. (1984). Desensitization of the traumatized hand. InRehabilitation of the Hand (J. M. Hunter, L. H. Schneider,E. J. Mackin and A. D. Callahan, eds) pp. 493–502,Mosby.

Beasley, R. W. (1969). Reconstruction of amputated fingertips.Plast. Reconstr. Surg., 44, 349–52.

Chase, R. A. (1960). Functional levels of amputation in thehand. Surg. Clin. North Am., 40, 415–23.

Fisher, G. T. and Boswick, J. A. (1983). Neuroma formationfollowing digital amputations. J. Trauma, 23, 136–42.

Gross, S. C. and Watson H. K. (1989). Revision of painful distaltip amputations. Orthopedics, 12, 1561–4.

Grunert, B. K., Matloub, H. S., Sanger, J. R. and Yousif, N. J.(1990). Treatment of posttraumatic stress disorder afterwork-related hand trauma. J. Hand Surg., 15A, 511–5.

Grunert, B. K., Smith, C. J., Devine, C. A., et al. (1988). Earlypsychological aspects of severe hand injury. J. Hand Surg.,13B, 177–80.

Harvey, F. J. and Harvey, P. M. (1974). A critical review of theresults of primary finger and thumb amputations. Hand, 6,157–62.

Hovgaard, C., Angermann, P. and Hovgaard, D. (1994). Thesocial and economic consequences of finger amputations.Acta Orthop. Scand., 65, 347–8.

Louis, D. S., Jebson, P. J. L. and Graham, T. J. (1999).Amputations. In Green’s Operative Hand Surgery (D. P.Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 48–94,Churchill Livingstone.

Nystrom, A., Backman, C., Backman, C., et al. (1991). Digitalamputation, replantation and cold intolerance. J. Reconstr.Microsurg., 7, 175–8.

Swanson, A. B. (1964). Levels of amputation of fingers andhand: considerations for treatment. Surg. Clin.. North Am.,44, 11–5.

Wilson, R. L. (1981). Management of pain following peripheralnerve injuries. Orthop. Clin. North Am., 12, 343–59.

Wilson, R. L. and Carter-Wilson, M. S. (1983). Rehabilitationafter amputations in the hand. Orthop. Clin. North Am., 14,851–72.

14

The arthritic hand

Arthritic conditions which affect the handinclude: osteoarthritis, rheumatoid arthritis, gout,psoriatic arthritis, systemic lupus erythematosus(SLE) and scleroderma. The last three are rela-tively uncommon and sometimes present sim-ilarly to rheumatoid arthritis. This chapter willaddress the two more common types of arthritis,i.e. osteoarthritis (OA) and rheumatoid arthritis(RA).

Osteoarthritis

Osteoarthritis is the most common form of arthri-tis to affect the hand. It can be primary in originor be secondary to trauma. Primary idiopathicOA is a degenerative condition characterized bya disorder of hyaline cartilage. It mostly affectsthe DIP joints of the fingers and the CMC jointof the thumb and is commonly seen in post-menopausal women (Harvey and Conolly, 1997)(Fig. 14.1).

The characteristic osteophytes which becomeprominent as the cartilage degenerates are knownas Bouchard’s nodes at the PIP joint and Heber-den’s nodes at the DIP joint (Fig. 14.2). Thesigns and symptoms of hypertrophic OA usuallyhave a gradual onset. Occasionally OA willpresent in an acute and severe erosive formwhere the symptoms of pain, stiffness anddeformity are marked.

In haemachromatosis, a condition in whichthere is high absorption and deposition of iron,the MCP joints of the index and middle fingersare characteristically affected.

Pathogenesis

The pathogenesis of OA is complex. Osteoarthritisis not simply a failure of articular cartilage. Jointloading, lubrication and vascular/bony changes allcontribute to its development. Genetic predisposi-tion is also an important factor.

In the early stages of the disease, spurs developalong the joint margin and there is associatedsynovitis. At this stage, the cartilage can lookreasonably healthy but histologically, there is an

Figure 14.1. The CMC joint of the thumb is acommon site for osteoarthritis in postmenopausalwomen. Where arthritis is advanced, there may becontracture of the first web space with secondaryhyperextension of the MCP joint.


active, synthetic mitotic process occurring.Osteoarthritis is therefore a biologically mediatedphenomenon and not just a ‘wear-and-tear’ pro-cess.

Arthritic tissue is biologically very active. If ajoint is immobilized for 6 to 8 weeks, the thicknessof the cartilage is reduced and proteoglycans, themolecules that provide cartilage elasticity, are lostwith the bone becoming osteoporotic. The cartilageno longer synthesizes the extracellular matrixresponsible for the biomechanical functions ofcartilage which include the provision of smoothbearing surfaces and load transmission. When thejoint is then mobilized, the cartilage can return tonormal within three weeks; in other words, carti-lage actually heals.

Signs and symptoms

These are usually of gradual onset and include anyor all of the following:

1. Pain.2. Swelling.3. Stiffness.4. Instability.5. Deformity.6. Bony outgrowths (osteophytes).7. Crepitation.8. Weakness.

Radiological changes do not necessarily correlatewith the clinical picture. Marked joint erosion can

be seen in a patient with relatively few symptoms.Conversely, a patient may present with severediscomfort and minimal radiological evidence ofdegeneration.

Principles of treatment

The aims of treatment are:

1. Alleviate pain.2. Improve range of movement.3. Improve functional ability.

Treatment can involve one or more of thefollowing:

1. Drug therapy: non-steroidal anti-inflammatorydrugs, corticosteroid injection.

2. Hand therapy: heat, compression garments,splints, gentle exercise, functional assessment.

3. Surgery: arthrodesis, soft tissue arthroplasty,implant arthroplasty.

Drug therapy

Joint pain produces inhibition of muscle power.The aim of pain relief with medication is to reversethis inhibition so that muscle power can berestored.

Anti-inflammatory agents are commonly pre-scribed. These can include oral and topical pre-parations. Corticosteroid injections can give goodrelief from pain and inflammation. Relief may beshort-lived but in many cases has significantduration. Injections can be repeated.

Hand therapy

Hand therapy for patients with OA is usuallylimited to postoperative procedures such as softtissue or implant arthroplasty. Because OA is achronic condition, the patient will need to rely onself-help strategies to manage symptoms. The roleof the therapist in conservative management ismore one of teaching rather than activetreatment.

A lycra pressure glove can help alleviate painand swelling. Sometimes symptoms are restrictedto a single interphalangeal joint; in this case,Coban compression wrap (2.5 cm) or a neoprenefingerstall can be used.

Temporary immobilization of the 1st CMC joint(trapeziometacarpal joint) with a thermoplastichand-based thumb post can help relieve pain.

Figure 14.2. Characteristic osteophytes becomeapparent as the cartilage degenerates. At the PIP jointthey are known as Bouchard’s nodes. More commonly,osteophytes are seen at the DIP joints (Heberden’snodes). The presence of Heberden’s nodes is usuallythe first manifestation of osteoarthritis in the hands.

The arthritic hand 185

Where immobilization is impractical, a flexibleneoprene support can be used (Fig. 14.3).

Vigorous passive exercise to individual jointsis contraindicated, however gentle flexion band-aging combined with heat (e.g. immersion inwarm water) is an effective precursor to active

exercise. The pressure of the bandage shouldprovide a light stretch which does not producepain. The bandage is kept in position for 15 to20 minutes and the manoeuvre can be repeatedseveral times daily, particularly in colder weather(Fig. 14.4). The wearing of a thermal glove in

Figure 14.3. (a) Conservative management of painful basal thumb arthritis includes temporary immobilization ofthe joint with a thermoplastic thumb post which restricts movement of the CMC joint during activity. (b) Aneoprene thumb/wrist wrap provides pain-relieving support whilst allowing motion. This support is particularlyhelpful where basal thumb arthritis is associated with more generalized arthritis of the wrist. The heat-retainingproperties of the material make this an ideal support during the winter.

(a) (b)

Figure 14.4. (a) Gently bandaging the fingers into flexion for short periods will improve flexibility. The wristshould be extended during wrapping to help accommodate maximum finger flexion. (b) The effectiveness offlexion bandaging can be significantly augmented if gentle heat is applied. Placing the hand in warm water issimple and effective.

(a) (b)


winter is recommended for patients whose jointsstiffen readily in the cold.

Functional assessment

Osteoarthritis involving the joints of the hand cancompromise function. Pinch and power grip can besignificantly reduced. A functional assessmentcommonly reveals the following difficulties:

1. Inability to turn door and car keys.2. Peeling and cutting of vegetables.3. Opening jars and tins.4. Grasping cutlery or toothbrush.5. Playing recreational sports most of which rely

on a firm grasp.

Keys and small handles can be built up withthermoplastic materials or Handitube. Myriad aidsto daily living are now available in most depart-ment stores.

Surgical treatment

Transient episodes of pain are a feature ofosteoarthritic joints. A joint can be very painful forweeks at a time and then settle completely, givinglittle further trouble. The main indication forsurgery is pain that is persistent and does notrespond to conservative measures. Occasionally,deformity and instability can be the indication for

surgical correction. A terminal phalanx that isdeviated may be not only ugly, but may alsointerfere with hand function. As a rule however,loss of function is due to the pain which resultsfrom stress to the joint (Harvey and Conolly,1997).

Surgical options

Surgical options for the treatment of osteoarthritisinclude:

1. Arthrodesis (i.e. fusion).2. Arthroplasty (implant or soft tissue

suspension).3. Excision of mucous cysts and/or osteophytes

(DIP joint).

The choice between arthrodesis and arthroplastywill be dictated by the patient’s age, activity leveland general health. Where strength, stability and amore predictable outcome are important, jointfusion is the preferred procedure.

For patients who place low demands on theirhands and who are primarily seeking relief of painwith the preservation of some movement, arthro-plasty may be indicated.

Arthrodesis

Thumb carpometacarpal joint (1st CMCjoint)

Fusion of this joint is indicated in the youngerpatient requiring a painless stable thumb withpowerful pinch grip. Younger patients are alsounlikely to have involvement of adjacent joints(i.e. pantrapezial arthritis) which is a contra-indication for this procedure. Stiffness of the MCPjoint is also a contraindication.

The patient should understand that there will bepermanent loss of some thumb movement, i.e.retropulsion. The patient will be unable to flattenthe hand or adduct the first metacarpal, making itdifficult, for example, to grip a golf club.

The thumb is fused in a functional position usingK-wire fixation, tension band wiring or plate andscrews. The first metacarpal is positioned in 40degrees of palmar abduction and 20 degrees ofradial abduction. There should be sufficient prona-tion to enable pulp-to-pulp contact of the thumb tipwith the fingers (Weiland, 1999).

Figure 14.5. Aids to daily living are now available inmost department stores. Commonly used utensils, e.g.vegetable peelers, have enlarged handles with aslip-resistant finish to improve grip function.


Aftercare

The thumb is immobilized for 6 to 8 weeks in aforearm-based splint which also immobilizes theMCP joint. The mobility of all unsplinted jointsshould be maintained.

Proximal interphalangeal joint

The commonest indication for PIP joint fusion issingle digit post-traumatic OA in the youngerpatient. Prior to this procedure, the patient’soccupation must be carefully assessed as a fusedPIP joint can be a liability if the patient needs towork with the hand in a confined space.

Consideration needs to be given to the mostsuitable angle and the patient should understand thatthis procedure is irreversible (Buck-Gramcko,1985). Generally, the angle of fusion increasesslightly from the radial to the ulnar side of the hand.For the long and ring fingers, the angle is usually 45degrees. Functional demands dictate that this angleis slightly greater for the little finger and slightlyless for the index finger PIP joint. Followingexcision of the articular surfaces, the bony align-ment is maintained with tension band wiring.

Aftercare

The postoperative plaster can be replaced severaldays after surgery with a single finger dorsalthermoplastic splint that extends midlaterally oneach side of the digit for extra protection. This splintis maintained for 4 to 5 weeks or longer if bonyunion is incomplete. Gentle active MCP and DIPjoint movement is commenced within 24 to 48hours of surgery.

Distal interphalangeal joint

Osteoarthritis appears to have a predilection for theDIP joints. The development of Heberden’s nodes isusually the first manifestation of this disease in thehands. These nodes are the result of the exostoses atthe articular margins and are usually of cosmeticsignificance only.

For patients undergoing DIP joint mucous cystexcision, removal of osteophytes can be carried outat the same time. This gives temporary cosmeticbenefit but usually the osteophytes soon reappear.

The DIP joint is fused if there is gross instabilityassociated with loss of function, persistent pain andgross deformity. A fused DIP joint is stable, painlessand more cosmetically acceptable. The patient

should understand however, that DIP joint fusionwill affect grip function as the finger(s) cannot curltightly around small handles and objects. Where thethumb IP joint is fused, pinch grip will be affected,e.g. picking up a small object such as a pin from aflat surface. The angle of fusion usually ranges from0 to 20 degrees of flexion. Fixation is maintainedeither by Herbert screws or a K-wire and cerclagewire (Harvey and Conolly, 1997).

Aftercare

Postoperative protection for 2 to 3 weeks can beprovided by small dorsal splints using a thinthermoplastic material such as Polyform Light orsimply by applying one or two layers of Cobancompression wrap. Gentle active movement of theMCP and PIP joints is commenced 24 to 48 hoursafter surgery.

Wrist

Osteoarthritis of the wrist is usually secondary totrauma. It is frequently seen following un-unitedscaphoid fractures and scapholunate instabilitypatterns. It can also be the sequel to inflammatoryarthritis (Hastings, 1999).

Although wrist arthroplasty is an option, a lastingresult cannot be guaranteed, particularly in theyounger patient. Fusion, therefore, remains the onlyprocedure that will give a predictable result andrelief of pain. More conservative treatment, such aslimited carpal fusions which preserve some motion,are feasible if the degenerative changes are confinedto the scaphoradial region of the wrist joint (Watsonand Hempton, 1980). The indications for wristfusion are:

1. Intractable pain that does not respond toconservative measures.

2. The active younger patient who requires astrong, durable wrist.

The angle of fusion will depend on hand dominanceand the functional requirements of the patient(Weiss et al., 1995 and Field et al., 1996). Where theprocedure is performed bilaterally, considerationwill need to be given to toileting needs where slightwrist flexion is required. Mostly, the wrist is fusedin slight extension (15 to 20 degrees) for optimalfunction.

A corticocancellous bone graft is taken from theiliac crest or lower radius and fixation is achievedusing a compression plate which extends from the

FCR

Temporaryfixation ofMCP joint

FCR

Sc.

CTd.

(a) (b)


dorsum of the radius down to the third metacarpal.Cortical screws are used over the radius andmetacarpal regions and cancellous screws help fixthe carpal bones to the graft.

Aftercare

Fusion of the wrist is a major procedure which oftenresults in significant postoperative pain and swell-ing. The patient should maintain bed rest andelevation for the first 2 to 3 postoperative days. Theimmediate postoperative plaster will need to berenewed at least once to accommodate changes inoedema.

The wrist is protected with a removable splint andmovement of the fingers, thumb and other upperlimb joints is commenced within a day of surgery.The wrist should not be loaded until there isradiological evidence of bony union, usually at 10to 12 weeks.

Removal of the plate is an option but is delayedfor 12 months until there is no doubt that the grafthas consolidated and that fusion is complete.

Arthroplasty

The use of prosthetic arthroplasty spans almost halfa century. Silicone elastomer implants (Swanson,1968 and Niebauer et al., 1969) became available inthe 1960s and despite problems with ‘fracturing’and recurrence of deformity, the modified Swanson

silicone implant has been a reliable and acceptedform of arthroplasty since that time.

Newer implants are currently being trialled. The‘Neuflex’ silicone MCP joint prosthesis, intro-duced by Weiss, incorporates a flexed posture inthe joint hinge which has resulted in improvedMCP joint flexion range. Postoperative care is thesame as for other silicone implants.

Linscheid has developed a new MCP surfacereplacement arthroplasty similar to that for the PIPjoint. The proximal component is composed of achromium-cobalt alloy and the distal component ismade of ultrahigh-molecular-weight polyethylene.

Arthroplasty is the preferred option in the olderpatient with overall lower demands on the hand.The main arthroplasty procedures for both osteoar-thritis and rheumatoid arthritis are:

1. Suspension arthroplasty of 1st CMC joint(excision of trapezium).

2. Implant arthroplasty of the 1st CMC joint.3. Implant arthroplasty of PIP joint.4. Implant arthroplasty of MCP joint(s).

Suspension arthroplasty of 1st CMC joint(excision of trapezium)

Excisional arthroplasty has a long history andgives good pain relief and a mobile thumb(Froimson, 1970). Many surgeons now prefer thissoft tissue procedure as it eliminates the risk

Figure 14.6. (a) Suspension arthroplasty involves excision of the trapezium and ligamentous reconstruction usinga slip of the FCR tendon. (b) The slip of tendon is used both to reinforce the ligamentous suspension and to fillthe cavity left by the removal of the trapezium. The MCP joint is sometimes held in slight flexion with a K-wirefor a short period after surgery. Where hyperextension of the MCP joint is a problem, permanent stabilization bycapsulodesis or fusion is indicated.


associated with silicone synovitis. The procedureinvolves excision of the trapezium and liga-mentous reconstruction to prevent metacarpal dis-placement (Fig. 14.6).

A slip of the FCR tendon is used both toreinforce the ligamentous suspension and to fill thecavity left by the removal of the trapezium. TheMCP joint may need to be stabilized by capsulo-desis or arthrodesis as indicated.

A complication of this procedure is migration ofthe metacarpal. If there is proximal migration, apainful pseudoarthrosis can develop between themetacarpal and the distal end of the scaphoid.Radial displacement of the metacarpal can result inan adducted thumb.

Aftercare

Following surgery, the thumb and wrist are immobi-lized for 6 weeks with the wrist held in neutral orslight extension and the thumb in about 50 degreesof palmar abduction and 30 degrees of MCP jointflexion. Full movement of the thumb IP joint isallowed. On removal of the splint, gentle activeCMC joint movements and light unresisted activitycan be commenced. Normal use of the hand canusually be resumed 12 weeks after surgery (Fig.14.7).

Implant arthroplasty of the 1st CMC joint

The trapezium is replaced by either a siliconeelastomer implant (Swanson, 1972b) or one of the

newer implants which eliminate the problem ofsilicone particulate synovitis (Fig. 14.8). The maincomplication of implant arthroplasty is dislocation.This can be prevented by careful repair of thecapsule and capsuloligamentous reinforcementusing a strip of tendon, the most common beingflexor carpi radialis. The MCP joint should beassessed for hyperextension deformity as thisincreases the tendency toward lateral and dorsalsubluxation of the implant. A mild deformity canusually be corrected with a short period of K-wirefixation (2 to 3 weeks) following correction of thebasal joint deformity. If the deformity is quitemarked, i.e. greater than 25 degrees, it can becorrected with fusion or proximal advancement ofthe volar plate.

Aftercare

Postoperative management is the same as forsuspension arthroplasty. Complications that canoccur with this procedure include: radial neuritis orneuroma, radial artery damage, risk of infectionwith the introduction of a large foreign body ordislocation of the prosthesis.

Implant arthroplasty of the PIP joint

Adequate bone, soft tissue cover and an intactflexor/extensor mechanism are prerequisites for asuccessful outcome following this procedure.Patient selection is important. Young active patientsrequiring a strong grip and engaging in heavy

Figure 14.7. The thumb and wrist are immobilized for6 weeks. The wrist is held in neutral or slightextension and the thumb is held in about 50 degrees ofpalmar abduction and 30 degrees of MCP jointflexion. The thumb IP joint is left free and should beexercised regularly throughout the day.

Figure 14.8. The trapezium is replaced by either asilicone elastomer implant (Swanson) or one of thenewer implants which eliminate the problem ofsilicone particulate synovitis.

(a)

(b)


manual labour are not suitable candidates forimplant arthroplasty. Because of lateral stressesimposed on the index finger during pinch gripactivity, PIP joint implant arthroplasty is lesssuitable for this digit. This procedure is generallyindicated for the isolated disability of the middle,ring or little finger (Berger et al., 1999) (Fig. 14.9).

Implant arthroplasty of the PIP joint is occasion-ally indicated for the rheumatoid patient with severeswan-neck or boutonniere deformity. Reconstruc-tion of the extensor mechanism will then benecessary.

Surgical technique

The joint is approached from either the dorsal orvolar aspect depending on whether or not flexortendon surgery is indicated. To expose the joint, thecollateral ligaments and palmar plate are releasedproximally. The head of the proximal phalanx isresected and spurs are removed from the base ofthe middle phalanx. The medullary canals of bothphalanges are reamed in a rectangular shape to takethe implant. Following implant insertion, the

ligaments are reattached to the proximal phalanxwith appropriate tension to provide good lateralstability and alignment (Fig. 14.10).

Aftercare

The aftercare regimen will depend on whether ornot there has been tendon reconstruction to correcta swan-neck or boutonniere deformity. The mostimportant postoperative considerations are:

1. Protective splinting of the joint for 6 weeks toavoid lateral deviation.

2. Early commencement of gentle active andpassive flexion/extension exercises, i.e. 3 to 5days after surgery in the absence of extensortendon reconstruction (usually for RA).

Figure 14.9. X-ray showing implant arthroplasty ofthe right little finger PIP joint in a 52-year-old manwho had had post-traumatic arthritis for some yearswith gradual loss of joint flexibility. He was keen torestore flexion to the little finger so that he couldcontinue his passion for playing golf. Figure 14.10. (a) The head of the proximal phalanx is

resected and spurs are removed from the base of themiddle phalanx. The medullary canals of bothphalanges are reamed in a rectangular shape to takethe implant. (b) The implant is inserted and theligaments are reattached to the proximal phalanx withappropriate tension to provide good lateral stabilityand alignment.


Where there has been extensor tendon reconstruc-tion for swan-neck or boutonniere deformity,active movement is delayed for 10 days. Followingcorrection of a swan-neck deformity, the PIP jointis maintained in 15 degrees of flexion throughoutthe 6-week splinting period. Following correctionof a boutonniere deformity, the PIP joint ismaintained in neutral extension.

The postoperative plaster cast is replaced by adorsal thermoplastic finger splint 2 to 3 days aftersurgery. The splint should hold the PIP joint inneutral extension (other than for correction ofswan-neck deformity) and reach midlaterally onboth sides of the digit to prevent lateral movement.It should also include the DIP joint (Fig. 14.11).

Oedema control

Postoperative digital swelling is usually markedand can be addressed with a single layer of 2.5 cmCoban wrap used over the dressing. This is appliedwith great caution to avoid lateral stress to the PIPjoint. Coban should only be applied by thetherapist during the treatment session rather thanby relatives at home. It is important that the splintis fitted following Coban application otherwise thesplint will be too tight. A liberal coating of powderover the Coban will prevent the heated thermo-plastic material from adhering to the wrap duringmoulding. The dorsal finger splint will usually

need to be remade after several days as swellingsubsides.

Exercise protocol

In the absence of extensor tendon reconstruction,gentle active and passive flexion and extensionexercises are commenced 3 to 5 days followingsurgery. These can be performed within the splintby simply releasing the distal strap. The patientshould attempt 6 to 10 active and active-assistedrepetitions every 2 to 3 hours during the 1st weekof exercise. If the splint is removed for exercise, allfingers are flexed and extended together to providelateral stability. By the 2nd week, exercise sessionscan be performed 1 to 2 hourly with 10 to 15repetitions.

To maximize PIP joint motion, it is sometimesnecessary to immobilize the DIP joint in extensionusing a thin thermoplastic material to avoidbulkiness during active flexion exercises. An MCPjoint blocking splint is effective if the patient isoverusing intrinsic musculature; this will be evi-dent if efforts to move the PIP joint result inhyperflexion of the MCP joints (Fig. 14.12).

Figure 14.11. On the 2nd or 3rd postoperative day, theplaster cast is replaced with a dorsal thermoplasticfinger splint that holds the digit in extension (exceptfollowing swan-neck correction).

Figure 14.12. An MCP joint blocking splint can helpconcentrate flexion force at the PIP joint if the patientis overusing intrinsic muscles and ‘hyperflexing’ theMCP joints. It may also be necessary to block the DIPjoint in extension with a small dorsal splint tomaximize flexion at the PIP joint (not shown).


Anticipated flexion range

Flexion range of the PIP joint following arthro-plasty is in the vicinity of 70 degrees. Withconsistent effort, the patient can usually achieve thisrange within 2 weeks of surgery (Fig. 14.13). Wherestiffness is a problem, a hand-based dynamic PIPflexion splint is used intermittently throughout theday. At all other times, the dorsal splint is usedthroughout the 6-week postoperative period.

Flexion range is readily lost if the patient doesnot persevere with the exercise/splinting regimen.Some patients have a greater propensity to stiff-ness; however, all patients are advised to maintaintheir home programme for at least a year.

Light activity is begun following splint removal.For protection during activity in weeks 6 to 12, thedigit can be buddy-strapped to an adjacent finger toprovide greater lateral stability.

Implant arthroplasty of MCP joint(s)

Implant arthroplasty of the MCP joints can be usedfor a single post-traumatic joint or to replace joints

which have been destroyed by rheumatoid disease(Fig. 14.14).

Surgical technique

Through a dorsal transverse incision, a soft tissuerelease of the joints is performed. The lateralligaments and volar plate are usually releasedproximally and remain attached distally. The headof each metacarpal is resected. The metacarpal andphalangeal intramedullary canals are reamed toaccept the appropriately sized implant. To avoidextensor tendon lag, the extensor tendon is reefedlongitudinally.

Aim of postoperative management

The aim of postoperative treatment is to gain abalance between healing and the application ofcontrolled motion so that the newly formingcapsule will permit flexion/extension while simul-taneously providing lateral and rotational stability.The deposition and remodelling of collagen aroundthe implant will vary from patient to patient. Theprogramme of prolonged splinting and early move-ment will therefore need to be tailored to theindividual patient.

Immediate aftercare

The hand is maintained in its postoperative plasterfor the first 2 to 3 days in elevation. This is achievedeither with pillows or a non-constrictive sling.Careful attention is given to the alignment of thefingers to ensure that they do not rest in ulnardeviation. Small gauze squares are placed between

Figure 14.13. The 52-year-old patient (see Figure14.9) obtained 70 degrees of active PIP joint flexionrange within two weeks of surgery. He was fitted witha gentle dynamic hand-based flexion splint in the 3rdpostoperative week when some tightening over thedorsum of the joint was becoming evident. The patientwas advised to maintain passive and active flexionexercises and intermittent flexion splinting for at leasta year after surgery.

Figure 14.14. Implant arthroplasty of the MCP joint(s)can be used for a single post-traumatic joint (such asin the case of this 48-year-old man who sustained acrush injury) or to replace joints which have beendestroyed by rheumatoid disease.


the digits to help maintain a slightly radial position.Cold packs can be used to help manage oedema andto alleviate pain. Gentle shoulder and elbowexercises are carried out regularly throughout theday.

On the 2nd postoperative day, active and activeassisted MCP joint flexion and extension exercisesare commenced. The fingers are moved in a pain-free range as a single unit to maintain correctalignment. The exercises are practised 5 to 10 timesevery 2 to 3 hours. When the patient has achieved agood range of intrinsic MCP joint flexion range,global flexion can be attempted, i.e., simultaneousflexion of the MCP, PIP and DIP joints.

Dynamic extension outrigger

On the 3rd or 4th postoperative day when oedemahas subsided and some wound healing has occurred,the hand is fitted with a dorsal dynamic extensionsplint which is used during the day. The splint holdsthe wrist in 25 to 30 degrees of extension. Fingerslings are placed on the proximal phalanges andhold the MCP joints in neutral extension with gentleelastic band traction (Fig. 14.15). The slings shouldplace the digits in a slightly radial orientation to helpprevent recurrence of ulnar drift. A resting splint isused for greater comfort at night.

Exercise protocol

Active MCP flexion exercises, with 5 to 10repetitions, are performed hourly against the gentletension of the rubber bands which will then returnthe joints to neutral extension. The tension of these

bands is monitored daily for signs of fatigue andadjustments are made as necessary. Particularattention is given to the flexion range of the ring andlittle fingers. Full flexion of the index and middlefingers is less critical to grip function. The patient isencouraged to aim for 45 to 60 degrees of flexion atthe index/middle fingers and 70 degrees of flexionat the ring/little fingers. If this cannot be achievedwith relative ease, removing the slings of the ulnartwo fingers during exercises may be necessary togain a greater flexion range.

If attempts at active MCP joint flexion result in a‘hook’ grip from overuse of the extrinsic flexors, itwill be necessary to immobilize the interphalangealjoints in extension with small finger splints so thatthe flexion force can be transmitted through theMCP joints. When this difficulty has been over-come, global (or composite) flexion is attempted.

The reconstructed joint will begin to ‘tighten’during the 2nd postoperative week. Movement notgained prior to this time will be difficult to achieve.It is therefore important that the patient is seenregularly during these early weeks so that progresscan be monitored.

Sutures are removed at 2 weeks and gentle oilmassage to the scar is commenced. A layer of OpsiteFlexifix film or Hypafix will help flatten the scar aswell as prevent irritation by the splint.

Dynamic MCP joint flexion splinting

A dynamic MCP joint flexion splint can be usedintermittently throughout the day from the 3rd weekonward to help overcome joint tightness. Theextension outrigger and night splint are worn at allother times until the 6th postoperative week whenthe hand can be used for light daily activity. Somesurgeons prefer to maintain the outrigger and nightsplint for a 12-week period. Lightly resisted activityis commenced at 8 weeks and gradually upgraded.

Intermittent dynamic flexion splinting may needto be maintained for some months followingsurgery. Decisions on just how long the splinting/exercise regimen should be maintained are made ona case by case basis (Fig. 14.16).

Rheumatoid arthritis

Rheumatoid disease is the most common of theconnective tissue disorders. It is a systemic diseaseand is really an inflammatory synovitis rather thanan arthritis (Ferlic et al., 1983).

Figure 14.15. A dorsal dynamic extension outrigger isfitted 3 to 4 days postoperatively. Finger slings areworn on the proximal phalanges and hold the MCPjoints in neutral extension with gentle elastic bandtraction.


The pathogenesis of RA is thought to be animmunological response occurring in the synovialtissues. The inflammatory synovium forms apannus which grows over and infiltrates cartilage,tendons and ligaments and can result in:

1. Stretching of the joint capsule.2. Erosion of cartilage and subchondral bone.3. Disruption of ligamentous insertions.4. Impaired tendon glide.5. Nerve compression when present in closed

compartments, e.g., the carpal tunnel.

These factors combine to cause pain, stiffness anddeformity. Rheumatoid disease can also be asso-ciated with skin and pulmonary nodules, purpura,vasculitis and intrinsic muscle fibrosis.

Stages of rheumatoid disease

Rheumatoid arthritis can be divided into fourclinical phases, the timing of which will vary frompatient to patient:

1. Synovitis of joint and tendon mechanismsresulting in pain and swelling; no deformity isseen at this early stage. However, tendon glidemay be impaired and crepitant.

2. Joint subluxation and/or dislocation is seentogether with synovitis; the deformity can bepassively corrected.

3. The deformity has become fixed; no jointdestruction.

4. Joint destruction is evident.

Principles and types of management

Management of the rheumatoid patient requires amultidisciplinary approach involving several or allof the following health professionals: familyphysician, rheumatologist, surgeon, therapists,social worker and orthotist (Sones, 1971).

Because rheumatoid arthritis is not a staticcondition, evaluation and treatment are an ongoingprocess. Involvement of hand structures cannot beviewed in isolation because the disabling effects ofthis disease are manifold, usually involving numer-ous joints and other tissues or organs. Thepsychological and social implications of thischronic and disabling condition also need to beconsidered in the overall assessment.

Medical management

Drug therapy is the first line of defence used tocontrol the disease process. Drugs used in treat-ment include salicylates, steroids, gold, anti-malarials, cytotoxics (methotrexate) and immuno-suppressants. Each may be effective for aparticular patient; however, every drug can havesignificant side effects and patient response anddosage must be carefully monitored andregulated.

Figure 14.16. A dynamic MCP joint flexion splint isused intermittently after the 3rd postoperative weekwhen tightness over the dorsum of the joint(s) usuallybecomes apparent.

Therapy

Many patients now diagnosed with rheumatoiddisease are well controlled with the newer drugregimens and may have little need of therapyintervention. In those patients not responding wellto medication and where pain, stiffness anddeformity are troublesome, the goals of therapyare:

1. To provide support to painful joints with nightand intermittent day splinting.

2. To maintain and/or increase joint mobility withgentle active and active assisted movementsperformed in a pain-free range.

3. To maintain and/or improve muscle strengthwith isometric exercise.

4. To determine functional problems and recom-mend aids to daily living and modifications tothe patient’s home-work-leisure environment.

5. To teach the patient joint protection techniquesand provide information about the disease.

Apart from providing support to painful, inflamedjoints, splints are sometimes used to place the wrist,


thumb or digits in a more functional position, e.g. asoft splint to correct ulnar drift of the fingers willsometimes enhance pinch grip function. It should benoted, however, that splints do not reverse deform-ities and probably do little to prevent furtherdeterioration of an already existing deformity.

Deformities of the rheumatoidhand

Dorsal subluxation of the ulnar head

This is characterized by a prominent ulnar head.Wrist synovitis generally begins in the ulnarcarpus, stretching the ulnar carpal ligaments andthe triangular fibrocartilaginous complex (TFCC).The consequences of this are three-fold and areknown as the ‘caput ulna syndrome’:

1. The distal ulna dislocates dorsally.2. The carpus supinates in relation to the hand.3. The ECU tendon subluxes volarly.

These factors result in painful and restrictedforearm rotation, loss of wrist extension and aradially deviated wrist from the unopposed ECRLand ECRB muscles. Attrition ruptures of the ulnarextensor tendons are commonly associated withthis syndrome which is seen in about a third ofpatients with rheumatoid disease.

Collapse deformity of the wrist

This deformity is characterized by radial deviationof the metacarpals and concomitant ulnar deviation

of the MCP joints. It involves the radiocarpalligaments, the destruction of which results inscapholunate dissociation and rotational instabilityof the scaphoid (volarly) and the lunate (dorsally).The subsequent loss of carpal height results in animbalance in the extensor tendon mechanism. Thiscollapse deformity is thought to be responsible forthe recurrence of ulnar drift of the fingers follow-ing MCP joint arthroplasty (Fig. 14.17).

Ulnar translocation of the carpus

This deformity also involves the radiocarpal liga-ments which have undergone the attritional effectsof chronic synovitis. This resultant ligament insuf-ficiency can cause the carpus to slide down theradius and translocate ulnarly (Fig. 14.18).

Volar subluxation/dislocation of the MCPjoints and ulnar drift of the fingers

The finger MCP joints are particularly vulnerableto the deforming forces of rheumatoid diseasebecause they allow motion in two planes and aretherefore less stable (Fig. 14.19).

The aetiology of MCP joint deformity involveswrist pathology, tendon forces, imbalance of

Figure 14.17. Collapse deformity of the wrist ischaracterized by radial deviation of the metacarpalsand concomitant ulnar deviation at the MCP joints.Note the erosion at the MCP joints.

Figure 14.18. Ulnar translocation of the carpusinvolves the radiocarpal ligaments which haveundergone the attritional effects of chronic synovitis.The carpus translocates ulnarly due to ligamentinsufficiency. (Reproduced from Garcia-Elias, M.Carpal instabilities and dislocations. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkissand W. C. Pederson, eds) p. 873, ChurchillLivingstone, with permission.)


intrinsic musculature and the effects of gravity andpinch grip force. The extensor mechanism isstretched as a result of chronic synovitis causingthe tendons to slip ulnarly. Flexor tendon forcescan further stretch already compromised volarcapsular and ligamentous structures.

Boutonniere (button-hole) deformity

This deformity is characterized by flexion of thePIP joint and hyperextension of the DIP and MCPjoints. Due to proliferative synovitis, the centralextensor tendon is weakened, lengthened and mayrupture. The extension force of the tendon istherefore diminished. The lateral bands fall belowthe axis of the joint, flexing rather than extendingit. There is secondary shortening of the obliqueretinacular ligament which results in DIP jointhyperextension and limited active flexion of thisjoint. Hyperextension of the MCP joints resultsfrom compensatory efforts to extend the PIP joint.In the early stages, this deformity is passively

correctable. As the joint capsule gradually con-tracts, the deformity becomes fixed.

Swan-neck deformity

This deformity is characterized by PIP jointhyperextension and DIP joint flexion. The deform-ity can originate at either the PIP or DIP joint (Fig.14.20). Where there is flexor tendon synovitis,difficulty in initiating finger flexion with theextrinsic flexors may result in excessive flexioneffort being transmitted through the MCP joints viathe intrinsic musculature. With the MCP joints inthis flexed position, the intrinsic muscles are ableto exert a greater force through the central extensortendon and if the PIP joint volar capsule andpalmar plate are stretched as a result of the diseaseprocess, hyperextension at this joint readily ensues.As the deformity develops, the lateral bands slipdorsally, further accentuating hyperextension ofthe PIP joint with reciprocal flexion at the DIPjoint.

Where there is elongation or rupture of the distalextensor tendon, the swan-neck deformity can besecondary to a mallet-type deformity.

Thumb

Like the fingers, the thumb can develop a bou-tonniere or swan-neck deformity. In the case of theformer, the primary problem lies with synovitis ofthe MCP joint. In the case of the latter, the primary

Figure 14.19. Ulnar drift of the fingers is a commondeformity in rheumatoid disease.

Figure 14.20. Swan-neck deformity is characterizedby PIP joint hyperextension and DIP joint flexion.With the MCP joints locked into a flexed position, theintrinsic muscles exert a greater force through thecentral extensor tendon. Because the PIP joint capsuleand volar plate are already stretched from the diseaseprocess, hyperextension of the PIP joints readilyensues.


problem occurs at the CMC joint. Both deformitiesare exacerbated by forces generated during pinchgrip activity.

The tendons of the thumb, i.e. FPL, EPL, EPBand APL, can be affected by attrition rupture ordisplacement. Attrition rupture most commonlyinvolves the EPL tendon. The intrinsic musculatureof the thumb can become contracted.

Surgical management

The presence of deformity is not necessarily anindication for surgical intervention. The rheuma-toid hand can have surprisingly good function inthe presence of marked deformity. It must be bornein mind that surgery can worsen function. Thepatient must also understand that surgery cannotrestore the hand to its pre-diseased state and thatweakness remains a feature of the condition. Also,surgery should be considered in the context of thepatient’s medical, psychosocial and economicsituation. Consultation with relevant family mem-bers and other health professionals involved in thepatient’s care is important in determining the bestpossible outcome.

Aims of surgery

1. Alleviate pain.2. Slow the progress of the disease.3. Enhance function.4. Improve cosmesis.

The type of procedure performed will be influ-enced by the stage of the patient’s disease, theeffectiveness of drug treatment in managing prog-ress of the disease, the age of the patient, generalhealth and functional requirements.

If the patient is seen in the early stages of thedisease, surgical procedures that may have apreventative role are carried out first. These willinclude tenosynovectomy and joint synovectomy.Wrist procedures that relieve pain and/or correctdeformity (i.e. resection of distal ulnar head,partial or total wrist fusion) usually precedesurgery of the MCP and PIP joints. Finally, thethumb is aligned in a position of function relativeto the reconstructed fingers.

Reconstructive procedures that have a morecertain outcome, e.g. partial or total wrist fusion,should be performed before more complex proce-dures such as joint replacement and soft tissuereconstruction. Where other upper limb joints are

involved, i.e. the shoulder and elbow, these mayneed to be addressed prior to surgery of the hand.Reconstruction of the hand will be of little use ifthe patient cannot place the limb for effectivefunction.

Wound healing following any surgical proceduremay be impaired due to the side effects ofprescribed drugs, e.g. corticosteroids, or to vasculi-tis and poor tissue nutrition.

Types of surgical procedures

1. Tenosynovectomy/joint synovectomy.2. Tendon repair or transfer.3. Resection of the distal end of the ulna (Darrach

procedure).4. Joint replacement (arthroplasty).5. Soft tissue reconstruction/intrinsic release.6. Joint fusion (arthrodesis).

1. Tenosynovectomy/joint synovectomy

Because rheumatoid arthritis is a disease of thesynovium, the sheaths surrounding many of thewrist and hand tendons can be involved. Dorsally,the extensor tendons are surrounded by synovialsheaths only at the wrist. Volarly, tendons glide insynovial-lined sheaths at the wrist, in the palm andin the fingers. Tendon involvement may precedejoint involvement by months.

Tenosynovitis can cause the following: (a) pain,(b) restriction of tendon glide and (c) attritionrupture which occurs when the synovial tissueeventually infiltrates the tendon substance.

Restricted tendon glide will result in jointstiffness and secondary deformity (Fig. 14.21).Because dorsal skin is thinner, swelling in this areais more apparent than when present in the palm.Compression of the median nerve is a potentialcomplication. Trigger finger is common due tosynovial hypertrophy within the flexor tendonsheaths.

Tenosynovectomy is indicated if drug therapyhas not succeeded in controlling proliferativesynovitis after 3 to 6 months of treatment. At thetime of prophylactic tenosynovectomy, 50 to 70per cent of patients with tenosynovitis are found tohave infiltration of the tendon (Millender et al.,1974).

Hypertrophic synovium is dissected away fromthe tendons with small scissors or a rongeur.Frayed extensor tendons are repaired where fea-sible or sutured to an adjacent extensor tendon.


Volarly, flexor synovectomy is carried outtogether with carpal tunnel decompression (Vainio,1957) and the removal of bony spicules, e.g. overthe scaphoid to prevent FPL rupture. Flexor tendonnodules are excised. Following surgery, it is hopedthat active finger flexion will equal passive flexionrange. The wrist joint is assessed and synovectomyis performed if there is evidence of jointinvolvement.

Aftercare

The wrist is supported for 2 weeks. Gentle activefinger movement is commenced the day aftersurgery. Following dorsal tenosynovectomy, theMCP joints should be maintained in extensionbetween exercise sessions to prevent extensor lag.These joints are splinted in the extended positionuntil the patient can demonstrate active MCP jointextension. Finger extension exercises should beperformed extrinsically. This is achieved by hold-ing the interphalangeal joints in flexion wherepossible (using Micropore or Coban wrap) duringactive extension of the MCP joints.

Following flexor tendon synovectomy, emphasisis placed on individual stabilized IP joint flexionand extension exercises.

2. Tendon repair or transfer

Extensor tendon attrition rupture occurs mostfrequently at the distal end of the ulna and atLister’s tubercle (EPL). Single tendon rupture ismost common in the little finger. Ruptured exten-sor tendons do not always result in loss of functionand can at times be difficult to distinguish frompre-existing joint deformity (Feldon et al., 1999)(Fig. 14.23).

Following attrition rupture, end-to-end repair israrely possible. Mostly the tendon stump is suturedto the adjacent extensor tendon (Fig. 14.24). At thetime of repair, dorsal tenosynovectomy and ulnarhead excision may be carried out.

In the case of multiple extensor tendon rupturesthere is usually an available extensor motoravailable for tendon transfer. If not, FDS to the ringfinger can be utilized. In the case of EPL rupture,thumb extension can be restored with an extensorindicis transfer (Smith, 1987). Tendon transfer iscontraindicated in the presence of MCP jointdeformity unless this is first corrected with implantarthroplasty.

The most common flexor tendon to rupture isflexor pollicis longus. This rupture results fromattrition caused by a scaphoid osteophyte and is

Figure 14.21. Proliferative flexor tendon synovitis canresult in pain on active flexion and restrict tendonglide as in the right hand of this patient. Tendoninvolvement may precede joint involvement by manymonths.

Figure 14.22. Incision sites for flexor teno-synovectomy.

EDC EIP


referred to as Mannerfelt’s lesion (Mannerfelt andNorman, 1969). Because of tendon fraying andretraction, the tendon can rarely be repaired.Fusion of the thumb IP joint in a functionalposition may be indicated.

3. Resection of the distal end of the ulna(Darrach procedure)

Excision of the distal ulna can be carried out on itsown if symptoms are confined to the distalradioulnar joint or be combined with radiocarpalsynovectomy in the case of early erosive changes.

Following resection (2 cm or less), the dorsaledge of the distal ulna is bevelled and covered witha soft tissue layer to prevent tendon attrition. Softtissue reconstruction is carried out if the triangularfibrocartilage has been destroyed. This is importantin stabilizing the distal ulna and to correct carpalsupination. The distal ulna can be stabilized usinga flap of volar capsule or a strip of ECU tendon.Where the ECU tendon has displaced volarly, it isrepositioned dorsal to the axis of wrist flexion andretained by a ‘sling’ made from the extensorretinaculum.

Aftercare

Postoperatively, the wrist and fingers are splintedin extension with the forearm in supination in asugar tong splint. Gentle active finger movementsare begun the day after surgery with the fingerssplinted in extension between exercise sessions

until active finger extension can be demonstratedby the patient.

Where satisfactory soft tissue reconstruction wasable to be achieved, a short arm splint is used afterthe first few days, otherwise the forearm ismaintained in supination in the sugar tong splint for3 weeks. Those patients using a short arm splint cancommence gentle active forearm rotation as soon aspostoperative pain and swelling have subsided.

For several months following surgery, the ulnacan have a tendency to sublux. Forearm rotation cantherefore be painful and accompanied by a ‘click’.This problem usually settles.

4. Joint replacement (arthroplasty)

Wrist arthroplasty has shown inconsistent resultsand the indications for its use are limited. Arthro-plasty of the MCP joints, however, has shown itselfto be an effective procedure that has withstood thetest of time.

Where MCP joint deformity is associated withmarked wrist involvement, the wrist will need to be

Figure 14.23. Attrition rupture of the extensor tendonsoccurs most frequently at the distal end of the ulnaand at Lister’s tubercle (EPL). Extensor tendon rupturecan be difficult to distinguish from pre-existing jointdeformity. Single tendon rupture is most common inthe little finger.

Figure 14.24. Following attrition rupture of the EDCtendons to the ulnar three fingers, the following salvageprocedure can be performed in the absence of MCP jointdeformity. The stump of the extensor digitorumcommunis of the middle (long) finger is suturedside-to-side to the index finger EDC. The tendon ofextensor indicis proprius (EIP) is transferred to extensordigitorum communis of the ring and little fingers.


addressed first. If tenosynovectomy is required, thisshould precede joint replacement by severalmonths.

Where finger deformity involves all three joints,MCP joint arthroplasty is carried out at the sametime as correction for swan-neck deformity. In thecase of boutonniere deformity, the PIP joint iscorrected first. Arthroplasty of the PIP joint isperformed less frequently than MCP arthroplasty inthe rheumatoid hand and the two procedures are notcarried out in the same digit. (See section on‘Osteoarthritis’ for aftercare following implantarthoplasty.)

5. Soft tissue reconstruction/intrinsicrelease

Procedures for soft tissue reconstruction andrelease will vary according to the type of deformityand whether or not the deformity is flexible orfixed. These procedures are frequently carried outin conjunction with either implant arthroplastyand/or joint fusion. They include: reconstruction ofthe extensor mechanism, lateral band mobilization,extensor tenotomy, flexor tendon tenodesis, recon-

struction of the oblique retinacular ligament andeither skin release or dermadesis.

6. Joint fusion (arthrodesis)

Joint fusion is used to stabilize a dislocated orpainful joint as an alternative to implantarthroplasty.

Partial or limited wrist fusion is indicated forpatients with collapse deformity. This procedureinvolves fusion of the scaphoid and lunate bones tothe radius. The fusion may be supplemented withan autogenous bone graft and requires approx-imately 10 weeks of immobilization in a short armcast. It is anticipated that patients will retain 25 to50 per cent of motion following this procedure.

Radiocarpal fusion is indicated for patients withestablished ulnar carpal translocation. Midcarpalfusion is often unnecessary as this joint is usuallyspared in the disease process due to the paucity ofligaments. Synovium is concentrated in areaswhere ligaments are plentiful.

Fusion of individual joints in the fingers andthumb is often performed in association with eitherimplant arthroplasty and/or soft tissue reconstruc-tion. Because of poor bone stock, prolongedimmobilization may be necessary using bothinternal and external splints. Mobility of all jointsproximal and distal to the fusion should bemaintained.

References

Berger, R. A., Beckenbaugh, R. D. and Linscheid, R. L. (1999).Arthroplasty in the hand and wrist. In Green’s OperativeHand Surgery (D. P. Green, R. N. Hotchkiss and W. C.Pederson, eds) pp. 147–91, Churchill Livingstone.

Buck-Gramcko, D. (1985). Compression arthrodesis of joints inthe hand. In The Hand (R. Tubiana, ed.) pp. 703–6, W. B.Saunders.

Feldon, P., Terrono, A. L., Nalebuff, E. A. and Millender, L. H.(1999). Rheumatoid arthritis and other connective tissuediseases. In Green’s Operative Hand Surgery (D. P. Green,R. N. Hotchkiss and W. C. Pederson, eds) pp. 1651–739,Churchill Livingstone.

Ferlic, D. C., Smyth, C. J. and Clayton, M. L. (1983). Medicalconsiderations and management of rheumatoid arthritis. J.Hand Surg., 8, 662–6.

Field, J., Herbert, T. J. and Prosser, R. (1996). Total wrist fusion:A functional assessment. J. Hand Surg., 21B, 429–33.

Froimson, A. I. (1970). Tendon arthroplasty of the tra-peziometacarpal joint. Clin. Orthop., 70, 191–9.

Harvey, F. J. and Conolly, W. B. (1997). Osteoarthritis. In Atlasof Hand Surgery (W. B. Conolly, ed.) pp. 335–57, ChurchillLivingstone.

Figure 14.25. Where there has been extensive jointdisruption, arthrodesis can relieve pain and providestability as in the case of this wrist. To improveforearm rotation, replacement of the ulnar head wasalso carried out.


Hastings II, H. (1999). Wrist (radiocarpal) arthrodesis. InGreen’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) pp. 131–46, ChurchillLivingstone.

Mannerfelt, L. G. and Norman, O. (1969). Attrition ruptures offlexor tendons in rheumatoid arthritis caused by bony spursin the carpal tunnel. A clinical and radiological study. J. BoneJoint Surg., 51B, 270–7.

Millender, L. H., Nalebuff, E. A., Albin, R., et al. (1974). Dorsaltenosynovectomy and tendon transfer in the rheumatoidhand. J. Bone Joint Surg., 56A, 601–10.

Smith, R. J. (1987). Tendon transfers for rheumatoid arthritis. InTendon Transfers of the Hand and Forearm (R. J. Smith, ed.)pp. 215–43, Little, Brown.

Sones, D. A. (1971). The medical management of rheumatoidarthritis and the relationship between the rheumatologist andthe orthopaedic surgeon. Othop. Clin. North Am., 2,613–21.

Swanson, A. B. (1968). Silicone rubber implants for replace-ment of arthritic or destroyed jointsin the hand. Surg. Clin.North Am., 48, 1113–27.

Swanson. A. B. (1972b). Disabling arthritis at the base of thethumb. Treatment by resection of the trapezium and flexible(silicone) implant arthroplasty. J. Bone Joint Surg., 54A,456–71.

Vainio, K. (1957). Carpal tunnel syndrome caused by tenosyno-vitis. Acta Orthop. Scand., 4, 22–7.

Watson, H. K. and Hempton, R. E. (1980). Limited wristarthrodesis. Part 1: The triscaphoid joint. J. Hand Surg., 5,320–7.

Weiland, A. J. (1999). Small joint arthrodesis. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 95–107, Churchill Livingstone.

Weiss, A. P. C., Wiedeman, G., Quenzer, D., Hanington, K. R.,Hastings, H. and Strickland, J. W. (1995). Upper extremityfunction after wrist arthrodesis. J. Hand Surg., 20A,813–7.

Further reading

Bass, R. L., Stern, P. J. and Nairus, J. G. (1996). High implantfracture incidence with Sutter silicone metacarpophalangealjoint arthroplasty. J. Hand Surg., 21A, 813–8.

Brattstrom, M. (1987). Joint Protection and Rehabilitation inChronic Rheumatic Disorders. Aspen Publishers.

Brumfield, R. Jr., Kuschner, S. H. and Gellman, H. (1990).Results of dorsal wrist synovectomies in the rheumatoidhand. J. Hand Surg., 15, 733.

Clawson, M. C. and Stern, P. J. (1991). The distal radio-ulnarjoint complex in rheumatoid arthritis: an overview. HandClin. 7, 373.

Conolly, W. B. (1997). The rheumatoid hand. In Atlas of HandSurgery (W. B. Conolly, ed.) pp. 359–84, ChurchillLivingstone.

Linscheid, R. L. and Beckenbaugh, R. D. (1991). Arthroplastyof the metacarpophalangeal joint. In Joint ReplacementArthroplasty (B. F. Morrey, ed.) pp. 159–72, ChurchillLivingstone.

Linscheid, R. L., Murray, P. M., Vidal, M. A. and Beckenbaugh,R. D. (1997). Development of a surface replacementarthroplasty for proximal interphalangeal joints. J. HandSurg., 22A, 286–98.

Madden, J. W., Arem, A. and DeGore, G. (1977). A rationalpostoperative management program for metacarpophalangealimplant arthroplasty. J. Hand Surg., 2(5), 358.

Melone, C. P. Jr. and Taras, J. S. (1991). Distal ulna resection,extensor carpi ulnaris tenodesis, and dorsal synovectomy forthe rheumatoid wrist. Hand Clin. 7, 335–43.

Nalebuff, E. A. (1969). Hand surgery and the rheumatoidpatient. Surg. Clin. North Am., 49, 787–97.

Niebauer, J. J., Shaw, J. L. and Doren, W. W. (1969). Silicone-dacron hinge prosthesis. Design, evaluation and application.Ann. Rheum. Dis., 28 (Suppl.), 56–8.

Ruther, W., Verhestraeten, B., Fink, B. and Tillmann, K. (1995).Resection arthroplasty of the metacarpophalangeal joints. J.Hand Surg., 20B, 707.

Sigfusson, R. and Lundborg, G. (1991). Abductor pollicislongus tendon arthroplasty for treatment of arthrosis in thefirst carpometacarpal joint. Scand. J. Plast. Reconstr. Surg.Hand, 25, 73–7.

Sorial, R., Tonkin, M. A. and Gschwind, C. (1994). Wristarthrodesis using a sliding radial graft and plate fixation. J.Hand Surg., 19B, 217.

Swanson, A. B. (1972a). Flexible implant arthroplasty forarthritic finger joints: rationale, technique and results oftreatment. J. Bone Joint Surg., 54A, 435–55.

Swanson, A. B. (1979). Flexible implant arthroplasty of theproximal interphalangeal joint. Ann. Plast. Surg., 3,346–54.

Swanson, A. B. (1995). Pathomechanics of deformities in handand wrist. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 1315–27, Mosby.

Swanson, A. B., Swanson, G. de G. and Leonard, J. B. (1995).Postoperative rehabilitation programs in flexible arthroplastyof the digits. In Rehabilitation of the Hand: Surgery andTherapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds)pp. 1351–75, Mosby.

Tonkin, M. A., Hughes, J. and Smith, K. L. (1992). Lateral bandtranslocation for swan neck deformity. J. Hand Surg., 17A,260.

Terrono, A. L., Millender, L. H. and Nalebuff, E. A. (1990).Boutonniere rheumatoid thumb deformity. J. Hand Surg., 15,999.

Terrono, A. L., Nalebuff, E. A. and Philips, C. A. (1995). Therheumatoid thumb. In Rehabilitation of the Hand: Surgeryand Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan,eds) pp. 1329–43, Mosby.

Watson, H. K. and Weinzweig, J. (1999). Intercarpal arthrode-sis. In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) pp. 108–30, ChurchillLivingstone.

15

The complex hand injury

Introduction

Complex injuries of the hand are those that involvevarying degrees of tissue loss; this can includeskin, tendons, nerves, vessels or bone. Digital lossfrequently occurs with these injuries which canresult from a crush, burn, an explosion, high-pressure injection, gunshot wound or from severeinfection. The injury can involve either the dorsumof the hand, the palmar aspect of the hand, or bothhand surfaces (Fig. 15.1).

These are open injuries with risk of infectionand interruption of the healing process. Complexinjuries with the best prognoses are those involvingthe dorsum of the hand only. The worst prognosisis associated with volar hand injuries where thereis loss of skin, flexor tendons and digital nerves.

Surgical and therapeutic management of thesepatients can last for many months and may involvenumerous reconstructive procedures. Treatmentdecisions will need to be based on the individualcircumstances of the patient. Factors that willinfluence these decisions will include: the patient’sage, occupational needs, ability to co-operate withprotracted aftercare, leisure pursuits and financialsituation.

Psychological considerations

The patient’s reaction to the injury will warrant asmuch attention by treating staff as the actual injury(Brown, 1999). These patients require muchencouragement and reassurance. Where indicated,formal counselling should be provided. The phys-

ical, emotional, psychosocial and financial con-sequences of many complex hand injuries can bedevastating. Occupational retraining is frequentlynecessary. The patient will need to make enormousadjustments, sometimes over several years, in allof these areas.

Patient education

Education of the patient is a very importantcomponent of the aftercare programme. Therapymeasures, i.e. exercise, splinting, scar managementand functional activity, do not take place in thetherapy environment alone. They need to bemaintained consistently on a daily basis. Thepatient and relevant family members will need tounderstand the rationale, sequence and frequencyof use of the various therapy measures. The patientshould demonstrate the exercise and splintingregimen to the therapist to ensure that there is fullunderstanding of their application. Regular reviewis important so that modifications to the pro-gramme can be made commensurate withprogress.

Treatment

The primary medical and surgical management ofthese injuries will often determine the ultimateoutcome of hand function. These injuries warrantspecialist care and patients should be transferred toa specialist unit after their condition has beenstabilized.


1. Restoration of blood flow

The first consideration in management of thecomplex injury is restoration of blood supply. Thesigns of arterial insufficiency include pallor,decreased temperature, increased pain and loss ofpulse. Major arteries should be repaired; however,venous repair is seldom required. Major handinjuries are often accompanied by extreme oedemaand the hand is monitored for signs of compart-ment syndrome which will warrant decompressionof the forearm, carpal tunnel or hand spaces.

2. Prevention of infection

Prevention of infection is of paramount importanceand includes the following measures:

(i) Antibiotics and tetanus immunization

Wounds are cultured at the time of debridement.Those patients whose wounds are deemed to be atrisk of infection, e.g. bites, deep penetrating

wounds or contaminated wounds following a crushor mangling injury, are started on intravenousantibiotics.

(ii) Wound debridement

The purpose of debridement is to decrease the riskof infection and to prepare the damaged tissues forhealing (Haury et al., 1978). Debridement involvescleansing of the wound and the removal of foreignbodies and devitalized tissue. Potentially tightcompartments, e.g. the carpal tunnel, are left openafter debridement and closed when swelling hassubsided. Cleansing is carried out using low-forcepulsating jet lavage (Brown, 1995). A seconddebridement several days later will allow time fordemarcation of non-viable tissue.

(iii) Wound care

Following debridement the wound is covered withparaffin gauze and multiple gauze swabs to form a

Figure 15.1. (a) This 28-year-old electrician sustaineda crush/degloving injury to the dorsum of his leftdominant hand while at work. (b) Followingdebridement and K-wire fixation of the fractures to theindex and middle finger metacarpals, the defect wascovered with a groin flap. Thinning of the flap andextensor tendon reconstruction were performed at alater date. (c) Some months later the patient underwentfurther elective surgery that involved transmetacarpalamputation of the middle finger and fusion of theindex finger MCP joint to provide a stable andpain-free pinch grip. Full interphalangeal joint flexionprovided a ‘hook’ grip in the absence of MCP jointflexion. This patient was unable to return to hispreinjury occupation and retrained in computer studies.

(a) (b)

(c)

The complex hand injury 205

bulky dressing which extends from the elbow tothe tips of the fingers. Gauze is also placedbetween the finger webs. The hand is held in the‘position of function’ with a plaster, i.e. wristslightly extended, the MCP and IP joints slightlyflexed and the thumb in palmar abduction. If therehas been extensive damage to the dorsum of thePIP joints, the hand should be kept in the ‘positionof safe immobilization’, i.e. MCP joints in max-imum flexion and IP joints in maximum extension.The forearm is then supported on a pillow or foamwedge with the hand held slightly higher than theheart.

Where a skin graft or flap is not indicated,wounds are left unsutured and allowed to heal bysecondary intention. Careful wound managementis integral to preventing infection and controllingscar formation. An adherent dressing should neverbe forcibly removed as this will result in furthertrauma. Wound trauma, pain and the associateddistress can impact on the wound microenviron-ment and potentially impair healing (Hunt andHussain, 1992). In the case of grafts or flaps,pressure and shearing forces are avoided for thefirst 2 postoperative weeks.

3. Restoration of skeletal stability

Tendons have a great propensity to becomeadherent if they are not taken through their glidingamplitude. For this to be possible, the skeleton

must be stabilized as quickly as possible so thatmovement can be initiated.

Reduction of fractures and dislocations shouldideally occur within hours or days of injury beforeoedema and fibrosis make reduction increasinglydifficult. While reconstruction of skin, tendons andnerves can be deferred, reconstitution of theskeleton is a priority (Swanson et al., 1991). Ifthere has been direct traumatic bone loss or severecomminution, primary corticocancellous bonegrafting will be necessary.

Fixation with K-wires is versatile and hasrelatively few complications. Rigid internal fixa-tion with plates, screws and cerclage wires isgaining greater acceptance as the ‘hardware’ andtechniques have become increasingly refined.Their use, however, does necessitate the avail-ability of proper instruments and training in theirapplication.

4. Wound closure

The timing of wound closure will depend on thecondition of the wound, soft tissue availability andreconstructive considerations. Where there is anydoubt about the success of wound closure, itshould be delayed (Burkhalter, 1985). Wounds thatare properly cared for can be safely left open formany days and will usually fare better whenmanaged in this way. The risk of infection isgreatly decreased when reconstruction is deferredin the case of the contaminated wound.

Where there is exposure of other structures, i.e.tendons and nerves, these must be kept moist withappropriate dressings. An open wound does notpreclude mobilization of the fingers where this isnot contraindicated, e.g. as in the case of skeletalinstability. Planned skin coverage, such as apedicled flap or soft-tissue transfer, can be under-taken when the wound is considered ready (Chowet al., 1986 and Godina, 1986).

5. Reconstruction

The type of reconstructive procedure undertakenwill vary from patient to patient depending onspecific tissue loss. Procedures can includemuscle-tendon reconstruction, tendon transfer,nerve grafting or flap debulking (Buechler andHastings, 1999). These procedures are performedwhen maximum soft tissue and joint mobility havebeen achieved.

Figure 15.2. The skeleton is stabilized as quickly aspossible so that movement can be initiated. This50-year-old cabinetmaker underwent replantation ofthe right middle and ring fingers and digital nerverepair to the index finger after a circular saw injury.Gentle early protected movement was commencedafter 7 days when vascular stability had beenachieved.


Hand therapy

The complex hand injury, regardless of whichtissues have been involved, is characterized byadhesion formation and subsequent joint stiffness.Hand therapy should begin as soon as possible,preferably while the hand is still in its initialdressing. Appropriate pain relief should be pro-vided to enable the patient to co-operate withtreatment.

The degree of damage sustained by the handfollowing a complex injury can vary significantlyfrom one patient to the next (Fig. 15.3). A ‘step-by-step’ therapy prescription can therefore not begiven. Each case will require careful evaluationand the treatment programme will need to betailored to the individual. While treatment ofcomplex injuries will often require application ofthe full therapy armamentarium, the principles andaims of treatment remain the same, these being:uncomplicated wound healing, early movementand restoration of function.

Oedema management

Many complex hand injuries, particularly thoseresulting from a crush injury, are accompanied by

gross oedema. Where this persists, soft tissuefibrosis and joint stiffness are inevitable.

The hand should be elevated at all times andactive motion should be commenced as soon aspossible unless contraindicated. Gentle compres-sion bandaging can be initiated in the absence ofvascular compromise, grafting or flaps.

Early active motion

All upper limb joints that have not been directlyinvolved in the injury must be put through range ofmotion exercises regularly throughout the day.This applies particularly to the shoulder joint of theolder patient. It is easy to focus on the hand onlywhen damage there has been extensive.

Many hand specialists now allow the com-mencement of early protected active motion aftertendon repair. This is particularly important fol-lowing a complex injury where the risk of adhesionis greatly increased. The reader should refer to therelevant chapters for the treatment protocols usedfollowing tendon repair.

In the absence of tendon repair and where thereis skeletal stability, active movement can becarried out with more ‘vigor’. Active exerciseshould be performed in a systematic fashion that

Figure 15.3. The degree of damage in complexinjuries can vary significantly. This 30-year-oldinsurance worker sustained a two-thirds radial-sidedamputation of the left wrist from a circular saw injurythat occurred in his home workshop. Surgery involvedORIF of a number of carpal bones and distal radius,carpal ligament reconstruction and repair of multipleflexor/extensor tendons and the median and radialnerves.

Figure 15.4. Stabilized movements are more effectivein promoting differential flexor tendon glide. An MCPjoint blocking splint is used 1 to 2 hourly during theday.


does not involve merely wriggling the fingersevery now and then. Active stabilized flexion/extension exercises of individual digits and jointsare performed every 1 to 2 hours with 5 to 10repetitions initially. Stabilized movements aremore effective in promoting differential tendonglide (Fig. 15.4). The session can be completedwith composite fist-making exercises. The patienttends to fatigue quickly at this early stage so over-exercise should be avoided. The frequency oftreatment sessions and number of repetitions canbe increased commensurate with improvement.

Passive movements are avoided during the earlystage of therapy to protect injured structures. Ifindicated, they should be performed with greatcaution. The patient should experience only a mildstretching sensation rather than pain. As a precau-tion, the joints proximal and distal to the joint beingmoved can be held in protected positions, e.g. toprotect the extensor mechanism during passiveflexion exercises of the PIP joint, the MCP and DIPjoints are maintained in maximum extensionthroughout the manoeuvre (Stewart, 1995).

Muscle strengthening and endurance training areincorporated into the programme from about the6th week. Resisted exercises are initially gentleand increased week by week. Exercise putty can beused several times a day for short exercise sessionsthat are interspersed with functional activities.

Splinting

Splinting, both static and dynamic, is integral tothe management of the complex injury. Initially,static splints are used to immobilize, support andprotect the hand. When sufficient healing hasoccurred, splinting takes on a corrective role as theremodelling scar tissue declares itself in the formof soft tissue tightness/contracture and joint fibro-sis/stiffness.

Both static and dynamic splints are used toaddress these problems. Corrective splinting isonly begun when the treating surgeon has beenconsulted. The corrective force applied by thesplint should initially be negligible. The reason forthis is two-fold:

1. Excessive force can result in damage to healingstructures, i.e. tendons, nerves, vessels orbone.

2. The patient’s individual response to correctivesplinting needs to be carefully monitored;splinting should not result in undue pain,swelling or an inflammatory response.

Commonly used splints

1. Serial static volar extension splints to overcomeflexor tightness.

2. Serial wrist casting into extension.3. Dynamic MCP/IP joint flexion splints (Fig.

15.5).4. Dynamic extension outriggers for PIP joint

flexion deformity.5. Blocking splints to facilitate specific tendon

glide, e.g. an MCP joint blocking splint tonegate the effect of the intrinsic muscles andthereby isolate the extrinsic finger flexors.

6. Dynamic Capener splint for PIP joint flexiondeformity.

7. Soft splinting, e.g. a neoprene finger stall toovercome IP joint flexion deformity.

8. C-splint to overcome contracture of the thumbweb.

Where splinting needs are complex, several ofthese splints can sometimes be incorporated intoone. For example, a dynamic flexion or extensionoutrigger can incorporate a dynamic thumb exten-sion component. Also, when permitted (usuallyaround week 8), a dynamic PIP joint extensionoutrigger can be used to provide resisted flexionexercises. Conversely, a dynamic flexion splint canbe used to provide resisted extension exercises.

Figure 15.5. This 35-year-old process workersustained a roller crush injury to his right forearm.This resulted in fractures of the radius and ulna. Thepatient developed a compartment syndrome andrequired forearm and hand fasciotomies. His dynamicflexion splint incorporated a padded lumbrical bar toaddress MCP joint stiffness. Simultaneous dynamictraction was applied to the interphalangeal joints vianylon filament and rubber bands attached to hooks thatwere glued to the fingernails. A compression gloveworn beneath the splint controlled oedema andprovided scar compression.


Splints can simultaneously provide a static anddynamic force. Where the contracture resultsprimarily from soft tissue shortening rather thanbeing specific to a joint, e.g. following repair ofmultiple tendons at the wrist, the proximal jointscan be placed on slight stretch with the static splintbase while a dynamic component directs a correc-tive force at the more distal joint(s) (Fig. 15.6).

The splinting timetable will need to be adapted toeach individual’s needs. Complex hand injuriesfrequently result in restriction of both flexion andextension range. Where this is the case, splints willneed to be alternated regularly. Splints should beworn during sleep and intermittently throughout the

day. Night splinting generally addresses extensionrange while day splinting aims to increase flexionrange. Splints should be removed regularly duringthe day so that the hand can be used (Fig. 15.7).

Scar management

Therapy measures to influence collagen formationshould be employed as soon as wound healing iscomplete, i.e. from about the 3rd week onward.Gentle scar massage is carried out regularly duringthe day to soften scar prior to exercise and as ameans of desensitization. The intensity of massagecan gradually be increased as skin toleranceimproves. Some form of compression should beapplied to scar tissue almost around the clock. Thiscan be achieved with a pressure glove, silicone gelsheeting, a neoprene garment or fingerstall orsilicone elastomer moulds (Kirscher and Shetlar,1979) (Fig. 15.8). Oils and creams used formassage should be fully removed prior to applica-tion of the pressure garments or silicone gel.

Where scar tissue is particularly dense, siliconegel sheeting is used beneath a pressure glove (Fig.15.9). If scar sensitivity is a problem, the area iscovered with Opsite Flexifix (Boscheinen-Morrinand Shannon, 2000). Other materials are thenapplied over the Opsite layer. Even when Opsite isused alone, some scar softening will be noted. Thehand can be used with the glove or gel in place andsplinting can be applied over these materials.

Because scar maturation can continue for manymonths, the patients are advised to maintaincompression therapy for at least 3 to 4 months.

Figure 15.6. This dynamic outrigger splint was usedto correct tightness of flexor pollicis longus (seeFigure 15.3). The static base of the splint provides agentle corrective stretch to the thumb MCP joint whilethe outrigger applies gentle traction to the IP joint.

Figure 15.7. (a) Early stage of therapy: this outrigger splint applied gentle dynamic traction to the interphalangealjoints of the fingers while the thumb underwent serial static splinting that was strapped onto the outrigger (seeFigure 15.3). (b) Later stage of therapy: soft tissue ‘clawing’ of the digits was gradually overcome with sustaineddynamic and static extension splinting.

(a) (b)


Scar maturation varies from person to person andsome patients will demonstrate a pale and flat scarseveral weeks after starting scar management.These patients can leave the gel or garment off forseveral consecutive days to determine whether thescar has ‘regressed’ and requires further treatment.Patients are advised to protect grafts and flaps fromthe sun. The area should ideally be covered for fullprotection or a block-out sunscreen should beused.

Functional activity

The patient should use the hand for light self-caretasks as soon as possible. Modification of everydayutensils such as cutlery, comb, toothbrush, etc.,may be necessary until a functional flexion rangehas been restored. In some cases, these modifica-tions will be permanent. The patient is encouragedto attempt increasingly challenging tasks aroundthe home as endurance, stamina and strengthimprove. Return to pre-injury hobbies and sportingactivities is encouraged. Again, modification ofequipment may be necessary.

A vocational rehabilitation officer shouldbecome involved as soon as the acute and subacutestages of therapy have been completed. Eventhough further reconstructive surgery may bescheduled, the residual functional deficits areusually apparent by this time. If return to pre-injurywork is not feasible, vocational assessment andretraining options will need to be explored. Somepatients have unrealistic perceptions of either theirultimate functional outcome or their choice ofalternative career. Others become so depressed thatdecisions over even the simplest daily matters arebeyond their capabilities. Referral to a psychologistor psychiatrist is a priority in both situations.

Discharge from formal therapy should not occursuddenly. Patients with major hand trauma can beanxious about leaving the protective therapy envi-ronment. Formal therapy visits should therefore bescaled down gradually to enable the patient tomake the necessary emotional adjustment. Evenwhen there is little to do in terms of hand therapyprocedure, the reassurance and encouragement thatthe therapist continues to provide are an importantelement of the patient’s overall care and ultimaterecovery.

Figure 15.8. Silicone gel is used to manage dense scartissue. Opsite Flexifix is applied to areas ofhypersensitivity or the paraesthesia that is associatedwith nerve regeneration. The outlined area on theradial aspect of the index finger denotes area of Opsiteapplication (see Figure 15.2).

Figure 15.9. A pressure glove controls oedema,provides scar compression and protects the hand whenthe patient returns to work. The palmar areas of theglove can be reinforced with leather for extraprotection and to extend the life of the glove.


References

Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix:an effective adjunct in the management of pain andhypersensitivity in the hand. Aust. J. Occup. Ther., (submittedSeptember, 2000).

Brown, P. W. (1995). Simplified wound lavage. Tech. Orthop.,10, 154.

Brown, P. W. (1999). Open injuries of the hand. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkissand W. C. Pederson, eds) pp. 1607–30, ChurchillLivingstone.

Buechler, U. and Hastings, II, H. (1999). Combined injuries. InGreen’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) pp. 1631–50, ChurchillLivingstone.

Burkhalter, W. E. (1985). Complex injuries of the hand. In TheHand and Wrist: Current Management of Complications inOrthopaedics (S. C. Sandzen, Jr., ed.) pp. 241–57, Williams& Wilkins.

Chow, J. A., Bilos, Z. J., Hui, P., et al. (1986). The groin flap inreparative surgery of the hand. Plast. Reconstr. Surg., 77,421–5.

Godina, M. (1986). Early microsurgical reconstruction ofcomplex trauma of the extremities. Plast. Reconstr. Surg., 78,285–92.

Haury, B., Rodeheaver, G., Vensko, J., et al. (1978). Debride-

ment: an essential component of traumatic wound care. Am.J. Surg., 135, 238–42.

Hunt, T. K. and Hussain, Z. (1992). Wound microenvironment.In Wound Healing: Biochemical and Clinical Aspects (I. K.Cohen, R. F. Diegelmann and W. J. Lindblad, eds) pp.274–81, W. B. Saunders.

Kirscher, C. W. and Shetlar, C. W. (1979). Microvasculature inhypertrophic scars snd the effects of pressure. J. Trauma, 19,757.

Stewart, K. M. (1995). Therapist’s management of the complexinjury. In Rehabilitation of the Hand: Surgery and Therapy(J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp.1057–73, Mosby.

Swanson, T. V., Szabo, R. M. and Anderson, D. D. (1991). Openhand fractures: prognosis and classification. J. Hand Surg.,16A, 101–7.

Further reading

Conolly, W. B., Morrin, J. and Davey, V. (1984). Mutilatinginjuries. In Mutilating Injuries of the Hand (A. CampbellReid and R. Tubiana, eds) pp. 15–26, ChurchillLivingstone.

Michlovitz, S. L. (1986). Biophysical principles of heating andsuperficial heat agents. In Thermal Agents in Rehabilitation(S. L. Michlovitz, ed.) pp. 99–118, F. A. Davis.

16

Microvascular free tissue transferJames Masson

Definition

A free flap is a composite block of tissue that issurgically removed from a donor site in the bodyand transferred, in one stage, to a recipient sitewhere its circulation is restored by microvascularanastomoses.

Introduction

Microvascular free tissue transfer allows recon-struction of complex hand defects. In the hand andupper extremity, free tissue transfer is mostcommonly used to provide soft tissue cover. It isalso used in skeletal reconstruction and in theprovision of functioning muscle units.

Less commonly, free flaps are used to providevascular conduits where there has been disruptionof critical vascular inflow and outflow. Adequateprecedent has now been established for using freeflaps as the definitive form of soft tissue cover inthe upper extremity in emergency situations.

Soft tissue coverage

When covering a soft tissue defect in the upperextremity, free tissue transfer is an option in thosesituations where flap coverage is required, i.e.where the defect cannot be closed by a skingraft.

These situations include:

1. Where there is exposed bone, devoid ofperiosteum.

2. Where there is cartilage devoid ofperichondrium.

3. Where there are tendons without their overlyingparatenon.

4. Where vessels or nerves have beenreconstructed.

Conventional two-staged pedicledprocedures

Although capable of producing a similar endresult, these procedures do have shortcomings. Bydefinition, they require two surgical proceduresand are therefore time-, labour- and cost-intensive.Most of the larger flaps, such as the pedicled groinor abdominal flaps, are too bulky for reconstruc-tion of the dorsum of the hand or forearm andrequire further procedures to defat or liposuck theflaps to optimize their contour. The greatestproblem with pedicled reconstructions, however, isthe enforced immobilization of the reconstructedpart.

A relatively simple procedure, such as a cross-finger flap, can result in PIP joint flexion con-tracture and stiffness after only 7 to 10 days ofimmobilization. Pedicled groin flap reconstruc-tions of hand defects are often left for 2 to 3weeks before flap division. Only minimal shoul-der, elbow and hand mobilization is possible andthis is an especially worrying situation in thecase of the elderly patient. Postoperative oedemaand stiffness are compounded by the position offorced dependency of the hand following thisprocedure.


Advantages of microvascular free tissuetransfer

These include:

1. The transfer is performed at one operativeprocedure.

2. Transferred tissue has a predictable vascularity,unlike some pedicled reconstructions which canundergo varying degrees of ischaemic necrosisat their tips.

3. The tissue that is transferred can be selected soas to most closely resemble the requirements ofthe recipient site defect whilst minimizingdonor site morbidity.

4. As the hand is not bound to any other part of thebody, normal postoperative elevation is possibleand the hand can be readily placed in theposition of safe immobilization.

5. Depending on the nature of the reconstructionthat has been performed, early postoperativemobilization is possible.

Problems associated with free tissuetransfer

1. Microvascular technical skill and equipment arenot available everywhere, especially away frommajor teaching institutions.

2. These procedures can be lengthy and, apartfrom the fiscal restraints that this might incur,consideration has to be given to the preventionof intra-operative pressure areas, nerve palsiesand deep venous thrombosis.

3. The greatest risk of microvascular surgery isvascular thrombosis and flap loss. In mostpublished series, the flap survival rate forelective free tissue transfer should now be97 per cent or greater, so flap loss should be arare occurrence.

Choice of free flap

The choice of free flap for soft tissue cover will bedetermined by:

1. The size of the defect.2. The contour of the defect.3. the nature of the wound.

Fasciocutaneous flaps

Fasciocutaneous flaps are the most commonlyused, but fascial flaps and muscle flaps also have aplace.

1. Radial and ulnar forearm flaps

These flaps are based on the arteries after whichthey are named. The large calibre of the vesselsmakes these transfers very reliable. Skin fromthese sites is thin, relatively hairless and is wellsuited to resurfacing defects on the dorsum of thehand and forearm.

The major disadvantage of these flaps is thedonor site, which must be grafted, leaving a largedepression on the volar forearm. The other con-cern, which has more academic than clinicalsignificance, is the sacrifice of one of the majorvessels to the hand.

2. Lateral arm flap

The lateral arm flap provides skin of a similarconsistency to the forearm flaps, but avoidssacrifice of a major vessel. As long as the flap is nowider than 6 cm, the donor site can normally beclosed in a linear fashion, leaving an acceptabledonor site. Sacrifice of the posterior cutaneousnerve of the forearm, however, does lead to loss ofsensibility distal to the elbow and this is trouble-some in some patients (Fig. 16.1).

3. Groin

The same skin that is used in a pedicled groin flapcan be elevated as a free flap, based on either thesuperficial circumflex iliac or the superficialinferior epigastric vessels. A very large piece ofskin can be harvested from this site whilst stillallowing primary closure of the donor site which iswell hidden near the groin crease. As with thepedicled version, however, secondary defatting isoften required.

4. Scapular and parascapular flaps

These two skin flaps from the back have enjoyedsome favour. The scapular and parascapular flapsare based on the same primary vascular axis as thelatissimus dorsi muscle. As with the groin flap,large areas of skin can be elevated. Once again,however, the flaps tend to be a little fat and thedonor site scar on the back often stretches out.

5. Neurovascular first web space flaps

Critical sensibility of the fingertip can be restoredby free neurosensory flaps or microvascular toe-pulp transfer. The first web space flap of the foot

Microvascular free tissue transfer 213

consists of the lateral aspect of the great toe and themedial aspect of the second toe. It is supplied bythe first dorsal metatarsal artery (FDMA), a branchof the dorsalis pedis artery, or the first plantarmetatarsal artery. Its innervation is through boththe deep peroneal nerve and the medial plantarnerve. The main advantage of the first web spaceflap for sensory reconstruction in the hand isreplacement of pulp skin with similar thin, gla-brous skin with concentrated sensory receptors.This allows the best chance for restoration offunctional sensibility.

The toes are the source of many free flaps forreconstruction of the hand. Thumb loss, especiallyat, or proximal to, the MCP joint, can bereconstructed with a free, whole great toe, or second

toe. The second and third toes can be used toreconstruct missing fingers in certain congenitaland post-traumatic conditions (Fig. 16.2). Vascu-larized toe joint transfers have been used to replacedestroyed PIP and MCP joints; however, thelongevity of these reconstructions remains to beseen.

Fascial flaps

Because some of the commonly used fasciocuta-neous flaps are either too fat for dorsal handreconstruction or leave an unacceptable donor sitescar, the search for a tissue source that avoids theseproblems was undertaken. Fascial flaps satisfy boththese requirements. They have several advantages:

Figure 16.1. (a) Oblique transmetacarpal amputationof the left hand. (b) The middle finger has beentransferred to the base of the thumb. (c) Design oflateral arm flap. (d) The defect was covered with afasciocutaneous lateral arm flap.

(a) (b)

(c)

(d)


1. They provide thin, pliable cover without bulk.2. They are readily contoured to the defect.3. For the most part, they leave an inconspicuous

donor site scar.4. They are useful where a gliding surface is

required for tendons and nerves.

Fascial flaps are used most commonly for defectson the dorsum of the hand, the volar hand and wristand in the first web space, especially followingrelease of extensive contractures.

The only problems with these flaps is theirrelatively limited size and the fact that they requirea skin graft to cover them. Occasionally, skin graft‘take’ can be variable due to haematoma formationbeneath them.

The temporoparietal fascia can be harvested as afree flap, taking a piece of tissue as large as14 � 10 cm. The donor site is hidden beneath thehair and providing that care is taken duringelevation of the flap, alopecia should not be aproblem. The radial and ulnar forearm flaps andthe lateral arm flap can also be raised as fascialflaps only, leaving a linear donor site scar.

Aftercare following fascial flaps

Following free fascial flaps, the area is rested forthe 1st postoperative week after which gentlemovement is begun. To prevent hypertrophicscarring, pressure therapy, e.g. silicone scar gel, isinstituted after 3 weeks.

Muscle flaps

The malleability of muscle flaps makes them wellsuited to difficult contour problems in the upperextremity. This is especially the case in large, post-traumatic defects (Fig. 16.3).

Muscle flaps have a better vascularity thanfasciocutaneous flaps and are more readily able todeliver antibiotics to infected, or potentially infec-ted wounds. For this reason, they are useful in themanagement of chronic osteomyelitis.

The muscle selected will be determined by thesize and contour of the defect. For small defects,the serratus anterior is useful as it has a longpedicle and minimal donor site morbidity. Sim-ilarly, gracilis is useful in long, thin defects.

Figure 16.2. (a) Defect resulting from a fan blade injury to the left hand. (b) A good functional result wasachieved following transfer of the second toe to the ring finger.

(a) (b)


For wounds of moderate size, the rectus abdomi-nis is well suited. Careful abdominal wall closureshould minimize the risk of postoperative hernia-tion and weakness. The latissimus dorsi muscle isused where a large area or volume of muscle isrequired. Despite its size, its loss results in minimalmorbidity for the patient.

Skeletal reconstruction

Conventional non-vascularized corticocancellousbone grafting is the most common technique usedfor reconstructing bony defects in the upperextremity. There are, however, certain clinicalsituations in which the technique will not

Figure 16.3. (a) This acute infective compartmentsyndrome of the left forearm occurred after a pitchfork injury. (b) Radical debridement of the ischaemictissue resulted in substantial loss of flexormusculature. (c) Elevation of right latissimus dorsimuscle flap. (d) To restore flexor function, thefollowing primary tendon transfers were performed.Brachioradialis was used to restore function of flexorpollicis longus and extensor carpi radialis longus wasused to restore function of flexor digitorum profundus.The transfers were covered with a latissimus dorsi freeflap and split skin graft.

(a)

(b)

(c)

(d)


predictably produce bony union. Reconstructionwith vascularized bone is then required. Thesesituations include:

1. Long bone defects of greater than 6 cm, eitherfollowing trauma, or as a result of debridementafter infection.

2. Defects following tumour excision, especiallywhen supplemented with radiotherapy.

3. Chronic non-union of long bones, where tradi-tional grafting procedures have failed.

Fibula

The fibula is the most common source of vascu-larized bone for long bone defects. Up to 30 cm ofprimarily cortical bone can be harvested, based onthe peroneal vessels. In children, the cartilaginoushead of the fibula can be harvested in continuitywith the bone to reconstruct the distal end of theulna. Where required, such as in the humerus, thefibula can be osteotomized, due to the segmentalnature of its blood supply, to produce a ‘double-barrelled’ reconstruction. Although the fibula willhypertrophy to near the size of the surroundingbone under stress anyway, osteotomizing the bonein this way increases the volume of bone and thestrength of the reconstruction.

Radius and iliac crest

Although it is possible to harvest part of the radiuswith a radial forearm flap, the volume of bone soobtained is relatively small and there is significantrisk of subsequent fracture of the donor bone. Inthe same way, the iliac crest can be harvested on avascular pedicle, and has been so described inreconstruction of scaphoid non-unions. More sim-ple pedicled options from the dorsum of the wrist,however, are probably more appropriate in thissetting.

Functional muscle flaps

Muscle function can be irreversibly lost throughnerve damage (e.g. brachial plexus injuries) ormuscle injury (e.g. Volkmann’s ischaemic con-tracture). Where muscle function is lost throughnerve injury, it is sometimes possible to restoresome function by nerve repair, grafting or trans-fers. Alternatively, muscle or tendon transfersmight restore some of the lost function. In the caseof Volkmann’s ischaemic contracture, release ofthe contracted muscle mass with a muscle slide or

transfer of tendons, might restore active finger andthumb flexion.

There comes a point, however, where there areinsufficient motors to restore the functionsrequired. In these situations, new motors will needto be ‘imported’. In brachial plexus injuries, thegracilis muscle is well suited for restoration ofelbow flexion. It can also be used at the forearmlevel to restore finger flexion. It is expendable inthe leg, with minimal morbidity from its harvest,and is the appropriate length for both of thesereconstructions. Other muscles which have beenused for these functions are: the latissimus dorsi,the tensor fasciae latae and the medial head of thegastrocnemius. The motor nerve to the musclemust be coapted to an appropriate recipient motornerve in the upper extremity and the new originand insertion of the muscle must be re-establishedunder appropriate tension.

Aftercare for restoration of finger flexion

During the 3 week immobilization period, thetransplanted muscle is placed in a relaxed positionwith the wrist and finger MCP joints splinted inmoderate flexion so that there is no tensionbetween the flexor tendons and the transplantedmuscle. Gentle passive finger flexion and active IPjoint extension is commenced after 5 to 7 dayswhen vascular stability has been achieved. Thereshould be consultation with the treating surgeonprior to commencement of these exercises.

Gentle passive stretching of the wrist and fingersis begun between 4 to 6 weeks after surgery.Regular stretching exercises can be augmentedwith gentle prolonged stretch using serial splinting.It will usually take 6 to 8 weeks to re-establish thepreoperative passive extension range. The aim is toobtain full passive muscle extension and toimprove tissue gliding at the musculo-tendinousjunction in readiness for active exercise uponreinnervation.

Depending on how far from the hilum of themuscle the donor nerve has been divided, someflicker of activity should be evident by about 3months. Active exercise, with gravity eliminated,is then commenced. The exercise and activityprogramme is gradually upgraded commensuratewith progress. The exercise programme should becontinued for at least 12 months after the return ofmovement. Maximum strength, which will beabout 50 per cent of normal, will take approx-imately 2 years to achieve.


Emergency free flaps

In complex hand trauma, there are well establishedprinciples of surgical management. These are:

1. Wound debridement, removing dead or poten-tially dead tissue.

2. Restoration of skeletal stability.3. Provision of soft tissue coverage.4. Soft tissue reconstruction, dealing with injury to

the nerves, vessels and tendons.

Traditionally, these steps have been performed asmultiple staged procedures. Over the past decade,however, commencing with the work of Lister andScheker (1988), there has been a trend towardsperforming the entire reconstruction within thefirst 24 hours after injury, including, where neces-sary, free tissue transfer.

Concerns of increased flap failure rates in theacute setting have not been borne out by publishedseries which show survival rates equal to, if notbetter than, elective free flaps. The ability toprovide immediate flap coverage means that recon-struction of underlying structures can be performedat the same time. Vessel, nerve, bone and tendonrepairs or grafts can therefore be performed,avoiding the need for subsequent procedures.

The main problem with the traditional manage-ment of complex post-traumatic hand wounds isthat each operative step introduces more scarring,immobilization and resultant loss of motion. Thismakes each subsequent procedure more difficult.Although the skeleton and soft tissues might wellbe reconstructed successfully, the end functionalresult might not reflect the lengths and complexityof the surgery. In contradistinction, the literature todate shows that the treatment strategy of perform-ing the entire 3-dimensional reconstruction withinthe first 24 hours after injury has the followingbenefits:

1. Significant reduction in infection and flapfailure rates.

2. Reduction or elimination of secondary oper-ative procedures.

3. Reduced hospitalization and associated medicalcosts.

Aftercare

Following a free tissue transfer procedure, the limbis protected with a windowed non-constricting slabduring sleep. The hand is elevated to heart level

only as extreme elevation may interfere witharterial flow. Many surgeons use anticoagulants(e.g. intravenous dextran 40 or heparin, low-doseaspirin) to prevent thrombosis of the microsurgicalanastomoses.

No dressings are applied to the surface of theflap which is monitored every hour for the first 48hours after surgery. Assessment includes: flapcolour, temperature and capillary refill. Whereavailable, pulse oximetry and implantable venousDoppler probes are also useful.

The patient and their environment are kept warmand the patient should abstain from caffeine andnicotine. The patient should be ambulant as soon aspossible after surgery, ideally on the first post-operative day. All joints that are not included in thecast should be exercised.

Where healing progresses uneventfully, the flapis usually stable by 8 to 10 days after surgery.Oedema control is limited to elevation for the first2 weeks to prevent vascular compromise. Gentlecompression with Coban wrap can then be com-menced. When vascular status allows, at about 14days, movement of involved joints can becommenced.

References

Lister, G. and Scheker, L. (1988). Emergency free flaps to theupper extremity. J. Hand Surg., 13A, 62.

Further reading

Chen, S. H. T., Wei, F.-C., Chen, H.-C., et al. (1992).Emergency free-flap transfer for reconstruction of acutecomplex extremity wounds. Plast. Reconstr. Surg., 89(5),882–8.

Chick, L. R., Lister, G. D. and Sowder, L. (1992). Early free-flap coverage of electrical and thermal burns. Plast. Reconstr.Surg., 89(6), 1013–9.

Foucher, G. (1999). Vascularized joint transfers. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 1251–70, Churchill Livingstone.

Godina, M. (1986). Early microsurgical reconstruction ofcomplex trauma to the extremities. Plast. Reconstr. Surg.,78(3), 285–92.

Gordon, L. (1999). Toe-to-thumb transplantation. In Green’sOperative Hand Surgery (D. P. Green, R. N. Hotchkiss andW. C. Pederson, eds) pp. 1299–326, Churchill Livingstone.

Jones, N. F. and Lister, G. D. (1999). Free skin and compositeflaps. In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkiss and W. C. Pederson, eds) pp. 1159–200, ChurchillLivingstone.

Katsaros, J., Tan, E. and Zoltie, N. (1991). The use of the lateralarm flap in upper limb surgery. J. Hand Surg., 16A,598–604.


Manktelow, R. T. and Anastakis, D. J. (1999). Functioning freemuscle transfers. In Green’s Operative Hand Surgery (D. P.Green, R. N. Hotchkiss and W. C. Pederson, eds) pp.1201–19, Churchill Livingstone.

May, J. W., Chait, L. A., Cohen, B. E. and O’Brien, B. McC.(1997). Free neurovascular flap from the first web of the footin hand reconstruction. J. Hand Surg., 2, 387–93.

McCabe, S. J. and Breidenbach, W. C. (1999). The role ofemergency free flaps for hand trauma. Hand Clinics, 15(2),275–88.

Ninkovic, M., Deetjen, H., Oehler, K. and Anderl, H. (1995).Emergency free tissue transfer for severe upper extremityinjuries. J. Hand Surg., 20B, 53–8.

O’Brien, M. McC. and Morrison, W. A. (1987). ReconstructiveMicrosurgery. Churchill Livingstone.

Scheker, L. R., Langley, S. J., Martin, D. L. and Julliard, K. N.(1993). Primary extensor tendon reconstruction in dorsal handdefects requiring free flaps. J. Hand Surg., 18B, 568–75.

Singer, D. I., Moore Jr., J. H. and Byron, P. M. (1995).Management of skin grafts and flaps. In Rehabilitation of theHand: Surgery and Therapy (J. M. Hunter, E. J. Mackin andA. D. Callahan, eds) pp. 277–90, Mosby.

Wei, F.-C. and Santamaria, E. (1999). Toe-to-finger reconstruc-tion. In Green’s Operative Hand Surgery (D. P. Green, R. N.Hotchkisss and W. C. Pederson, eds) pp. 1327–52, ChurchillLivingstone.

17

The burnt hand

Burns involving the hand can occur as an isolatedinjury; however, they are frequently associatedwith major burns to the body that constitute amedical emergency requiring respiratory and cardi-ovascular stabilization. While the first priority oftreatment is to save life, good initial care of thehand is imperative if a favourable functionaloutcome is to be achieved (Sheridan, 1995).

The hand is at risk from burn injuries in manyoccupations. Its exposed position means that itfrequently comes in contact with hot objects,liquids and numerous chemicals (Davis, 1987).The appearance of the hand following a burn injurycan be deceptive. The immediate effects of a tarburn, for instance, often look disastrous; however,because tar cools quickly, the depth of the burnwill be less than that resulting from fat or greasewhich will hold the heat for a longer period oftime.

Pathophysiology

The dorsum of the hand, which is the mostcommon site for burns, has a thin subcutaneouslayer and therefore poor insulation. This facilitatesheat conduction to important deeper structuressuch as tendons and joints. The hand has arelatively large surface area. Rapid heat gain in thedermal and subdermal layers can therefore quicklyoverwhelm the microcirculation and progressiveischaemia is then added to the original thermalinsult.

Every burn is accompanied by inflammation andoedema. Because there is damage to both the skinbarrier and deeper tissue, infection is likely. Allthese factors predispose to fibrosis which mayextend from the superficial layers to the muscles,tendons and joints and beyond the immediate areaof the burn.

Figure 17.1. The three depths of burn.


Causes of burn

1. Thermal burns

Thermal burns are the most common and includeflame and flash burns or contact with hot liquids,objects or steam. The former generally occur onthe backs of the hands when these are used toprotect the face. If the hands are used to extinguishflames, the volar aspect of the hands will beaffected. Contact burns, e.g. with a radiator, hotplate, etc., generally involve the palmar aspect ofthe hand.

2. Electrical

Superficial burns from an electrical short aregenerally flash burns rather than actual conductiveelectrical burns and are managed in the same wayas thermal burns. True electrical burns are usuallydeep and, whether from low voltage (domestic) orhigh voltage (industrial) currents, they have anentrance wound and exit wound. High voltagecurrents result in necrosis of muscles, vessels andnerves beneath an apparently minor skin burn.Severe electrical burns require urgent decompres-sion and fasciotomy on the day of injury. Toeliminate all devitalized tissue, several debride-ments are usually needed. Such extensive debride-ment may necessitate flap coverage (Chick et al.,1992).

3. Chemical burns

Prolonged contact with chemicals such as picric,hydrochloric, hydrofluoric and other acids andalkalis may saturate the skin and produce neuritis,vasculitis and deep burns. Chemical burns shouldbe extensively irrigated with running water as soonas possible. Early excision may be required if theinjury is sufficiently deep. Hydrogen fluoride is acommon cleaning agent that is used in manyindustries. Contact with this chemical (usually atthe finger tips) is painful and requires prompttreatment to avoid infiltration and inflammation ofthe distal phalanx (Achauer, 1999).

4. Friction burns

Friction caused by moving machinery, rope orfrom the hand being dragged over a surface, cancause deep burns (Fig. 17.1).

Degrees of burn injury

The depth of the burn will determine whether thewound will heal spontaneously or will requiregrafting. Many burn injuries present with featuresfrom all three categories of burn.

1. Superficial partial-thickness

Superficial partial-thickness burns involve theepidermis and may also involve the upper dermis.Features of these burns include:

(i) Swelling.(ii) Erythema.(iii) Blistering.(iv) Pain.

Deep epithelial cells survive and spontaneoushealing occurs within 2 to 3 weeks with a goodfunctional and cosmetic result.

Wound management

Superficial burns can be covered with an antibacte-rial cream such as silver sulphadiazine and pro-tected with a plastic bag during the day to allow thepatient to carry out gentle active exercise and toperform self-care tasks (Fig. 17.3). Light dressingsand a ‘position of safe immobilization’ splint are

Figure 17.2. This 25-year-old freight operatorsustained a severe crushing and friction burn injury tohis left upper arm, forearm and hand when his limbbecame trapped for 90 minutes in a conveyor belt.Immediate treatment involved open reduction andinternal fixation of comminuted fractures of the radiusand ulna, fasciotomies of the forearm and extensivewound debridement. Wound coverage to the hand andarm was achieved with meshed split-thickness skingrafts.

The burnt hand 221

then applied at night. The hand is cleansed daily inwater and the wound is debrided of loose tissue.

2. Deep partial-thickness

These burns involve damage to the dermis andepidermis. If the wound becomes infected, the burnmay convert to a full-thickness injury. While theseburns can heal spontaneously, they are prone tohypertrophic scarring which will compromise bothfunction and cosmetic appearance. Skin grafting istherefore the preferred treatment option (Fig.17.2).

3. Full-thickness burns

These burns destroy the epithelium and superficialnerve endings and are therefore painless. Theyhave a grayish, waxy or charred appearance. Theseburns do not heal spontaneously and will requiregrafting.

Severe burns are usually accompanied bymarked oedema due to increased capillary permea-bility and the large fluid loads usually needed tomaintain intravascular volume (Achauer, 1999).

The devitalized tissue resulting from deep burns isknown as eschar. Where deep burns are circum-ferential, this inelastic tissue, combined withoedema, can result in a tourniquet effect. Unlessrelieved by escharotomy (digital, intrinsic, radialor ulnar), this disruption to circulation can result inischaemic necrosis of muscles, nerve damage organgrenous digits (deLinde and Miles, 1995).

Complications related to burn injuries

1. Swelling.2. Sepsis.3. Ischaemia.4. Scarring of skin, tendons and joints.5. Subsequent contracture.

In the early postburn stage, the main problem issepsis which can convert a simple superficial burninto a deep one. Most burns are surface-sterilizedby the nature of the injury. Those that have becomeinfected have been contaminated by the subsequentenvironment or by organisms in the glandular orfollicular elements of the unburnt tissue.

Stiffness results from a combination of inflam-mation, oedema and fibrosis of healing tissuesincluding skin, tendons and joints. A commoncomplication of dorsal hand burns is a buttonholedeformity resulting from damage to the extensorapparatus over the PIP joint. Nail deformities arealso common (Fig. 17.4).

Figure 17.3. Superficial burns are coated with anantibacterial cream such as silver sulphadiazine cream.The hand is then covered with a loosely fitting plasticbag that is secured at the wrist and enables the patientto exercise and use the hand freely during the day.

Figure 17.4. Buttonhole deformity is commonfollowing severe burns to the dorsum of the hand fromdamage to the extensor apparatus over the PIP joints.


Skin grafting

Skin grafting is indicated when healing has notoccurred by the 3rd week. Wounds that are nothealed by this time and which are allowed togranulate, will inevitably result in hypertrophicscarring and contracture. Early grafting will facili-tate rehabilitation, hence reducing the risk ofpermanent stiffness and decreasing the extent ofscar formation (Mahler, 1987).

Most burn injuries can be satisfactorily resur-faced with split-thickness skin grafts. Unless graftsare in short supply, sheet grafts rather than meshgrafts should be used as these produce less scartissue and provide a superior functional result(Achauer, 1999). Where burns to the body havebeen extensive and donor skin is scarce, ‘Allo-derm’ (i.e. cadaveric dermis) or synthetic dermalsubstitutes can be used. For the management ofdeep burns to the palm, the use of full-thicknessskin grafts is indicated, particularly in the paediat-ric patient. Formal therapy time and use ofpressure garments is reduced following a full-thickness skin graft (Schwanholt et al., 1993).

Therapy following burn injury

Aims of treatment

1. Prevention of deformity.2. Maintenance of joint mobility.3. Restoration of full or maximum function.4. Provision of psychological support.

Treatment

Early medical/nursing care involves control of painwith appropriate analgesia, systemic antibiotics,anti-tetanus cover and wound/graft care. Dressingsshould be loose enough not to inhibit joint motion.Therapy management includes:

1. Oedema control

Oedema is significant following most seriousburns. The hand should therefore be elevated at alltimes when not being exercised or used. In theearly stages of management, the arm is supportedwith a foam wedge with the hand elevated to heartlevel (Rivers et al., 1991). The elimination ofswelling is most important in minimizing thefibrosis that results from its persistence.

Compression dressings are not used until aboutthe 5th postinjury day when vessels are regaining

their normal permeability (deLinde and Miles,1995). By the end of the 1st week, the nature of theswelling will have changed from being very firm tohaving some ‘give’ when indented; gentle com-pression therapy is then begun. This can beachieved with elastic bandages applied to the handand forearm and Coban wrap to the digits.

2. Support splinting

The most common deformity associated with moreserious burns is the ‘claw’ deformity. This deform-ity involves extension of the MCP joints (initiallyfrom marked dorsal hand oedema), flexion of thePIP joints, adduction of the thumb and flexion ofthe wrist. The extensor tendons lie just beneath thethin dorsal skin and are therefore easily damaged.Where there is destruction of the central slip overthe PIP joint, a buttonhole deformity may developbecause of volar migration of the lateral bands.

To counteract this posture, the hand is splintedas closely as possible to the ‘position of safeimmobilization’ (POSI). This position involves:

(i) 20 to 30 degrees of wrist extension.(ii) Maximum flexion of the MCP joints.(iii) Maximum extension of the IP joints.(iv) Palmar abduction of the thumb to avoid

contracture of the 1st web space.

The splint is worn at night and during periods ofinactivity throughout the day. To minimize the riskof stiffness, overuse of the splint should beavoided. If pain is causing the patient to keep thehand splinted or immobile, this should beaddressed with appropriate analgesia. Initially, thesplint will require regular adjustment in responseto oedema resolution and improved range ofmotion. If the splint is applied in the first 3 to 5days after injury, it is held in place with gauzewraps rather than with compression bandagingwhich may compromise circulation at this veryearly stage.

Figure 17.5. To counteract the ‘claw’ deformitycommonly associated with burns, the hand is splintedin the ‘position of safe immobilization’ when the handis not being exercised or used. This splint will needregular adjustment as oedema subsides.

The burnt hand 223

3. Early active movement and function

If skin grafting has been carried out, the hand isrested in a POSI splint for 7 to 10 days until thegraft is stable, otherwise, active (and very gentlepassive) exercise is begun from the day of injury.Exercises can initially be performed in a warmcleansing bath that will reduce pain and helpfacilitate movement.

All upper limb joints should be moved regularlyduring waking hours. The patient is encouraged topractise short, but frequent, active exercise ses-sions. Emphasis is on intrinsic flexion of the MCPjoints and intrinsic IP joint extension, grossgripping, maintenance of the web spaces andopposition of the thumb to all digits.

All exercises are carried out within pain-freelimits. As pain decreases, gross active flexionexercises can be accompanied by gentle over-pressure into flexion. Passive manoeuvres cangradually become more ‘forceful’ as tolerated.Active exercise is considerably less painful thanpassive exercise which should be performed slowlyand with great care. Over-enthusiastic passivemanoeuvres will result in increased oedema,haemorrhage and fibrosis. Also, exercises that areperformed actively (or actively assisted) are moreeffective in reducing swelling and in maintainingand regaining muscle strength. When stabilizing thehand during exercise, support is given over areas ofeschar (which is painless), rather than on granula-tion tissue (deLinde and Miles, 1995).

In the case of deep burns, temporary K-wirefixation of the PIP joints can help facilitateflexion of the MCP joints and protect vulnerableextensor tendons which may be prone to rupture.The wires can be inserted within a few days ofinjury and remain in place for 2 to 3 weeks whileskin coverage is completed. Stiffness of the PIPjoints is sometimes inevitable, but will not be asdisabling as an extension contracture of the MCPjoints.

If disruption to the extensor tendon is managedconservatively, the PIP joints are splinted inextension with a volar splint that permits MCP andDIP joint motion. If there is actual tendonexposure, dressings that maintain moisture andencourage healing will need to be applied (Saffleand Schnebly, 1994).

As soon as possible, the hand should be used forlight self-care activities. Where flexion range isrestricted, everyday utensils such as cutlery, tooth-brush, etc., are enlarged with foam or other softmaterials to enable grasp.

4. Corrective splinting

As healing progresses, the propensity to con-tracture will increase and corrective splinting isoften required. This will usually involve:

(i) MCP joint flexion splinting.(ii) PIP joint extension splinting.(iii) Web spacers, e.g. serial C-splinting to over-

come a tight web space.

The loss of skin mobility resulting from contract-ing scar on the dorsum of the hand will restrictglobal finger flexion although the range of move-ment of individual finger joints can be surprisinglygood, i.e. when the more proximal and/or distaljoints are relaxed.

To address this, the dynamic flexion splint canincorporate a lumbrical bar to flex the MCP jointswhile flexion force to the IP joints is achievedthrough traction applied to hooks that are glued tothe fingernails (if these have not been involved inthe burn). Otherwise, loops are gently applied tothe distal phalanges (Fig. 17.5).

Flexion deformities of the PIP joints can bemanaged with neoprene finger stalls which allowflexion and provide excellent scar compression.The fabric used in custom-made pressure glovesalso provides an effective ‘extension’ force to thedigits. Where flexion deformities require a strongerextension force, hand-based dynamic outriggers orCapener splints are used over the compressiongarment.

Thumb web contractures are managed with serialC-splints or with dynamic extension splinting

Figure 17.6. During wound healing and subsequentscar maturation, the skin on the dorsum of the handcan contract quite markedly and limit digital flexion.This problem is addressed with dynamic flexionsplinting which applies a force at the MCP and IPjoints simultaneously.


which can be incorporated into the MCP jointflexion splint. Tight finger web spaces can be gentlystretched with foam, gauze or cotton wool. Thesematerials are unlikely to cause pressure areas andcan be readily modified as the webs stretch.

5. Skin care and scar management

The newly healed skin will initially be quite fragileand require protection from overzealous handling,injury and sun exposure. The skin is gentlymassaged with a non-irritating oil or lotion severaltimes each day to maintain suppleness and as anearly desensitization exercise.

The skin is assessed regularly to determine itsreadiness for a custom-made compression glove.When used too early on fragile skin, these garmentscan be ‘abrasive’ and result in skin breakdown.When pressure therapy with a custom-made glove iscommenced, the fit will need to be assessedregularly to ensure that pressure is being main-tained. The glove should fit snugly but should notinterfere with circulation. To help reduce friction tofragile skin during glove application, the gloveshould incorporate a zipper. Gloves need to bereplaced about every 2 months due to gradual loss ofthe material’s elasticity. Patients are usually fittedwith two gloves to enable regular laundering of thegarment.

Concave areas of the hand where pressure is notbeing maintained, e.g. the palm of the hand, willrequire an insert. Silicone gel can be used in areaswhere the cavity is not large; however, deeper areas

can be ‘filled’ with ‘Silicone Elastomer’ moulds orthermoplastic splinting material. Scar that is partic-ularly raised and dense warrants use of silicone gelin conjunction with the garment even wheregarment compression is good (Katz, 1992). Well-moulded splints also provide effective pressure andare worn over the garment and silicone gelsheeting.

Pressure therapy will need to be maintained formany months as scar maturation can take from 6 to24 months to occur. Scar that has fully matured islight pink or white in colour and fairly flat, smoothand supple in texture. This is in contrast to immaturescar which is thick, red and tight. To know whetherpressure therapy can cease, the patient can leave thegarment off for several consecutive days and checkfor any deterioration in skin texture and/or colour.

6. Psychological support

Serious burns can result in permanent deformity,loss of digits, scarring and functional loss. Theemotional, psychological and economic conse-quences can be enormous. Even minor burns withminimal cosmetic disruption can be devastating forsome patients. Patients will need much encourage-ment during their rehabilitation which may last formany months. Reconstructive surgery, sometimesinvolving numerous procedures, will lengthen thisprocess.

If staff observe that the patient is not coping,consultation with a psychologist or psychiatristshould be arranged. States of anxiety and/ordepression will need to be addressed if the patient isto be able to comply with the treatmentprogramme.

Reconstructive procedures

Joint contracture

The severely burnt hand with established PIP jointcontractures is generally not amenable to tendon orjoint reconstruction (Achauer, 1999). These jointscan undergo fusion in a functional position, i.e. 55to 60 degrees of flexion. Restoration of MCP jointflexion will require flap coverage as a first-stageprocedure and release of joints as a second-stageprocedure. Dynamic flexion splinting is institutedimmediately after surgery.

Soft tissue contracture

Contracture of the digital web spaces involves skinonly and is corrected with a V-M-plasty. Adduction

Figure 17.7. A custom-made pressure glove is fittedwhen grafts and wounds are fully healed. Where scaris particularly dense and unyielding, silicone gel isused in combination with the glove. Corrective splintsare worn over the glove.

The burnt hand 225

contracture of the first web space, however,involves fibrosis of the adductor muscle and thefirst dorsal interosseous muscle (Dmitriyev andPetrov, 1989). Correction of this deformityrequires the division of fascia and muscle. Resur-facing with a skin graft or flap may be necessary.

Amputation

Severe burn injuries can result in amputationdeformities. To restore some length to the thumband/or fingers, the web spaces can be deepened bya procedure that is basically an exaggeratedversion of the V-M-plasty. This process is knownas phalangization.

Thumb function can be restored with transfer ofremnant digits, i.e. pollicization. If skin coverage isinadequate, a groin or free flap will be requiredprior to this procedure. The alternative option is atoe-to-thumb transfer. Where skin coverage isadequate and skin is supple, some thumb met-acarpal length can be gained through bone distrac-tion techniques (Stern and MacMillan, 1983).

Deformity of the nail bed

Nail bed deformities resulting from digital burncontractures can be corrected with proximal flapswhich will provide good protection during activityand overcome the problem of repeated tissuebreakdown.

References

Achauer, B. M. (1999). The burned hand. In Green’s OperativeHand Surgery (D. P. Green, R. N. Hotchkiss and W. C.Pederson, eds) pp. 2045–60, Churchill Livingstone.

Chick, L. R., Lister, G. D. and Sowder, L. (1992). Early freeflap coverage of electrical and thermal burns. Plast. Reconstr.Surg., 89, 1013–9.

Davis, A. T. (1987). The burnt hand. In Hand Injuries: ATherapeutic Approach (M. I. Salter, ed.) pp. 173–188,Churchill Livingstone.

DeLinde, L. G. and Miles, W. K. (1995). Remodeling of scartissue in the burned hand. In Rehabilitation of the Hand:Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D.Callahan, eds) pp. 1267–94, Mosby.

Dmitriyev, G. I. and Petrov, S. V. (1989). Surgery for adductioncontracture of the thumb after burn. Acta Chir. Plast., 31,236–42.

Katz, B. E. (1992). Silastic gel sheeting is found to be effectivein scar therapy. Cosmetic Dermatol., 6, 32.

Mahler, D., Benmeir, P., Ben Yakar, Y., et al. (1987). Treatmentof the burned hand: early surgical treatment (1975–85)versus conservative treatment (1964–74). A comparativestudy. Burns, 13, 45–8.

Malick, M. H. and Carr, J. A. (1982). Manual on theManagement of the Burn Patient. Harmaville RehabilitationCentre Educational Resource Division.

Rivers, E., Solem, L. and Ahrenholz, D. (1991). Improvedmanagement of post-burn oedema in the upper extremityusing a foam elevation wedge. (Abstract). American BurnAssociation Meeting, Baltimore.

Saffle, J. R. and Schnebly, W. A. (1994). Burn wound care. InBurn Care and Rehabilitation: Principles and Practice (R. L.Richard and M. J. Staley, eds). F. A. Davis.

Schwanholt, C., Greenhalgh, D. G. and Warden, G. D. (1993).A comparison of full-thickness versus split-thickness auto-grafts for the coverage of deep palm burns in the very youngpaediatric patient. J. Burn Care Rehabil., 14(1), 29.

Sheridan, R. L., Hurley, J. and Smith, M. (1995). The acutelyburned hand: management and outcome based on a ten-yearexperience with 1047 acute hand burns. J. Trauma, 38,406–11.

Stern, P. J. and MacMillan, B. G. (1983). Reconstruction of theburned thumb by metacarpal lengthening. Burns, 10,127–30.

18

Chronic regional pain syndrome

Introduction

Pain, like oedema, is a normal consequence ofhand trauma. It serves a useful biological functionand in most instances resolves uneventfully. In asmall number of patients, however, the pain statewill persist, worsen or develop weeks (usually 3 to4) following initial trauma. This abnormal post-injury response can result in central pain imprint-ing and have devastating effects on hand function(Koman et al., 1996).

Classification

The past 100 years have seen considerable changeto pain nomenclature. Some of the earlier usedterms include: algodystrophy, Sudeck’s atrophy,causalgia (minor and major), shoulder-hand syn-drome and sympathetically mediated pain. Theseterms have been used under the umbrella of ‘reflexsympathetic dystrophy’. Workers in this fieldbelieve that there has been an overemphasis on thesympathetic nervous system and that the term‘reflex sympathetic syndrome’ has been used toobroadly (Merskey and Bogduk, 1994). The term‘chronic regional pain syndrome’ (CRPS) hastherefore been adopted.

The new classification emphasizes clinical char-acteristics (Jaenig, 1995) and includes varioussubgroups. Disorders which were previouslyreferred to as ‘RSD’ are now known as Type 1 –CRPS. Those referred to previously as ‘causalgia’are now known as Type 2 – CRPS (Koman et al.,1999).

Type 1

Reflex sympathetic dystrophy – pain, functionalimpairment, autonomic dysfunction, dystrophicchanges without clinical peripheral nerve lesion/injury.

Type 2

Causalgia – pain, functional impairment, auto-nomic dysfunction, dystrophic changes with adiagnosable peripheral nerve injury.

Type 3

Other pain dysfunction, e.g. myofascial pain.

These conditions are then categorized furtherdepending on whether they respond to sympatheticintervention, i.e., pain is sympathetically main-tained (SMP) or sympathetically independent ofpain (SIP). This chapter will deal with themanagement of the first two types.

Clinical phases of chronic regional painsyndrome

The first 3 months of CRPS represent the acutephase. The next phase is the subacute phase andlasts for a further 3 months. The condition isconsidered to be in the chronic phase from the 6thmonth onward (Fig. 18.1).


Early recognition

Chronic regional pain syndrome can be reversedsuccessfully in the first two phases; however,stiffness and disuse which have become entren-ched over many months cannot be reversed withconservative means. Early recognition of thiscondition and prompt intervention are the key to asuccessful outcome.

It was previously thought that certain person-ality types were at greater risk of developingCRPS. While this view is no longer held, it isimportant to remember that unremitting pain hasmajor psychosocial consequences (Covington,1995).

Symptoms and signs

1. Pain

The pain response associated with CRPS isfrequently disproportionate to the inciting injuryand/or surgery and is called hyperalgesia. Patientscommonly describe the affected area as having a‘burning’ sensation. Some patients state that theirhand ‘feels hot inside’; others experience throb-bing or shooting sensations.

Extreme sensitivity to innocuous stimuli, e.g.light touch or a movement of air over the hand, isa common manifestation; this is known as allody-nia. Paraesthesia, or ‘pins and needles’, can beanother component of pain.

The pain symptoms of CRPS are commonlyexacerbated by cold and movement, particularly

passive movement. Holding the hand down in adependent position also increases pain (as well asincreasing swelling and causing discoloration).

2. Oedema

Swelling is a common but not universal feature ofCRPS. Its presentation can vary from mild tomarked and it tends to be unresponsive to conven-tional treatment methods such as massage andcompression. Indeed, these measures often worsenthe oedema or frequently cannot be tolerated asthey exacerbate pain. Loss of skin creases, partic-ularly on the dorsum of the interphalangeal joints,is commonly observed (Fig. 18.2).

3. Stiffness

When the joints of the hand are swollen and eachattempt at movement results in pain, stiffness canrapidly ensue; this applies particularly to the olderpatient or one with a complex injury.

Persisting oedema results in soft tissue fibrosiswhich impedes tendon glide and intrinsic musclefunction. Periarticular thickening is another con-sequence of longstanding oedema.

4. Autonomic dysfunction

Most CRPS patients exhibit some degree ofvasomotor dysfunction (Pollock et al., 1993). Theaffected hand will be ‘hot’ (vasodilation) or ‘cold’(vasoconstriction) to the touch, may sweat pro-fusely (hyperhidrosis) or be dry (anhidrosis).

Figure 18.1. Stiffness and disuse that have becomeentrenched over many months cannot be reversed byconservative measures. Early recognition of CRPS andappropriate intervention are essential to ensure asuccessful treatment outcome.

Figure 18.2. Chronic regional pain syndrome of recentonset. Note the gross oedema, lack of skin creasesover the joints and the sheen of the skin.

Chronic regional pain syndrome 229

The hand may also be discoloured, i.e. red, blueor purple, and often has a mottled appearance. Thisbecomes more marked when the hand is dependentand often reverses dramatically when the hand isthen elevated. Distinct red areas are sometimespresent over the dorsum of the index and middlefinger MCP joints.

5. Trophic changes

These changes involve skin, nails, hair and bone.The skin frequently has a glossy appearanceresulting from nutritional changes. The fat pads atthe tips of the fingers atrophy, causing the nails tocurve downward, thus giving a ‘pencil-pointing’appearance. Flattening of the cuticle base and rugaepattern may be observed. The nails can becomethickened and rigid and the hair may coarsen.

Osteoporosis results from demineralization andbecomes evident on X-rays at about the 5th week.In the early stages of the disease, osteoporosis isseen in the polar region of the long bones, i.e. themetacarpal and phalangeal bones. In advancedcases of CRPS, osteoporosis is evident in thecarpal bones.

Possible triggers of CRPS

While CRPS can result from a trivial injury, thereare certain injuries, surgical procedures or irritationof specific nerves that result in a higher incidenceof this condition. They include:

1. Distal radial fractures which frequently affectthe median nerve and require prolonged castimmobilization.

2. Carpal tunnel decompression where there canbe injury to the palmar cutaneous branch of themedian nerve.

3. Decompression of the first dorsal compartmentfor de Quervain’s syndrome where there can beinjury to the superficial branch of the radialnerve.

4. Palmar fasciectomy for Dupuytren’s disease(incidence of about 7 per cent in Australia).

5. Injury to the dorsal branch of the ulnar nerveduring procedures involving the distal ulna orfrom trauma to this area.

6. Digital amputations with neuroma formation.


Whilst this condition can occur in patients rangingin age from the late teens to the elderly, the average

age is 45 years. Women develop this conditionthree times more often than men. There is astatistical relationship to smoking. This syndromecan be confined to a single digit, involve the wholehand and occasionally, the entire upper limb.

It can sometimes be difficult to distinguish thesigns and symptoms of a CRPS from those thataccompany any significant hand trauma.

The therapist should suspect the onset of CRPSif:

1. Symptoms of pain, stiffness and swelling do notbegin to subside after several weeks of handtherapy.

2. There is a sudden increase in the abovesymptoms that cannot readily be explained, e.g.by overuse of the hand on the previous day.Hand oedema that worsens in the early eveningand subsides by morning can also be anindicator.

3. The patient suddenly exhibits or reports signs orsymptoms that have been previously absent,e.g. sensations of burning or heat, mottling ofthe skin, excessive sweating or swelling thatcannot be accounted for.

4. A patient who has not had nerve damage reportsaltered sensory perception, e.g. when touchingthe face or hair, the patient will describe thetexture as being ‘rough’ in comparison to theunaffected hand.

Diagnostic testing

The diagnosis of CRPS is usually made on clinicalfindings. Investigations that can help confirm thediagnosis include:

1. X-ray which will show osteoporosis after the5th week (Bickerstaff et al., 1991).

2. Bone scan.3. The ‘skin wrinkle test’ for the assessment of

sympathetic function (Vasudevan et al., 2000).4. Diagnostic blocks such as a stellate ganglion or

somatic nerve block. A positive response willindicate that pain is being sympatheticallymaintained and that the use of oral sym-patholytic drugs is indicated.

Treatment

The patient with CRPS is generally managed bestby a team approach. The members of this teamshould include: the specialist, the patient’s family


practitioner, a pain specialist (anaesthetist) and ahand therapist. Most cases of CRPS will reversequite quickly after suitable treatment strategieshave been instituted. Where the condition isprolonged and is impacting on the patient’s copingmechanisms and affecting family/work dynamics,the inclusion of a psychologist and rehabilitationconsultant may be warranted. There are commonlythree components to patient management:

1. Hand therapy.2. Pharmacological intervention (non-invasive

and invasive).3. Psychological support.

In a small number of patients, surgery may beindicated.

Hand therapy

The hand therapist has frequent and close contactwith the patient and is often the first to recognisethe signs and symptoms of CRPS. If the specialistfavours a conservative approach to management,the patient will be started on transcutaneous nervestimulation (TENS) and the active ‘stress-loadingprogramme’ described by Watson and Carlson(1987). If the response to TENS is favourable, thepatient is loaned a unit for home use. The therapyprotocol will need to address the entire upper limbto avoid restriction of shoulder movement fromsecondary adhesive capsulitis.

The ‘stress-loading’ programme comprises trac-tion and compression exercises that provide stress-ful stimuli to the extremity without joint motion.This programme has been used for 30 years. It issimple to execute, non-invasive and appropriatelyplaces some onus of care onto the patient.

Until pain, swelling and autonomic signs haveabated, all other hand therapy treatment modalitiesare delayed. Prior to commencement of theprogramme, the patient is warned that increasedpain and swelling are a typical response for thefirst few days and generally settle.

Method

The ‘compression’ exercise requires a scrubbingbrush. The patient assumes the quadruped position.The scrubbing brush is held in the affected handand the patient begins scrubbing a smooth surfacesuch as plywood board using a backward-forwardmotion. The patient should lean over the arm andmaintain elbow extension (Fig. 18.3).

Where it is impractical or difficult for the patientto assume this position, scrubbing can be per-formed on a tabletop. The motion should becontinued for 3 minutes and be performed threetimes daily. After several days, the sessions areincreased to 5 minutes, and then to 7 minutes aftera fortnight. The upgrading of the programmeshould be commensurate with the patient’s abilityto cope.

The ‘traction’ component of the programme isachieved by carrying a lightly weighted bagwhenever the patient is standing or walking. Forease of grasp, rubber insulation tubing can be cutand taped over the handles of a disposable plasticbag. The tubing provides an enlarged, comfortableand slip-resistant ‘handle’. The initial weight in thebag is approximately 0.5 kg; this is graduallyincreased to a 2.5 kg weight (Fig. 18.4).

Other therapy measures

When pain has begun to subside, appropriatetherapy measures to overcome residual oedemaand stiffness are commenced. These measures are

Figure 18.3. The ‘compression’ component of the‘stress-loading’ programme involves the patientassuming the quadruped position and scrubbing asmooth surface using a backward-forward motion withthe elbow extended and the patient leaning over thearm. This motion is initially performed for 3 minutes,three times a day.


introduced gradually and response to them isassessed to avoid exacerbation of the condition.

Pressure garments

Pressure gloves or compression wraps for oedemaare used cautiously as they frequently aggravatepain and/or swelling. They should be worn forshort periods initially, i.e. 15 to 30 minutes. If thereis no adverse response, the wearing time isincreased.

Exercise

Exercise should commence with active rather thanpassive motion as the latter often provokes pain.When passive exercise is commenced, it is bestperformed by the patient rather than thetherapist.

If wrist stiffness is a problem, priority is given toregaining extension so that finger flexion can beoptimized. The wrist can be serially splinted usinga volar plaster which is held in place with a crepebandage. A wrist that is comfortably supported isalso less painful (Fig. 18.5).

The exercise regimen should be performedhourly and include all upper limb joints. Repeatedactive movement of the more proximal jointscannot be overemphasized. Exercise involving thefingers and thumb should be carried out in asustained and systematic fashion with emphasis onstabilized interphalangeal joint exercises.

Splinting

The MCP joints are frequently stiff and mayrequire a dynamic flexion splint. Interphalangealjoint finger stiffness can be overcome by gentlybandaging the hand into flexion with a wide crepebandage and immersing the hand in warm waterfor 15-minute periods several times a day. Thiscombination of stretch and warmth is highlyeffective in increasing joint flexibility prior toactive finger flexion exercises.

Opsite Flexifix

Over the past 18 months, the author has been usingOpsite Flexifix to help manage the causalgic painthat many CRPS patients experience (Boscheinen-Morrin and Shannon, 2000). The use of Opsite inthis way follows from a study carried out by theKing’s College Hospital in London (Foster et al.,1994). It concluded that Opsite used on unbrokenskin in diabetics was effective in relieving the painof peripheral neuropathy. The Opsite is applied tothose areas of the hand which are most sympto-matic (Fig. 18.6).

Figure 18.4. The ‘traction’ component of theprogramme involves carrying a lightly weighted bagwhenever standing or walking. For ease of grasp,insulation tubing is cut open and taped over thehandles of a disposable plastic bag.

Figure 18.5. Where wrist stiffness is a problem, serialplaster splinting to restore extension is important tofacilitate finger flexion.


Functional activity

The patient is encouraged to use the affected handin appropriate normal daily activity. Activity iscarefully upgraded in accordance with the patient’sprogress. The ‘stress-loading’ programme can bescaled back as improvement is noted. The time-frame of management will vary from patient topatient; however, the programme should be reinsti-tuted at the first sign that symptoms of CRPS maybe recurring.

Psychological implications

Chronic regional pain syndrome is a distressingcondition. Apart from the physical discomfort, thepatient is unable to engage in normal work andrecreational activities and relationships with familyand friends soon become strained. These patientsfrequently become depressed if the conditionpersists for more than a few weeks. If this is thecase, referral to a psychologist or psychiatrist isindicated.

Pharmacological treatment

The pharmacological approach to managing CRPSis complex and under constant review (Czop et al.,1996). Drugs are often used in combination withone another or with intravenous regional sym-pathetic blocks.

The following categories of drugs are used:

1. Antidepressants – the most commonly used arethe tricyclic group, e.g. Tofranil, Sinequan.

2. Anticonvulsants – e.g. Dilantin, Tegretol.3. Membrane-stabilizing agents – e.g. Lidocaine.4. Calcium channel blockers – such as Procardia

and Norvasc which are arterial vasodilators.5. Corticosteroids – e.g. prednisone.6. Adrenergic compounds – such as Catapress and

Dibenzyline.

As with any drug, patients need to be carefullyscreened for suitability prior to prescription andthen monitored for potential side effects.

Regional intravenous sympathetic block

The Hannington-Kiff blockade (1974) for sym-pathetic pain is a modification of the analgesicdrug infusion described by Bier in 1908. Theseblocks, using intravenous drugs such as guanethi-dine (Field et al., 1993), reserpine and bretyliumtosylate, usually need to be repeated 3 to 5 times at2 to 3 week intervals. Their therapeutic effectusually becomes apparent 2 to 3 days followinginfusion when hand therapy techniques can beemployed with maximum efficacy. Guanethidineand reserpine are no longer available in the UnitedStates.

Surgery

When the clinical signs and symptoms of CRPShave settled, surgery may be necessary to correctthe neural or mechanical trigger of the painsyndrome, i.e. a neuroma may require resection orthe median nerve may require further decompres-sion. Other patients may need to undergo release ofsecondary joint contractures. All surgical patientswill require sympatholytic medication during andafter surgery to avoid potential recurrence of theirsymptoms.

For patients with an entrenched pain syndrome,the place of chemical or surgical sympathectomy iscontroversial.

References

Bickerstaff, D. R., O’Doherty, D. P. and Kanis, J. A. (1991).Radiographic changes in algodystrophy of the hand. J. HandSurg., 16B, 47–52.

Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix:an effective adjunct in the management of pain andhypersensitivity in the hand. Aust. J. Occ. Ther., (submittedfor publication).

Covington, E. C. (1995). Psychological issues in reflexsympathetic dystrophy. In Reflex Sympathetic Dystrophy: A

Figure 18.6. To help relieve the ‘burning’ sensationsin this gentleman’s hands following bilateral opencarpal tunnel decompression, Opsite Flexifix wasapplied to the reddened areas of discomfort. The areaof application is outlined.


Reappraisal. Progress in Pain Research and Management.Vol. 6 (W. Jaenig and M. Stanton-Hicks, eds) pp. 191–215,IASP Press.

Czop, C., Smith, T. L., Rauck, R. and Koman, L. A. (1996). Thepharmacologic approach to the painful hand. Hand Clin., 12,633–42.

Field, J., Monk, C. and Atkins, R. M. (1993). Objectiveimprovements in algodystrophy following regional intra-venous guanethidine. J. Hand Surg., 18B, 339–42.

Foster, A. V. M., Eaton, C., McConville, D. O. and Edmonds,M. E. (1994). Application of Opsite film: a new and effectivetreatment of painful diabetic neuropthy. Diab. Med., 11,768–72.

Jaenig, W. (1995). The puzzle of ‘reflex sympathetic dys-trophy’: mechanisms, hypotheses, open questions. In ReflexSympathetic Dystrophy: A Reappraisal. Progress in PainResearch and Management. Vol. 6 (W. Jaenig and M.Stanton-Hicks, eds) pp. 1–24, IASP Press.

Koman, L. A., Smith, T. L., Smith, B. P. and Li, Z. (1996). Thepainful hand. Hand Clin., 12, 757–64.

Koman, L. A., Poehling, G. G. and Smith, T. L. (1999).Complex regional pain syndrome: reflex sympathetic dys-trophy and causalgia. In Green’s Operative Hand Surgery(D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) pp.636–66, Churchill Livingstone.

Merskey, H. and Bogduk, N. (1994). Classification of chronicpain. Descriptions of chronic pain syndromes and definitionsof pain terms. Prog. Pain Res. Management, 1, 39–43.

Pollock, F. E. Jr., Koman, L. A., Smith, B. P. and Poehling, G.G. (1993). Patterns of microvascular response associatedwith reflex sympathetic dystrophy of the hand and wrist. J.Hand Surg., 18A, 847–52.

Watson, H. K. and Carlson, L. (1987). Treatment of reflexsympathetic dystrophy of the hand with an active ‘stressloading’ program. J. Hand Surg., 12A, 779–85.

Vasudevan, T. M., van Ru, A. M., Nukada, H. and Taylor, P. K.(2000). Skin wrinkling for the assessment of sympatheticfunction in the limbs. Aust. N. Z. J. Surg., 70, 57–9.

Further reading

Amadio, P. C., Mackinnon, S. E., Merritt, W. H., et al. (1991).Reflex sympathetic dystrophy syndrome: consensus report ofan ad hoc committee of the American Association for HandSurgery on the definition of reflex sympathetic dystrophy.Plast. Reconstr. Surg., 87, 371–5.

Atkins, R. M., Duckworth, T. and Kanis, J. A. (1990). Features

of algodystrophy after Colles’ fracture. J. Bone Joint Surg.,72B, 105–10.

Blanchard, J., Ramamurthy, S. Walsh, N., et al. (1990).Intravenous regional sympatholysis: a double-blind compar-ison of guanethidine, reserpine and normal saline. J. PainSymp. Management, 5, 357–61.

Boas, R. A. (1995). Complex regional pain syndromes:symptoms, signs and differential diagnosis. In Reflex Sym-pathetic Dystrophy: A Reappraisal. Progress in PainResearch and Management Vol. 6, (W.Janig and M. Stanton-Hicks, eds) pp. 79–92, IASP Press.

Bohm, E. (1978). Transcutaneous electrical nerve stimulation inchronic pain after peripheral nerve injury. Acta Neurochir.,40, 277–87.

Campbell, J. N., Raja, S. N., Selig, D. K., et al. (1994).Diagnosis and management of sympathetically maintainedpain. Prog. Pain Res. Management, 1, 85–100.

Dobyns, J. H. (1991). Pain dysfunction syndrome. In OperativeNerve Repair and Reconstruction (R. H. Gelberman, ed.) pp.1489–96, J. B. Lippincott.

Duncan, K. H., Lewis, R. C., Racz, G. and Nordyke, M. D.(1988). Treatment of upper extremity reflex sympatheticdystrophy with joint stiffness using sympatholytic Bierblocks and manipulation. Orthopaedics, 11, 883–6.

Feinmann, C. (1985). Pain relief by anti-depressants: possiblemodes of action. Pain, 23, 1–8.

Grundberg, A. B. (1996). Reflex sympathetic dystrophy:treatment with long-acting intramuscular corticosteroids. J.Hand Surg., 21A, 667–70.

Jupiter, J. B., Seiler, J. G. and Zienowicz, R. (1994).Sympathetic maintained pain (causalgia) associated with ademonstrable peripheral nerve lesion. J. Bone Joint Surg.,76A, 1376–84.

Melzack, R. (1975). Prolonged relief of pain by brief, intense,transcutaneous somatic stimulation. Pain, 1, 357–73.

Mullins, P. (1992). Reflex sympathetic dystrophy. In Conceptsin Hand Rehabilitation (B. Stanley and S. Tribuzi, eds) F. A.Davis.

Ochoa, J. L. (1992). Reflex sympathetic dystrophy: a disease ofmedical understanding. Clin. J. Pain, 8, 363–6.

Saplys, R., Mackinnon, S. E. and Dellon, A. L. (1987). Therelationship between nerve entrapment versus neuromacomplications and the misdiagnosis of de Quervain’s disease.Contemp. Orthop., 15, 51–7.

Walsh, M. T. (1995). Therapist’s management of reflexsympathetic dystrophy. In Rehabilitation of the Hand:Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D.Callahan, eds) pp. 817–33, Mosby.

Index

A1–A5 pulleys, 28A2 pulley splitting for ulnar nerve palsy, 78Abdominal flaps, 211, 215Abductor digiti minimi deformity, 66Active exercise, 18Active range of motion, 4Active short arc motion protocol, 49–50Activities of daily living, 11

aids, 26, 186Age and fracture outcome, 127, 146–7‘Alloderm’, 222Allodynia, 228Amputation, 175–82, 225

classification, 175complications, 178postoperative therapy, 178–80psychological aspects, 176–7reconstruction, 180–1, 225surgical technique, 178

Angiogenesis, 16Annular pulleys, 28Anterior interosseus syndrome, 91Arm:

dynamic rotation splint, 156flaps, 212muscle fibre length, 72rotation exercises, 155–6

Arthritis, post-traumatic, 152Arthrodesis, 186–8, 200Arthrolysis, 139Arthroplasty, 188–93, 199–200Arthroscopy, 146, 152, 168, 170Assessment, 1–13Axonotmesis, 59Axons, 57

Ballottement test, 168Bandages, 21, 22Barton’s fracture-dislocation, 147, 148Bennett’s fracture, 130Bone:

grafts, 215–16healing, 121–2scans, 146, 157, 161, 168

Bouchard’s nodes, 183Bouquet osteosynthesis, 124Bouvier’s manoeuvre, 66Bower’s hemiresection interposition arthroplasty,

172Brachial plexus:

gliding exercises, 87, 88injuries, 216

Burns, 219–25amputation, 225chemical, 220claw deformity, 222complications, 221depth, 220–1electrical, 220exercise, 223friction, 220hand therapy, 222–4nail bed deformities, 225oedema control, 222pathophysiology, 219pressure therapy, 224psychological aspects, 224reconstruction, 224–5scar management, 224skin care, 224skin grafts, 222

236 Index

Burns – continuedsplinting, 222, 223–4thermal, 220

Buttonhole deformity, 48, 196

C1–C3 pulleys, 28Callotasis, 181Callus formation, 121Camitz palmaris longus opponensplasty, 75Capener splint, 20Capitate fractures, 163Capitate–lunate instability pattern, 169Capsulodesis of metacarpophalangeal joint, 77–8Caput ulna syndrome, 195Carpal dislocations, 163–4Carpal fractures, 157–63Carpal instability, 164–9

grading, 166Carpal ligaments, 144–5Carpal tunnel syndrome, 84–90

assessment, 85–6autonomic findings, 86causes, 83, 86, 152motor signs, 86

nerve gliding exercises, 87presentation, 85splints, 86–7stages, 86, 87, 88surgical decompression, 88–90

complications, 89endoscopic, 89open, 88postoperative exercises, 89postoperative pillar pain, 90return to activities, 90scar hypersensitivity, 90scar management, 89

Carpometacarpal joint, first:arthrodesis, 186–7arthroplasty, 188–9

Carpus, 144ulnar translocation, 195

Causalgia, 227Chemical burns, 220Chronic regional pain syndrome, 227–33

causes, 152, 229diagnosis, 229drug therapy, 232exercises, 230, 231functional activity, 232hand therapy, 230–2nail changes, 229oedema, 228

Opsite Flexifix management, 231, 232osteoporosis, 229pain, 228phases, 227–8presentation, 229pressure garments, 231psychological aspects, 228, 232reversal, 228signs and symptoms, 228–9skin changes, 229splinting, 231stiffness, 228surgery, 232sympathetic block, 232vasomotor dysfunction, 228–9

Clam-digger position, 118, 123Claw hand, 66, 222CLIP, 169Coban wrap, 18–19Colles’ fracture, 147, 149Complex hand injuries, 203–10

blood flow restoration, 204emergency free flaps, 217exercises, 206–7fracture management, 205functional activity, 209hand therapy, 206–9infection prevention, 204–5oedema management, 206prognosis, 203psychological aspects, 203reconstruction, 205scar management, 208–9splinting, 207–8vocational assessment, 209wound management:

closure, 205debridement, 204dressing, 204–5

Compression exercises, 230Compression screws, 120Computed tomography, 146, 147, 157Contact inhibition, 16Corticosteroid injections, 100–1, 103Crepe bandages, 22Cruciate pulleys, 28Cubital tunnel percussion test, 91Cubital tunnel syndrome, 92–5

nerve gliding exercises, 92, 93spontaneous resolution, 92surgical options, 92–4

postoperative nerve gliding exercises, 94scar hypersensitivity, 95scar management, 94

Index 237

Daily living, 11aids, 26, 186

Darrach procedure, 171–2, 199de Quervain’s disease, 99, 102–4

aetiology, 102corticosteroid injections, 103diagnostic test, 102, 103differential diagnosis, 102–3presentation, 102splinting, 103surgery, 103–4

Debridement, 204Dermofasciectomy, 110Diabetes, 83, 100Digit, see Finger; ThumbDisk-Criminator, 9Dislocation:

carpal, 163–4distal radioulnar joint, 169–70proximal interphalangeal joint, 135–8

Distal interphalangeal joint:flexion range measurement, 5fusion, 187

Distal radial fracture, 146–57arthroscopy, 152assessment, 147classification, 147–8closed reduction:

K-wire fixation, 148, 150plaster immobilization, 148

complications, 152external fixation, 150–2immobilization, effects of, 153–4open reduction and internal fixation, 150outcome, 146–7therapy:

during fixator immobilization, 151–2during immobilization after closed reduction,

152–3on cast removal, 153–6

Distal radioulnar joint, 143, 145, 169–72dislocation, 169–70fractures, 169osteoarthritis, 171–2

Distraction lengthening, 181Double crush syndrome, 83Dressings, 16Duchenne’s sign, 66Dupuytren’s contracture, 107–115

aetiology, 107defined, 107presentation, 107–8surgery:

complications, 111

contraindications, 109incisions, 109indications, 109oedema management, 112–13outcome, 109postoperative exercises, 113–14postoperative management, 111–14postoperative splints, 113procedures, 110–11scar management, 113skin closure, 111wound care, 112

Dynamometer, 10–11

Elbow flexion test, 91Elderly, 127, 146–7Electrical burns, 220Endoneurium, 57Endotenon, 27Epicondylectomy, 93Epineurium, 57–8Epitenon, 27Epithelial cells, 15–16Evaluation, 1–13Examination:

physical, 2–3tactile, 2–3visual, 2

Exercises, 17–18active, 18passive, 18

Extensor carpi radialis longus transfer, 76–7Extensor carpi ulnaris tendon:

inflammation, 104subluxation, 170

Extensor digitorum communis, 44Extensor indicis proprius opponensplasty, 75Extensor pollicis longus rupture following distal

radial fracture, 152Extensor tendon, 43–56

anatomy, 43–5repair, 45–6, 198

postoperative management, 46zones, 45–54

I and II, 46–8, 54III and IV, 48–50, 54V and VI, 50–3, 54VII, 54

Exudates, 15–16

Family involvement, 17Fascial flaps, 213–14

238 Index

Fasciectomy, 110Fasciocutaneous flaps, 212–13Fasciotomy, 110Fibroblasts, 16, 29Fibula, bone harvesting, 216Finger:

flexion range, 4functions, 176scissoring, 122tip injuries, 177–8ulnar drift, 195–6web span measurement, 5

Finkelstein test, 102, 103‘Flare’ reaction, 112Flexor carpi radialis transfer, 79Flexor carpi ulnaris:

tendovaginitis, 104transfer, 79, 80–1

Flexor digitorum superficialis exercise, 34Flexor pollicis longus repair, 38Flexor pulley advancement, 78Flexor retinaculum, 84Flexor tendon, 27–42

anatomy, 27–8blood supply, 28, 29healing, 29nutrition, 28–9pulleys, 27–8reconstruction, 40–1repair, 29–40, 198–9

active motion protocols following, 32–3contraindications, 29early mobilization following, 31exercises, 33–4, 35–8oedema management, 34postoperative management, 31–8scar management, 35splints, 33technique, 29–30timing, 29zones, 30–1

sheath, 27repair, 29

synovial fluid, 28–9Forearm:

dynamic rotation splint, 156flaps, 212rotation exercises, 155–6

Fracture, 117–32, 205assessment, 117callus formation, 121carpal, 157–63classification, 117–18complications, 120–1

fixation methods, 119–20external, 120intramedullary, 120screws, 120wires, 119–20

healing, 121–2in elderly, 127, 146–7metacarpal, 122–5open reduction and internal fixation, 119–20phalangeal:

distal, 129–30proximal and middle, 125–9

plates, 120position of safe immobilization, 118proximal interphalangeal joint, 138–9radioulnar joint, distal, 169radius, distal, 146–57stable, 118thumb, 130–1unstable, 119–20

Free tissue transfer, 211–18advantages, 212free flap choice, 212–17in emergency, 217postoperative care, 214, 216, 217problems, 212

Friction burns, 220Froment’s sign, 66Functional assessment, 11

Gnosis tests, 9–10Goniometers, 5–6Grip strength, 10–11Groin flaps, 211, 212Guyon’s space, 84

Haemachromatosis, 183Haldex gauge, 4Hamate fractures, 162–3Hand:

bathing, 154prostheses, 181–2sensory innervation, 7ulnar border hyperaesthesia, 66

Handitube, 26Hannington–Kiff blockade, 232Healing process, 15–17, 29, 73, 121–2Heberden’s nodes, 183Herbert ceramic ulnar head, 172History taking, 1Hitch-hiker’s test, 102Hormonal changes, 83, 86

Index 239

Hulten’s variance, 143–4Hydrogen fluoride burns, 220Hyperalgesia, 228Hyperhidrosis, 3

Iliac crest, bone harvesting, 216Imbibition, 28Index finger:

abduction, tendon transfer for, 79function, 176

Inflammatory disease, 99, see also Rheumatoidarthritis

Inflammatory phase of healing, 15–16, 29, 121Innervation density tests, 8–9Interossei:

dorsal, 44volar, 44

Interphalangeal joint, see Distal interphalangealjoint; Proximal interphalangeal joint

Intrinsic plus position, 118, 123Ischaemia in compression neuropathies, 86

Jamar dynamometer, 10–11Joint stiffness, 3, 139

Kienboeck’s disease, 161–2Kirschner wires (K-wires), 119Kleinert regimen, 31

Lag screws, 120Little finger function, 176Lumbricals, 44Lunate fractures, 161–2Lunotriquetral dissociation, 168–9Lycra, 21, 22

Magnetic resonance imaging, 146, 157, 161, 170Mallet finger, 46–8Mallet thumb, 54Mannerfelt’s lesion, 198Manual muscle testing, 11Massage, 154, 208Medial epicondylectomy, 93Median nerve:

branches, 84–5compression, 84–91gliding exercises, 87lesion, 64–5

opponensplasty for, 73–5sensory retraining after, 68–9

sensory innervation, 7

Metacarpal:distraction lengthening, 181fracture, 122–5

Metacarpophalangeal joint:capsulodesis, 77–8contracture, 108dorsal hood, 43dynamic flexion splinting, 193implant arthroplasty, 192–3thumb, 140volar subluxation/dislocation, 195–6

Microenvironmental dressings, 16Microfoam, 21, 22Midcarpal instability, 169Midcarpal joint, 143Middle finger function, 176Minimal active muscle-tendon tension, 53Moberg pick-up test, 9–10Monkey hand, 64Monofilaments, 7–8Motor fibres, 57Multiple crush syndrome, 83Muscle:

atrophy, 60fibre length, 72fibrosis, 60flaps, 214–15

functional, 216–17manual testing, 11

Myelin sheaths, 57Myofibroblasts, 16

Nail bed deformities, 225Nail changes:

chronic regional pain syndrome, 229nerve injury, 60

Neoprene, 21, 22–3Nerve:

anatomy, 57–8axonal transport, 57axonotmesis, 59blood supply, 58–9compression, 83–98

causes, 83–4clinical features, 84diagnosis, 84

conduction velocity, 6, 8degeneration, 60fibres, 57gliding exercises, 87, 88, 92, 93, 94, 96injury types, 59–60lesions, see specific nervesmedian, see Median nerve

240 Index

Nerve – continuedmotor fibres, 57myelin sheaths, 57neurapraxia, 59neurotmesis, 59–60nodes of Ranvier, 57radial, see Radial nerveregeneration, 60, 61

monitoring, 10repair, 60–4

epineurial, 61fascicular/perineurial, 61healing, 61patient education, 62postoperative management, 61–4scar management, 62sensory retraining after, 68–9

sensory fibres, 57sutures, 61ulnar, see Ulnar nerve

‘Neuflex’ prosthesis, 188Neurapraxia, 59Neurotmesis, 59–60Ninhydrin sweat test, 10‘No man’s land’, 30Nodes of Ranvier, 57Nodules, 3

Obesity, 86Oblique retinacular ligament, 44–5Occupation, 86Oedema:

acute/chronic differentiation, 3Coban wrap, 18–19fluctuation, 6management, 16, 18–19measurement, 6transudate, 15

Oil massage, 154, 208Open wound technique, 111Opponensplasty, median nerve palsy, 73–5

Camitz palmaris longus, 75extensor indicis proprius, 75superficialis of ring finger, 73–5

Opsite Flexifix, 24–5, 231, 232Osteoarthritis, 171–2, 183–93

distal radioulnar joint, 171–2drug therapy, 184functional assessment, 186hand therapy, 184–5pathogenesis, 183–4signs and symptoms, 171, 184surgery, 171–2, 186–93

Osteoporosis, 147, 229Osteotomy, wedge/rotation, 123–4

Pain, 15and inflammation, 15assessment, 3–4-reducing dressings, 16, 19, 24–5scales, 4

Palmar aponeurosis pulley, 27Palmar fasciitis, 152Palpation, 3Parascapular skin flaps, 212Paratenon, 27Passive exercise, 18Passive range of motion, 4Patient education, 62, 203Pedicled reconstruction, 211Perilunate dislocation, 163–4Perineurium, 57Phagocytosis, 15Phalanges:

distraction lengthening, 181fractures:

distal, 129–30proximal and middle, 125–9

Phalangization, 225Phalen’s test, 85–6Physical examination, 2–3Pick-up test, 9–10Pillar pain, 90Pilon fracture, 138–9Pinch grip, 11Pisiform, 143Place and hold exercises, 36Point localization, 9Position of function, 205Position of safe immobilization, 118, 123, 222Posterior interosseus nerve syndrome, 95Power grip, 10–11Pressure therapy, 22, 224, 231Pronator syndrome, 90–1Prostheses, 181–2Proximal interphalangeal joint:

anatomy, 133–4assessment, 134–5collateral ligaments, 133–4contracture, 108–9dislocation, 135–8flexion deformity prevention, 19, 34–5, 125,

136, 223fractures, 138–9fusion, 187implant arthroplasty, 189–92

Index 241

signs and symptoms of injury, 134surgery, 139–40volar plate, 134

Psychological aspects, 11–12, 176–7, 203, 224,228, 232

Pulleys, 27–8advancement, 78

Radial forearm flaps, 212Radial fracture, see Distal radial fractureRadial nerve:

compression, 95–6superficial, 96

gliding exercises, 96lesion, 66–8, 79

splinting, 67–8tendon transfer, 79–81

sensory innervation, 7Radial tunnel syndrome, 95–6Radiocarpal joint, 143Radiographs, 117, 135, 146, 147, 157, 161,

165–6, 168, 170Radioulnar joint, distal, 143, 145, 169–72

dislocation, 169–70fractures, 169osteoarthritis, 171–2

Radius:bone harvesting, 216fracture, see Distal radial fracturetilt and inclination, 143

Range of motion, 4–6active, 4passive, 4torque, 4

Reconstruction, 40–1, 180–1, 205, 224–5, seealso Free tissue transfer

Reflex sympathetic dystrophy, 227Regenerative phase of healing, 16Remodelling, 16–17, 29, 122

splints, 20Retinacular ligaments, 44–5Rheumatoid arthritis, 193–200

deformities, 195–7drug therapy, 194hand therapy, 194–5phases, 194surgery, 197–200

arthrodesis, 200arthroplasty 199–200Darrach procedure, 199soft tissue reconstruction, 200tendon repair/transfer, 198–9tenosynovectomy/synovectomy, 197–8

Ring finger:function, 176superficialis opponensplasty, 73–5

Rolando’s fracture, 130–1

Sauve–Kapandji procedure, 172Scaphoid, 144

blood supply, 157fractures, 157–60

diagnosis, 157open reduction and internal fixation, 159–60presentation, 157salvage procedures, 160short arm cast, 159Watson scaphoid shift test, 165

Scapholunate advanced collapse deformity, 164Scapholunate dissociation, 164–8

assessment, 165–7conservative treatment, 167presentation, 165

late with arthritis, 167–8radiology, 165–6surgery, 167

Scapholunate ligament, 145Scapular skin flaps, 212Scar:

management:Coban wrap, 19silicone gel, 23–4

palpation, 3remodelling, 16–17

Scissoring of digits, 122Semmes–Weinstein monofilaments, 7–8Sensibility testing, 6–10Sensory fibres, 57

lesions, 60Sensory retraining, 68–9Serial casting, 19‘Shear’ test, 168Silicone gel, 23–4Simian hand, 64Skeletal reconstruction, 215–16Skier’s thumb, 140–1Skin:

denervation, 60, 64dryness, 3nodules, 3palpation, 3sweating, 3swelling, see Oedematactile adhesion reduction, 60temperature, 3, 60thickening, 3wrinkle test, 10, 229

242 Index

SLAC wrist, 164Smith’s fracture, 147Soft splints, 21–3Soft tissue:

palpation, 3reconstruction/intrinsic release, 200

Splinting, 19–23dynamic/static, 19principles, 20–1remodelling splints, 20serial, 19soft splints, 21–3

Sports, carpal fractures, 162–3Steroid injections, 100–1, 103Stiffness, 3, 139Stress-loading programme, 230Sugar tong splint, 169Superficialis:

opponensplasty, 73–5transfer, 77, 79

Swan-neck deformity, 47, 196Swanson silicone caps, 172Sweat test, 10Sweating, 3Swelling, see OedemaSympathetic block, 232Synovectomy, 197–8Synovial sheath, 27

Tactile adhesion reduction, 60Tactile examination, 2–3Tactile gnosis tests, 9–10Temperature of skin, 3, 60Temporoparietal fascia, 214Tendon:

adherence, 155constriction, 99–104endotenon, 27epitenon, 27extensor, see Extensor tendonflexor, see Flexor tendonfunction, 27glide exercises, 39inflammation, 99paratenon, 27reconstruction, 40–1repair, see under Extensor tendon; Flexor

tendonstress effects, 27transfer, 71–82, 198–9

contraindications, 71healing, 73

junctions, 73pathway, 72preoperative preparation, 71prerequisites, 71single/dual, 72tendon choice, 71–2tension, 72–3

Tenodesis effect, 5Tenodesis, static, 78Tenodesis manoeuvre, 36–7Tenolysis, 38–40Tenosynovectomy, 197–8Tenosynovitis, 99, 197Terry Thomas sign, 164, 165Therapists, 17Thermal burns, 220Thumb:

adduction restoration, 78–9carpometacarpal joint:

arthrodesis, 186–7arthroplasty, 188–9

deformities, 196–7extensor injuries, 54–5fractures, 130–1function, 175–6joint injuries, 140–1mallet thumb, 54metacarpophalangeal joint, 140reconstruction using toe, 180–1, 213, 225skier’s thumb, 140–1ulnar nerve palsy, 78–9web contractures, 223, 224–5web span measurement, 5

Tinel’s sign, 10, 86, 91Toe:

transplantation, 180–1, 213, 225web space flaps, 212–13

Tomography, 146, 147, 157Torque range of motion, 4Touch, see Tactile headingsTraction, 120

exercises, 230Transcutaneous electrical nerve stimulation

(TENS), 25–6, 230Trans-scaphoid perilunate dislocation, 163–4Transudate oedema, 15Transverse carpal ligament, 84, 85Transverse retinacular ligament, 44Trapezium excision, 188–9Treatment tools, 17–26Triangular fibrocartilage complex, 145

tears, 170Triangular ligament, 45Trick movements, 65, 66, 67

Index 243

Trigger finger/thumb, 99–102corticosteroid injections, 100–1presentation, 100splinting, 101surgery, 101–2

Triquetro–hamate–capitate ligament laxity, 169Triquetrum fractures, 160–1Two-point discrimination/localization, 8–9

Ulnar carpal impingement, 170–1Ulnar carpal instability, 168Ulnar collateral ligament injury, 140–1Ulnar forearm flaps, 212Ulnar head:

dorsal subluxation, 195prosthesis, 172

Ulnar nerve:compression, 91–5

assessment, 91–2presentation, 91

gliding exercises, 92, 93, 94lesion, 66, 75

tendon transfer, 76–8thumb adduction restoration, 78–9

sensory innervation, 7Ulnar tunnel syndrome, 95Ulnar variance, 143–4

Vincular blood supply, 28, 29Visual examination, 2Vocational rehabilitation, 209Volar plate, 134suluxation/dislocation, 195–6Volkmann’s ischaemic contracture, 216Volumeter, 6

Waking numbness, 85Wallerian degeneration, 60Wartenburg syndrome, 96Washington regimen, 32Watson scaphoid shift test, 165Web space;

contractures, 223, 224–5deepening, 225flaps, 212–13

Web span measurement, 5Wedge osteotomy, 123–4Wound:

debridement, 204dressings, 16healing, 15–17open wound technique, 111

Wrinkle test, 10, 229Wrist, 143–73

anatomy, 143–5arthroscopy, 146, 152assessment, 146collapse deformity, 164, 195drop, 66–7flexion test, 85–6fusion, 187–8movements, 145–6nerve injuries, 62osteoarthritis, 187splinting:

dynamic, 155serial, 154–5support, 86–7, 154

X-rays, 117, 135, 146, 147, 157, 161, 165–6,168, 170

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The Hand- Fundamentals of Therapy