Hand and Wrist Surgery - part 5 ppsx

T E N D O N I N J U R I E S 222 A B Figure 36–4. (A). Lateral radiograph and (B). a radiograph of a type 3 avulsion secured with two cortical screws. were placed with bicortical purchase (Fig. 36–4). The fragment was seen to be stable with a range of motion. The tourniquet was deflated, hemostasis obtained, and saline irrigation performed. The skin was closed with 4–0 nylon simple sutures, a bulky dressing applied, and a dorsal blocking splint applied with the wrist in 30 de- grees of flexion. The fingers were splinted in the intrinsic-plus position to relax the FDP tendon and prevent postoperative stiffness. Type 1 and 2 injuries necessitate exploration at the level of the PIP joint, where an additional palmar zigzag incision is used to expose the flexor sheath (Fig. 36–3). A transverse incision is made into the sheath just distal to the A2 pulley or through the C1 pulley. If the FDP tendon is not found at this level, then an additional inci- sion is made in the palm and the flexor sheath is opened proximal to the A1 pulley. If the tendon is found at this level, it is classified a type 1 injury. The long and short vincula are ruptured, and the blood supply to the tendon is theoretically compromised. The tendon is retracted proximal to the flexor sheath, preventing this source of nutrition via intrasynovial diffusion. This necessitates earlier repair, within 7 to 10 days, to pre- vent possible necrosis and myostatic contracture that may develop. A 4–0 Prolene suture is placed as a core suture in the proximal tendon stump. An infant feeding gastrostomy tube or Swanson suture passer is placed in retrograde fashion from just distal to the A2 pulley (at the PIP level incision) through the flexor sheath. Care is taken to place the tube/suture passer through the flexor superficialis decussation and to exit proximal to the A1 pulley. The tube/suture passer is attached to the core suture, and the tendon is pulled distally to the level of the PIP joint. Next the tube/suture passer is fed retrograde under A4 (from the DIP level incision) and the tendon is pulled distally to the level of A V U L S I O N S O F T H E F L E X O R D I G I T O R U M P R O F U N D U S 223 the avulsion at the distal phalanx. Care is taken to preserve the A2 and A4 pulleys to pre- vent bow-stringing postoperatively. A 25-gauge needle is used to spear the tendon at A4 to secure its position. A bone trough is created at the proximal volar aspect of the distal phalanx. Two heavy needles are drilled through the bony trough volarly, exiting dorsally and distally through the nail plate. The core suture ends are pulled through the eye of the needles and pulled through the distal phalanx and nail. They are pulled snug and tied securely over a button on top of the nail while flexing the finger. Any remaining stump of tendon at the base of the distal phalanx is sutured over this repair for additional security and healing potential. The sheath can be left open or repaired, depending on the surgeon’s philosophy. The closure and postoperative care are similar to the type 3 in- jury described before. The suture and button are removed at 6 weeks after surgery. If the tendon was initially found at the level of the PIP joint upon exploration, it is classified a type 2 injury. The long vinculum is assumed to be intact, providing a source of nutrition to the tendon and preventing further retraction of the tendon into the palm. The short vinculum from the distal end of the middle phalanx is rup- tured. The tendon still lies within the flexor sheath and retains nutrition via in- trasynovial diffusion. Due to these factors, the repairs have been reported more than 2 months after injury. A 4–0 Prolene core suture is placed in the distal tendon end, and pulled underneath A4 as described before. The suture is pulled through and tied to a button as described for a type 1 injury. If upon surgical exploration a type 4 injury is found, then reduction and fixation of the bony fragment would be performed with screws, as described before. The tendon avulsion from this bony fragment would then be repaired to the distal pha- lanx, as described for a type 1 or 2 injury. Postoperative Management This patient was seen the following week and started on a flexor tendon zone 1 pas- sive range of motion protocol, as described by Evans. A dorsal blocking splint was placed to keep the wrist in 30 degrees of flexion and the MP joints in 60 degrees of flexion. A second dorsal splint was applied to the digit to maintain 45 degrees of flexion at the DIP joint. Passive flexion of the digit was allowed out of the splint several times daily. A modified passive hook fist and passive PIP extension was al- lowed with the MP joints flexed. Place and holds were performed for the FDS. Wrist extension to 10 degrees was allowed with the fingers flexed under therapist su- pervision. Sutures were removed at 10 days and radiographs obtained at follow-up visits to ensure reduction of the fragment and progression of healing. At 21 days, active range of motion was instituted with a full fist place and hold, and the digital blocking splint was discontinued. At 28 days the patient was started with tenodesis wrist exercises, gentle isolated FDS exercises, and hook fisting. At 35 days, full DIP active motion was allowed, including extension. After bony union was confirmed radiographically and clinically, strengthening with resistance was started at 8 weeks; at 12 weeks the patient was allowed to return to full activity at work and in sports. Alternative Methods of Management Alternatively, Bier block or local anesthesia can be used. Care must be taken with local anesthesia, as the palm may also need to be blocked in case of a missed or converted type 1 injury. A midlateral exposure can be used in the digit rather than a volar zigzag, depending on the surgeon’s preference. T E N D O N I N J U R I E S 224 The tendon end can be secured to the distal phalanx by passing the core suture ends around the bone, rather than through it. It can still be secured over a button on the nail, as described before. Another method is to anchor the suture to the dis- tal phalanx using a bone suture anchor. This leaves the nail bed and plate intact, and obviates the need for later suture removal. Chronic (>3 months) untreated cases can be left alone if asymptomatic. If there is bothersome instability or pain in the DIP joint, this can be treated by tenodesis or fusion. If the remaining proximal stump of the profundus tendon is tender, this can be excised from the palm. Another somewhat laborious approach would be to per- form one- or two-stage tendon grafting through the superficialis, allowing active use of the DIP joint. Complications Rerupture of the tendon can occur early or late. This should be repaired emergently as with the initial injury. Infection, skin slough, stiffness, and irritation at the wound and button site are infrequent. A slight loss of extension at the DIP joint commonly occurs. Nonunion or malunion of a bony fragment is a rare possibility, and can be prevented with careful attention to the bony reduction and fixation. Suggested Readings Carroll RE, Match RM. Avulsion of the flexor profundus tendon insertion. J Trauma 1970;10:1109–1118. Eglseder WA, Russell JM. Type IV flexor digitorum profundus avulsion. J Hand Surg [Am] 1990;15A:735–739. Ehlert KJ, Gould JS, Black KP. A simultaneous distal phalanx avulsion fracture with profundus tendon avulsion: a case report and review of the literature. Clin Orthop 1992;283:265–269. Evans RB. A study of the zone I flexor tendon injury and implications for treat- ment. J Hand Ther 1990;133–148. Leddy JP. Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77–83. Leddy JP, Bechler J. Flexor tendon avulsion from the distal phalanx. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore: Williams & Wilkins; 1996:120–128. Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg [Am] 1977;2A:66–69. Schneider LH. Fractures of the distal phalanx. Hand Clin 1988;4:537–547. Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx–Case report. J Hand Surg [Am] 1981;6A:600–601. Strickland JW. Flexor tendons–acute injuries. In: Green DP, Hotchkiss RN, Peder- son WC, eds. Operative Hand Surgery, 4th ed. Philadelphia: Churchill Livingstone; 1999:1877–1883. Trumble TE, Vedder NB, Benirschke SK. Misleading fractures after profundus ten- don avulsions: A report of six cases. J Hand Surg [Am] 1992;17A:902–906. Section VIII Fractures and Dislocations of the Hand A. Phalanx Fractures Distal Phalangeal Fractures Kevin D. Plancher Mallet Fractures Kevin D. Plancher Proximal Phalangeal Shaft Fractures Kevin D. Plancher Proximal Phalangeal Condylar Fractures Carrie R. Swigart B. Metacarpal Fractur es Metacarpal Neck Fractures Kostas J. Constantine and Thomas R. Kiefhaber Metacarpal Shaft Fractures Robert J. Goitz, Sokratis Varitimidis, and Dean G. Sotereanos Metacarpophalangeal Joint Injuries: Fractures (Intraarticular) at the Base of the Proximal Phalanx, An Arthroscopic Technique Joseph F. Slade III and John D. Mahoney Metacarpal Head Fractures Paul R. Greenlaw and Mark R. Belsky C. Dislocations: Phalanx and Metacarpals Volar Dislocations of the Proximal Interphalangeal Joint Lisa L. Lattanza and Steven Z. Glickel Lateral Dislocations of the Proximal Interphalangeal Joint Christopher H. Martin and Steven Z. Glickel Dorsal Dislocations of the Proximal Interphalangeal Joint Rosa L. Dell’Oca and Amy Ladd Distal Interphalangeal Joint Dislocations John D. Wyrick Dorsal Metacarpophalangeal Dislocations (Irreducible) Benjamin Chang and Mark Katz Volar Metacarpophalangeal Dislocations (Irreducible) Benjamin Chang and Mark Katz D. Thum b and Carpometacarpal Joint Ulnar Collateral Ligament Injuries: “Skier’s Thumb” Kevin D. Plancher Carpometacarpal Joint Injuries: Bennett’s Fractures (Arthroscopic and Percutaneous Screw Technique) Joseph F. Slade III and John D. Mahoney Carpometacarpal Joint Injuries: Bennett’s Fractures (Wire Technique) Michael Jablon Complex Fractures at the Base of the Thumb: Rolando Patterns John A. Girotto, Shrika Sharma, Thomas J. Graham Carpometacarpal Joint Dislocation Andrew L. Haas and Kevin D. Plancher D I S T A L P H A L A N G E A L F R A C T U R E S 227 PEARLS • Expect patients 50% of the time to have cold intoler- ance, hypersensitivity, and paresthesias. • Sew these flaps with chromic or catgut sutures. Suture to the nail should be absorbable to avoid painful removal in the office. PITFALLS • Attention to detail in lifting the V-Y flap in the subcuta- neous tissue will provide sur- vival of the tissues. • Adequate incision and drain- age with antibiotics will avoid infection in most cases. 37 Distal Phalangeal Fractures Kevin D. Plancher History and Clinical Presentation A 35 year old carpenter was on the job using a table saw. He forgot to engage the safety and cut the tip of his finger. He presents to the emergency room with exposed bone at the tip of his finger after a transverse cut to his fingertip. Physical Examination There is no soft tissue covering the end of the bone. Approximately 40% of the nail and nail matrix are present. Diagnostic Studies Anteroposterior (AP), lateral, and oblique radiographs of the injured digit were ob- tained. The finger was assessed for foreign objects, joint dislocation, subluxation, and fractures. Differential Diagnosis Distal phalanx fracture Vascular injury Nerve injury Mallet fracture Distal phalanx (P3) dislocations Diagnosis Open Distal Phalanx Fracture with So ft Tissue Loss The type of injury, the functional goal, and possible complications often determine the treatment of fingertip injuries. Factors to consider include finger sensitivity, a nontender finger, maximum length, nail appearance, normal joint movement, and cosmesis. On initial diagnosis, the viability of the tissues should be assessed to deter- mine which tissue is unlikely to survive. It must also be determined what can be sac- rificed and what must be preserved to maintain function. Transverse amputations are the easiest to repair. Treatment is determined by the coverage of the bone. The amount of nail following injury is also important in de- termining treatment. Depending on the level of amputation, blood vessel and nerve status must also be determined. In oblique dorsal amputations, if the nail is only partially injured, an attempt must be made to preserve it. The condition of the nail matrix is also important. Oblique palmar amputations are difficult to treat. Thenar flaps are an option. The goal of treatment in a palmar amputation is to provide a re- constructed pulp, which is sensitive and well cushioned. F R A C T U R E S A N D D I S L O C A T I O N S O F T H E H A N D 228 Surgical Treatment For this patient the volar V-Y flap or Atasoy technique was used to provide coverage of exposed bone with adequate padding. The patient was most concerned with fin- gertip tenderness and function of the finger. The finger was prepared and a lidocaine metacarpal block supplemented with bupivacaine provided anesthesia. A Penrose drain was placed on the digit to act as a tourniquet. The wound was irrigated and surgically cleaned, and debridement of the skin edges was performed. A pattern of the defect was transferred onto the pal- mar skin proximal to the defect. The skin pattern was made ~1 mm larger. The pal- mar skin incisions were marked from the lateral edges of the defect site to enclose the skin pattern and continued proximally and obliquely to meet in the midline of the finger at the distal crease (Fig. 37–1). The skin was incised through the dermis sharply and the flap was dissected from the periosteum and the flexor sheath. The Grayson’s and Cleland’s ligaments that surround the neurovascular bundles and connect the flap to surrounding tissues were bluntly dissected and divided with dissection scissors (Fig. 37–2). The flap was mobilized to allow advancement of the flap without tension (Fig. 37–3). Hemostasis was maintained with a bipolar cautery. The flap was then sutured to the nail with nonabsorbable sutures (Fig. 37–4). The apex of the V was closed with interrupted sutures, which were kept close to the Figure 37–1. The palmar skin incisions are marked from the lat- eral edges of the defect site to enclose the skin pattern and continue proximally and obliquely to meet in the midline of the finger at the distal crease. Figure 37–2. The Grayson’s and Cleland’s ligaments that surround the neurovascular bundles and connect the flap to surrounding tissues are bluntly dissected and divided with dissection scissors. D I S T A L P H A L A N G E A L F R A C T U R E S 229 Figure 37–3. The flap is mobilized to allow advance- ment of the flap without tension. Figure 37–4. The flap is sutured to the nail with nonabsorbable sutures. F R A C T U R E S A N D D I S L O C A T I O N S O F T H E H A N D 230 skin edge to avoid interference with the vascular supply. The tourniquet was de- flated and blood supply to the flap was verified. The finger was treated with Xero- form, a light dressing, and a protective tip splint. The patient was instructed to keep the finger elevated for 2 days. The dressing was changed 5 days postoperatively and the patient was prescribed active exercises of the proximal interphalangeal (PIP) joint. Sutures were removed at 14 days postoperatively and the patient was in- structed to keep the protective splint on for 4 to 6 weeks postoperatively. Alternative Techniques The lateral V-Y flap technique uses flaps from the lateral side of the digit to close fingertip defects. Digital anesthesia is obtained with metacarpal block. The bone is debrided and the wound is irrigated. The dorsal incision is made from the amputa- tion site to 2 mm lateral to the nail fold and continued proximally midway between the palmar and dorsal surfaces of the bone. The incision length is twice the width of the flap. The oblique incision is made from the palmar edge of the defect to intersect with the dorsal incision (Fig. 37–5). Advancement of the flaps requires complete release of the dorsal-lateral fibrous bands (Fig. 37–6). With tension on the distal aspect of the flap, the fibrous septum is dissected. The two flaps are advanced Figure 37–5. The oblique incision is made from the palmar edge of the defect to intersect with the dorsal incision. Figure 37–6. Advancement of the flaps requires complete release of the dorsal-lateral fibrous bands. . sitting at 45 degrees. 38 Mallet Fractures Kevin D. Plancher History and Clinical Presentation A 4 5- year-old left hand dominant professional squash player was lunging for a shot and fell, landing. [Am] 1983;65B:606–607. Darder-Prats A, Fernanadex-Garcia E, Fernanadex-Gabarda R, Darder-Garcia A. Treatment of mallet finger fractures by the extension-block K-wire technique. J Hand Surg [Br]. oblique and spiral frac- ture patterns may be fixed with 1 . 5- mm screws if the frac- ture is two to three times diam- eter of the phalanx. • Loupe magnification is helpful when using 1. 1- or 1 . 5- mm screws. PITFALLS Screw